Twins survived breast cancer in different countries. One in the UK paid nothing for treatment, but her US-based sister paid $14,000.

  • Twin sisters both got breast cancer, one living in America and one in England. 
  • The US-based twin paid $14,000 for her treatment, and the UK-based twin paid nothing.
  • Even with good health insurance, navigating the system was still a maze of negotiating costs and being overbilled. Health experts say this is typical of America's system.
  • Visit Insider's homepage for more stories.

It may come as no surprise to most Americans that Nancy Groce, a 67-year-old federal employee based in Washington, paid $14,000 to be treated for breast cancer, in addition to the $3,500 premium she paid her insurance company annually.

But her case is particularly striking given that, across the ocean, Nancy's twin sister Nora, a university professor in London, was diagnosed with breast cancer at the same time. Her treatments were completely free.

Both siblings received treatments at two respected university hospitals, and both are now in remission.

The two sisters wrote a case study of their experience for medical journal BMJ, with the goal of informing people what negotiating with the American healthcare system is like, even what was widely considered to be good insurance. 

Nancy was a government employee who used private healthcare, while Nora's treatment was covered by the NHS, the UK's national health service. But while Nora took six weeks off to have a double mastectomy in 2014, and was encouraged by her boss to take off more time if she needed to, Nancy says she could only take two weeks off work to handle a lesion found in one of her breasts, scheduling radiation appointments for the crack of dawn so she could work the rest of the day.

The stress of mounting bills and paperwork gave Nancy high blood pressure (which brought more bills and paperwork)

Nancy had never had blood pressure problems before this ordeal, but in the months spent dealing with her health issues and negotiating with insurance companies, hospital billing offices, and its expenses, her blood pressure skyrocketed — which meant more tests, prescriptions, and bills to pay.

"I have access to really good healthcare in the US," Nancy told Insider. "It's not a question of the quality."

"Our quarrel was with the system, not with individuals," Nora added.

Nancy, a well-educated woman with a PhD, works in a complex work environment, and is often required to negotiate with people. And yet, she says, she still felt overwhelmed navigating the system, trying to understand which aspects of her breast cancer treatment would be covered by her insurance.

Many bills were only partially covered, and some doctors refused to work with her insurance. Some appointments required her to call the billing offices and negotiate. 

"At one point, a contractor from my insurance company called me from out of the blue, trying to talk me into getting a cut-rate MRI someplace in Manhattan to save the money for the insurance company," said Nancy. "My insurance company had shared my personal information about cancer, which can have a significant impact on people's jobs, with an outside contractor, who wasn't even a medical expert."

Halfway through her radiation treatments, Nancy received a bill for $40,000. It was a billing error, but in the weeks it took the hospital to decipher their mistake, Nancy began to think about mortgaging her home.

"How much education you have is irrelevant because the system is just set up to be baffling," said Nancy. 

Nora only had to fill out 3 forms for her 3 operations, which were all free

Nora signed just three pieces of paper to consent to the three surgeries she had: two lumpectomies and a double mastectomy.

"As Americans we've just come to accept that every time you deal with a medical profession, it's going to be a mess. And I think people hesitate to go to doctors because they don't want to deal with unexpected bills and surprise payments," said Nancy. 

"And the paperwork!" said Nora. 

Nora spent most of her life in the US, working at the Yale School of Public Health for 20 years, before moving to the UK to become a director of the Leonard Cheshire Disability Research Centre at the University College of London.

State-side, she says, she felt riled watching people go into managerial positions at insurance companies and make more money than doctors.

Nora described US healthcare as a grocery store: someone (the insurer) plants themselves in front of the store and declares that nobody can buy food unless they paying them first, with a 100% markup. That store clerk will decide what you can and can't eat, and how much you will pay for it. If you don't like it, you can go to a food bank or starve.

"Our taxes [in the US] go into medical schools, we subsidize nursing schools and health systems and hospitals," said Nora. "We're already paying for 90% of the care but then there's this for-profit system that's saying they're managing everything and are making it very difficult for people to get to the care we already have in place."

Most other countries have a philosophy that people shouldn't go into debt over medical bills

Americans are often told they receive the world's best healthcare, but the data shows that is far from true. The US spends twice what other countries spend on healthcare, in part because everything in the US, from doctors to devices to hospital stays, costs more. But America's health outcomes are far worse. And more and more well-insured individuals are getting bankrupted by America's insurance system.

"One thing we know is stress can be bad for you," said Michael Gusmano, an associate professor at the Rutgers School of Public Health. "When they're sick, people don't want to worry about insurance and want their decisions to be independent of financial considerations."

But research shows people without insurance, or who are underinsured, will often defer care because of cost concerns.

If you have a chronic illness in France, you are exempted from out-of-pocket medical bills because the French don't want to discourage people from seeking medical care. In England, care is free for everyone on the NHS, though sometimes there is a cost for prescription medication — except for over-60s, who get free prescriptions too. There is also a private healthcare system if Brits want to pay.

"But America's fragmented public-private system doesn't have good mechanisms for negotiating price, unlike other countries," said Gusmano. In those countries, the government legislature negotiates a healthcare budget for the year, so there is no room for the ambiguity and opacity in America's system.

"'It's a matter of philosophy, that these countries don't believe people should experience financial hardship over medical bills," said Gusmano. "I would argue that's a universal belief in most places but America."

America is slowly inching towards the international standard, an expert says

Gusmano says America's come a long way from the pre-2010 era, when people could be denied coverage for pre-existing conditions. In fact, there's a lot of bipartisan support not allowing insurance to do that, even though it was common practice until recently. Then, if someone had a pre-existing condition they could either be denied coverage or have to pay sky-high premiums.

"We're not France, we're certainly not Norway, but many members of the American public no longer find it acceptable to let people go without care for financial reasons," he said.

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