A Tale Of Two CT Scanners — One Richer, One Poorer

Lambert here: The numbers are an outrage, but you’ll never guess the weak-tea bottom line…. That’s right! Be a smart shopper. I expect more from KHN, although not NPR. Nevertheless, a useful cautionary tale. But it’s not really the scanners that are rich, or poor, is it?

By Alison Kodjak, NPR News. Originally published at Kaiser Health News.

Benjamin Hynden, a financial adviser in Fort Myers, Fla., hadn’t been feeling well for a few weeks last fall. He’d had pain and discomfort in his abdomen.

In October, he finally made an appointment to see his doctor about it. “It wasn’t severe,” he said. “It was just kind of bothersome. It just kind of annoyed me during the day.”

The internist, Dr. John Ardesia, checked him out and referred him for a CT scan at a nearby imaging center. The radiologist didn’t see anything wrong on the images, and Ardesia didn’t recommend any treatment.

A few weeks later, Hynden, who has a high-deductible health insurance policy with Cigna, got a bill for $268. He paid it and moved on.

But three months later, in mid-January, Hynden was still feeling lousy. He called up Ardesia’s office again. This time, the doctor wasn’t available. A nurse practitioner, concerned that Hynden might be suffering from appendicitis, advised him to go to the hospital right away.

“I was a little worried,” Hynden recalled. “When he told me to go to the ER, I felt compelled to take his advice.”

Hynden arrived later that morning at Gulf Coast Medical Center, one of several hospitals owned by Lee Health in the Fort Myers area. The triage nurse told him the problem wasn’t his appendix, but she suggested he stick around for some additional tests — including another CT scan — just to be safe.

“It was the exact same machine. It was the exact same test,” Hynden said.

The results were also the same as the October scan: Hynden was sent home without a definitive diagnosis.

And then the bill came.

Patient: Benjamin Hynden, 29, a financial adviser in Fort Myers, Fla.

Total Bill: $10,174.75, including $8,897 for a CT scan of the abdomen

Service Provider: Gulf Coast Medical Center, owned by Lee Health, the dominant health care system in southwest Florida.

(Story continues below.)

Medical Procedure: A computed tomography scan, commonly known as a CT or CAT scan, uses X-rays to create cross-sectional images of the body. Hynden got his October scan at Summerlin Imaging Center, a standalone facility in Fort Myers that offers a range of diagnostic tests, including X-rays, MRI and CT scans.

Rick Davis, co-owner of Summerlin, said his center is small and independent, so he doesn’t have much bargaining power. That means insurance companies pretty much dictate what he can charge for a scan. In Hynden’s case that was $268, including the cost of a radiologist to read the images.

Ultimately, what Medicare decides to pay for a scan sets the standard. “The Medicare fee schedule is what all the other companies use as their guideline,” Davis said. “It’s basically the bible. It’s what everyone goes by.”

Summerlin’s office manager, Kimberly Papiska, said that the maximum the center ever bills for a CT scan is $1,200, but that the rates insurance companies pay are usually less than $300.

Hynden was shocked when he got the second CT scan in January, and the listed price was $8,897 — 33 times what he paid for the first test.

Gulf Coast Medical Center is part of his Cigna insurance plan’s approved network of providers. But even with Cigna’s negotiated discount, Hynden was on the hook for $3,394.49 for the scan. The additional ER costs added another $261.76 to that bill.

What Gives: We called Gulf Coast Medical Center and its parent company, Lee Health, to understand why they billed nearly $9,000 for a single test. No one at the health center or hospital would agree to an interview.

Lee Health spokeswoman Mary Briggs responded with an emailed statement: “Generally that it is not unusual for the cost of providing a CT scan in an emergency department to be higher than in an imaging center. Emergency department charges reflect the high cost of maintaining the staffing, medical expertise, equipment, and infrastructure, on a 24/7-basis, necessary for any possible health care need — from a minor injury to a gunshot wound or heart attack to a mass casualty event.”

Do the hospital’s costs and preparations justify a list price that’s so much higher than the nearby imaging center’s tab? We asked some experts in medical billing and management for their thoughts.

Emergency rooms often charge people with insurance a lot of money to make up for the free care they provide to uninsured patients, said Bunny Ellerin, director of the Healthcare and Pharmaceutical Management program at Columbia Business School in New York. “Often those people are what they call in the lingo ‘frequent flyers,’” Ellerin said. “They come back over and over again.”

She said hospitals also try to get as much money as they can out of private insurance companies to offset lower reimbursements from Medicare and Medicaid.

Even in that context, the price of Hynden’s CT scan was off the charts.

Healthcare Bluebook, a health care pricing tool, says the range for an abdominal CT scan with contrast, like Hynden had, in Fort Myers is between $477 and about $3,700. It pegs a fair price at $595.

The higher price from Gulf Coast Medical Center and its parent company could be a result of their enormous pricing power in Fort Myers, said Gerard Anderson, a professor of health policy and management at Johns Hopkins University.

Lee Health owns the four major hospitals in the Fort Myers area, as well as a children’s hospital and a rehabilitation hospital, according to its website. It also owns several physician practices in the area. When you drive around Fort Myers, the blue-green Lee Health logo appears on buildings everywhere.

“Anybody who’s in Fort Myers is going to want to get care at these hospitals. So by having a dominant position, they have great bargaining power,” Anderson said. “So they can raise their rates, and they still do OK.”

Anderson said his research shows hospital consolidation has been driving prices higher and higher in recent years. And because more and more people, like Hynden, have high-deductible insurance plans, they’re more likely to be on the hook for huge bills.

So Lee Health and other dominant hospital systems mark up most of their services on their master price lists — the list that prices a CT scan at Lee Health at $8,897. Anderson calls those lists “fairy-tale prices” because almost no one actually pays them.

“Everybody who’s taken a look at it agrees — including the CFO of the organization — that it’s a fairy-tale thing, but it does have relevance,” Anderson said.

The relevance is that insurance companies typically negotiate what they’ll pay at discounted rates from list prices.

So from the master price of $8,897, Cigna negotiated Hynden’s bill down to $5,516.14 — a discount of almost 40 percent. Then Cigna paid $2,864.08, leaving Hynden to pay the rest.

“If it wasn’t for that CT scan, I don’t think this whole thing would have been so difficult and so blatantly obvious that they’re extremely overcharging for that service,” Hynden said.

Resolution: Hynden never got a definitive diagnosis from the CT scans. Several weeks after his second test, however, he went to a nearby urgent care center, also run by Lee Health, and underwent an ultrasound on his abdomen. That test, which cost about $175, revealed some benign cysts that he said his doctor said are likely to go away on their own.

The Takeaway: Tests and services are almost always going to be more expensive in an emergency room or hospital setting. If your doctor suggests you go to an ER, it might be worth asking whether an urgent care or walk-in clinic would suffice.

Sources: Explanations of Benefits provided by Benjamin Hynden and interviews.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.


  1. Phil Snead

    Universal, single payer could not possibly be worse for sick people than this government-subsidized racketeering. Thank you for republishing this story. People should not need a lawyer in order to access care at a fair cost.

    1. Masonboro

      “government-subsidized racketeering”

      Did you even read the post ?

      The whole point is that Medicare and Medicaid are the cheapest and that private (repeat, private) monopolies are massively driving up costs.

      “hospitals also try to get as much money as they can out of private insurance companies to offset lower reimbursements from Medicare and Medicaid.”

      First commenter strikes again.

  2. John Beech

    Republican voter here, but very interested in single-payer. Come 2020, I may vote Democrat. Except the Democrats are running away from single-payer, or Medicare-for-all as well. heavy sigh.

    1. Oregoncharles

      there are other options. Assuming that there are only two, buying into the myth, is a big part of our problem.

      And I don’t think the Libertarians support Medicare-for-all. I don’t think they even support Medicare, given their principles.

      1. onihikage

        there are other options. Assuming that there are only two, buying into the myth, is a big part of our problem.

        So long as our voting system restricts every individual to voting for only one candidate per position, it is not a “myth” that we only have two choices. I believe our actual biggest problem is that everybody is thinking in terms of which of the two mandatory teams they are on and which they will vote for, including the user you replied to, with statements such as “I might vote for a Democrat,” or “I am a [party member].”

        The interests of corporate oligarchs (both native and foreign) have captured so many and have so much influence on both sides of the aisle and in the media that individual candidates and their particular characteristics matter much more than their party affiliation, so long as they’re on one of the big two teams. In that sense, those who say “both sides are the same” are not strictly wrong, but they usually reach the wrong conclusions, such as that voting doesn’t matter, or that voting for a third party president is ever in your own best interest.

        For the few who are politically informed to make a difference, they have to participate where their vote or activism has the greatest effect, and that means voting in and canvassing for local and primary elections. But even that can be difficult, and many don’t have the time or effort to spare.

    2. JohnnySacks

      Problem #1 – lack of consistency in marketing. Pick the most marketable name and consistently sell it. Lesson #1 learned in 2016 – the sales pitch is the platform, implementation details are secondary and to be avoided at all costs.

  3. oaf

    “If your doctor suggests you go to an ER, it might be worth asking whether an urgent care or walk-in clinic would suffice”.
    I would like to thank you for this tip, as no ACA coverage…
    …due to conscientious objector status….
    …unfortunately; this is not an allowed defense for not buying into ACA. The penalty is cruel.

    1. roxan

      I find that urgent care centers vary quite a bit, so check into whether they are equipped for x-rays, etc. I think none of them do IVs, but I could be wrong. There is usually one around that is open late hours and does more in depth care. I go to one that offers primary care, as well. It’s a better model than the usual fare–no waiting weeks for appointments, no piles of useless paperwork, no lectures. Just address what’s bothering me–the way doctors used to….

  4. Michael

    I’m an American living in France. Despite public perception there is not entirely single-payer here. Everybody has a Carte Vitale (the French translate to social security card) that pays basic medical expenses. Most people also have a mutuelle, private insurance that pays some or all of the rest. Most doctors and clinics are private and set their own rates. For example, the base rate social security pays is €25 for a doctor visit. But we have a doctor who speaks fluent English that we like; he charges €35. Social security pays €25, our mutuelle pays €13.50, and we pay €1.50. Clinics work the same; there are public one’s and private one’s. I don’t know if government caps rates but nobody would ever charge €10K for a CAT scan – nobody would show up (prices are discussed beforehand). I needed a CAT scan and I remember it cost about €120 with analysis; insurance paid for that 100 percent.

    One oddity that’s different than the US is the sicker you are, the higher a percentage that insurance covers. My daughter was in the hospital for two-days with a terrible viral stomach flu. She had a private room, they ran many tests to rule out food poisoning, bacteria, appendix — everything they’d do in the US — and the final bill was … nothing. But we could have gone to a posher clinic in Paris (well, we couldn’t – we arrived at the nearest ER with a very sick child, but assuming we could) and the rates would’ve been higher. But we still would’ve walked away with little or no bill.

    For those who think it’d be awful for medical providers do the math. Assume my primary care doctor sees about 15 patients a day at €35. That’s €525/day, €2,625/week, and €11,366/month, and €136,395/year. But what about malpractice insurance? It’s cheap because medical injuries are paid for by the government and bad doctors are handled through licensing. Billing staff? None – he puts our green Carte Vitale into a machine and types in a code. Electronic records systems? Provided by the government to him for free. Front office staff? None – he has a phone service that handles appointments and there’s a cheap electronic version of the same. Besides rent, virtually all that billing goes to him. It’s less than US doctors make but still allows a very nice lifestyle plus doctors have no student loans. I’d imagine US doctors see many, many more than 15 patients/day (my doctor might too – I’m guessing on that).

    1. Knot Galt

      There is a mathematical formula in there somewhere. I think ACA lobbyists figured out the formula long ago and the equation is tucked away in some vault.

      But I already know the answer;
      Capitalism = Let the Buyer beware

  5. diptherio

    I don’t know what this guy is complaining about. He saved 40%! We should all thank our lucky stars that we live in a country with such tremendous bargains in healthcare! [/sarc]

    1. WheresOurTeddy

      My favorite part is the big “64%” with a circle around it to make it seem like you got screwed less than you actually did

  6. HotFlash

    As a Canadian, I feel compelled to make these comments so that you can see how the rest of the First World lives. Have a friend, a roofer, who was having some issues w/his right arm and it was interfering with his working. His doc suspected some nerve thing and sent him for a *series* of MRI’s. I forget how many he had, I think at least three sessions of 2-3 hours each (I drove him to the hosp for them). Cost to him, nada. The MRI’s showed some stuff they didn’t like, his doc sent him to a neuro-specialist, who referred him to another neuro-specialist who was one of the three world authorities on what they figured he had. That doc wanted more/better MRI’s from another hosp and that was another 2-3 sessions as they had to do his entire spine. Cost to him: NADA, zip, zero, zilch.

    Bad news. it was what they thought, syringomyelia, not treatable in his case, or at least the surgery would likely leave him paraplegic or worse, and so far he has decided not to. His choice.

    Once diagnosed, he was eligible for and got, after filing out many forms (I helped with that, he’s not a paper-type guy) ODSP benefits, which, while not princely, allow him to have as decent quality of life as a guy in pain waiting for a tumor to crush his spinal chord can reasonably have, eg, own apt, Internet (vital for a shut-in), food, and, truth to tell, cigarettes. He gets the payment, it is up to him to decide how to spend it.

    Damn socialist Canadians, haven’t they heard of GoFundMe?

    1. WheresOurTeddy

      thank you for this. the contrast must be repeated loudly and often.

      my chronically ill republican sister from Seattle (who is not wealthy) still tells me “health care is not a right”, despite the fact she’d be destitute, dead, or both if our father was poor.

  7. Keith Newman

    Another Canadian here, living in Quebec. In the last three years my sister has had two bouts of cancer and one burst appendix. She saw multiple specialists was operated on 3 times, had radiation treatment and ongoing physio. I accompanied her to 7 or 8 appointments. She was very competently treated. One test could have been more timely; it took a couple of weeks. It didn’t matter medically but put her on edge waiting. Total cost to her of everything: ZERO. Keep in mind as well that Canadian health care covers the entire population and costs, in terms of percent of GDP, about 10.5% versus 18% for the US.
    One serious failing of Canadian medicare is that pharmaceuticals outside of hospitals are not covered. You get them US style: covered with a co-pay if you have a reasonably good job, if you’re over 65 (and under 25 in Ontario since Jan. 1, 2018) or are poor. In Quebec everyone is covered but the co-pays are high so 12% of people aren’t able to afford their medicines. Since the coverage is US style, we get US style results: it’s unfair, and vastly overpriced.
    However there is a major campaign underway here to include pharmaceuticals by the labour movement, health economists, retiree associations (I’m a retiree), nurses associations, doctors, etc. One of the demands is that pharmaceuticals covered by the public plan be safe, evidence-based and cost-effective.Yikes! Big pharma is having kittens over that one. The opponents are the usual suspects, big pharma and the insurance companies, who say the current system is fine but admittedly needs a few tweaks. Sadly our Minister of Finance is a former insurance salesman (“benefit consultant“) but also conveniently clueless. He was caught on video telling the usual suspects not to worry, that the system was fine but did need a few tweaks to help those that fall through the cracks. So we’ll see what happens. It’s the closest we’ve come to including pharmaceuticals in public health care in 50 years. I’ll keep you posted..

    1. Arthur Dent

      One thing about Canadian pharmaceuticals. Even though the government doesn’t cover general prescriptions, they do negotiate the prices for obtaining them. So if you are paying for them out of your pocket it is basically the same price as an insurance company pays, unlike the US.

      That is why many Americans living along the border go into Canada to buy prescription drugs and why the pharmaceutical industry has fought to make that illegal, on the basis that the Canadian versions are dangerous and not vetted by FDA quality procedures which are presumably far more strict in the deregulated US than the socialist Canadian regulatory agencies.

  8. Ohnoyoucantdothat

    You guys will get a kick out of this – after you choke on your morning coffee. As some of you know, I live in Crimea with my family. Last year my wife had a seizure and an MRI was ordered. The clinic down the street was one of 3 having a working machine. Now, this is an older Siemens scanner, bought from a clinic in Sweden but adequate for the job. They did a head scan and charged us a grand total of 3000 rubles – about $50 including having the scan looked at by the radiologist. The neurologist who ordered the scan charges us $17 for his consultation. Have no idea how a clinic in US can charge thousands of dollars for the same procedure. Insane!

    1. WheresOurTeddy

      “Have no idea how a clinic in US can charge thousands of dollars for the same procedure”

      The word you’re looking for is “greed”.

      1. gulagknownasamerica

        “Greed” is too kind a word. What people need to realize is this is yet another example of one chronic failure after another after another, ad nauseum… from a long history of failed health policies and procedures from political leaders, to failed business models and failed managers meant to extract as much money from you as possible, to healthcare professionals who give bad advice in an attempt to own as little responsibility as possible.

        It isn’t just greed. It is corruption, incompetence, mismanagment, etc. all culminating in an epic failure know as America. As another reader put it, call it a failed state already. And it’s just not Canada you have to look to in order to see this in comparison. Look at America compared to any other metric of an industrialized nation to see the systemic epidemic of failure. Can we at this point assume Cal-PERS is not the exception but the norm?

        To keep describing these failures as isolated incidents is to bury your head in the ground while everything around you, which is meant to bring dignity into your life, is being corrupted, pilfered and turned into worthless meaningless garbage, which they expect you to happily pay a premium for. It’s just not health insurance. It’s your life.

  9. sharonsj

    Disheartening to read this just hours before yet another visit to a doctor where I might find out what is wrong with me. A bunch of tests, including a CT scan, found nothing and I still have no idea what the bill is. (I only have Medicare.) If I need major surgery or intensive treatments, that will happen only if my state or some charity can kick in funding, or I go to Cuba. Still waiting for America to be great again (snark).

    1. Oregoncharles

      Yes, surgery on Medicare can be a problem. I had bilateral hernia repair (which didn’t last long – that comment about mesh should have been a tipoff). Even with Medicare, the hospital was unable to tell me what the net cost would be. Turns out Medicare has a co-insurance policy, so my net cost was $1500. That’s cheap surgery, but it was a shock for me (I should have talked with Medicare before hand); for a lot of people, it would have been bankrupting.

      Now I’m looking at doing it again; maybe I should discuss that with the surgeon whose work didn’t hold up..

  10. Oregoncharles

    And Hynden still doesn’t know what’s wrong with him. I think I see a big part of the problem:

    ” A nurse practitioner, concerned that Hynden might be suffering from appendicitis, advised him to go to the hospital right away.

    “I was a little worried,” Hynden recalled. “When he told me to go to the ER, I felt compelled to take his advice.”

    Hynden arrived later that morning at Gulf Coast Medical Center, one of several hospitals owned by Lee Health in the Fort Myers area. The triage nurse told him the problem wasn’t his appendix, but she suggested he stick around for some additional tests — including another CT scan — just to be safe.”

    (Incidentally, at least around here, there’s a more appropriate place to go; they’re called “Immediate Care” or something similar, drop in clinics. Usually they have their own lab or arrangements with one. More expensive than a regular appointment, but much cheaper than the emergency room.)

    The nurse practitioner and triage nurse are both at fault for so casually suggesting such an expensive procedure – and both should have known. It’s also a substantial dose of X-rays, too much to do “just to be safe.” Of course, if he’d known the price, he wouldn’t have had it done. So that’s the other big issue: deliberately opaque pricing.

    However, there are reasons we don’t ask the price of medical procedures beforehand, and not just because we think we have insurance. It’s an example of why there cannot be a market in health care: lives, and even just pain, are more important than money. We don’t ask which is the cheapest doctor, unless we’re really in trouble; we ask which is the best. And if it’s for someone else, a child or elder or someone unconscious, it would be unethical to price-shop. That’s why they can get away with opaque, arbitrary pricing.

    Even more fundamentally, there cannot be a functioning market without reasonably equal information, and not just about prices. That isn’t and can’t be true in medicine; we go to the doctor precisely because they know more than we do. Granted, we could and should research our medical issues ourselves, and at this point Hynden would be well advised to do that; as Yves has demonstrated, similar skills apply. But that, too, is a tax on time. Not everyone has taken even basic biology. I talked with a father whose child was being treated for leukemia (and looked alarmingly near death); the poor guy had no clue what the doctors were talking about. Basically, despite their supposed Hippocratic Oath, we have a system that ruthlessly takes advantage of our ignorance, and frequently doesn’t even deliver the needed results – as Hynden discovered.

    It’s all just another case for single payer, of course, as well as for better education; but I think it’s important to destroy the “market” approach as thoroughly as possible. It’s the reasoning of a vampire squid.

    1. Leslie C

      When I took my dog to the expensive emergency specialist vet, I was given a quote for the minimum it would be (including some testing based on his symptoms when entering). Before doing any further testing or procedures, the doctor came out and explained what was suggested and why and how much it would cost to do the tests or procedures, including an overnight stay at the facility for observation. For a dog, a loved dog, but some of the same types of care that would apply to a person.

  11. WheresOurTeddy

    If you live in a society that does not provide the following
    1) Food
    2) Housing
    3) Health Care
    4) Employment
    5) Education

    to all who want them, you live in a FAILED STATE. If you live in a society that does not provide those 5 things to everyone who wants them, while allowing concentrated wealth in the Bezos/Gates/Buffett class, you live in an IMMORAL STATE.

    1. Knot Galt

      Thank you for that lucid apropos definition
      Ingredients for an immoral, failed State;
      1) Food ———-> Industrial-Chemical playground
      2) Housing ——> Bank Owned Ponzi Scheme
      3) Health Care -> Adding insult to injury
      4) Employment > 90% is slave labor
      5) Education —> MBA = More Bad Actors?

  12. clarky90

    Of the many ways to commit genocide; guns, machete, gas chambers, poisoned water supplies, forced exile to the Arctic…..

    Extreme taxation/fining/charging (seemingly, as in USA Medical Billing) is rarely included. The crime is masked as a “normal tax or bill”, except the “taxation rate” approaches 100%. Death by confiscation.

    Causes of the Holodomor


    “Although famine, caused by collectivization, raged in many parts of the Soviet Union in 1932, special and particularly lethal policies, described by Yale historian Timothy Snyder in his book Bloodlands: Europe Between Hitler and Stalin (2010), were adopted in and largely limited to Ukraine at the end of 1932 and 1933. Snyder lists seven crucial policies that applied only, or mainly, to Soviet Ukraine. He states: “Each of them may seem like an anodyne administrative measure, and each of them was certainly presented as such at the time, and yet each had to kill”:

    1) From 18 November 1932 peasants from Ukraine were required to return extra grain they had previously earned for meeting their targets. State police and party brigades were sent into these regions to root out any food they could find.

    2) Two days later, a law was passed forcing peasants who could not meet their grain quotas to surrender any livestock they had.

    3) Eight days later, collective farms that failed to meet their quotas were placed on “blacklists” in which they were forced to surrender 15 times their quota. These farms were picked apart for any possible food by party activists. Blacklisted communes had no right to trade or to receive deliveries of any kind, and became death zones.

    4) On 5 December 1932, Stalin’s security chief presented the justification for terrorizing Ukrainian party officials to collect the grain. It was considered treason if anyone refused to do their part in grain requisitions for the state.

    5) In November 1932 Ukraine was required to provide 1/3 of the grain collection of the entire Soviet Union. As Lazar Kaganovich put it, the Soviet state would fight “ferociously” to fulfill the plan.

    6) In January 1933 Ukraine’s borders were sealed in order to prevent Ukrainian peasants from fleeing to other republics. By the end of February 1933 approximately 190,000 Ukrainian peasants had been caught trying to flee Ukraine and were forced to return to their villages to starve.

    7) The collection of grain continued even after the annual requisition target for 1932 was met in late January 1933.

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