Too much? or Too little? The American health care system has often been called “a paradox of excess and deprivation” (Enthoven and Kronick, 1989) and we’ve yet to find a middle ground. Some people are uninsured, not properly insured, and/or have medicaid/medicare coverage that physicians simply won’t take.
Picture the pregnant woman who cannot find a physician who will accept her insurance. Without proper pre-natal care, the woman will suffer from severe headaches, and will have been diagnosed with hypertension (high blood pressure) and preeclampsia (fluid retention). This woman will give birth to a stillborn baby.
Sad, I know. Unfortunately having too much medical care can also be rather harmful.
Picture the senior citizen who has minor back pain easily treated with over the counter painkillers (ibuprofen, acetaminophen etc…) To make sure the back pain is nothing to worry about, he goes to his doctor’s office and is prescribed a stronger painkiller and later develops a bleeding ulcer which resulted in a two-week hospital stay, $17,000 later.
Ridiculous, I know, but the story gets worse…
Since the 1980’s, the goal of the American Health Care system has been to reduce excess rather than fix the issue pertaining to those who lack health care.
Because rising health care costs were considered more of a problem than the lack of medical care. The executors behind this idea figured that if we can make health care more affordable, then the people who cannot afford it may be entitled to adequate health services.
Chances are, if you cannot afford healthcare as of now (and there are affordable health care plans in this country for everyone) then chances are, you won’t be able to afford it later.
This week’s topic: How do you pay for health care, and what does it get you?
Glad you asked. Lets talk about the 4 major ways of paying for health care.
Out of Pocket Payment:
So your little brother breaks his arm during football practice and is taken by your mom to the emergency room at the hospital about 15 minutes away. The orthopedist orders an x-ray and places a cast on the arm. Your mom paid about $900.00 out of pocket.
This form of payment, where the patient directly pays the physician is not a very common practice anymore. However, about a century ago, a barter system was usually used to pay for medical services. Unfortunately, paying for a house call with chickens won’t work anymore. Here’s why:
Some people believe health care is a basic human right, therefore, people who cannot afford to barter (or pay out of pocket) need an alternative to paying for health care.
There’s no constant price for health care. Just like all cars, computers, foods, and musical instruments cost different sums of money, so do different health care procedures. Who knows, chest pain may require a small bottle of aspirin: $3.50, or it could involve an endoscopic evaluation from a doctor: $600.00, or perhaps even open heart surgery, triple bypass: $75,000.00, followed by a two week hospital stay with multiple surgeries and endoscopic treatment: $250,000.00 (aspirin IV not included). This example represents the unpredictability of need and cost as well as the importance to rely on a patient’s need to rely on a physician’s recommendation. No one knows what a symptom may lead to, nor how much it costs. Sorry Farmer Zeke, those potatoes, a pig, and 2 chickens won’t cover this hospital visit.
Individual Private Insurance and Employment Based Private Insurance:
Points two and three encompass most of the American population today and is how many individuals pay for themselves (and their family’s) health care costs. Let’s take a look into how they work.
Individual insurance is financed through a steady (yet sometimes fluctuating) cost called a premium. Premiums are usually paid monthly and are usually a large enough sum of money to make the patient complain. Premiums are paid to a health care plan that will reimburse the health care professional (physician, hospital) for the services done. Cool, sounds reasonable. Read on.
The unfortunate side of this story is that sometimes, a $300.00/month Premium wont cover Little Johnny’s bone marrow transplant, especially since his family cannot afford the wider coverage and had to take out a several-thousand dollar deductible on their plan (this means that Little Johnny’s family will have to pay a large amount of the hospital bill out of pocket). If Little Johnny lives to see college after his procedure, he probably won’t be able to afford it anyway. Sad times.
In employment based insurance, works the same way as individual insurance. The main difference is that the employer will pay a premium to cover his workers and the workers will pay a small premium to pay for coverage as well. Everything after that works just about the same as individual health insurance. Again, thats nice. Read on.
A retired employee at age 70 used to pay a premium of about $25.00/month (paid by the employer). When he retired, he was shocked to find out that his premium for 70 year old retired men was raised to $100.00/month. This worker denied insurance because he could not afford it. What happens if he becomes ill? Is 70 old enough to pass away?
Finally, the fourth mechanism of paying for health care in this country is:
Government Financed Insurance:
This form of insurance (Medicare, Medicaid) was enacted by the government to cover two large demographics in America since the 1950s: The poor, and the elderly. The poor usually held jobs that did not offer a health care benefit, or were unemployed. And the elderly were unemployed due to retirement and could not afford individual health care services premiums without a steady income. What to do?
Medicare is broken up into two parts: Part A and Part B.
Part A: People over the age of 65 and collect social security are able to utilize medicare’s benefits. In fact, once you turn 65, you’re automatically enrolled in Medicare, retired or not, so long as you’ve been paying into social security for 10 years (minimum). If not, then you have to pay a monthly premium.
People under 65 who are totally and permanently disabled can utilize medicare after 24 months of social security benefits. People requiring important medical procedures (dialysis, transplants) can be admitted to Part A without a 2-year wait.
It’s financed by Social Security, and everyone pays that special percentage out of their paycheck to cover it. You all know the one.
Services included are hospitalization, skilled nursing facilities, home health care, and hospice care. Nursing homes are covered but medicare pays nothing. Sorry!
Medicare pays “X” amount of dollars depending on how long the patient utilizes the benefit. The longer the stay at the hospital, the less Medicare pays. Sorry!!
Medicare Part B works with all the benefits of Part A, but has better coverage as a monthly premium of about 70 dollars paid by the patient (in addition to taxes and Social Security).
Part B will cover all medically necessary services, some preventative care (vaccines and scans) and will not cover outpatient medications and dental work, eye exams, and hearing tests.
Well, that was a mouth full! I think that when it comes down to it, even with the attempt of the nation to lower health care costs, people, somewhere, will never be able to afford health care to take care of their ailments. Chances are, the insurance they pay for will cover most of their needs, but as their luck will have it, they will contract a disease or medical problem that their insurance just wont cover.
When looking from an ethical standpoint, one must ask: Can anyone put a price on a human life? Do insurance companies reserve the right to declare which tumors are more deadly than others, or which fractures they’ll pay for? I wonder if Grandma and Grandpa will live long enough to see their grand children get married? If not, then, well…I hope they have good life insurance!
Be concerned. Speak out. I’m anxious to hear your comments.
This is fredbertino, who saw Liquid Tension Experiment’s 10th Year Anniversary Concert and shook hands with John Petrucci, Mike Portnoy, and Jordan Rudess yesterday, signing out.
Information provided by: Understanding Health Policy: A Clinical Approach, Fourth Edition by Bodenheimer and Grumbach (C) 2005 McGraw Hill Companies, Inc.