Expensive in the USA but cheap in Europe

Factual Questions
101

Since Germany is a mix of public health insurance and private insurance next to each other, we can see this. Normal employees are required to pick one of the official health insurance companies. Their families can join at no extra cost. They pay a fixed percentage of their wage income, their employer pay (roughly) the other half, it all goes into pool, so the healthy Clients pay for the others. No individual assessment, no lifetime caps.

But if you earn above a certain amount; are self-employed/ free-lancer or a state official (Beamte) - then you are exempt from the requirement and can choose to insure yourself with a private Company. This is then an individual risk assessment, and your rate is not based on your income, but a fixed amount. If you want your Family insured, too, each Person costs extra. The older you get, the more expensive the rates become. (The private companies do a lot of Advertising to get Young People to Switch by telling them how low their rates are compared to mandatory insurance - but Keep silent about how difficult it is to Switch back and how they can get in old Age when Money is low).

Small-time free-lancers often go without insurances because it’s too expensive, until they Need healthcare, and it bites them in the ass.

State officials are mostly private insured, and at first say how much nicer it is to get preferred Treatment. But it’s a huge paper hassle because for every single Thing, the doctor or Hospital sends them a bill, then they have to fill out a form for their health insurance, and another for their employer (who refunds up to 70% of the expenses). They have to pay the bill quickly, but the re-imbursement can take 4-5 weeks.
(In both cases, fraud has happend, that is, doctors/ hospitals billing for Services not rendered or billing for more expensive things. Some Claim that if the Patient sees the bill before passing it on, this would be prevented; but a) getting a copy of the bill could also be done with legal insurance b) legal insurance is already a complicated Point-System with abbreviations to the code book of approved Treatments that I doubt many patients would figure out billing fraud if cleverly done).

This https://www.tk.de/centaurus/servlet/contentblob/589226/Datei/1717/TK-brochure-welcome-to-germany.pdf is a bilingual PDF explaining the German social System from the POV of one health insurance (TK). Not in Detail, but for new arrivals.

102

In Norway, we generally pay a flat fee for each item. This includes travel to and from the hospital you have chosen, if hospital treatment is involved. However, the total fees you pay are capped at about 250 $ per year. (With a bit of +/- for the exchange rate). That is the maximum yearly outlay on medically necessary goods and services.

Its automatic, you won’t be charged after hitting the maximum. I don’t believe children are charged any co-pays in any case.

103

I was hospitalised overnight on a drip in Austria due to an allergic reaction and they required me to pay a standard charge for the treatment and private room…the grand total of 19 euro! (I thought they said 90 first of all and thought that was a pretty good deal!)

104

constanze – Thanks for the info and also the other post about private insurance. Yes, I was aware that higher-income earners and civil servants could opt for risk-rated private insurance in Germany, but I think a significant point here is that only about 10 or 11% of the population does this, and everyone else has statutory health insurance (Gesetzliche Krankenversicherung).

Regarding co-pays, I am not in the US so perhaps one of our American contributors can discuss the details – AFAIK co-pays apply for every item claimed as in any insurance. My experience is with single-payer and there are no co-pays or deductibles here for medically necessary procedures, which as you point out helps avoid needless complexity and also avoids discouraging people from seeing a doctor if they need to. The health card is swiped at the beginning of the visit (or it may already be on file) and that takes care of all payment matters.

105

A co-payment is a fixed amount paid by the patient for a given service. For example, I pay $35 to see a primary care physician, regardless of what the physician actually charges the insurer. The copayment is waived for certain visits/services such as an annual physical/gynecologist appointment under the ACA (and most plans did that anyway since regular checkups tend to reduce costs in the aggregate).

In most plans, you have coinsurance for some services instead of (or possibly even in addition to) a co-payment. Coinsurance is also charged to the patient, but as a fixed percentage of the cost of service rather than a fixed absolute sum. My health plan has coinsurance for hospital visits. I think it’s something like 15%, with other percentages applying for things like diagnostic testing. There is an annual out-of-pocket maximum after which copays and coinsurance are waived.

Many plans now also have a deductible, in which the patient pays 100% of all charges up to, say, $3,000.00.

106

The U.S. has a lot of different variations on health insurance plans.

For example, I have a high-deductible plan. That means I pay the first $2750 of medical care (including prescriptions) out-of-pocket – there’s no insurance coverage, even though it has to be run through my insurance company to verify that and to record how much I paid. Then, I pay 20% of the next tier (except 40% for “preferred” brand name prescriptions and 60% for non-preferred, and 40% for out-of-network medical care), until I have paid $5,500. After that, my insurance pays everything, as long as it is a covered service (for example, there is a limit on the number of visits to the chiropractor they’ll pay for; after that, I’m on my own). Plus, there are certain services that are always no-cost: immunizations, annual physical, “age appropriate bone density screening”, etc., except that these are not no-cost if I don’t go to an in-network provider, and in fact the money I pay for some of them out-of-network won’t count towards my deductible and co-insurance.

Now, figure out how much time, money, effort, processing power, etc., it takes to keep track of all of that.

107

You pay the first $2750 for each what? Each doctor visit? Each surgery in an ongoing line of surgeries for the same illness? For ongoing medication each month? How does it work?

108

I am not Isamu but I have a high deductible plan now too so I think I can answer appropriately. The deductible is what you pay during each plan year (typically the same as a calendar year) for any treatment you need until you meet your deductible with only a few exceptions like basic preventative care.

Let’s say you get a case of Strep Throat or a broken pinky finger and you have insurance. There are two problems here. The first is that no one is going to be able to tell you how much it is going to cost to fix that until after you are treated because there are no standard rates other than the fake ‘rack rates’ that are greatly over-inflated to the point of absurdity.

The real rates are negotiated between your doctor and insurance company even if they aren’t the ones paying for it. The other is that you are still going to have to pay for it yourself. If your case of Strep Throat or broken pinky finger costs $2000, then you have to pay for it yourself even though your insurance company is still in the middle.

All of that is ridiculous but it gets worse. If you got Strep Throat on Christmas and then broke your pinky finger on New Years Day (a week apart), those would generally fall under two different plan years and the deductible will reset so you would owe up to $2750 x 2 or $5500.

A $2750 deductible isn’t unrealistic at all these days and many people have it much worse (I do personally). Deductibles several times higher than that are much more common than they were even a few years ago especially for families. That means that, not only do you have to pay hundreds of dollars a month for health insurance but, you also can’t use it because you have to pay potentially thousands you don’t have to actually use it. That has a chilling effect on the American healthcare system for middle-class people.

I stopped going to the doctor 2 years ago for chronic problems because I can’t afford to and I am not poor at all. I was able to before but now I can’t because I have to spend that money on useless health insurance that costs more than most people’s rent. If I go, I will still get a huge bill that no one can explain and for dubious benefit for seeing an actual doctor for less than 15 minutes.

109

I’ve certainly noticed this when I’ve seen people discussing used car prices in the US. (This may be more of a UK thing than Europe as a whole-- I believe that used cars are particularly cheap in the UK for some reason. We do have fairly strict annual road-worthiness tests which result in some vehicles becoming uneconomic to repair.)

As a comparison, I just looked on Auto Trader UK (biggest used car site) and Auto Trader US (I don’t know if that is a good choice for the US market). I chose a 2007 Toyota Yaris, just because I know that car is sold in both countries (albeit with different specs, but it’s about as close as we can get).
They’re in the £1.5K to £3K range in the UK ($1.8K to $3.7K). In the US, the range seems to be $4K to $8K. I don’t know if there’s sales tax on top of that.

110

Did you read the article?

111

Thank you.

Here Chance und Risiko bei Privater Krankenversicherung - Kolumne - DER SPIEGEL is a German language commentary on whether one should choose private or public insurance*. It details all the pitfalls of the private insurance and unknown developments in the future**, but no positives of private insurance or negatives*** of public insurance, despite cuts to public insurances in past years.

  • For people who don’t want the hassle or have pre-existing conditions or a family, can choose a public health insurance even if not required to. They than pay a fixed percentage - double of the mandatory employees, because they also pay the employer part - on their whole income (so also rent or capital income, not just wage). It’s still cheaper.

** Private insurance companies put part of their money in long-term investments to pay for future treatments. Officially, clients can choose to pay higher rates right from the start and save part of that intentionally, but very few do so, they want more spending money when young and building their life.
But because of the financial crash, recession and low return on investments, insurance companies have had to raise their rates steeply recently to make up for the lost interest rates they had calculated with.

*** To make things further complicated: for those people who are mandatorily insured in a public health insurance, but not satisfied with the catalogue of approved measures, or who have heard tales that privately insured people get “better” things, there is the option for a private Zusatz (additonal) insurance. It depends, of course, on personal risk, a check-over and fixed amount. You get things like the option to a single room in a hospital instead of 2, 3, or 4 bed room; having the chief physician instead of just any physician treat you, etc.

There are critics that point out that depending on your personality, a single room may be much more boring, and having people to talk to help you in your recovery; or that the chief physician is so busy with admin things while his assistant sees much more cases that the assistant is better qualified for actual treatment.

What a lot of people do get, though, is additional dental health insurance, because public health insurance only pays the cheapest option, like amalgan fillings instead of ceramic inlays (because dental costs can be expected for every client unlike other health costs), and having to cover part of the bill even then. The private insurance covers another part.

112

The first $2750 of medical care between January 1 and December 31. (Yes, this is single coverage; the deductibles for my employer’s family plan are substantially higher, but I don’t know the ins and outs. There are both “per-person” and “per-family” deductibles, too.)

I heard a report of a woman who gave birth around Christmas; the baby was premature and spent a couple of weeks in the NICU. One hospitalization, two plan years, two deductibles.

113

Another thing that often comes up in those discussions is that certain doctors are in contract with certain insurance companies, so for certain specialist or a small insurance company, there might be only one or two in your area, leading to long wait times or driving distance.

Here, doctors take either only public insurance, both public and private or only private insurance. It’s often said (as a criticism of the bureaucratic, complex system introduced to lower costs) that public patients require so much admin time from the doctors office and delay in imbursement to the doctor that they can no longer afford to only take public ones, and mix it.

There have also been hidden tests, either by testing services or health insurances, where doctors offices were phoned up for an appointment and the waiting time recorded. (For a non-emergency visit, it shouldn’t be longer than 2-4 weeks). A lot of offices asked if the patient was public or private insured, (which they shouldn’t) and if private, the waiting time was suddenly reduced. The last test I remember, causing an uproar, was the average waiting time for private pateints was 2 weeks, for public patients 4 weeks.

I have not experienced long wait times as public patient, but then, my visits to specialsts are mostly non-emergency check-ups. Emergencies are either hospitals directly or “go to the next office and get bumped to the top of the queue in the waiting room, that what emergency means” (and on the wekend, there are special doctors on wait where you can call).

So that’s what always confuses me: how can doctors offices in the US system make their offices profitable if a patient can get an appointment the next day? Either somebody gets bumped - but that’s never mentioned - or the appointment book is mostly empty - but then the doctor wouldn’t earn anything.

If I have to wait more than 4 weeks for an appointment, either the office is badly organized, or the doctor is such a famous specialist that he has too many patients. I once had one doctor where no matter what time the appointement was for, I had to wait several hours, but that was bad organisation: scheduling each appointment 15 minutes apart, but the doctor talks for 45 minutes messes up the schedule. I changed to another practice after the third time.

114

$2750 deductible is very cheap.
Our deductible is $7000 for the two of us, and we still pay $1,200/month.
The whole US system sucks, and anyone who says otherwise either has someone else paying for them (like, their employer), or has never used it.

115

What I have seen with specialists here is a divided appointment book: urgent cases will be seen Tuesdays and Thursdays from 8 to 12, for example, while non-urgent cases will be scheduled during the remaining timeslots. If you want a routine follow-up appointment, you can’t have it on Tuesday morning for love nor money; that slot simply won’t be offered to you. That does mean the doctor will occasionally have a Tuesday free, but if s/he estimates the number of emergencies accurately, it will be a rare Tuesday; meanwhile, if you really need an urgent appointment, you can usually get one within a day or two. Balancing the schedule that way is an art form.

From what I’ve seen, myself and in my extended family, it’s not so much a public/private split as WHICH public or WHICH private. For example, some years ago I made the mistake of signing up for an HMO plan my then-employer offered, and quickly discovered that while lots of primary care doctors were providers in the plan, oddly enough none of them were accepting new patients. These days, I have a Blue Cross plan, and pretty much everybody takes that insurance.

Family members on Medicare report they don’t really have much problem finding doctors–Medicare payments are relatively low, but they pay promptly and don’t dicker too much. On the other hand, Medicaid here in Kansas pays far less than Medicare, doesn’t pay promptly, and has a reputation for quibbling, second-guessing, and rejecting proper claims, so nobody wants to deal with it unless they have to. (I’ve mentioned before an elderly relative who had to select a pediatrician as her primary care provider, because the pediatrician was the only one in her locale who would take a Medicaid patient. That left her a good half-century older than the doc’s remaining patients, with a completely different set of health needs, but the state didn’t see any problem.)

116

Why are state officials excluded from the regular state run system? Seems like an odd exception to make.

117

Mostly because the system is old and was started by Bismarck not for humanitarian reasons, but to counter the attraction of the social democrats, whose ideas of “you have basic human rights to live decently” were appealing and gaining them large followers. So on one hand, the Sozialistengesetze (socialist laws) forbade anything that looked socialist, on the other hand, the laws starting the different branches of social insurance aimed at lessening the wort evils to take away the reasons people were disgruntled with the system. So originally, it was lower income employees who had to be insured, and why still today, employees above a certain ceiling are not required to.

The law by now is formulated that people who “are eligible for subsidies” are not required to get insurance. The people who are eligible for subisidies are state officials, so it’s a roundabout way. The number of people who are civil servants in that sense has declined because the reputation of Beamte as lazy uncaring is negative, they cost the state more than normal employees and so the state has considered which activities require an official with oath for lifetime and where a normal salaried employee is enough, too. Police and prison guards are obvious cases for professions important for the state, but teachers or clerks are questioned.

That’s also why, unlike e.g. the UK, we don’t have one national insurance, but a bunch of different companies - the AOK (General regional health insurance) took everybody, the TKK (technicians…) took only people employed as technicans, the Knappschaft (miners) took people who worked as miners… until the law was changed in 1996 and people could freely choose regardless of which professioin one works at, which started a competition among insurance companies to offer low rates or more additional services to attract healthy, well-earning clients. After a few years, the market consolidated and smaller, specialised companies being swallowed by the big ones.

Here is an english overview of the development of the system

118

There is a lot of critiscm not only on health insurance, but more on pension system. Currently, only employees pay into the pension fund. Back in Bismarck’s time, when the population age pyramid was a pyramid, this worked. Today, jobs are disappearing, many are not paying enough, and the population age is an inverted pyramid.

Experts are pushing for a Bürgerversicherung = citizens insurance, where (like the income tax) all income, including capital, is applied towards a percentage, and then (like those funds the US system uses?) and instead of paying directly out for todays retirees, invested for the future.

Similar, the health system currently is trying to save costs, but making it far to complicated while also making it worse for patients (with the point system). One insurance for everybody would be more efficient.

119

Even in the UK, many (non wealthy) people have private health insurance as a ‘top up’. As recognised above, UHC often means waiting lists, especially for non life-threatening problems. A company I used to work for had a heavily discounted scheme which I joined. I went to see my GP with a minor problem (nasal polyps) and he told me that there was a 6 month waiting list to even be seen by a consultant. When I mentioned my insurance, it became totally different. He phoned the consultant’s secretary and we compared diaries to find a mutually convenient time/date. A week after that I was in theatre having the polyps removed.

If you have a heart attack, get stabbed or crash your car, the NHS is second to none. If you have an ingrowing toenail or polyps, you have to take your turn in the queue. Of course, the third option is to pay for the surgery from savings, either in the UK, or abroad.

120

“In fact, U.S. health care spending is wildly uneven.About 5 percent of the population — those most frail or ill — accounts for nearly half the spending in a given year, according to a separate government study. Meanwhile, half the population has little or no health care costs, accounting for 3 percent of spending.”

Could this be the real problem with healthcare costs in the USA? 5% percent of the population who are very sick. How do Europeans avoid this? Do they treat their severely ill in a different way?