Why An ER Visit Can Cost So Much — Even For Those With Health Insurance

TERRY GROSS, HOST:

This is FRESH AIR. I'm Terry Gross. You wouldn't believe what some emergency rooms charge, or maybe you would because you've gotten bills. For example, one hospital charged $76 for Bacitracin antibacterial ointment. One woman who fell and cut her ear and was given an ice pack but no other treatment was billed $5,751. My guest, Sarah Kliff, is a health policy journalist at vox.com who spent over a year investigating why ER bills are so high even with health insurance and why the charges vary so widely from one hospital to the next.

Through crowdsourcing, she collected over a thousand ER bills from around the country. She interviewed many of the patients and the people behind the billing. She's reported her findings in a series of articles on Vox. She's also spent years reporting on the battle over health insurance policy. We'll get some updates on the state of Obamacare a little later in the interview.

Sarah Kliff, welcome back to FRESH AIR. Why did you want to do an investigation into emergency room billing?

SARAH KLIFF: You know, I wanted to do this because the emergency room is such a common place where Americans interact with the health care system. There are about 140 million ER visits each year. It's a place where you can't really shop for health care. You can't make a lot of decisions about where you want to go. So I think that is big-picture what got me interested.

Small picture was actually a bill that someone sent me almost three years ago now, where they took their daughter to the emergency room. A Band-Aid was put on the daughter's finger, and they left. And they got a $629 bill. And they said - you know, they - the parents sent this to me, saying, how could a Band-Aid cost $629? And I said, I don't know, but I'm going to find out. And that kind of opened up the door to this, you know, multi-year project I've been working on right now. It started with trying to figure out why a Band-Aid would cost $629.

GROSS: OK. So let's get to that $629 for treatment that was basically a Band-Aid placed on a finger. You investigated that bill.

KLIFF: Yes.

GROSS: Why'd it cost so much?

KLIFF: So what cost so much was really the facility fee. So this is a charge I hadn't heard about before as a health care reporter. This is a charge that hospitals make for just keeping their doors open, keeping the lights on, the cost of running an emergency room 24/7. So if you look at that particular patient's bill, the Band-Aid - you know, I hesitate to say only - but the Band-Aid only cost $7, which, as anyone who's bought Band-Aids knows, is quite expensive for a single Band-Aid.

But the other $622 of that bill were the hospital's facility fees for just walking in the door and seeking service. And these fees are not made public. They vary wildly from one hospital to another. And usually patients only find out what the facility fee of their hospital is when they receive the bill afterwards, like that patient, you know, that sent me this particular bill.

GROSS: And does the facility fee vary from facility to facility?

KLIFF: It does significantly. You know, I've seen some that are in the low hundreds. I've seen some that are in the high thousands. And it's impossible to know what facility fee you're going to be charged until you actually get the billing documents from your hospital. And if you try and call up a hospital and ask what the facility fee is, usually you won't get very far.

So it's this fee that, from all the ER bills I've read, is usually the biggest line item on the bill. But it's also one that is very, very difficult to get good information about until you've already been charged.

GROSS: So you're paying the facility fee to basically share in the cost of running the emergency room.

KLIFF: Yes, that's how hospital executives would describe the fee.

GROSS: But you don't know that when you're going to the emergency room.

KLIFF: You don't, no. And you don't know how much it'll be. You don't know how it's being split up between different patients. You don't know any of that.

GROSS: So is this also why one bill had $60 for the treatment of ibuprofen and another $238 for the treatment of eyedrops?

KLIFF: Yeah. And, you know, this is something I see all the time reading emergency bills - I've read about 1,500 of them at this point - is that things you could buy in a drugstore often cost significantly more in the emergency room. And the people I talked to who run hospitals will say this is because they have to be open all the time. They have to have so many supplies ready.

But I think one of the things that I find pretty frustrating is, you know, patients aren't usually told, we can give you an ibuprofen here, or you can pick some up at the drugstore if you leave, and the cost will be a fraction of what we would charge you here. That information often isn't conveyed to patients who are well enough, you know, to go to a drugstore on their own. But it's just huge variation for these simple items.

One place I see this a lot is pregnancy tests. If you're a woman who's of childbearing age, you go to the emergency room, they will often want to check if you're pregnant. I've seen pregnancy tests that cost a few dollars in emergency room. The most expensive one I saw was over $400. I believe that was at a hospital in Texas. It's just widespread variation for, you know, some pretty simple pieces of medical equipment.

GROSS: I want to get back to the $60 ibuprofen. Is that - does that include the facility fee? Or is that just for the ibuprofen, and the facility fee is separate?

KLIFF: That's just for the ibuprofen. The facility fee is totally separate.

GROSS: So how do they justify that?

KLIFF: They say they have to stock, like, a wide array of medicine, so they have to have everything on hand from ibuprofen, from, you know, expensive rabies treatments - I've talked to a lot of people who've been to the emergency room for exposure to bats and raccoons - and that they need to have all these things in stock. And, you know, one of the things you pay for at the emergency room is the ability to get any medication at any hour of the day right when you need it. I don't necessarily buy that explanation, to be clear. That's what I've heard from hospital executives.

I think it's pretty telling that ibuprofen has a very, very different price depending on which emergency room you go to. The fact that there's so much widespread price variation suggests to me that it's not just the cost of doing business driving it, that there's also business decisions being made behind ibuprofen that are driving the prices different hospitals are setting.

GROSS: Now, of course, trips to the emergency room aren't always as simple as getting a Band-Aid or ibuprofen or some eyedrops. I want you to describe the case of a young man who was hit by a pole on a city bus in San Francisco.

KLIFF: Yeah. So this patient, his name is Justin. He was a community college student in northern California, was walking down a sidewalk in downtown San Francisco one day. And there was a pole hanging off the back of the bus that wasn't where it's supposed to be. It essentially flew off the back of the bus, hit him in the face and knocked him unconscious.

And the next thing he knows, he's waking up at Zuckerberg San Francisco General, which is the only Level I trauma center in the city. He ends up needing a CT scan to check out some brain injuries. He needs some stitches. And then he's discharged. He ends up with a bill for $27,000.

But, you know, as I began figuring out through my reporting, San Francisco General does not contract with private insurance, and they end up pursuing him for the vast majority of that bill. He has $27,000 outstanding. And somewhat ironically, San Francisco General, it is the city hospital. It is run by the city of San Francisco. So this student is hit by a city bus, taken by an ambulance to the city hospital and ends up with a $27,000 bill as a result.

GROSS: So did he have insurance?

KLIFF: He did. He had insurance through his dad.

GROSS: So why doesn't Zuckerberg San Francisco General Hospital contract with private insurers?

KLIFF: So what they have told me when I've talked to some spokespeople there is that they are a safety net hospital, and that is, you know, definitely true. They generally serve a lower-income, often indigent population in San Francisco that would have trouble getting admitted and seeking care at other hospitals in the city. So they have told me that their focus is on serving those patients and that therefore, you know, they're not going to contract with private insurance companies.

The thing I found a little bit confusing about that, though, is there are lots of public hospitals, say, that, you know, also serve low-income populations. And some of them for their inpatient units, you know, for their scheduled surgeries, they're not going to contract with private insurance because they want to make sure beds are available for the publicly insured folks and people on Medicaid and Medicare.

But when it comes to the emergency room, you know, every other public hospital I was in touch with would contract with private insurers there because people don't decide if they're going to end up in the emergency room. So, you know, that's the justification they offered, that it is a hospital meant to serve those with public insurance. But it is not something you see public hospitals typically doing.

GROSS: Isn't - I think legislation was proposed in California to change that. Did that pass?

KLIFF: It's still pending in the California State Assembly. And the hospital has also promised to reform its billing practices, although we haven't seen what exactly their new plan is yet.

GROSS: So the position that Justin was in is that, like, he's unconscious. He's not asking to be taken anyplace. (Laughter) But he's unconscious. He's taken to the emergency room and ends up getting this $27,000 bill. I mean, that just seems so unfair, especially since he has insurance.

KLIFF: Yeah.

GROSS: Like, it's supposed to cover him for things like that (laughter).

KLIFF: Yeah. You know, there's one other patient who kind of makes this point really well who was also seen at San Francisco General. Her name is Nelly. And she fell off a climbing wall and, somewhat amazingly, you know, turns out she had a concussion. But one of the first things she does is she calls her insurance's nursing hotline to ask, should I go to the ER?

And they say yes. And she says, can I go to Zuckerberg San Francisco General? It's the closest. They say, no, don't go there. It's not in network. Go to another hospital. She gets to the other hospital, but the other hospital won't see her because she's a trauma patient. She fell from a really high height. And San Francisco General is the only trauma center in San Francisco. So she tries to go to an in-network hospital. She's then ambulance-transferred to Zuckerberg San Francisco General, and she ends up with another bill over $20,000 that the hospital was pursuing from her until I started asking questions from it, and the hospital ultimately dropped the bill.

But I think it's just such a frustrating situation for someone like Justin, for someone like Nellie (ph). They're either shopping for this good unconscious, they're really trying to do the right thing, and the health care system is just so stacked against the patient. It's so stacked for the hospital to be able to bill the prices that they want to bill.

GROSS: So apparently, the moral of the story is if you want to challenge your emergency room bill, you should get Sarah Kliff to write about you. (Laughter).

KLIFF: It's - (laughter). That's what some people have said. But there's only one of me, and there's about 2,000 bills in our database. And, you know, we have had over $100,000 in bills reversed as a result of our series. But I don't think it's a great way to run a health care system where we just, you know, the people who get their bills reversed are those who are lucky enough to have a reporter write a story about them.

GROSS: Yes. Agreed. Let me reintroduce you. If you're just joining us, my guest is Sarah Kliff. She's a senior policy correspondent at Vox, where she focuses on health policy. She also hosts the Vox podcast, "The Impact," about how policy actually affects people.

So we're going to take a short break, and then we'll talk more about emergency billing. And then later, we'll talk about what's left of Obamacare, and what the president and Congress and candidates are saying about health care, after this break. This is FRESH AIR.

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GROSS: This is FRESH AIR. And if you're just joining us, my guest is Sarah Kliff. We're talking about emergency room billing and why it's so unpredictable and often so incredibly high. She's a senior policy correspondent at Vox, where she focuses on health policy. She also hosts the Vox podcast, "The Impact," about how policy affects people.

So we were talking about the hidden facility fee, which most people don't know exists, and is responsible for a large chunk of a lot of emergency room bills. There's also, like, a trauma unit fee. It's a similar hidden fee in hospitals that have trauma centers in their emergency rooms. So explain the trauma fee and how that kicks in.

KLIFF: Yeah. This is something I also had never heard of till I started reading a lot of emergency room bills, and this is the fee that trauma centers charge for essentially assembling a trauma team to meet you when you're coming in and those folks out in the field, maybe the EMTs, for example, have determined that you meet certain trauma criteria.

So I've talked to people who have been charged trauma fees who were in serious car accidents. One case was a baby who fell from more than 3 feet, and that's considered to trigger a trauma activation. So this is essentially the price for having a robust trauma team - a surgeon, an anesthesiologist, nurses - all at the ready to receive you when you get to the hospital.

And again, these fees can be pretty hefty. San Francisco General, which, I've done the most reporting on their billing, you know, they can charge up to $18,000 for their trauma activation services. I wrote about one family who was visiting San Francisco from Korea when their young son rolled out of the hotel bed. They were nervous. They didn't know the American health care system well. So they called 911, which sent an ambulance, brought him over to the hospital. Turns out, he was fine. They gave him a bottle of formula. He took a nap and went home.

And then a few months later, they get an $18,000 charge for the trauma team that assembled for when that baby came to the hospital. And these are another, you know, pretty significant fee that, again, you don't really know about. You have no idea that the trauma team is assembling to meet you when you're coming into the hospital. You just find out after the fact. And you also have no say in the decision to assemble trauma. That's really left up to the hospital, not the patient.

GROSS: So I'm going to have you compare two possibilities. You go to an emergency room, and the bill is very high. There's two people who have the same problem who go to the emergency room. One of them has a copay. One of them has a high deductible that they haven't paid off yet. How are they treated differently, in terms of what they're billed for the emergency room visit?

KLIFF: Well, the person with the deductible will likely be billed significantly more. You know, if they're just, let's say, at the start of the year, they are going to essentially have to bear the costs of that emergency room visit up until the point they hit their deductible and the insurance kicks in, whereas the person who has a co-payment, they're just going to have to pay that flat fee and, you know, probably not worry about paying more, but there's often surprise bills lurking in the corner that could affect both of those patients as well.

GROSS: Like what?

KLIFF: So one of the most common things we see is out-of-network doctors working at in-network emergency rooms. So you know, you have an emergency, you look up a hospital, you see their ER is in network, so you go there. It turns out that emergency room is staffed by doctors who aren't in your insurance. There's pretty compelling academic research that suggests 1 in 5 emergency room visits involves a surprise bill like that one.

GROSS: That seems so unfair. How are you to know - if you're choosing a hospital that's in network, how are you to know whether the doctor treating you is in network or not?

KLIFF: You know, you really - there isn't a great way to tell, to be honest. This is - you know, when I had to go to the emergency room over the summer, you know, this is something I worried about. You know, I was seeing a doctor who worked for the hospital, but they were sending off my ultrasound to be read by a radiologist who I was never going to meet. I couldn't ask them if they were in-network. I just kind of had to cross my fingers and hope for the best, and luckily, I didn't get a surprise bill.

But I've talked to multiple patients who, you know, tried to do their research, who thought they were in network, only to get a bill, often for thousands of dollars, after leaving the emergency room, from someone who, you know, never mentioned to them, hey, I'm not in your network like this hospital is.

GROSS: So the bill that you'd get would be for the difference between what you pay when somebody is - when a doctor's in network and what you pay when they're not in network?

KLIFF: Yeah, often it's just what that out-of-network doctor wants to charge. So a good example of this is a patient I wrote about in Texas named Scott (ph), who was attacked in downtown Austin, left on the street unconscious, some bystander called him an ambulance, and he woke up at a hospital. And one of the first things he does, because this is the United States, is he gets on his phone and tries to figure out which hospital he is at, and, you know, is that in his insurance network? And he finds out - good news - it is. And a surgeon comes by, tells him he's going to need emergency jaw surgery because of the attack that happened.

So he says, OK. You know, he's not really in a place to go anywhere. Gets the surgery. Goes home. A few weeks later, he gets an $8,000 bill from that oral surgeon, who the insurance companies paid a smaller amount. The oral surgeon didn't have a contract with the insurance and said, you know, I think my services are worth a lot more, so pursued the balance of the bill from Scott.

GROSS: I have to say, I mean, that does seem unfair to the patient because they haven't been informed. They can't make a choice about it if they don't know. And, like, $8,000 is a lot of money.

KLIFF: Yeah. And I think, you know, even more, let's say he did say he was out of network. It kind of puts the patient in an unfair situation, too. You know, one of the things we talk about a lot in health policy is, what if we had more transparency? What if we let patients know the prices? What if we let patients know who is in and out of network? And that - it would be a good step.

But, you know, I think with someone like Scott, sitting in a hospital with a broken jaw, there's not much you can do with that information. He doesn't have, you know, the ability to go home, like, research, like, make an appointment with a new surgeon. So, you know, it'd be great if he knew that the doctor was out of network. It'd be even better if he had some kind of protections against those type of bills.

GROSS: What kind of protection could there be?

KLIFF: So we're actually seeing a lot of action on this in Congress. There's some pretty strong bipartisan support for tackling this specific issue and essentially holding the patient harmless. When there is a situation like Scott's, for example, where there's this $8,000 bill, that's really a dispute between a health insurance company and a doctor, where the doctor says, I want more money, the insurer says, I want to pay you less money. And what Congress wants to do - what a few states have already done with their laws - is said, you can't go to the patient for that money. You, the hospital, and you, the health insurance company, you have to get down to a table and work things out together.

And some state laws will set certain amounts that are allowed to be charged, other ones will force the insurance company and the hospital into an arbitration process. But the general concept is to take the patient out of this billing situation because, like you said, Terry, they really aren't in a position to negotiate. They aren't in a position to shop. They shouldn't be the ones who are left holding the bag at the end of the day.

GROSS: My guest is Sarah Kliff. She covers health policy for Vox. After a break, we'll talk more about why ER bills can have some unpleasant surprises, and she'll give us an update on Obamacare. And Maureen Corrigan will review two books about forgotten stories from Hollywood. I'm Terry Gross, and this is FRESH AIR.

(SOUNDBITE OF JESSICA WILLIAMS TRIO'S "KRISTEN")

GROSS: This is FRESH AIR. I'm Terry Gross. Let's get back to my interview with journalist Sarah Kliff, who covers health policy and how it affects people for Vox. For the past year and a half, she's been writing about why emergency room visits can be so expensive and the pricing so secretive and mysterious, as well as inconsistent from one hospital to the next. She collected over 1,000 bills and tracked down stories behind the billing. She interviewed many of the patients and the people behind the billing to decipher why ER bills can have some surprise costs.

Here's another surprise that often awaits people who go to emergency rooms - some insurance plans only cover true emergencies, and whether it is a true emergency is sometimes determined after the diagnosis is made. So how are you supposed to know before the diagnosis whether you're going to be categorized as a true emergency or not? Like, if you go to the hospital, you don't know if you have a broken bone or not.

KLIFF: Right.

GROSS: Somebody needs to X-ray it and tell you.

KLIFF: Right. The whole point you go to the emergency room is to help them figure out what the emergency is and what treatment you need. This is a policy that the insurance company Anthem has been pioneering for a few years. It's been in Kentucky. It's been in Georgia - a few other states. And, you know, I wrote about one patient out in Kentucky named Brittany, who - she was having really severe abdominal pain. She called her mom who is a nurse, and the nurse said, that might be appendicitis. You've got to get to the emergency room. Turns out it wasn't appendicitis. It was an ovarian cyst. She got it treated elsewhere later down the line.

And Anthem, you know, sent her a letter saying, we're not going to cover that visit because it was not a true emergency. She appealed it. Her appeal was denied. This is another one where, once I started asking them about it, the bill suddenly disappeared. But - and it seems like as Anthem has gotten more attention for this policy - they haven't announced it publicly, but some pretty compelling data The New York Times got their hands on suggest they've backed off this policy.

But it's just, you know - there are so many traps you can fall into going into an emergency room. It just feels like you're walking into this minefield, and this is kind of one of those mines that's lurking in there.

GROSS: Hospital pricing and emergency room pricing seems to vary so much from hospital to hospital. Are there, like, national guidelines that help determine what a hospital or a hospital emergency room charges for services? I mean, who decides, and why is there such a variation?

KLIFF: So hospital executives get to decide, and I think that is why there is such variation. There aren't really guidelines that they're following. You know, one thing you could do as a hospital executive - you could look at what Medicare charges - those prices are public - and, you know, maybe use that as a benchmark. There are some databases. There's one called FAIR Health, for example, where you could look and see, you know, some information on what local prices typically are. But in terms of, you know, what you want to charge, that's kind of up to you as someone running a hospital.

One of the things that's really, really unique about the United States, compared to our peer countries, is that we don't regulate health care prices. Nearly every other country in the developed world - they see health care something as, you know, akin to a utility that everyone needs, like electricity or water. It's so important that the government is going to step in and regulate the prices. That doesn't happen in the United States. You know, if you're a hospital, you just choose your prices. And, you know, that is, I think, why you see so much variation and why you see some really high prices in American health care.

GROSS: So what advice do you have for people who actually need an emergency room and don't want to get hit with a shocking bill afterwards?

KLIFF: Yeah, this is, you know, one of those questions - it just makes me a little frustrated that - 'cause this is the most common question I get - right? - is, how do I - how do we - how do I prevent a surprise bill? And I find it kind of upsetting that, you know, it has to be on the patient because honestly, there really isn't a great way to do this. I've talked to so many patients who tried so hard to avoid a big medical bill and weren't able to.

You know, there's certain things, yes, you can do. You can look up the network status of your hospital. You can try and badger each doctor you see about whether they are in network. You can try to be a really proactive patient, but I think that's just such a huge burden on people who are in, like, really emergent situations. And some people don't have that opportunity, you know, like Justin Zanders, the guy we were talking about earlier who was taken to a hospital while he was unconscious. I cannot think of anything he could've done to avoid that bill. It just was not possible.

GROSS: So your advice is, good luck.

KLIFF: Short of that, I mean, good luck. You know, I'm actually in the middle of reporting a story right now about people who have successfully negotiated down their bills. And, you know, you can certainly - if you do end up with a surprise bill, you can call up the hospital, see if there's a discount. Sometimes there will be. Sometimes there won't. You can call again. Customer service representatives - different ones - often offer you different discounts, I've learned from interviewing patients. You can ask for a prompt pay discount if you pay right away.

You can - you know, one health attorney who negotiates these a lot on behalf of patients - he says one of his favorite tactics is to choose the amount you want to pay; send a check with that amount; and in the note, write, paid in full; and hope they don't come after you after that. I have no idea if that works or not, but he says it works for his patients. But it's a mixed bag. And at the end of the day, the hospital has all the power. You can ask for discounts. You can ask nicely. You can ask angrily. It's up to the hospital if they want to grant you that or not.

GROSS: So what is the status of Obamacare now? You know, Republicans promised to repeal and replace. That didn't work out. So have Republicans given up on repeal and replace?

KLIFF: For the time, it seems pretty clear that repeal and replace is dead on arrival, especially with Democrats taking control of the House this year. Those proposals aren't being talked about as much. They're not really going anywhere. The one big thing we did see Republicans succeed at is repealing Obamacare's individual mandate, the requirement that all of us carry health insurance. That happened as part of the big tax package that passed at the end of 2017.

So we've seen, you know, President Trump, for example, essentially declare victory, declare that repealing the individual mandate is repealing Obamacare, so we're good on that goal. But, you know, generally, Obamacare is still standing. There are millions of people getting their coverage through the Affordable Care Act still today.

GROSS: So now that there's no individual mandate, conservative attorney generals are challenging Obamacare - the Affordable Care Act - and saying it's no longer constitutional after Congress's repeal of the individual mandate. Could you explain that?

KLIFF: Yeah, so this is a challenge that's come up through the courts in the past few months. Obamacare is constantly being challenged in court. It's been through multiple Supreme Court suits. This one - you know, it's a multiple-part argument, so I'll try my best to walk through it.

GROSS: OK.

KLIFF: So essentially, it starts with the fact that the individual mandate - they weren't quite able to repeal it for boring technical reasons. But what they were able to do is change the fee for not having health insurance from $700 to $0. So it - in all practical terms, it feels like repealing it because there is no fee for not carrying health insurance. The individual mandate was upheld as a tax when the Supreme Court said, yes, this is constitutional. The government has a right to tax people. Now that there is no fee associated with not carrying health insurance, the conservative attorneys general who are bringing this case argue that it's not a tax anymore, and therefore, it is not constitutional. That whole defense that John Roberts wrote in 2012 is moot. So that's the first part of it.

They go even further and say the individual mandate is so core to the Affordable Care Act, it is not severable. And if you, the courts, rule the individual mandate unconstitutional, then you need to rule all of Obamacare unconstitutional. And the first judge who heard this case - he is a, you know, judge in a district court in Texas. He agreed with them. He agreed that - first step - that the individual mandate is no longer constitutional. And second step, that means that the entirety of Obamacare has to fall. This is now being appealed up to the 5th Circuit Court of Appeals.

And I will say there are a lot of critics of this case. There are a lot of people who were parties to previous Supreme Court challenges to Obamacare who think this is a bad legal argument and that it will not succeed. But it is already, you know, gone through the district court level. It's moving up to the appellate court level. It is something that is in the mix that could become a threat to the Affordable Care Act.

GROSS: Well, if it goes to the Supreme Court, it would be very interesting to see what Justice Roberts says since he voted for the ACA, saying that the individual mandate was a tax.

KLIFF: Yeah. You know, and I think where some legal scholars would see it shaking out is that the - someone like John Roberts, he might agree, OK, yeah, the individual mandate is unconstitutional, but would not make the leap to the second half of this, that the rest of the law has to fall.

I think one of the most compelling arguments against this case is that Congress knew what they were doing when they repealed the individual mandate. You know, they had the opportunity to repeal Obamacare. They didn't. They'd specifically took aim at this one specific part. So it feels like it might be a bit of a reach to argue that what Congress really meant to do was repeal all these other parts of the Affordable Care Act. But, you know, the Supreme Court is changing. We have a new justice. You know, we have a lot in the mix. So it's always an open question of how a decision like this could go.

GROSS: So correct me if I'm wrong here - the Department of Justice has sided with the conservative attorneys general who are challenging Obamacare, saying it's no longer constitutional, and I think that the Justice Department is also asking the judge to strike down the ACA's mandatory coverage of pre-existing conditions.

KLIFF: Yeah, that's right. So it's a kind of unusual situation. Usually, it's the Justice Department that is going to defend a federal law in court. But, you know, given the Trump administration's opposition to the Affordable Care Act, they have decided to side with the conservative attorneys general. They have a slightly different argument. They don't think all of Obamacare should fall if the mandate falls, but they do think some big parts, like you mentioned, the protections for pre-existing conditions, should be ruled unconstitutional if the mandate falls.

So this has led to a bit of an unusual situation where you've had this coalition of Democratic attorneys general step in and take over the case, basically saying that the federal government is going - is not going to defend the Affordable Care Act. We are going to defend the Affordable Care Act. So you have this coalition of Democratic attorneys general, led by the attorney general of California, stepping in and, you know, offering a defense as this case works its way up through the court system.

GROSS: Let's take a short break here, and then we'll talk some more. If you're just joining us, my guest is Sarah Kliff. She's senior policy correspondent at Vox, where she focuses on health policy. And she hosts the Vox podcast "The Impact," about how policy actually affects people. We'll be right back. This is FRESH AIR.

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GROSS: This is FRESH AIR. And if you're just joining us, my guest is Sarah Kliff, senior policy correspondent at Vox, where she focuses on health policy.

Do you think health insurance is shaping up to be a big issue in the 2020 campaign?

KLIFF: I do, and I think it's going to be a big issue both in the primary, where you're already seeing candidates get pressed on, should we still have private health insurance, and giving pretty different answers to that question.

And then I think one of the things you're also going to see is whoever is the Democratic nominee is probably going to run on Obamacare. They are going to point at the fact that President Trump tried to repeal the Affordable Care Act. That's pretty different than, you know, the 2012 election, where Democrats were pretty scared to run on Obamacare. It still wasn't popular. The benefits hadn't rolled out. In this past midterm and now again in the 2020 election, it seems pretty clear that Democrats are pretty excited to point out that Republicans wanted to repeal Obamacare. So I think it really will come up.

GROSS: What are some of the biggest falsehoods you've heard from politicians about health insurance costs or health insurance policy?

KLIFF: You know, one of the ones that's come up a lot is actually around the role of private health insurance. So I've - I don't know if it counts as a falsehood, but I think it's a bit of a misunderstanding of how health insurance often works is, you know, when I talk to single-payer supporters, most of them want to eliminate private insurance completely. They just don't think there is a role for it in the health care system.

And one of the things I think that's actually pretty interesting, when you look at any other country - you look at Canada, you look at the U.K., you look at France, which all have national health care systems - all of them have a private health insurance market, too. There are always some kind of gap in the system that the public insurance can't cover, where the government step - where the private industry steps in and offers coverage. In Canada, for example, their public health plan doesn't cover prescription drugs, so two-thirds of Canadians take out a private plan, often through their employer, like us, to cover prescription drugs, to cover their eyeglasses, to cover their dental. So I think that's a confusion I see a lot in the "Medicare for All" debate coming up right now.

I think the other thing I see a lot of confusion around - and we've talked about this a little bit with emergency room billing - is the role of transparency in health care. I see a lot of, you know, if we just made the prices public, like, that is what we need to do to fix the system, and I think that really misses the fact that, even if the prices were public, health care is so different from everything else we shop for. It might be - I think it is the only thing we purchase when we are unconscious.

GROSS: (Laughter).

KLIFF: And when you're unconscious, you're not really going to be great at price shopping. So I see that as, you know, a halfway solution that I often hear talked about here in Washington that would be great but is not going to suddenly result in, you know, prices dropping because they've been exposed in a spotlight.

GROSS: Is there a country that you think has a good health care model that we could borrow?

KLIFF: Oh, yeah. I've been thinking about this a lot lately actually. So I've gotten very interested in the Australia health care system, which is a little far away. But I think they're a really interesting model because they have a public system, everyone's enrolled in it, but they also really aggressively try and get people to buy a private plan, too, and that private plan will get you sometimes faster access to doctors, maybe a private room at a hospital.

It's really hard for me to see the U.S. creating a health care system, similar to Canada's actually, where you can't buy private insurance, where if you're rich or you're poor, everyone waits in the exact same queue, you can't jump to the front of the line. Because I think wealthier Americans have gotten so used to having really good access to health care that they would be very upset with a system like that.

I think Australia is a kind of interesting hybrid between, you know, where we're at in the U.S. right now and what Canada is like, where it says, yes, we're going to create a public system for everybody, but we're also going to have these private plans that compete against the public system. So I've become increasingly, you know, interested in how Australia's system works. And they have - about 47 percent of Australians are buying a private plan to cover the same benefits that the public plan does.

GROSS: So it's not supplemental. It's instead of.

KLIFF: Right. So it's very different from Canada. So in Canada, you can buy complementary insurance, you know, to cover the benefits the public plan doesn't but the government expressly outlaws supplemental insurance. You know, like, what people buy here to cover the gaps in Medicare, that is not allowed. You cannot buy your way to the front of the line in Canada.

One of my favorite sayings about the Canadian health care system is from a doctor in a book I read about Canadian health care is they said, you know, we're fine waiting in lines for health care in Canada as long as the rich people and the poor people have to wait in the exact same line. Their system is all about equality. And I just don't know that we're at a place as a country where we value the same sort of equality in our health care system.

GROSS: Is there any developed country around the world that has a system similar to ours with all these competing insurance companies and, you know, some government plans and, like, a thousand different bureaucracies that doctors have to deal with and that patients have to deal with?

KLIFF: Absolutely not. There's nothing like it. I mean, our system is so unique. I'd say the closest but it's not even close are a few countries that have national health care systems, but they do it through tightly regulated private health insurance plans. So if you look at, like, Netherlands or Israel, there isn't a government-run plan. Instead, in both countries, you actually have four tightly regulated health insurance plans that compete against each other for the citizens' business. I guess that's the closest, but that is so different from what we have here right now. There's really nothing like it in any developed country.

GROSS: Sarah Kliff, thank you so much for talking with us.

KLIFF: Well, thank you for having me.

GROSS: Sarah Kliff covers health policy for Vox, where you'll find her series about emergency room bills. After we take a short break, Maureen Corrigan will review two books about forgotten stories from Hollywood. This is FRESH AIR.

(SOUNDBITE OF GEORGE FENTON AND PHILHARMONIC ORCHESTRA'S "MISS SHEPHERD'S WALTZ")

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