Please explain US Healthcare to me

Great Debates
61

Disclaimer - I consider myself a programmer, but I’ve spent my entire career (8.5 years) programming in health benefits administration.

For the record, the traditional indemnity plan is far from dead in the US (though admittedly much more common for retirees). And HSAs are getting very common among large employers, though enrollments are still fairly low.

Actually it’s a very precisely defined term. You’re confusing yourself by thinking that several separate systems are all part of an overall umbrella called “HMO”, when they’re really unrelated competitors.

Not an HMO. I’m not sure what they exact term would be in this case, probably just “clinic”.

Not an HMO. You’ve covered most of the pertinent points about this system. I quite like them, as you usually get decent access to specialists without needing a referral. I would add that these networks can often be smaller than the other types. However, it’s not uncommon these days for them to be contracted with a POS, creating a kind of hybrid (with names such as “Blue Cross Blue Shield POS (PPO Network)”.

Also not an HMO. There are some important points that you missed:

  • There is usually a network involved, and coinsurance and copays will be significantly lower if you use a doctor, hospital, or specialist in-network. Many plans nowadays are “national plans”, which means that they have in-network doctors pretty much everywhere in the US.
  • I think that it’s the coinsurance that you’re thinking of with the “most charge more”, but it usually doesn’t have anything to do with the price the doctor charges. Coinsurance percentages are set by your employer when they contract with the plan, and you can negotiate your own if you’re buying coverage directly. Think of it as a sort of deductible. Routine care is often completely covered. Incidentally, most PPOs work this way as well.
  • Many (but not all) allow you to visit a specialist without a referral, though usually at a higher copay.
  • While traditionally more expensive to purchase than an HMO, it is not uncommon anymore for the reverse to be true. For instance, my POS costs about $1000 out of pocket less a year than the HMO I could have taken.

There are dozens of minor variations (several people mentioned Kaiser), but the basic distinguishing characteristic of a traditional HMO is the gatekeeper. These are doctors who contract with the plan (and no, they are not considered employees of the HMO, they’re still their own businesses). You choose your Primary Care Physician when you enroll in the plan, and they are the one you see for any non-hospital-emergency problem. They treat what they can, and then refer you to a specialist or hospital if you need one. The basic theory behind this is that your primary doctor is perfectly capable of dealing with most problems, and are relatively cheap. If you choose to ignore the PCP’s gatekeeper role and go directly to whomever you want, the HMO will pay nothing.

What the consumer is supposed to get out of giving up their control is the low monthly cost of the coverage, low copays, and no paperwork to file. After several years of rapidly escalating costs and constant pressure from unhappy consumers to loosen their controls, HMOs are sometimes no longer the lowest cost option and have tended to drift away from the “pure” model.

62

I don’t have an answer for the OP, but I’ve been through the US system and Canadian healthcare system without insurance. I received the same care with the big difference being the cost. With that in mind, I submit the following.
The last year I was in the US I had just started a new job. I was waiting for my insurance to come though with my 90 day waiting period. What do you know, I end up in the ER during that time with chest pains (It turned out to be non-heart related). I was driven to the ER by my wife. Spent about 4 hours there. Total cost of the visit around $1600.

In Canada, before I received my Care Card, I was hit by a car. I was taken from the scene in an ambulance on a backboard and neck brace. I spent about 4 hours in the ER being treated and released. Total cost of the bill including the fun filled ambulance ride - $164. The 4 xrays of my back cost me $45.

In both those above cases I received great care. I wasn’t cured in either case but I was assured I wasn’t going to die from what caused the visit. Both places recommended particular routes for follow up care. Of course, being between insurance in the States, I couldn’t afford the follow up treatment at that time. In Canada my follow up doctor visits are $27 each. My physio therapy are $40 a visit.

In the States about 10 years ago I trashed my ankle camping. The thing was swollen about the size of a blue, plucked, chicken. The first ER I was taken to had me wait 6-8 hours before being seen by a doctor. They took an xray, decided it wasn’t broken, and told me to go home and put my foot up for a few days. No crutches, nothing for the pain, not even an ace bandage or a bag of ice. When I complained he taped a flight splint around my ankle (AKA a cardboard box). Knowing it was well damaged we opted to visit a different ER. The next hospital was amazed the first hospital let me leave without doing anything for me. They gave me a splint, crutches and pain meds with a demand to see an orthopedic surgeon the next day. I ended up in a cast for 4-5 months and walked with a cane for a year. To this day my ankle still bothers me. (FYI: My insurance wouldn’t cover any sort of phsyio therapy.)

Now I suppose you’ll hear these same horror stories in socialized medicine. But the US and its “healthcare system second to none” isn’t immune – you just pay more for the screwups.

A few years back in the States I went through a round of operations in two years. They were covered by my insurance (3 operations cost me $3000 out of pocket) but it turned out to be a major clusterfu*k. Nothing but forms and never ending phone calls, and letters. All those horror stories you hear about social medicine wait times for treatment - I went though the same in the States with good insurance and in one case waited months for treatment only to be denied and having to start the whole process again.

I got a good idea on what a scam the US system is after the first operation. I don’t recall the actual numbers, but it went something like this. The doctors fee was about $4000. My insurance company paid him $2500 - which was all they would pay for this particular operation. The rest was written off by the doctor. Had I not had insurance I would have been billed, and owe, the full $4000. I was changed $12 for a couple of regular Tylenol, $20 for a bottle of nose spray, $80 for the gown I wore in the ER which I didn’t get to keep. The list goes on. The insurance company fully sets the price for medical treatment. The medical providers keep raising the costs until the insurance company says no. By that time, you’re paying $6 for a Tylenol.

So which is better? Pay a bit more at tax time and have everyone get the care they need or have the working poor or those without insurance not able to afford medical treatment?

63

I should emphasize here that depending on one’s income, the difference in the amount of tax paid isn’t as great as one might think.

64

Not to get into great political economy debates, but that’s quite a loaded question.

The problem is that for example my insurance and my doctors would cease to exist in their current form at their current cost and availability to me if European-style socialized healthcare in almost any fashion was implemented in the US. I’d pay more taxes and most likely lose ALL options I consider acceptable for my healthcare. Since the majority of people will take advantage of the free healthcare if it is truly available and good, the demand for private insurance would drop and they would have to be remade and remarketed as new luxury/specialty insurance plans. The number of private doctors will drop because it’s kind of difficult to compete with a government monopoly underselling everybody with ‘free’.

You will be essentially forcing me to either pay a lot more for sparsely available private medical treatment or go to the government facility. I can’t afford the former and I really don’t want to do the latter for many reasons. What happened to the principle of majority not oppressing the minority regardless if it was based on race, creed, national origin, social or economic status? That seemed to be the direction we were heading, or did that die with the 90s?

Being poor sucks. It has always sucked. Everywhere in the world. Trust me, I know firsthand. But you know, it’s ok that being poor sucks - because it’s possible to change that, not easy, and most won’t be able to, but possible. Being born poor is not a choice, and life is certainly a lot more difficult if you don’t have access to healthcare, but life is also a lot more difficult if you don’t have a car, a roof over your head, or comfortable shoes to wear, or even presentable clothing. Our society pledges that we do not let you starve to death, and we do not let you freeze to death, and we don’t let you bleed to death, and not get shot by criminals or invaded by enemies, and most individuals will choose to go to much greater lengths to help other people, but it is their choice.

I have severe sleep apnea, and I need my tonsils out and my soft palate reduced, and I might have a cavity, and my throat is sore and my head might hurt, but I can’t in good conscience declare that I am entitled to being treated at the expense of other people who are forced to pay? I’ve been medically needing my tonsils out for 16 years now. Before I moved to the US I didn’t do it because I didn’t want the government doing it, when I came here I didn’t do it because I couldn’t really afford to. I’m ok. My life would’ve been much better, but I’m ok. I’m not entitled to better.

If I’m quickly dying right now, I will get the best medical care whether I can pay for it or not. If I can, I will, if I can’t, I won’t, but I’ll get the care. If I’m dying slowly, well, we’re all dying slowly aren’t we, but what the hell happened to pride? :smack:

65

I have been trying to figure out where all the health care money we pay is going.

Some years ago I had a baby. At the time, his pediatrician offered a basic deal for the first year: $80, which covered unlimited visits and phone consultations and even a home visit if the doc deemed it necessary (highly unlikely). This covered all immunizations. After the first year, the basic office visit was $8. If there was lab work it might go up to $12.

Sixteen years later this kid’s youngest brother was born. At that time there was no one-year well-baby plan and an office visit cost $80 if you had no insurance.

What happened? In those 16 years the only other thing that increased tenfold in price was housing for first-time buyers. (The rest of us got the benefits of equity and appreciation.) There are more doctors at this practice now, but there are also more patients.

66

Why? I mean, you’ve got a lot of "much"s in there, but the evidence would seem to be against you. Every other stable democracy on earth, and many of the non-democracies, provide universal healthcare. If this system were so so so so so so so so so so so so so so horrible, as you imply, any of them can end it and go back to a US-style system (and their citizens would love them for it, since the system is horrible).

To the best of my knowledge, this has never happened, except in the case of collapsing governments like some of the Soviet republics.

People act like this would be some grand social experiment, risking our way of life. Hogwash – a bunch of other countries have done the experiment for us. Many of them have higher life expectancies and greater self-reported life satisfaction than America. The results are in, let’s get over ourselves and get this under control before more people die.

On a side note, is anyone else suprised this hasn’t flown the coop to GD yet?

67

Funny. That’s not what is happening around here. The basics are covered by government care. The extras are covered by private insurance provided by most employers.

The extra tax you pay, I don’t think you’d notice too much. Considering it is for the good of the people as a whole I think it is a very small price to pay. Not only that, but you have a consistant piece of mind your basics are covered in the event you change jobs, hit hard times, or any number of things that happen. The same can be said for your family, friends, and people you don’t know.

See above. Private insurance seems just fine to me.

Yes, greedy doctors will move to other places searching for the mighty dollar. But the worst care I’ve received in the states were FROM those very doctors. There are many fine teachers in the states even though many might make more flipping burgers. It’s the mindset. Once money is taken from the picture you have people entering the medical field to cure people and help others.

I’m not sure what you’re talking about. I’m NOT paying a lot more for private medical treatment nor am I forced to visit some sub-par government facility. The hospitals here in Canada are much the same as the one in the States.

But it is hard to break away from being poor when a collection agent is tapping your meek wages because you broke your arm.

And like any pledge drive on TV, it’s hard to get people to write those checks and follow through. Most countries will make that pledge (the States and Canada included) but those very things are happening.

I don’t know what country you came from, but you paint your native government hospitals as being a place to NOT get care.

Perhaps your native government is doing it wrong?

Look. I’m not saying the States should enable a public healthcare system. Honestly I can’t see Americans doing it -at least not right now. 10-20 years? Who knows? Is it the governments job to do it? No. Can a rich country like the US afford it? Yes. Right now they can plan to spend millions on bridges to Nowhere Alaska, they can afford healthcare for the people and the country would be better off.

All I know is with a little regulation a few cents a day from every tax paying citizen and the general public can have a basic healthcare plan that works. You’re not going to get a boob job or lipo, but you’ll be taken care of if you get sick or need sewing up.

68

Hey!

We have to sleep sometime!

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Moved to Great Debates

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69

More and more employers, even large ones, are starting to complain about having to provide health insurance – it’s becoming very expensive and it’s a competitive disadvantage on the global stage. So they’re either hiking up premiums for employees or cutting out health insurance altogether. It might be this that forces the U.S. government to institute universal health insurance, possibly along the lines of the Canadian system. I doubt very much that the U.S. would have a National Health Service that employs doctors.

70

Isn’t there a basic problem with all the folks saying increased public health care would necessarily require substantially increased taxes? That would not be the case if policy-makers instead re-evaluated their priorities.

71

Wow, this thread has gotten *way * bigger than I ever thought it would!

While some of the finer details of health insurance and HMOS. POS’s et al still elude me, I was actually surprised that Americans (or at least some of the Americans in this discussion) see decent healthcare more as a luxury rather than a right. This is just so foreign to what I was raised to expect that it’s still a little hard to comprehend.

72

Maybe we should widen the debate a little…

If a government is required to protect the lives of its citizens as part of it’s contract with them, should it also be expected to protect the health of those citizens who cannot afford to do so for themselves?

In other words - should free basic healthcare be a right rather than a privilege?

73

Or maybe not. People keep talking about how wonderful the American system is, when it just isn’t. The Commonwealth Fund did a great study (cite here) showing that the United States, when compared to Australia, Canada, Germany, New Zealand, and the UK came in dead last in the overall rankings, and last in 4 of 6 subcategories – all while spending 88% more per capita than our next most expensive rival (Canada). New Zealand, which ranked second overall, spends exactly a third of what we spend.

Look at any of the indicators put out by an organization such as the OECD, and the U.S. just doesn’t stack up that well. The Rand Corporation put out a very good report, in which I read such things as “Overall, about one half of recommended care is received” and “rates of common cardiac procedures vary widely” and “one-third of common medical procedures may not benefit patients.”

The U.S. healthcare system has evolved into dysfunction. It’s hugely expensive, and hugely complicated – so complicated, in fact, that most people don’t really understand it, as evidenced by the confusion in this thread over what an HMO is. Ask 99 out of 100 people about the money flow in healthcare, and they won’t have any idea how it works – how doctors get paid, how insurance companies set rates, how procedures or visits are billed, the role of the government payors, the role of medical coding, etc. And as someone who works in the healthcare industry, I’ll say that the confusion persists even inside the industry.

74

There is also the aspect that additional burdens are being placed on the consumer. Some folk maintain this is a benefit reflected in increased choices. I consider it an undesirable hassle.

Couple of examples - over the past 20 years we have been covered by a couple of HMOs. Tho we have generally been pretty healthy, over the past couple of years my wife and I underwent a couple of medical procedures - a colonoscopy and knee arthroscopy for me, and a foot surgery for my wife. On each occasion we went to our primary doctor, and followed his instructions, getting appropriate referrals at every step of the way. Yet in each instance, there arose some hassle with the HMO deciding over whether they would cover all the costs.

-For my colonoscopy, they required that it be performed in the hospital instead of the doctor’s office. After the procedure, they paid for the specialist, the procedure, the anesthesia - everything except the room in which the procedure was performed.
-After my wife’s foot surgery, they said they wouldn’t pay for the anesthesia she chose - as though she was ordering ala carte off a menu.
Both of these situations took over 6 months of phone calls and letters to straighten out.
-For my knee surgery, I can’t begin to estimate how many phone calls I needed to make to ensure that the ortho surgeon, hospital, anesthesiologists, etc. were covered. As I was working my way thru automatic phone hell the day before the surgery, I seriously thought that if I needed to make one more call I would give up and just go thru the rest of my life with a gimpy knee.

This month we switched to insurance. It will cost considerably more, but we figured at least we should have fewer billing hassles. Keeping my fingers (blue) crossed.

So here are my wife and me - both reasonably intelligent professionals, in relatively good health, seeking relatively conservative medical care, and trying every step of the way to comply with procedures. Despite paying hefty premiums and taxes, we found the system extremely cumbersome. Very hard for me to see that this is the best possible system deviseable.

75

Actaully, I was being completely facetious there, but I thought a smiley would be over the top. Lesson learned.

76

Nah… the irony meter is just at the shop. Don’t worry – we’ll pay more attention next time.

77

Operating from a position of total ignorance here (…no, really…) why did it cost you anything in the Great White North?

-Joe

78

I think this is a very good (and overlooked) point. People have become a little habituated to this burden, unfortunately, and yet these very same people will complain that they don’t want to have bureaucrats in charge of their health care. The current complexity of the payment mechanisms in healthcare imposes a huge burden, of both money and time, and while this burden could be significantly reduced by the proper use of information technology, U.S. healthcare is really behindhand in this regard.

79

I had just moved in. The car crash happened one month after landing in Canada.

We’re here on work visas, later we’ll become permanent resident. It takes several months to receive the Card Card. In fact, I’m valid Dec 1st but I’ve still not received the card. It is my understanding if something happens now the hospital will bill to my number once I give it to them at a later date.

I don’t want to give the impression Canada’s system is vastly superior to the States. What is better is the cost and how easy it is to have things done.

When I went to the ER up here I felt lost because I didn’t have 100 pieces of paper to fill out and sign. When my doctor had me get an xray I took a slip of paper to the lab, they asked me a handful of questions, I paid, and had my picture taken. The whole process took 10 minutes.

Canadians will complain about their healthcare because they hear stories on how great the system is in the States. I hear Americans bash the Canadian system and talk about how flawed it is. Perhaps one day I’ll see this but right now I don’t. From what I can tell (and from what my wife who works up here as a nurse tells me) the care is pretty damn close between countries.

80

I work in medical billing. Here’s my take on things:

Medicare is run from Washington, D.C., and is a federal-level program. It kicks in automatically as your primary insurance carrier at age 65, provided you have already retired. Other Medicare plans also kick in for various conditions, to cover certain things — for instance, Medicare Part A is available for people with end-stage renal disease and will pay for kidney dialysis.

Medicaid is a program that varies from state to state, and is run by a state government to more specifically target the needs of that state’s citizens. It may be known by different names in different states. Medicaid is available for those who qualify by dint of low income, pregnancy, short-term loss of income (such as being unable to work because you had back surgery).

Workers compensation is available to everybody who is injured on the job. The insurance is paid out of premiums deducted from your paycheck (that is, if the business is legal and above-board). The insurance may be run by the state, or it may be a private carrier if your employer qualifies as a self-insured company. If you’re injured as a result of your job, you do get coverage.

Tricare, or Champus is the insurance carrier for current and former members of the U.S. military. This is run by the U.S. government but is separate from Medicare.

Emergency rooms are (as mentioned earlier) are required by law to treat anyone who comes in, at least to the point of stabilizing the patient of any emergent condition. An ER does not have to do your liposuction or breast implants, or your routine allergy injections, or your physical checkups. If you come in with a broken leg, they will set it in a cast and send you on your way — but if you come back in four weeks later, they’re under no obligation to perform follow-up care, or give you a free wheelchair, etc.

Non-profit hospitals exist. In order to qualify for that status, the hospital must write off a certain amount of business as “charity.” Our local county hospital does so — a bit too much, perhaps, because we have found (since we work closely with them) that some of the patients which the hospital qualifies as “charity” can, in fact, pay their bills, and indeed may already have insurance. (I don’t believe our hospital checks too carefully before writing off someone’s bill.) Of course, the bills we send (as radiologists who merely read an X-ray or two) are small compared to the hospital’s potential fees for the Emergency Room visit.

Crime victims insurance exists in some areas, designed to help defray the costs of people who were the victims of crime.

Taxes pay for the above, to the best of my knowledge.

I think what you would call “universal health care” is what I’d call “private insurance,” which covers your car accidents, your house flooding or burning down or being burgled, your overall health and life, and so forth. Basically, if you’re no longer a child, if you or your parents can work, you’re not in the military, and you’re not retired, and you’re not in poverty, you’re expected to pay your own way. Whether this is right or not, I couldn’t say, but I believe that’s the intent.