First healthcare experience

Healthcare in the US! A hot topic. From the Swedish perspective, on the one hand some parts of the US system are completely unreal (with individual people being liable for huge medical expenses) while in other ways there is the potential for better treatment. If you’ve ever been in contact with the healthcare system in Sweden, it’s very likely you are quite familiar with the seemingly endless queues everywhere, even for simple things. The only time I was not subjected to a crazy queue was when I went to a private practice once (through insurance).

My status at the moment is that while I have insurance in Sweden that is supposed to cover me until the 18:th, I don’t really trust that it will work in practice, so I wanted to be careful before I get signed up with local health insurance. It was unlikely I’d need anything within a week or two of arriving anyway.

As it turns out, I managed to get a pill stuck in my throat within this period, so I figured I’d give healthcare a shot.

Attempt 1: Public healthcare

I went to SF General via bus and did a walk-in into the ER. After about an hour or two I went through triage (which in non-emergencies like this was basically just taking standard vitals and asking some questions to fill in paperwork). After that I had to register and then wait for someone to see me (a matter of hours apparently).

Everyone was extremely non-forthcoming about costs, and wouldn’t even answer seemingly simple questions like “Ok; so suppose I spend 15 minutes with a doctor, I’m not going to get billed $25,000 or something as a matter of course?”. I would have hoped the answer to that would have been a clear “no”, but they mostly just seemed to be unwilling to comment.

While the process was slow, it was convenient in the sense that I could just walk in, sit down, and wait with some minimal identification.

After triage when I registered to see someone, I got various documents about my rights as a patient and information on how to apply for reimbursement of expenses (if eligible).

In any case, I did not want to take the chance with the cost so I decided to bail out and see a private doctor instead.

Attempt 2: Private healthcare

I Googled and found a private doctor with good reviews on Yelp within 30 seconds. He was located within walking distance from SF General.

I called to book an appointment. They were able to quote me price ranges immediately on the phone (after a ~ 10 seconds wait) and I was able to make a booking about 1.5 hours from the time I called (the doctor was one that does house calls and he was out with a patient at the time I called). They were very flexible in dealing with me; for example they reserved an appointment for a few minutes while I confirmed I would indeed be leaving. I then called back and just confirmed to them I was showing up.

They took my credit card information on the phone to make the booking. Expected cost was $350-$600 depending on complexity of care.

I walked there expecting to wait until the allotted time, but he showed up about 50 minutes earlier so I was able to get in much quicker.

In the end, I had to pay $495. According to him (keeping in mind this is hearsay from someone who has a vested interest in me not deciding to use public healthcare in the future) an ER visit is usually $1500 just from being seen – and can easily be inflated by thousands if they e.g. call in specialists for a consult. If I take his word for it, the choice to just go with a private physician was a good one.

It will be interesting whether and how I can get the cost reimbursed through Swedish insurance. Even if it would normally be, I’m half expecting they will reject the claim on some bureaucratic ground like “you can’t go to a private doctor”.

It would be interesting to understand how the pricing the private doctor claimed affects the reported average per-capita health care costs in the US. If a large part of it is $1500+ for a few minutes spent at the ER, they would seem to be extremely inflated to me.

Future healthcare

The expectation is that as soon as I’m signed up with the HMO, the process will be much smoother. As far as I have understood it, you basically call up and make an appointment with a doctor working with the HMO depending on what type of issue you need help with. I expect (based on what I have heard so far) and hope it is similar to the experience I had calling a private doctor directly.

First day in SF – banking, phones and apartments

On my first full day in SF (not counting day of arrival), my priorities were to open a bank account (to facilitate paying for an apartment once found, as it often is not possible to do via e.g. credit card), get local in-expensive wireless 3G and/or LTE access, getting a local phone number, and looking at some apartments.

Get a local phone number

Having a native US phone number seems to make a lot of things easier. For one thing, most people don’t seem to know how to make international phone calls which complicates matters a lot whenever a person actually needs to call you (and it’s not just about registering a phone number as a matter of principle). For example, I had problems with my checked luggage on the way in, and the baggage handling person didn’t know how to call an international number so I ended up having to give them the number to my hotel.

Additionally, some services require it. For example, Uber wants you to have a local phone number. Bank of America had trouble entering an international phone number in their system when I created my account.

So, I recommend people to plan on getting a local number as soon as possible. In my case I have a transient Skype Online number, and I intend to transition to Google Voice as soon as the Galaxy Nexus is out and I can upgrade my Verizon account (Google Voice doesn’t seem to do VoIP on the phones, so I can’t use it on my HTC Desire HD over a data connection).

Get inexpensive mobile data access quickly

In my case, I got a wireless hotspot and associated data plan from Verizon. It is likely to work a lot better than your average hotel internet connection, and it’s so much easier to get around the city using public transportation when you can use Google Maps on your phone to navigate. Doing so without insane costs requires not using roaming data though. I recommend signing up for a local phone plan with data as soon as possible. (My use of a mobile hotspot was just the result of wanting to avoid buying a phone for use a few weeks only to then upgrade to the Galaxy Nexus.)

Opening a bank account

As I had surmised before going here, online banking is a bit different here. Often you protect your account by e.g. a password, and customer service authenticates by asking you personal information (this is probably why US people tend to treat certain information as more private than Swedes are used to, and why there seems to be more identity theft going on – but I’m just speculating).

I was able to walk in and open an account without fuss, with my passport and social security number (but I was “lucky” in that I had a social security number dating back to a period of being in the US on a student visa; if you don’t have a social security number there might be more fuss, but according to Bank of America customer service, when I asked prior to finding my social security card, I should have been able to create an account without it).

Normally, it takes a few days to get a debit/credit card, and it’s sent to your mailing address (maybe this is Bank of America specific, I don’t know). I was able to get a temporary one-month debit card however that I could walk out with immediately.

Transferring money form my SEB account to the Bank of America account is expected to take 3-5 days according to SEB. Some minor problems ensues with the transfer; SEB want’s a routing number/ABA number, and Bank of America has two – one for “electronic transfers” and one for wire transfers. After some back and forth the SEB representative seemed convinced I should be putting the one used for wire transfers in the text box on the international payment submission for the transfer to myself.

A point of convenience: You can deposit money into your account using an ATM (never seen that in Sweden). You can also transfer money between your accounts at the bank at the ATM. (May be Bank of America specific, but I suspect not.)

Getting a cell phone plan

In general the cell phone/plan market is a bit different in the US. In my particular case I went with Verizon because I knew I wanted Galaxy Nexus + LTE in a few weeks when that phone is released. My european HTC Desire HD is not compatible with Verizon’s network however (the phone works in the US, but not through Verizion; in SF it seems to be picking AT&T but sometimes I’ve seen T-Mobile as well). So be prepared to either be limited in your selection of carrier, or else having to get a new phone even if you don’t initially care about 3G/LTE speeds.

Finding an apartment

I am by no means going to be able to accurately represent the SF housing market as a whole. But, my experience so far is with an apartment community called Archstone (just happened to be the one, I’m not implying they are special). First off, despite people often saying how hard it is to find an apartment, there seems to be apartments pretty readily available as long as you’re not too specific about your demands and (I suspect) are not in need of well-below-normal price ranges.

Potential payment problems

Be prepared that you may not be able to walk in and pay the first month’s rent by e.g. credit card. You may need to use a check, or “bill pay” (which seems to be something similar to e-faktura except the other way around (push instead of pull)) used over here. In short, it’s easiest if you try to arrange to get the necessary amount of money into your US bank account as soon as possible (either by transfer or by withdrawing cash and depositing) so that you can more easily fulfill whatever requirements are imposed by the landlord.

Before arriving, talking to the relocation agent, I got the impression that landlords would often want to see proof of employment, credit reports, and may demand several months rent in advance initially. This is probably true, but is not always the case. With Archstone, there seemed to be almost no fuss at all other than that I could not pay by credit card. Basically no paperwork required.

In the end it’ll be up to the landlord, which might be a bigger commercial entity, a person, or a smaller entity. Presumably they are very different.

Contrasting with Stockholm rentals

Well, you can freaking get an apartment immediately. There is no multi-year queueing system that you have to go through (or know someone, etc) as there is in Stockholm. That said, it’s definitely more expensive. For a studio apartment around 40m^2, expect to pay $1800-$2500/month (can be even more, but assuming you want to keep it reasonable) for a good place.

Contrasting with a Stockholm/Uppsala BRF

(For non-Swedes: A BRF is an organization that owns buildings containing condos that the BRF members own the right to live in; in theory controlled by members in a democratic way. You pay a monthly fee that goes to e.g. heating, and then you buy the apartment which amounts to a monthly fee to the bank, and a requirement to be able to get the loan. Basically, if you want to easily get a place to live in Stockholm, being able to select where, and not queueing, you seem to have to buy a condo. EDIT: Someone pointed out that you can often get a place easier by finding sublets, and I think this is true. But, there’s a trade-off involved in having to use a sublet such as not knowing how long you can stay. Especially since there are rules that give the renter of a sublet automatic rights to stay there after a certain while, by law, so there is an incentive to kick people out before that time expires… I’m not sure how often that is an issue though.)

Comparing the expectations of a BRF with that of something like Archstone is… sort of difficult because the difference is fundamental. My personal view of the BRF system is that it is something that looks good on paper (democracy and such), but in practice pretty much sucks. Those making the decisions end up being those that have the time/inclination to spend effort on paperwork and bureaucracy, and I have never yet noticed a BRF being particularly service minded. For example, laundry rooms being booked very restrictively and wastefully, having 1 hour of opening hours per week for speaking to the BRF. Having to use that special hour to get the key necessary to drive into the area. Randomly getting papers in the mail saying “we need random person X to enter your apartment and you better react within a week” (e.g. someone doing an inspection or adjusting ventilation).

Looking at Archstone (again, I’m using it as the example but I’m certain they’re not alone in it, but I also assume there are plenty of independent landlords who will work quite differently) you have quite obviously a situation which is much more focused on providing a service to a customer (since it’s run by a commercial entity trying to make money, wanting to sell to customers). They have, and make a point to advertise, things like on-site fitness centers, ATM:s, grocery stores, starbucks, post offices, laundry services, 24/7 ability to report a problem, 24h guarantee of fixing reported issues, a proper garage (no queueing, again). There also seems to be quite a bit of flexibility in moving between apartments within Archstone without penalty; so upgrading/downgrading seems pretty easy as long as there are available units.

To me, the commercially run apartment community form is a much better fit than a Swedish BRF. In particular because:

• There is no need to make a personal investment, playing the housing market.
• No need for huge loans and mucking around with banks.
• No need to pay tens of thousands (or even hundreds of thousands) of SEK to a realtor on every move.
• It’s a service, and as such, I can contact the service provider at any time and they are interested in being helpful.
• No sudden “oops, bathroom must be renovated because someone measured water damage” surprises.

In short, I’m really looking forward to finally having a high-quality rental apartment instead of a condo.

Avoiding needing a car

SF is one of the best cities in the US when it comes to public transportation. There are buses, cable cars and underground trains that are part of Muni and there is a separate system called BART for longer-range subway service – plus the CalTrain for commuters.

In addition, there are services like Zipcar which allow you to pick up a car within a few blocks (walking distance) whenever you want to, without actually having to own one.

I have not yet tried Zipcar, but my plan is to utilize public transportation as much as possible, and combine that with Zipcar and Uber where necessary. I fully expect this to work quite well.