Yes, this is a problem. Though we do now have the “No Surprises Act”, which should help.
Depends on what you include. Personally I’m now on a high deductible plan, for basically the same reasons as why you don’t have pet insurance. But yes, some individual expenses can be 100% covered and I have gotten bills for $0.00. Meds generally have a co-pay, though.
It does sometimes. More commonly, the only payment is a co-pay which is ordinarily paid at the time of the visit. The largest co-pay I ever had was $95 for surgery but copays for the various insurance policies I’ve had ranged from $5 - $25 for an office visit. I think my deductible is $1250 per person - but I’m not sure because it doesn’t apply to in-network facilities and providers. But I never need to know what’s going on behind the scenes - if pre-authorization is needed the doctor’s office takes care of it, I don’t need to know where to mail claims because I don’t need to mail any. I don’t actually need to understand any of the stuff that makes your eyes glaze over - all I need to do is make sure my doctor/hospital is in-network which has never been a problem for me.
Where did you get this figure, and is this a case of covering medical expenses that the Canadian system doesn’t cover at all, e. g. meds, ambulance service, or similar?
My late husband lived in BC before we married. There, prescription meds and ambulance service were not covered, nor was dentistry.
He never had a problem getting the care he needed. When he broke his shoulder in the middle of the night, he took a taxi to the hospital, but was ina room before daybreak. And he got home health care until he could use his arm. When he had an epileptic seizure while visiting me*, BC covered his entire bill. When he returned to BC, he had a call to schedule appointments for the MRI before he got home from his primary care doctor.
*it was the first known time he had one, but we thought that was probably how he broke his shoulder in his sleep
A couple of cites:
Approximately 65% of surveyed Canadians have private supplemental health insurance, mostly through their employers.
To pay for uncovered care, two-thirds of Canadians rely on supplemental insurance plans typically paid by employers (as is the case in much of the U.S.)
Not saying that Canadian health care is bad by any stretch. But it’s not quite as simple as them covering 100% of everything, everywhere. There are some gaps. And yeah, prescription meds and ambulance service seem to be two of them (though it’s possible this varies by province).
Correct. When Medicare was brought in, first in Saskatchewan and then at the federal level, the focus was on coverage in your doctor’s office and in hospital. That basic outline has stayed the same ever since.
Supplemental insurance is for the things that aren’t part of Medicare, such as dentistry and pharmacies.
It is a little weird from an American perspective–or rather, from an American with a decent health care plan–that pharmacies aren’t covered by default. And yeah, I get that caps on med prices and such make it less of an issue. But still, most plans here have decent pharmaceutical coverage.
Lack of dentistry coverage, though? That we get. Which makes sense since it’s 95% routine care that shouldn’t really be handled by insurance anyway.
The Hall Royal Commission on Medicare in the 1960s (composed of Emmett Hall, a judge of the Suprême Court of Canada from Saskatchewan, appointed by PM Diefenbaker, Progressive Cconservative, also from Saskatchewan) did recommend that pharmacy be included.
However, by the time Hall reported, the Liberals were in power federally, and there was a major fight in the federal Cabinet over whether Medicare should be implemented at all, as a federal shared cost program. The progressive wing fought to have Medicare implemented, and the budget-watchers opposed it.
The progressive wing won the fight for Medicare on the hospital and doctors office model, but the budget-watchers got the pharmacy option excluded.
And that’s where we’ve been ever since.
Note that what the supplemental insurance is used for, accordingto the first article:
Public funding only covers these partially
Prescription drugs
Home care
Long-term care
Mental health care
These aren’t covered at all by public health care
Dental care
Vision care
Complementary medicine
Outpatient physiotherapy
Dental and vision care are not considered to be health care in the US system either, and are usually covered with separate insurance plans. My plan does cover prescription drugs - I don’t know about home care or long-term care. Mental health care is covered but is limited. Physiotherapy is covered by my health plan.
Complementary medicine coverage … edited to remove long passage that basically says that this is woo medicine
That first article is a very good summary.
I would just qualify your comments a bit. If something isn’t covered by Medicare, that doesn’t mean no public funding at all. There can be other social assistance plans specifically for long-term care, pharmaceuticals, and so on. Those may be means-tested, because they are not part of Medicare.
As well, dentistry can be covered by Medicare if it is medically required, such as some types of dental surgery (eg after a significant accident, major infections, and so on). If dental surgery is done in a hospital, it will likely be covered.
Nope, totally different. Supplemental coverage pays for much of what Medicare A and B don’t cover, such as some percent of hospital visits. There are several possible plans. I have a 100% coverage plan - I haven’t paid a penny for doctor or hospital visits in 8 years. The plan is so good they don’t offer it any more, but I’m grandfathered in.
It’s a matter of regular payments versus large shocks. I’m probably behind in that I suspect I’ve paid more premiums than I’ve gotten in benefits, but we can afford it and I likely have 20 more years to catch up. My wife is probably ahead since she’s had two new knees and a new hip.
There is a good thread on the problems of Medicare Advantage, which seem to be getting worse.
When your time comes, I recommend “Medicare for Dummies” which gives all the details.
A few qualifications to those blanket statements, wrt to the Medicare system in Canada.
Prescription drugs are not covered until the age of 65 in Ontario and I believe most other provinces, and then are fully covered, but Canada does have rigid price controls on prescription drug costs so they’re usually just a fraction of the cost in the US. Home care isn’t part of the single-payer system but in Ontario is covered under a separate program administered by the Ministry of Health. My elderly mother had excellent home care at no cost that included medical supplies and regular visits by a personal care worker, nurses, a doctor, and a nutritionist. Mental health care indeed suffers from inadequate coverage, but psychiatry is covered because psychiatrists are MDs. The big gap is that clinical psychologists aren’t covered, and they’re more useful for most people than psychiatrists.
In the “not covered at all” category, dental care is being rolled out in phases as a separate program. “Vision care” I think mostly means the cost of eyeglasses isn’t covered. When I visited an ophthalmologist some time ago and was diagnosed with cataracts, most of what was done was covered and cataract surgery will be fully covered.
In something I was reading recently it was stated that ambulance services also aren’t covered. This is one of those things where the statement is technically true but it doesn’t matter, because unless it’s used frivolously (in the opinion of the attending doctor) the cost is capped at $45, and even that is waived in many circumstances. Whereas in the US, if a patient’s insurance refuses to cover it, they can be dinged for thousands of dollars.
Same here in Luxembourg. Prescription drug costs are not covered and are out of pocket. But when I’m paying, say, five euros for a full course of antibiotics, I can’t be arsed to feel like complaining.
UK likewise. There are generous exemptions (over 60s, children, expectant mothers, the chronically ill get their prescriptions without charge), and a support scheme for people on low incomes, but everyone else pays £9.90 per item.
Doctors aren’t super-intelligent superhumans. They’re garden-variety smart people who went through an arduous educational and training process. They come in with their own biases and opinions, not all of which are scientifically valid.
And they sometimes prescribe procedures and medications that aren’t effective or (more likely) not in tune with the treatment guidelines for the conditions in question.
Look at it this way, if someone sprains their ankle without fractures or ligament tears, the usual treatment guidelines are most likely something like ice it for a few days, wear an ace bandage for compression, and stay off it for a couple of weeks. If a doctor prescribes someone Tramadol for a sprained ankle like that (it’s different if it’s more severe), that’s most likely outside the usual treatment guidelines, and insurance may choose not to cover that.
Lots of people don’t really understand how this works though; they assume that since their doctor prescribed it, that it is the right and proper treatment for their issue, and that it’s the insurance company being dickish if they deny it. That’s not to say that insurance companies don’t deny normal stuff all the time, but it’s not a one-way street either. Doctors can and do prescribe stuff that’s outside of the usual and customary treatments for things all the time, and it’s ultimately on them to justify that to the insurance companies.
In the United States, yes.
In other countries, doctors are not accountable to profit-based companies.
But they are probably accountable to some government body that sets standards of practice.
Yes, based on public statutes that establish professional standards, meant to protect the public, not based on private profit and Wall Street profit requirements.
If a doctor is alleged to have breached professional standards, that will be investigated through an administrative process that involves due process, after the fact.
Professional regulatory bodies do not bar service to patients at the moment of delivery. It is only if allegations are made and proven against the doctor, based on legal standards meant to protect the public, that there may be restrictions placed on the doctor’s future practice.
A patient may not even know if their doctor is facing professional discipline, because it won’t affect their care in the way that a denial of insurance will do.
Similarly, if a doctor is alleged to be over-charging, that will be investigated by the single-payer authority, using a different statutory process. That would be separate from the professional regulatory body. If a doctor is found to have over-charged the single-payer, they can be required to repay the over-charges. That will not have any effect on the service provided to the patient.
Right- that’s my point, not that it’s necessarily insurance companies. I was getting at the implication upthread that some proportion of denied coverage as unnecessary was some sort of de-facto insurance company screwing of patients.
I’d bet that some similarly large proportion of treatments/prescriptions are just not on the table in single-payer systems, because they’re not in the “approved treatments” list. Not quite the same as denied, but the same reasons.
One thing that I think a lot of people don’t understand is just how insurance companies work. They’re basically a form of gambling- you pay premiums for a defined sort of coverage, and the company is basically betting that it’ll happen at some mostly predictable rate, and engineering the premiums/coverages and payouts where they make money on things when that happens, and even more if it happens even less. This is true of all insurance companies, whether they’re healthcare, car, house, etc. They’re not some sort of subscription to healthcare, which is what a lot of people assume.
Where the healthcare companies go off the rails, IMO is that, like @Stranger_On_A_Train points out, they’re going above and beyond with the claim denial, burdens of proof, and so on to make profit, regardless of whether it’s humane or not. Even the automotive insurance and homeowners insurance companies aren’t so driven about it- I’ve never had them deny a payout. At best, it’s a little less than I expected, but usually it’s right in line with what my coverage would indicate. I don’t have to save frozen hailstones to prove the size of the hailstones before they’ll pay out; I don’t have to get generic shingles, and I’m not locked into a network of roofers.
Fwiw, i recently retired from working as an actuary in the property-casually industry. That’s the industry that writes auto and homeowners insurance. I used to hang out on a message board full of actuaries from all the disciplines, including life, health, and pension as well as p&c.
The p&c actuaries were a by far the biggest supporters of their industry, and generally felt that they were involved in making the world a slightly better place, by helping out their customers when something shitty happened to them, like a car crash or a house fire. Yeah, we saw (and tried to avoid paying for) fraud, and we didn’t want to be overly generous in paying claims. But our employers wanted to pay claims, and wanted to have a reputation if being there when you needed help.
The life actuaries were a lot more cynical. I think a lot of their business comes from people trying to avoid paying taxes. But they tended to be okay with their industry.
The health actuaries tended to write long screeds about how broken the whole system was. Their work is intrinsically similar to p&c work, but their job satisfaction was a lot lower.
I don’t doubt it. I did some IT work with a small P&C insurance company some years ago, and they had much the same attitude toward their job/industry. They considered it a responsibility to pay out promptly and in line with the customer’s coverage. And not to over-cover/under-cover the customer either.
But I’m still convinced that a lot of people think of health insurance as more of a subscription model that gives them access to nearly unlimited healthcare, and this causes a lot of confusion and anguish, because they don’t quite realize that in the US, you’re on the hook for your own care, and the insurance is supposed to defray some or all of that cost, depending on what it is and what your coverage is.