Health Care
11:56 am
Wed August 7, 2013

'Paying Till It Hurts': Why American Health Care Is So Pricey

Originally published on Wed August 7, 2013 2:05 pm

It costs $13,660 for an American to have a hip replacement in Belgium; in the U.S., it's closer to $100,000.

Americans pay more for health care than people in many other developed countries, and Elisabeth Rosenthal is trying to find out why. The New York Times correspondent is spending a year investigating the high cost of health care. The first article in her series, "Paying Till It Hurts," examined what the high cost of colonoscopies reveals about our health care system; the second explained why the American way of birth is the costliest in the world; and the third, published this week in The Times, told the story of one man who found it cheaper to fly to Belgium and have his hip replaced there, than to have the surgery performed in the U.S.

Rosenthal has also been investigating why costs for the same procedure can vary so much within the U.S. — by thousands of dollars, in some cases — depending on where it's being performed. Before becoming a journalist, Rosenthal trained as a doctor and worked in the emergency room of New York Hospital, now part of New York-Presbyterian Hospital.

She joins Fresh Air's Terry Gross to talk about why American medical bills are so high, and what needs to change.


Interview Highlights

On the goal of her health care series

"[The purpose is] to make Americans aware of the costs we pay for our health care. Because so many of us have insurance and we don't see the bills, we tend to think of health care as free. 'Why not get that colonoscopy? It doesn't cost anything. What's the difference if my hip replacement costs $100,000? I'm not paying.' But, in fact, we're all paying. And as we know, health care is a huge cause of individual bankruptcies now. Copays and deductibles are going up, and the nation — because it pays for a lot of medical care and subsidizes a lot of medical care — just can't afford the way we're doing this anymore."

On the man who went to Belgium to get a hip replacement

"In Belgium, he paid $13,660 for everything. That included his new hip implant, the surgeon's fees, the hospital fees, a week in rehab and a round-trip plane ticket from the U.S., soup to nuts.

"Now, if he had done that surgery in the U.S, it would've been billed at somewhere between $100,000 and $130,000 at a private hospital. ... So there's a huge difference. In fact, this gentleman, Mr. Shopenn, was a great consumer, and he tried to have it done in the U.S., and he priced out joint implants and found that the wholesale joint implant cost ... was $13,000. So in the U.S., for that $13,000 he could get a joint — a piece of metal and plastic and ceramic — whereas in Europe he could get everything."

On joint-makers keeping prices high

"You would think that if five different companies were making candy bars, that would drive the price of candy bars lower. But if five different companies are making joints and trying to sell them at $10,000 a piece, it's really in no one's interest to say, 'Hey, guess what guys? I'm going to sell mine for $1,000 because that's what it really costs me to make it.' Because then everyone loses money; the whole industry kind of implodes."

On the challenge of standardizing medical equipment

"It's hard to get the companies to, say, standardize the equipment ... so you can use a generic system to implant any brand of joint. It's not in their interest to do that. It's like saying to Apple and Microsoft, 'We want all of your programs to be completely interchangeable.' At some level, at a business level, you want your brand distinct, and you want to keep people in the universe of your brand. In many ways, it's a business decision as much as a medical decision."

On how billing practices in the U.S. compare to those in Europe

"Routinely, for most procedures in other countries, patients stay in the hospital longer; their hospital bills are much less. They tend to see things as a package. I think one of the most striking things when you look at the Belgian hospital bill, as opposed to the U.S. one, is on the U.S. hospital bill for a joint replacement, you see things like operating room fees, recovery room fees. And those [were on] one of the bills I looked at: operating room fees, $13,000; recovery room fees, $6,000; facility fees, x-thousand dollars.

"If you look at a European bill, those things don't exist. And you know, in fact, it was kind of funny when I started on this series — although sad in another way — when I would call some of the European hospitals and say, 'Well, what's your facility fee on that? What's your operating room fee?' and there was this puzzled pause at the other end of the line where they said, 'What do you mean an operating room fee? You can't do the surgery without an operating room. That's a part of our day rate for the hospital. It's all included.' "

On pregnancy costs in the U.S. versus Europe

"Because we pay one by one by one, we have this kind of more-is-better attitude, or 'Why not check and see if the baby is in good position? Why not check and see if the baby is growing?' Whereas in most other countries, the care of a pregnant woman is kind of dictated purely by medicine, what needs to be done. So it's not that in these European countries they aren't getting their prenatal testing and they're not getting their prenatal scans — they are, they're just not getting as many as we do. Because we kind of tend to use a lot of them for like-to-know rather than need-to-know, and again, that gets very, very expensive."

On what needs to change

"Every part of the system needs to rethink the way it's working. Or maybe what I'm really saying is we need a system instead of 20, 40 components, each one having its own financial model, and each one making a profit."

Copyright 2013 NPR. To see more, visit http://www.npr.org/.

Transcript

TERRY GROSS, HOST:

This is FRESH AIR. I'm Terry Gross. Americans pay more for health care than people in many other developed countries, and my guest, Elisabeth Rosenthal, has been finding out why. She's a New York Times correspondent who's spending a year investigating the high cost of health care. The first article in her series "Paying Till It Hurts" examined what the cost of colonoscopies reveals about our health care system.

The second explained why the American way of birth is the costliest in the world. And the third, published this week in the Times, told the story of one man who found it cheaper to fly to Belgium and have his hip replaced there than to have the surgery performed in the U.S. Rosenthal has also been investigating why costs for the same procedure can vary so much within the U.S., by thousands of dollars, depending on where it's performed.

Before becoming a journalist, Rosenthal trained as a doctor and worked in the emergency room of New York Hospital. She's also worked at the New York Times as an international environmental correspondent, a reporter in the Beijing bureau, and a metro reporter covering health and hospitals.

Elisabeth Rosenthal, welcome to FRESH AIR. What's the overall purpose of this year-long series that you're doing?

ELISABETH ROSENTHAL: It's to make Americans aware of the costs we pay for our health care. Because so many of us have insurance, and we don't see the bills, we tend to think of health care as free. Oh, why not get that colonoscopy, it doesn't cost anything. What's the difference if my hip replacement costs $100,000? I'm not paying. But in fact we're all paying.

And as we all know, medical care is a huge cost of individual bankruptcies now, co-pays and deductibles are going up, and the nation, because it pays for a lot of medical care and subsidizes a lot of medical care, just can't afford the way we're doing this anymore.

GROSS: So let's start looking at some of the costs and why things are so expensive. Your latest article in the series is on joint replacement. It focuses on a man whose insurance wouldn't pay for his hip replacement, even though he could hardly stand, because the insurance company considered it part of a pre-existing condition.

So he couldn't afford to pay for it in the United States, and he ended up going to Belgium. Can you compare what he paid in Belgium with what he would have paid in the U.S.?

ROSENTHAL: Yes, it's really shocking every time I say it. In Belgium he paid $13,660 for everything. That included his new hip implant, the surgeon's fees, the hospital fees, a week in rehab and a round-trip plane ticket from the U.S., soup to nuts.

Now, if he had done that surgery in the U.S., it would have been billed at somewhere between $100,000 and maybe $130,000 at a private hospital. Now, insurance wouldn't have paid that much, but they would have paid maybe $60,000, $70,000. So you know, there is a huge difference. In fact, this gentleman, Mr. Shopenn, was a great consumer, and he had tried to have it done in the U.S., and he priced out joint implants and found that the wholesale joint implant cost that he wanted was $13,000.

So in the U.S. for that $13,000 he could get a joint, a piece of metal and plastic and ceramic, whereas in Europe he could get everything. And this is at a high-quality hospital, top-of-the-line joint, top-of-the-line surgeon, so really no difference in quality.

GROSS: You know, why is there such a big difference in just the joint itself, the artificial joint itself, a big difference in price?

ROSENTHAL: Well, the irony is that Mr. Shopenn's joint that he got in Belgium was made by an American company. It's a company based in Indiana. So the fact is that we pay more for everything, even the identical thing, as people do in other countries. And that's partly because of the way we price medicine.

We don't have any, aside from Medicare and Medicaid, we don't have any national intervention in rate-setting, the way we do in electricity. So companies, when they're selling joints in the U.S., can price them however they want. You know, it's a bargaining situation between a hospital and a manufacturer, often with many intervening steps; whereas in Belgium, for example, or in France, there's a limit on what joint manufacturers, device manufacturers, can charge.

The government says we're going to make all these joints available to you, but this is what you can charge and you can't pay more, the way we do for electricity. But for some reason we're not willing to do that with health care.

GROSS: The joints, at least for hip replacement, are made by like five companies. Like most of them are made by five companies, four of which are in the United States, three of which are in a small town in Indiana called Warsaw, which is where your piece is datelined. You say some economists have described these five companies that manufacture joints as a cartel. Why?

ROSENTHAL: Well, because they don't actively work together. They emphasize this over and over again, that they don't actively set prices. But what you realize, especially when you go to a place like Warsaw, Indiana, where three of these big joint manufacturers are located, is that there's a lot of - it doesn't need to be said. It's kind of unspoken.

So you would think if five different companies were making candy bars, that would drive the price of candy bars lower, but if five different companies are making joints and trying to sell them at $10,000 apiece, it's really in no one's interest to say, hey, guess what, guys, I'm going to sell it for $1,000 because that's what it costs me to make it, because then everyone loses money, the whole industry kind of implodes.

So I think there's a lot of - you don't even need to say, hey, guys, let's cooperate on price. It just happens kind of automatically.

GROSS: And you write that generic joints or foreign-made joints have been kept out of the United States by trade policy, patents and an expensive FDA approval process that deters startups from entering the market. So does that mean that the policies we have are inhibiting the kind of competition that could drive prices down?

ROSENTHAL: Well, I suppose, depending on how you look it, at one level they're protecting us because of course you don't want low-quality joints coming into the country, but you could use the same argument as was once used for generic pharmaceuticals.

So I think at this point it's mostly inhibiting competition. Of course, you know, the FDA needs to require generic manufacturers to prove that they're manufacturing safely, that they meet high quality standards, they need their factories inspected, on and on and on. And that does make it hard for smaller manufacturers to enter this market.

But part of what makes it so difficult is just that these five companies kind of have it locked up. You know, their sales reps are in every hospital. They are at all the trade shows. They know the doctors. They know the hospital administrators. So it's just a really hard market to break into.

Now, part of that is we tend to think of the joint as just the piece of metal and plastic and ceramic, but in fact when you buy a joint from Zimmer or Biomet, which are two of the big companies, you're buying into a whole system. You're buying into a distribution system of joints.

There's a representative from the joint company in the operating room when you have that surgery. So should that person be there? I think that's a big question of ethics and economics that makes a lot of people uncomfortable, but that's the way we do it now. So it's very hard to replicate the full-service system that those five companies have now if you're a small startup, although some people are trying.

And you know, when you talk to people in the joint industry, in the joint manufacturing industry, their fear, which they'll tell you about, is uh-oh, in five to 10 years or 10 or 20 years, maybe we'll be seeing a lot more low-cost joints from Asia the way we saw TVs and air conditioners.

GROSS: So you said that there's often a representative from the joint manufacturing company in the operating room with the surgeon. What is the point of that? Is that like - I mean I know like when our printer in the office breaks, it's great to have somebody from the company come down and fix it. So I could see how maybe you'd want somebody from the manufacturer there in case there's like a technical issue. Is that why they're there?

ROSENTHAL: Yeah, I can give you the upside and the downside.

GROSS: Thank you.

ROSENTHAL: The upside is - is that, as I said, joints are not - you know, they don't exist in a vacuum. They come with these big tool kits to put them in. There are a lot of different choices. And the rationale is that if you have someone from the company there, he or she will be able to say, here, I've got the perfect wrench to get that hip in just the right place.

They know the tools backwards and forwards. They've seen a lot of joints put in. Now, the downsides are many and costly. The downsides are that obviously it costs something to have that person in the OR. It's an extra person whose salary is folded into the price of the joints. Second of all, it really ties the surgeon to a particular brand of joint.

So if a hospital says, you know what, Zimmer joints are getting really expensive, I want to buy Stryker joints next year, the surgeons will resist because they'll say, oh look, I know this guy from this one company, and they've always - you know, I know their whole system.

And the third thing is it allows for what's called upselling in the OR, where someone will say, hmm, that hip isn't working, how about a more expensive one I have in my bag. So economically the costs are many, and it's become standard practice. It wasn't always practice to have these people in the OR, and it's certainly not the practice elsewhere in the world.

GROSS: Is it controversial in the American health care system?

ROSENTHAL: There's a lot of controversy among orthopedists about whether this is a good thing or a bad thing. There's kind of a codependence that's evolved between the surgeons and the sales reps. And a lot of them, in fairness a lot of the orthopedists do not like this system at all, but it's hard to get the companies to say, standardize all the equipment in part so you can use a generic system to implant any brand of joint.

It's not in their interest to do that. It's like saying, you know, to Apple and Microsoft we want all your programs to be completely interchangeable. At some level, at a business level, you want your brand distinct and you want to keep people in the universe of your brand. So it's in many ways a business decision as much as a medical decision.

GROSS: Not to belabor the point here, but my guess would be that the joint replacement companies don't call the person in the operating room a sales rep. They probably call them, you know, an expert on joint replacement or something.

ROSENTHAL: They'll call them a representative or a tech, but it is the same person, generally, who, you know, does the selling. I mean, the person from the company will bring the joint to the hospital, because the hospitals don't routinely anymore keep them in storage. So the manufacturer stores the joint.

You say, you know, we need three, these kind of knees and two, these kind of hips next week. They'll bring them in, they'll bring the equipment, they'll bring - so they kind of, it's a full-service industry. Now, that has - that makes it easy at some level for hospitals and doctors, but it also comes at a price.

(BREAK)

GROSS: Doctors and hospitals, you say, have to sign nondisclosure agreements about the pricing, saying that they won't reveal the prices of the joints that they're using. Why are they asked to sign these agreements, and what are the results of signing them?

ROSENTHAL: It's partly a function of the crazy way we price all health care. There are list prices, as with hospitals, as with MRI scans, that are published. The list prices of joints will be, say, $11,000 to $18,000. But hospitals don't actually pay that price. No one pays that price. There's a great deal of bargaining.

But it's - the companies really don't want hospitals to know what kind of deals they're giving out to their competitors. So you don't know if you're getting a good deal or not a good deal, and basically they don't want you to know if you're getting a good deal or not a good deal because it keeps everyone a little bit off-balance.

And in fact the bargaining system between hospitals and the joint manufacturers is so complicated, and it makes the hospitals so nervous because they don't know if they're getting a good price, they then have to go out and hire - and I didn't even know this all existed - there are joint brokers. There are joint consultants. There's this whole intervening industry of people who have grown up to tell hospitals, are you getting a good deal on that joint you're purchasing?

And the problem is, of course, that each of those layers charges another 10 percent. So even if a hospital does bargain for a good price on the joint, they get the $7,500 price, there'll be added fees from the joint broker and the joint negotiator and the joint biller, and the last step is the hospital will mark up the joint too because they've spent all of this time and effort negotiating for it, that they want to factor that in, and they want to make some profit off this too.

You know, everyone is in a little bit of the mode, oh, well, the joint manufacturer is making this much money, so why shouldn't I, and I think it's kind of a feeding frenzy, and of course what everyone's feeding on are our insurance dollars and our medical bills and our health. So that's not good.

GROSS: You write that joint manufacturers in the United States paid a $311 million settlement to the Justice Department regarding accusations that the joint makers were paying kickbacks to surgeons back in 2007, and that year nearly 1,000 orthopedists in the United States received a total of about $200 million in payments from joint manufacturers for consulting, royalties and other activities.

Is that considered kickbacks?

ROSENTHAL: Well, I think it's the other activities which raised a lot of eyebrows. Yes, the accusation at the time, and there's still ongoing concern, was that some of these payments were the kinds of things that happen in a lot of medical specialties that the doctors' world have grappled with for many years now.

You know, if you are an orthopedic surgeon and you're paid $20,000 to speak about the wonders of joint replacement by the company whose joints you use, is that a kickback, is that a speaking fee? You know, there are a lot of gray areas. So we know that some of those payments went for legitimate research that you want orthopedists to be doing, but the suspicion, and I think the size of that fine and the size of the money that was paid out, leads you to believe that some of it was just kind of a loyalty payment.

GROSS: So now that we've talked about some of the costs and some of the hidden costs of joints for joint replacement surgery in the U.S., compare that to Belgium, where the person you profile decided to go for his hip replacement surgery because it wasn't covered by insurance and he couldn't afford the cost of doing it in the United States.

So how do they make it so cheap in Belgium, $13,000 as compared to what were the prices he was quoted here?

ROSENTHAL: So here it would have ended up costing over $100,000. He didn't price it out all the way because once the hospital came back and said our share will be 68,000, and then he knew the joint was 13, he kind of said, uh-uh, this is not going to work for me in the U.S.

So there are many, many differences. The first one is that the joint implant itself is priced by the country. Well, different countries do it differently. Some have a national negotiation, where they'll say we're going to purchase Stryker joints for all of our hospitals. So they have tremendous bargaining power, and they get a much better rate.

Others, like Belgium and France, set an allowed rate that can be charged for that particular joint in that country. So if you look in Belgium or in France, there are lists of all the joints, and this is what you can pay for them, and you can mark them up but only by $180 for the patient.

So it's - pricing is very, very regulated. Another big difference is that hospital day charges are three or four times as much in the U.S. as in most other countries. So even though routinely for most procedures in other countries, patients stay in the hospital longer, their hospital bills are much less.

Then again, they tend to see things as a package. I think one of the most striking things is, in the U.S. hospital bill for a joint replacement, you see things like operating room fees, $13,000; recovery room fees, $6,000; facility fees, you know, X thousands of dollars. If you look at a European bill, those things don't exist.

And you know, in fact it was kind of funny when I started on this series, although sad in another way. When I would call some of the European hospitals and say, well, what's your facility fee on that, what's your operating room fee, and they kind of - there was this puzzled pause at the other end of the line where they said, what do you mean an operating room fee? You can't do the surgery without an operating room.

It's just, you know, that's part of our day rate for the hospital. It's all included. So that's a huge difference. You know, that doesn't even exist. And then also down to the smaller items, when you look at pharmacy charges for European hospitals, where sometimes they are broken out - you'll see every medicine is less than a euro or, you know, a dollar, whereas on U.S. bills you see the things that people always notice and complain about: heating pad, $90; warming blanket, $30; Tylenol, $4.

So you know, it's really everything, which is what's striking. It's just everything.

(BREAK)

GROSS: This is FRESH AIR. I'm Terry Gross, back with Elizabeth Rosenthal, a New York Times correspondent who's doing a year-long investigation into the high cost of health care in America. Her series is called "Paying Till It Hurts." The first article was about colonoscopies, the second childbirth; the third - which was published this week - is about the high cost of hip and other joint replacements. She profiled one man whose insurance wouldn't cover his hip replacement. He saved tens of thousands of dollars by flying to Belgium and having the surgery performed there.

When we left off, Rosenthal was explaining that in many developed countries - like Belgium - there's a set price for the whole procedure. But in the U.S., every part of the procedure is priced a la carte - from the joint itself, to the operating room, the recovery room, and each pill and medication.

So how come we itemize in the United States all the different - all, you know, the operating room and the recovery room fee and the individual Tylenol, and other countries don't?

ROSENTHAL: Well, I think some of it has to do with...

(LAUGHTER)

ROSENTHAL: You know, the answer I kept getting over and over again in the series from economists is because you can. You know, if you're thinking of - if you are a profit-making hospital or hospital that needs to balance its budget or a practice that wants to make money, you look how to - and I hate this word - monetize what you do and get the most revenue from it. And you know, if you bundle in everything and say, well, the Tylenol's included in the price of the room, you know, you make less money than if you say, we're charging you, you know, a la carte for everything we do. And part of the problem is our system allows that. In most other systems there's - you just legally can't do that. So you know, the interesting thing is I think there are some interesting projects on the horizon that are being tried for American health care, where insurers or companies offer a bundled price and the hospital has to figure out a way to do it for that price. I mean that's how Medicare pays for inpatient care, so - and that's a lot of why Medicare charges are much less than the fee-for-service charges. You know, we're really the only country that pays for medicine that way, I think, or one of the few.

GROSS: If I understand you correctly, one of the reasons why a la carte pricing is so expensive is that everything that you're paying for a la carte has an individual markup. So you're paying markups on everything as opposed to like just one general markup.

ROSENTHAL: Yes. I think that's right. And if you say, well, OK, I'm paying - and this is literally off a bill from an orthopedic hospital in New York - you're billing me $15,000 for operating, the operating room costs. Well, what does that include? Oh, it doesn't include the blood pressure cuff? Oh, it doesn't include the anesthesia drugs? It doesn't - so you know, it kind of includes walking in the door - or being rolled in the door, because it's an operating room. So, you know, it just, it's a way to - it's called unbundling, is the medical term. But it really adds to the cost.

GROSS: So the person who you profile in your article on the cost of hip replacement decided to go to Belgium for his surgery because his insurance wasn't paying for it and it was tens of thousands of dollars cheaper there than it would have been in the United States. Belgium has mandatory national health insurance. It requires contributions from employers and workers and then that pays for 80 percent and the other 20 percent you have to pay for yourself - though apparently a lot of people or most people have supplemental insurance to cover that 20 percent.

ROSENTHAL: Mm-hmm.

GROSS: So what are some of the differences between what you get in Belgium - in terms not just of health care, but like of amenities...

ROSENTHAL: Right.

GROSS: ...and what you'd get at, say, you know, a good American hospital?

ROSENTHAL: Right. And I think one of the things that got me thinking about the costs of health care in the U.S. was that I had been a correspondent overseas for a number of years. I trained as a doctor originally, so I was very familiar with, before becoming a journalist, with U.S. hospitals, but then spent 10 years overseas - first in Beijing and then in Europe. And so I experienced a lot of different health systems. And when you go into a hospital in Stockholm or Rome, it has a very different feel. The care I got there was superb, I have to say, in both places when I needed it. But, you know, there wasn't a Starbucks in the lobby. There weren't waterfalls or a lot of potted plants. It was very utilitarian. And you know, I think Michael Shopenn, the patient I profiled, he was funny. He said when he first pulled up to the hospital in Belgium, he was like, oh my, I'm not sure I want to be here because it doesn't look fancy. But the infection rates are among the lowest in the world in Belgium. The care is superb. So you know, we tend to focus on, oh, wasn't this a great, I love this doctor's office, you get free coffee. Well, right, it's free coffee but we're paying a huge price for that free coffee.

GROSS: We just talked about joint replacement surgery. Let's move on to the cost of childbirth. And in your article about childbirth you profiled a couple, man and a woman, both professionals, who have health insurance but their health insurance did not cover childbirth. So they tried to price different hospitals and see what would it cost so that they could go with a place that might be relatively affordable. And they had a really hard time pricing it. Why was it so hard?

ROSENTHAL: Well, because even most hospitals don't know what they charge. Again, it partly comes back to this a la carte pricing. You know, well, how much does a pregnancy cost? It depends. Are you going to need four scans or three scans or six scans? But the range, even given the variability of pregnancy, the range was pretty astounding. This couple I profiled in New Hampshire - Renee Martin and her husband Mark - they went to their local hospital and said, well, what's this going to cost us, after they got pregnant. And the estimate they were given was between $4,000 and $45,000. So how can you plan for that if you're trying to be responsible?

GROSS: Right. Now, you also compare American health care costs for childbirth with European countries. And give us a sense of, you know, what the comparison is.

ROSENTHAL: Well, most European countries - I mean it's almost hard to even do an economic comparison because most countries feel that childbirth is a right, it's vital for perpetuating your citizenry and your country, and so there really shouldn't be a cost disincentive for having a child. So even though you could - you can come up with a cost for childbirth in other countries, patients almost always aren't actually paying it. It's the cost to the system. So the cost to the system - or the cost if you were coming from outside and for some reason were to have your baby in France or Great Britain, so anyway, the cost in other countries tends to be in the $5,000 range, often much lower - as opposed to, here, 20,000.

GROSS: And do you think the health care in European countries is inferior to what we get in the United States for childbirth?

ROSENTHAL: Well, if we're looking at infant mortality or maternal mortality rates, we're inferior to care in Europe. I think we tend to get more medicalized care. We have more use of scans. But I don't think that means we have better care. You know, we have this - again, because we pay one by one by one, we kind of have this more is better attitude or more is, you know, why not check and see if the baby is in good position? Why not check and see if the baby is growing? Whereas in most other countries the care of a pregnant woman is kind of dictated by - purely by medicine, what needs to be done. So it's not in these European countries they aren't getting their prenatal testing and they're not getting their prenatal scans. They are. They're just not getting as many as we do because we kind of tend to use a lot of them for like-to-know rather than need-to-know. And again, that gets very, very expensive.

The other big thing which you see in most other health systems is there is a much greater use of non-M.D. pregnancy providers - like nurse midwives, doulas; general practitioners for the early stages of pregnancy. We tend to go right to the OB, whereas in most other countries obstetricians tend to be the doctors who take the complicated cases. And you know what? I think it's partly your cultural perception of what's proper and needed and your expectation. People in Europe say they loved the way they gave birth, whereas people here, some of them might say, wow, where's my obstetrician? This makes me nervous.

GROSS: And, as we found out with this couple that you followed, childbirth isn't always covered by insurance. Now, that's about to change because under Obamacare, starting in January, insurance has to cover the cost of childbirth, right?

ROSENTHAL: Yes. One of the great things that the Affordable Care Act will do is it will say that pregnancy services have to be covered in insurance policies. Because until now, many, many insurance policies purchased on the individual market, more than half, didn't cover childbirth. Now, that's pretty shocking, and it was particularly shocking to those couples who thought, wow, I've done the right thing, I've gone out and bought insurance, only to discover that there is a little clause saying, sorry, not for pregnancy. But I think going forward, the thing we have to be concerned about is, well, what do you mean when you say maternity care is covered or pregnancy is covered? Because what you see in patients who have coverage for maternity is that there is a lot of stuff that's carved out. You know, the same thing we see in other parts of medicine - OK, you have to have pregnancy coverage. Well, will that cover midwife care if I want to go to a midwife? What we see now is that a lot of policies that cover pregnancy say, oh no, not a midwife. So if you want to go to a midwife, that's, you know, $2,000 of your own money. Will it cover pain control during pregnancy - epidural anesthesia, if you choose that? Again, not clear. So when you say it's covered, as we all have seen in our own insurance policies, that doesn't necessarily mean that your costs will be taken care of. So I think we need to be very careful about defining what coverage is.

(BREAK)

GROSS: Any other big-picture things you want to mention to us about childbirth costs?

ROSENTHAL: I think the big thing that really surprised me was - Oh, I also want to thank all of the readers who have sent in their comments because I've learned a tremendous amount from the comments. Another pretty shocking thing I learned from our reader comments was that, you know, pregnancy is nine months and co-pays and deductibles reset every January 1st. So I heard from a number of people who, you know, became pregnant in, say, 2012 and delivered in 2013, had $5,000-deductible policies, so ended up paying 5,000 in 2012 and 5,000 in 2013, which is kind of crazy.

GROSS: Wow. I never would've thought of that.

ROSENTHAL: Yeah. So this is why I say, you know, being covered for a pregnancy or a procedure, the devil is in the details, the way insurance policies are written today.

Yeah. And I should add, you know, with respect to pregnancy, I mean, gosh, it's a stressful enough time as it is. You know, it's joyful, it's stressful, you're worried about your new baby, you're worried, you know, every time it moves. You're like, oh, is everything OK? And when you talk to couples like the one I profiled, I mean these were really great people who were spending a pregnancy and are now spending their post-, you know, time with their new daughter, just worried about how they're going to pay for it. And that to me is a really sorry state of affairs. And it makes them very vulnerable too because when you're shopping while you're pregnant and a doctor says, hmm, you know, maybe we should get this heart scan, it's your, you know, your unborn child. You're not going to say, oh, I don't know, I don't think it's worth a thousand bucks to me. You're going to say, I'll find a way to pay for it. So it's a very - it's kind of like a financial minefield in some way when instead it should be this wonderful part of your life filled with, you know, joy and anticipation.

GROSS: Is this series that you're doing on health care costs affecting how you approach your own health care?

ROSENTHAL: Well, you know, I think I said I trained as a physician. I worked in an ER for a few years before converting to journalism, as it was, 20 years ago. I've always been a pretty conscious shopper of health care. But the problem is even if you're a good consumer you really can't be in the U.S. So I waste a lot of time on the phone trying to be a good consumer.

You know, my husband recently had a clot in his leg and had to get heparin shots for that. And I went to the pharmacy and the pharmacist said, oh, sorry, this is going to cost you $1,263. And I was like what? That's ridiculous. You know, this is an old medicine. It should - and, you know, meanwhile I'm worried that my husband is going to have a clot go to his lungs.

So, I, you know, don't argue as long as I should. But I think the problem is even if you're a really savvy consumer who knows a lot, it's really hard to find out prices and when you're shopping for medicine it's not like generally shopping for, you know, a car or a new couch where you can take your time. You know, my husband needed that heparin that night. So what bargaining power did I have?

Even though I knew it was overpriced. So I guess part of my goal in doing the series is to put this topic into the national conversation. I think so many people experience this, as I did two weeks ago at the pharmacy counter or when they open their explanation of benefits at home as, you know, Susan Foley, one of the hip patients in the last story, did and say, wow, these prices are ridiculous.

But then, you know, life goes on. Probably you're not paying them, if you have good insurance, or at least not paying the full amount. And anyway, no one - there's nothing on the ballot to check and say I'm unhappy about healthcare pricing. So my goal in doing the series and The Times' goal, I think, was to hopefully start a national conversation about these prices. Because they really are bankrupting not just the country but individuals as well.

I mean, I can't tell you how many commenters we've heard back from who've said, you know, health care is now the leading budget item for my family, above housing. Now, that's really, really a shame - to me, at least.

GROSS: You know, so many people are really frustrated with their insurance company because of the high cost of premiums and co-pays and things that aren't covered. But if you look at the larger system, as you're trying to do in this year-long series on health care costs, can you single out any one part of the system and say this is where the problem is? These are the bad guys. Or is, like, is the problem, like, divided every step of the way?

ROSENTHAL: I think the problem, and what makes it so hard to solve, is it's everywhere. And I feel bad saying that, because, I mean, certainly there are way too many administrative layers and I kind of have to laugh a little bit because the emails I get after each story are, like, oh, yes, there's a problem. It's all, well, we have a consulting service that will make that more efficient.

So the way we've solved every inefficiency is to bring in another layer. So I think it's everyone. And it's partly, you know, our expectations in the sense of, wow, we want a private delivery room with, you know, good wi-fi and great coffee. I mean, some of these hospitals, they're competing the way universities compete. You know, we have a great gym. We have room service. I mean, that's not really the essence of health care.

So I think if that's what we demand, we're really tracking our health care dollars in the wrong direction. So I think it's every part of the system needs to rethink the way it's working. Or maybe what I'm really saying is that we need a system, instead of 20, 40 components each one having its own financial model and each one making a profit.

GROSS: Elisabeth Rosenthal, thank you so much for talking with us.

ROSENTHAL: Oh, thank you.

GROSS: Elisabeth Rosenthal is a New York Times correspondent and is writing a series on the high costs of health care in America. You'll find links to her first three articles, about colonoscopies, childbirth and joint replacements, on our website freshair.npr.org. Transcript provided by NPR, Copyright NPR.

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