Please explain US Healthcare to me

Great Debates
1

Please explain the US healthcare system to me in words of one syllable and with lots of diagrams. As far as I can make out there is no such thing as free healthcare in the US - no matter how poor you are, you have to pay. If you can’t afford treatment or health insurance, you might be eligible for some sort of aid, otherwise you’re royally screwed. Is this true? If so, why doen’t the US provide a basic level of free healthcare to anyone that needs it? Don’t taxes pay for this?

What happens if you’re truly dirt poor and have no money or medical insurance of any kind and you need a tooth pulled, break a leg, or get diagnosed with cancer?

And what the hell is an HMO?

2

Yes, there is such a thing as free care (leaving aside all economic issues which state, in fact, that there isn’t.) However, the American system is extremely decentralized and has many, many parts.

First off, most people purchase insurance. You pays your insurance and they pay back any unusually large claims. One thing which I don’t like (as it’s pointless) is that they also pay a part of your everyday checkups and things. This is futile since you should be going anyway, but I suppose people feel like they’re getting it “free” and go more often than they otherwise would (which is good for your overall costs).

HMO’s are a bit complicated and often demonized to a ridiculous degree. It was a fad in the 90’s to call HMO people various horrible things and imagine them killing off old grannies or young kiddies to save a buck. People hate the concept of there being only so much money at any given time, and that it might well be neccessary to leave some to save others, but there it is.

Now, the government supplies Medicaid and Medicare, which are complicated propgrams which basically insure the very poor or the very old. Both programs are, in true American style, horrendous financial messes, though they are fairly effective at what they do.

Add onto this numerous hospital charities, private charities, state and local programs…

Overall, American medicine provides services equal to our “competitors” in Europe. It does so at a much higher cost, but provides much better services overall (not everything - many everyday things are more considerably more trouble but you get huge advantages in specialties). There’s also the fact that it keep the US supplied with the world’s best medical practices and most advanced techniques and technology, since we’re willing to pay for it.

The very poor do have difficulties getting the best care - and many of them simply domn’t want to pay into an insurance program. OTOH, our “best” care is very, very, very good. I don’t have it, and I live a comfortable existence with a good insurance for a decent price.

3

There’s also a large system of “free clinics” in many cities, supported by a variety of government and charity programs. These offer basic checkups and some simple procedures for the poor who live in the city. For the rural poor, things can be more difficult.

And there are all sorts of private organizations like Planned Parenthood which provide contraception and pre-natal care to the poor, and abortions in some places.

4

Everything stated above is correct and we do have some remarkable inefficiencies on one hand combined with top-notch care on the other. It is actually the quality of care that most people that most people with insurance get that makes it hard to sell centralized health care to the American public. Most people fear that the standard of their own care would go down and there may be some truth to that.

One thing that many people don’t realize is that everyone in the U.S. has access to health care and often excellent health care if they pick the right hospital. Emergency rooms are not allowed to turn anyone away and they don’t show preference for someone’s ability to pay during the initial treatment. Once someone enters the system via the emergency room, they have to be stable before they are released so a poor person could get a free stay at the best hospital if they come into their emergency room with a heart attack or something.

This is horribly inefficient of course but that is the way it stands now. The desperately poor wouldn’t have much of a problem because the hospital would never be able to collect on the bill but someone of modest means might have a big problem after they get out and get a bill for 10’s of thousands of dollars.

5

Hmmm…so what happens if I have no money in my pockets and get hit by a bus? Will the hospital treat me or kick me out? If they treat me, will they send me a bill later?

And what *IS * an HMO?

6

Health Maintenance Organization

If you get hit by a bus, the ambulance will take you to the nearest Emergency Room, where you will be treated.

7

Not so sure.

I did take several people to the ER while I was living in the US and every time the nurses would ask to see their insurance papers before asking for their names.

It’s one of those things that you don’t believe when you see it in a movie and then it smacks you in 3D.

8

Looks like **Shagnasty ** kind of answered one of my questions as I was asking it, but I guess another one would be - why do you have to pay for basic healthcare at all? Isn’t that what taxes are for? Granted you should have to pay for luxury services or a really nice room to yourself, but why doesn’t the US have basic healthcare available to all, without all the mess of insurance, Medicare and Medicaid?

And how do Medicare and Medicaid work? Is it like a health insurance scheme run by the government? Do people have to pay premiums like with any other health insurance scheme?

9

As Book Monster noted, all hospital emergency rooms are required by law to treat people in order of severity. The idea of hospitals tossing poor people out the door to die is a popular myth.

That said, once you’re stable, if you don’t have good insurance you probably won’t have access to the best drugs, treatments, physical therapy, etc. that you might need to make a full recovery.

10

If you don’t have any insurance and no money, you will be treated as well as anyone in the ambulance, emergency room, and any essential in-patient care that directly follows. They will send you a bill that is likley staggering later but hospitals can’t collect if the money just isn’t there and they are used to people not paying so they charge those that can more.

An HMO is a network of doctors created by an insurance company designed to keep costs down. People enrolled in the plan can see doctors in the network and the insurance company has negotiated rates with them. People that are insured in an HMO usually have to choose a primary care doctor that serves as a “gatekepper” and has to authorize visits to specialists rather than the patient just going whenever they want. Problems arise when the HMO denies patients access to (expensive treatments) that the doctors believe would be beneficial.

11

Emergency treatment is provided regardless of ability to pay. Failure to do so is against the law and yes, hospitals and doctors have been punished in the past for failing to respect that.

So… get hit by a bus, you’ll be transported to an appropriate facility depending on your injury. Minor problems? “Just” a broken leg? Nearest ER, by ambulance (usually). Massive, massive trauma? Helicopter flight to nearest trauma center capable of handling your problems. This will be done without question and without inquiring as to coverage status.

It’s after the initial emergency is taken care of that you might run into trouble if you’re uninsured. Yes, the hospital will send you a bill, and might even get aggressive about collecting money.

“Health Maintenance Organization”. The idea was that the doc is paid a fixed fee regardless of whether you’re healthy or not. The rationale is that the doc then makes the most money by maximizing your health, so you need his services less. If he does a poor job, he winds up giving you more services than his fee is worth.

While that might work for the general, healthy population you run into trouble with people with on-going chronic illness, rare diseases, some birth defects, and difficult problems. Those folks cost a lot of money to keep functional, and under the HMO system there is a disincentive to take them as patients because they will ALWAYS cost more money to treat. Although it’s nice to think of doctors as being altruists, the fact is they have to pay their bills, too, and can’t afford to run a chronic loss any more than anyone else.

12

An HMO is a “health maitenance organization.” The term is not precisely defined. It covers, for instance:

  1. A health clinic in a single building. You pay insurance and then only pay a small amount for service at the clinic. This was the first type of HMO I was familiar with, but seems to have died off. Pity – it worked quite well and the costs were low. But you didn’t have “choice,*” so customers weren’t interested.

  2. Preferred Providers Plan (PPO). These usually started as groups of physicians that group together. You go to individual physicians’ offices and your insurance will pay for the visits. There are higher rates if you use doctors not in the plan.

  3. Point of Service Plan (POS). You can use any doctor and get a set payment for each visit. Usually, the most expensive. Some doctors will accept the POS payment, but most charge more.

HMOs can be the clinic-based HMO, the PPO, or the POS, or other variations.

In all plans, you pay a monthly/quarterly fee to the HMO. If you go to a doctor, you usually pay an office visit fee (mine is $15). If the doctor sends you to a specialist, to take a medical test, or to a hospital, the insurance covers it (the amount depends on the plan). If it’s an emergency, you can go to the hospital emergency room without contacting your physician and that will be covered (our plan has a $50 co-pay).

All plans have hospital coverage (if an emergency or if your doctor admits you). The amounts vary. The most basic plans pay 80% of the cost over a set deductable (and 100% if it gets extremely high, say, $100,000). It limits the amount you need to pay, but can still leave you with large debts. A good plan will cover all medical costs in the hospital.

If you don’t have insurance, then you have to pay out of pocket. However, no hospital can turn you down if you cannot pay. There are something called “Hill-Burton Funds,” a Federal program that can be used to reimburse hospitals for costs of caring for patients who can’t pay. It doesn’t cover all the hospital’s costs, but for them, it’s better than nothing. The other costs of medicine for indigent patients are built into what the hospital pays.
*“Choice” is something of a myth; you are rarely free to choose your own doctors, even if you aren’t in a plan. Good doctors limit patients, and it’s hard to get any information about whether one doctor is better than another.

13

If you get hit by a bus, you will be brought, via ambulance to the nearest emergency room. You will be treated to the best of the doctors on duty’s ability.

They may try to bill you afterwards. They may or may not be able to collect.

There are basic types of health insurance plans, some are better than others, and they range in cost.

We have plans that cover darn near everything even remotely medical related, and these are expensive. You can see whatever doctors you want, and pay very little copays for prescription drugs, and office visits.

We have other plans where you have a “primary care provider (PCP),” who manages your care (Health Management Organization - HMO). These are less expensive than other plans. Your PCP must be seen first for any health care need (except ER type emergencies), and will refer you to a specialist if it is needed/appropriate. This specialist will also be part of the HMO group. It costs more to see someone that is not part of the HMO group (if it’s allowed at all).

More expensive plans will cover more things. As an example, just a few months ago, I was looking into getting a more comprehensive insurance plan for my wife and 2yo daughter outside of my employer (I was a contractor.), and we had to choose which plan would fit our needs. One of the choices, which changed the rates by about $300/mo, was whether or not a pregnancy would be covered (Maternity Rider) by the plan. As we are in childbearing years, proven fertile, and hoping for another one soon, we had to seriously consider our decision. We wanted to make sure that some of our routine care, as long with any accidents were covered for them. I could make due with the catastrophic (high deductable, low preventative coverage, max-payout) care plan that was available via my contracting company. [epilogue… the company I work for brought me on full-time, with now GREAT benefits, including FANTASTIC health care, so the choice was never made for outside insurance, but it was down to a matter of weeks]

Similarly, some plans are more flexible with things like experimental treatments, study involvement, and brand name drugs. Those that cover these things cost more. Those that do not cost less, and this is where we get the “HMOs are BAD. They don’t want to fix people. They want their customers to die!” :rolleyes: People (most often via their employer) have made choices to get a lower cost plan, and as a result, a few get horrible diseases that have no cure at the moment… but there is this study they’ve heard about… there is new research into a new drug that will save their life (perhaps)… and the mean old HMO won’t let them try the drug.

Or… what RealityChuck just said… he has more details on the names of the plans. I took too long to rant, I guess. :smiley:

14

Oh, and the rationale behind health insurance in the US was originally not to provide better health care; it was to make sure hospitals and doctors had a steady income during bad times.

15

Thye government has set rembersment for obligations to low for a long period. In Wisconsin there is no dentist that will accept a medicad person. The governor has worked in getting at least some type of service at a Madison school. My sister works for a large hospital and knows a few problems. Many hospital have closed the emergency services, because they can’t refuse an emergency case. You only get the emergency care, so if you broke an arm, you’ll have to take it off and not get progress checks done. They have long term payment planes for a person that has in the past paid them. The police in this large city bring people that are arrested and injured to the emergency room when they would have normaly been in jail for misconduct or such. The jail avoids providing medical care that costs it by doing this and the emergency room eats most of these cases. The insurance rates can be double when the yearly contract come around for companies, and a person making double the minimum wage here can just aford healthcare. Double the minimum wage in the U.S. is still below the proverty level, yet the government seems to thing slavery and indenturied service is gone here. It maybe technicaly, but in reality the wages in paid in this country leave you worse off then an identured servant, because they at least get feed and housed, which a minimum wage person many times doesn’t have.

16

Thanks for clearing up the HMO thing and for reassuring me that I won’t be left on the doorstep in an emergency. But I think my main question still remains - why should people have to pay for basic healthcare at all? If you pay taxes, shouldn’t you expect free, basic healthcare from the government?

17

Medicare and Medicaid are basically paid for out of taxes. Medicare covers older people (65+), with some exceptions; while Medicaid covers the poor. Medicaid is half funded by the states, and half funded by the federal government. Medicaid is considered by the providers as a poor payer, since what they pay doesn’t even cover costs. Medicare is better as a payer, particularly for certain kinds of things, though not typically as good as commercial insurers or HMOs.

What’s particularly confusing about American healthcare is that there’s no “system,” there’s a series of systems. We have both for-profit hospitals and not-for-profit hospitals (some religious and some not), we have big, national hospital systems and standalone hospitals, not to mention that we have a completely parallel system for veterans (the VA), as well as another one for the military and its dependents, plus a certain number of state hospitals… Then we have permutations such as the combined medical system/insurer (Kaiser Permanente), and doctor-owned hospitals, and for-profit chains of specialty hospitals and… I think you get the picture.

And as to why we don’t have a simpler, better, cheaper, tax-funded system, that’s something of a philosophical issue. It’s true that people think that American medicine at its best has no equal in the world, but if you ask me, that’s something of a myth. European countries with much cheaper, better systems also deliver the same kind of top-notch, high-tech care that people boast about here.

18

No.

19

Why not?

20

To explain it even more simply, a health maintenance organization is an insurance company combined with a medical practice. The HMO pays your costs, but you must take the health care that they provide themselves.