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In March, I had bladder surgery. The process took two steps, each a week apart from the other. In the second part, a small rectangle of metal was implanted into my lower back, against the bladder. It was intended to correct a nagging issue that had been problematic for years. Keeping details to a minimum, I found myself having to urinate more and more frequently. After a time the frequency could be as much as twenty to twenty-five times a day. My lifestyle suffered, as did my social life, so finally I sought help.

I tried minimally invasive procedures first, but they were largely ineffective. I'd had six months to contemplate surgery, and eventually recognized that surgery was probably the only real option I had left. The procedure was scheduled, I met with the surgeon, and two weeks later I arrived at the hospital. Medical procedures no longer intimidate me or make me feel nervous. Instead, I feel impatient, eager to have everything complete and out of the way.  

Because I have Medicare, I routinely receive an itemized statement in the mail. It thoughtfully provides the precise cost and a basic explanation of each charge. This is a welcome change, one that has been equal parts enlightening and frustrating. Now that I know a little, I recognize how much I do not understand about the full process.

Before I became disabled, I had private insurance through my employer. My insurer never provided such information, leaving me mostly ignorant about billing and precisely how much money had exchanged hands. What little information I had at my disposal was often minimal and sketchy, more about the bottom of the bottom line. I'd be sure to know about precise figures if I ever exceeded coverage ranges, but those were about the only instances where I dealt with health insurance jargon and real numbers.

What has complicated the health care discussion is the complexity of the system, which is maddeningly imprecise. Not all charges are the same. Only an accountant might know for sure to explain who is charged what, but what I've seen reminds me more of a stock market than an industry. A dollar is not always a dollar.

It seems that medical treatment, like a share of stock or the exchange rate of currency, might forever be subject to the hand of the market. We may well have a market system in place already, one not entirely dissimilar to that which will go into effect on January 1, 2014.

In the meantime, consumers are often not informed of what they owe, line by line, until services have been rendered. The price of every component of surgery, for example, depends completely upon each patient's insurance carrier or method of payment. Hospital systems, where most Americans go to have surgical procedures, each have learned to extract as much money as is possible. Under the previous system, surgeons profited handsomely from Medicare, but now I believe that every doctor's profit will be more reasonable. Some have objected to the pay cut, but we have too many specialists who have learned they can make twice as much for the same amount of work.  

Three years ago, we clamored for transparency within health insurance companies. The resulting legislation passed and signed into law sought to take those demands seriously. What we may have failed to recognize then could spell significant problems sooner rather than later. The practice of medicine and the system built around it has become very profitable over the years, and no one wants to give it up. Doctors don't want their salaries to go down for the sake of anyone's parity. Hospital systems want to keep building gleaming new wards and buildings.

Here is one example. Yesterday, in the mail, I finally received the total cost of surgery, as charged to insurance. Some charges were matter-of-fact, but a few seemed excessive. At the conclusion of my first procedure, a nurse sat with me as I came to from the anesthesia. Mostly awake, I chatted with the surgeon as she made her rounds. My vital signs were monitored. When I was comfortable enough to leave, I stood up slowly and headed home.

I appreciate the dignity of care I was provided. I know each of these elements are important, but I'm not sure how a hour's work for, at most, three people collectively merits a $6,000 bill. That day alone, Medicare was charged slightly under $53,000. The surgery was not especially invasive. It required a few small incisions to implant the device. These charges are excessive and indicative of the numerous flaws sought to be corrected.

The second procedure was even more expensive. This time, Medicare was charged slightly more than $74,000. It proceeded much as the previous surgery had taken place a week before. If care alone was the problem, I would have little that merits complaining. Even with the benefit of observing each charge for myself, I have to guess as to its meaning. Someone within the system knows what it means, while the rest of us are left in the dark.

Explaining to a confused nation of the changes yet to come would be difficult, but it is necessary. What has always disappointed me about the American health care system is its over-reliance upon rules and procedure. The health care reform law has heaped more rules upon rules, but I concede there may have been no other way.

Our President once was unafraid to take a chance and speak to Americans like adults. It befuddles me that he remains stock still, impassive, and wholly not involved in the great roll out, which should be a triumphant moment. Instead, he has kept silent, while what may well be his signature success is lampooned by a chorus of skeptics.  

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