Can someone explain American health care for me?

Factual Questions
1

The thread about medicare/aid got me thinking. From our perspective, and the background noise about health care reforms during the Clinton years, I realize that my notions of how it actually works are kinda hazy.

Private hospitals (which we have too), obviously charge the real cost, unless you have a private insurance. Is health care unavailable for those on social security / the homeless / unemployed? I get the impression that there are hospitals owned by the cities (Chicago General, or some such?) where those less fortunate can receive care. Medicare/aid (and if my memory serves me) Blue Cross (?) seems to be involved, somehow too.

I really don’t want this to turn into GD/Pit terrotory, but what’s the big deal, anyway? And what was the controversy about with Clinton’s reform?

2

For the ones on Soc Sec, welfare,etc Medicare /Medicaid is accepted at most private hospitals. For those w/ nothing-the “safety net” is municipal hospitals-usually county,sometimes city run . The four largest hospitals are county(apart from giant stae run mental hospitals with thousands of patients[ half the patient beds are there] NYC: Bellevue & Kings County; Chicago: Cook County; LA: LAC-USC Medical Center.

Re: Clinton-the main problem was the same coverage for mental/drug/alcohol/ as for let’s say cancer or heart disease. The argument was $$$- too expensive. There might have been some socialistic, British style features too, not sure.

3

Emergency rooms are required by law to treat anyone who shows up. If you need hospitalization and can not pay you can be declared indigent and the government will pay the cost. Sometimes you will be transferred to a teaching hospital instead of a regular hospital but I am not sure how often this happens.

4

Let’s back up a little here for our non-U.S. friends and define some terms.

Social Security - the United States program for elderly and disabled. Soert of a government pension plan.

Medicare - a U.S. health insurance program for people receving Social Security.

Medicaid - an insurance program run by each individual state for their residents who are either too poor or ineligible for private health insurance. (Blue Cross is simply one of many private insurance companies)

Some states, counties and cities operate their own hospitals and health clinics, or subsidize private facilities in their areas. This is supposed to ensure that no one is deprived of health care.

In real life, Medicare does not provide very complete coverage (prescription drugs, for example, are not covered) and private insurance plans that supplement Medicare can range from excellent to very bad, and be very expensive.

Medicaid programs have very restrictive income limits, so a person can be working at a minimum wage job but earn to much to qualify for that state’s Medicaid program. Also, private health care givers are not required to accept either Medicare or Medicaid programs.

Private insurance plans do not have any standards to meet, so they can range wildly in price and quality of coverage. Also, private insurers are free to refuse coverage to those they feel are high-risk.

That leaves publicly owned or subsidized clinics as the provider of last resort. But health care costs are rising too quickly for most public agencies to keep up with them. Patients are expected, in theory, to contribute to the cost of their own care, but many do not pay their bills. Also, particularly in rural areas, health care providers simply may not exist, forcing patients to travel many miles for care.

Any government program that calls for universal health care coverage faces debate on three issues:

The cost to the government/taxpayers

The argument that the government will inevitably set the price of service and/or limit the amount or services a doctor can prescribe

Whether individuals and health care providers can or should be permitted to purchase private insurance in addition to the universal program – which would lead to providers who would select only patients with superior coverage/ability to pay, which would cause the same problems as the current system.

I hope this clears things up a little.

5

See, back when my folks were growing up health insurance was only used in catastrophic cases. If you just had a cold or broke an arm or something, you typically just paid for this out of your pocket. Which wasn’t that bad, as doctors could only charge people so much. Prices were kept in line.

But then the unions stepped in, getting better and better health benefits. It became cheaper for auto workers for example to pay the $10 co-pay than to pay for the actual costs. LBJ’s “Great Society” program also placed upward pressure on prices, as many more people could go to the doctor for “free”. Combine this with the explosion of lawyers - the huge number of medical malpractice lawsuits has made malpractice insurance go through the roof, costwise - and there’s just no incentive for prices to come down.

Take animal doctors for example. Many of the procedures they perform are similar to (or even the same as) the ones human doctors do. And they charge a fraction of the cost. Example: getting my dog neutered cost $50. My dad’s vasectomy cost around $800 for essentially the same operation.

I know this is getting into GD territory, but it’s true: most people in the US only use their auto insurance in case of a true emergency. But if people started charging the insurance company for oil changes, it wouldn’t take any time for an oil change to cost $400.

6

Another key point to our current system, and one which I think is largely responsible for this fine mess, is that for the past 40 or 50 years, employers have used health insurance to attract employees. It’s a nice thought - take care of a worry for the employees so they can be happy and healthy, plus take advantage of group bargaining power. The trouble is that it’s become an expectation, so people who are hard to get insured are now also hard to get employed. And it’s been viewed as a limitless service - no stone will be left unturned to make sure that I’m healthy, no matter what the cost.

As medical technology has advanced, the cost of this “limitless” idea has skyrocketed. For the last few years, we’ve been hitting the point where medical care has to be rationed by someone, and people don’t like it.

7

[hijack] A dog neuter for $50? Mmm, not to piss on your theory, which is essentially sound, but someone who is doing surgery for that little is probably cutting a lot of corners about anesthetic monitoring and sterility practices. I might shop around for a new vet if I were you.[/hijack]

Standard of care is something else that contributes to high prices for healthcare. It costs a lot more to do things to the gold standard, trust me. At most vets, it costs about $100 for a dog neuter. When one of my cow-orkers had one of our surgeons neuter her dog, it cost nearly $500. That dog got the absolute Cadillac of surgical thoroughness, as well as gold-standard pre- and post-op care, and it required a lot of really friggin’ expensive disposables and medications.

Vets can get by with “good enough”. Human doctors can’t. What works perfectly well for 85% of similar cases just isn’t good enough for most human practitioners, because of the threat of malpractice lawsuits in that 15%. So you have to do a lot more tests, prescribe more expensive drugs, use a lot more sterile equipment, etc., etc. just in case. And that really, really drives up the cost of health care.

DrJ was working with an Irish med student last year, and they talked a lot about the differences in how medicine is practiced there versus here. In Europe, they tend not to do all the diagnostics that are standard here, relying instead on very thorough physical exams and a few carefully chosen tests. The doctors may not be able to see as many patients in a day, which makes for longer waits for healthcare, but it does greatly reduce the average cost per patient.

8

Here’s another way to look at the system using specific examples:

  1. A person (we’ll call him Billy-Bob) finds affordable health care with an insurance company (Helpful Healthcare Provider).
  2. Billy-Bob (after uttering a phrase like “Hey y’all, watch this”) gets a ride to the emergency room at a hospital (Swampwater Medical) with a serious condition (a fire poker sticking through his torso).
  3. The doctor on duty (Dr. Cleatus) sees Billy-Bob is fading fast. He isn’t going to make it to the operating room. The family pleads for him to do something, ANYTHING, so he tries pulling out the poker.
  4. Billy-Bob doesn’t make it. His relatives (the Crampets) sue Swampwater Medical and Dr. Cleatus for malpractice (after all, he wasn’t even a licensed poker remover).
  5. Swampwater Medical and Dr. Cleatus’ malpractice insurance company (Justin Case Insurance) ends up paying a multi-million dollar award. As a result, it now charges all the doctors in the county huge premiums.
  6. Dr. Cleatus doesn’t make enough to cover the new premiums, and leaves practice to go back to oat farming.
  7. In the meantime, the Crampets get a bill from the hospital for the poker removal. The procedure isn’t recognized by Helpful Healthcare Provider.
  8. The Crampets are outraged. They drum up public support, and congress passes the Billy-Bob Bill, which requires all insurance companies to cover poker removal.
  9. Swampwater Medical, already hurting from increased insurance premiums, now must offer huge salaries for doctors to maintain minimal staff because they have to cover their own malpractice insurance premiums and pay off even larger student loans (from that extra semester of medical school that covers poker removal). Swampwater Medical must now charge huge fees for procedures just to keep operating.
  10. Helpful Healthcare Provider is crushed by the huge payouts for treatment at Swampwater Medical. Affordable healthcare dies on the table. Now there’s people who can’t afford healthcare so decide to go without it.
  11. The people without healthcare still insist on getting injured now and then, and continue to seek treatment at Swampwater Medical, which can’t refuse them emergency care.
  12. Now without even the insurance company payments from many of their patients, Swampwater Medical is continually forced to redefine “minimal care”.

As a final note, there’s one more issue that comes up when universal health care is discussed: Will it cover controversial procedures (abortions, acupuncture, chiropractics, etc)?

9

Another factor that may or may not mirror the situation outside of the US –

Let’s say you go into the medical center for a procedure – let’s say a pre-op MRI, an X-ray and some blood work, followed by surgery and some post-surgical physical therapy.

The “official” charges for these procedures is astonishingly high:

MRI $2700
Xray $800
blood work $1400
surgery $45000
PT $750 per session x 14 sessions = $10500

So let’s say you have insurance. You receive a statement. The statement indicates that the medical center regards the charges as “paid in full”, i.e., “this is not a bill”, but here’s what the insurance company actually paid:

MRI $450
Xray $175
blood work $350
surgery $9000
PT $250 per session x 5 sessions + $150 x 9 sessions = $2600

So…the amount the medical providers actually receive is significantly lower than the “list price”. Furthermore, different insurance companies reimburse at different rates, and medical providers either do or do not accept various medical insurance depending (in part) on what kind of rates the insurance companies are inclined to pay.

Medicare is notoriously stingy about what it will pay. Medicaid, oddly enough, is a mixed bag, and under some circumstances pays rather nicely (or used to at any rate; this may have changed).

Uninsured people are given the bill with the “list price” and in many cases are expected to pay up front before the procedure. Fully knowledgeable uninsured people may be able to bargain and haggle, knowing that the medical providers would not be getting this kind of money from an insurance company (even an expensive private insurance company). Mostly, though, people see these extraordinarily high fees and compare them to the cost of insurance premiums and co-pays and gladly embrace their insurance, not realizing it is an illegitimate comparison.

10

There is nothing worse than the fact that the uninsured are expected to pay amounts that far exceed the value of the service provided. That is because, in order to get a fair value for their services overall, physicians have to dramatically inflate their prices so that health insurance providers (including the government), when the do pay a percentage of the “actual” cost, will end up paying a reasonable amount.

11

To hijack with an amusing story:

I received a call once from a lawyers office. They had settled a “slip and fall” and the amount recovered did not even cover their fees plus expenses. They asked me to negate my charges, and said that all the other physicians they had contacted had agreed to do so. After thinking for a minute I told them I would reduce my charges by the exact same percentage they were reducing their charges, and would do so as soon as I received a letter telling me what that percentage was. This was in the early 1990’s, and I am still anxiously awaiting their letter.

12

The bottom line, Gaspode, is that the US Insurance Industry is in actual fact an organized gambling outfit. For all intents and purposes, they do exactly what bookies and casinos do: they take bets. In paying insurance fees, we are in effect betting that we will get sick, and the insurance companies are betting that we will not. Coupled with the conflict of interest that it’s the insurance companies themselves who, by and large, are free to define the word “sick,” and you have a house bank that cannot lose. The billions of dollars that Americans spend every year on healthcare only go partially to doctors and hospitals; a great chunk of it goes to line the pockets of the bookies–excuse me, the insurance industry–in return for covering the bets. So the process is this: money flows from the patient to the doctor, and the insurance industry has insinuated itself into this process in order to siphon from that flow of fees. And this is the system that most Republicans, including of course our fearless goofball, scuse me, our fearless leader, things is a good thing. This of course is because he is paid to say so by the bookies who profit from the status quo. So the healtcare system in the US is the way it is because it provides a way for the insurance bookies and conservative politicians to take money away from sick people. This is why we’re the greatest country on earth.

13

In America, almost all people with decent full time jobs have health insurance provided through their employer. Most health insurance plans make getting medical care extremely reasonable, and generally one does not have to save/go into debt for medical expenses.

Other people purchase health insurance without going through an employer. This is extremely expensive- often five to eight hundred dollars a month.

Some people get health insurance through the government, but this is limited to the elderly, children, and other groups who generally cannot provide for themselves. A healthy but unemployed or working poor adult generally cannot get health insurance from the government.

Those that do not have health insurance will always be able to recieve emergency care. They will be charged for this afterwards. Hospitals are lax in collecting, but this debt will follow them around until the can pay it. People without health care cannot get non-emergency procedures (checkups, diagnostic and preventative care/ care for non-life threatening illnesses, even cancer treatments) without paying, often upfront.

Most of these people (like me) just hope they don’t get sick or hurt. If they do get sick, they can expect any life-savings or property they have to be wiped out pretty quickly and will likely be in debt for decades. A trip to the emergency room for a couple stiches can easily cost several thousands of dollars. The cost of any sort of hosptialization can quickly add up to tens or hundreds of thousands of dollars. I know that would wipe me out, and I’m personally scared to death over it. So when I get a really bad cold, I gotta hope like heck it’s not a bacterial infection, because there is no way I’m going to risk wasteing hundreds to see a doctor unless I’m pretty much sure it is pneumonia or bronchitus. If I get a rash, I hope it goes away, and if I have a non-critical problem ( constant stomach aches or something) I live with it and hope it’s not cancer or something.

The arguments regarding universal health care are potrayed as being about the limits of the state (Americans are very concered with anything that even vaguely resembles socialism) and “personal responsibility”. It often boils down to an “I got mine, you got to get yours” mentality. Those that are insured (the majority of adults in steady jobs) can only lose. Universal health care would mean they risk wait times, not being able to choose their own doctor (an obsession in America, where many people stay with one doctor from their birth on) and having more expensive diagnostics and experiemental treatments be unavailible to them. Those that are not insured have only to gain. The health care system fundamnetally does not work on any level for them, and basically anything would be better than the care they recieve now.

14

Checking back in. Interesting reading.

Just to give a POV: We have, what many Americans would regard as, socialized medicin. After all, Sweden was once the model for the welfare state.
However, that doesn’t mean there are no private clinics, hospitals or GPs. In fact, I would venture to say that the majority of the physicians practicing are working privately. The fee for going to a private clinic or a publicly owned is the same (but varies from ciounty to county). The problem is, there are often waiting times, so people with lotsa dough, can pay to get a procedure done outside the health care system, thus effectively skipping the wait.
Having private clinics mean that many have their own doctor and stick to that. There is quite a turn-over at public facilities, so chances are, you won’t be seeing the same doctor all the time there.

But let me get this straight - Even the most down and out, showing up at an emergency room with a gunshot wound (fatal right now if not treated) will get care. The same person, showing up two weeks later, with a strange lump (cancer and fatal if not treated, but taking longer time), will not receive treatment unless paying up front, even at a publicly owned facility?

15

The last sentence isn’t necessarily the case. You may “simply” be billed for it, and have bill collectors sic’d on you if you don’t pay. However, the “most down and out” might well be able to qualify for Medicaid, and probably would be sent to a social worker or similar type at the hospital, to help that person deal with the paperwork required.

The people who are usually in the worst situation here are those who are “underemployed” - working a couple of part-time jobs, say, or one “part-time” job that’s just barely under full-time hours so that the employer can get out of benefits for that class of employee. They’re the ones referenced earlier as making “too much” money for Medicaid, but making too little income to afford a decent insurance plan.

16

Gaspode If the person with the lump shows up a ritzy private hospital emergency room with a lump, they will probably make him wait a long time, then perform a cursory exam, and then direct him to a city or county clinic or hospital.

If the person with the lump goes to a city or county hospital, or a hospital that sees a lot of indigent people (or people who claim to be so) and then bills the county, she will get an exam and whatever treatment she needs.

However, in both cases, the person with the lump may very well end up spending some time in a non-private room or even a ward! A fate many of my “why don’t we have public health care?” friends consider beyond the pale.

17

Not to remove this from GQ and into GD, but to use petre’s example, there are conditions for which government intervention is a good thing.

Here in Pennsylvania, we have a higher incidence of diabetes mellitus than in other states. (According to this site, it’s 6.8% of the population.) Because insurance companies limit the quantities of things like diabetes testing supplies, labwork, insulin needles, and medications, people were not testing as frequently as they needed to. Consequently, the state’s medical costs were going up due to complications, which can get quite costly to treat. As a result, the state passed a law requiring insurance companies to pay for these supplies as prescribed by the patient’s physician. Therefore, if Mr. Smith has to test his glucose level five times per day, his insurance company must pay for 2 boxes of test strips, lancets, alcohol pads, and whatever else he needs, per month. (Most of this stuff comes 100 to a box.) Ditto for medications. If Mr. Smoth takes medications 3 times per day, his insurance company (if he has a drug plan) must cover 90 tablets per drug.

This has saved the commonwealth a lot of money in Medicaid costs by preventing complications. A good example of government stepping in to make the insurance companies do the right thing.

Robin, who notes the palpable irony in Gov. Ridge signing the Diabetes Benefits Law in Hershey.

18

The Hillary Clinton health proposal was to go to a “single-provider” system, ie all the individual insurance companies would go away. Canada has this (right?).

19

Huh? Even we don’t have a single provider.

And if I get j.c. right, people feel that public health care should provide them with a single room? (Huh? again).

I know my own country and Spain the best, but generally in most EU countries, everyone, regardless of social standing, can get good, if not excellent, care under the current system. Excellent care is there for those who want to pay, or have insurance.

The more I read in this thread, the more it feels like the US has a public health care, sorta, kinda, mebbe. I’m all for free enterprise, but (and now I’m moving to debate territory) from my POV, it seems that it would be quite possible to offer a basic good health care, for the indigent, without socializing the whole insurance industry or making all medical facilities publicly owned.

20

I can only imagine what this hillbilly melodrama looks like to the OP, reading this from Sweden.