Natalie‘s comment on Tuesday’s post about health care issues reminded me of the fact that many of my readers are not American, and that many of them don’t know a lot about health care in America. Which is, you know, totally reasonable, because I know zero about health care policy outside the United States, beyond having a vague understanding of how some European health care systems work. In addition to not knowing a lot about the specifics of health care in America, foreign readers may also not be accustomed to the jargon used in the United States to talk about health care issues, so I decided I’d do a very quick overview of how health care in America works, currently, and talk about some of the language being used in the health care debate. (Keep in mind that this is “quick” in this ain’t livin’ terms, not “quick” in real world terms; there is a lot of ground to cover here, so you may want to pull up a chair and a bar of marzipan.)
Now, I want to stress that I am not a health care policy expert, a health care provider, or even an allied health professional. So, this is going to be a very broad overview with some gross simplifications, and while I am trying to be as accurate as possible, I may get some information wrong, in which case I would appreciate it if more knowledgeable readers would correct me. I also want to open the floor to questions from non-American readers: if you’ve been wondering about things but been afraid of asking, now is a good time to do it. If I can’t answer your questions, hopefully one of the docs who reads can.
Welcome to America!
Health care in America is really complicated, because we have a number of different systems going on, some of which sometimes actively conflict. I’m going to start by talking about the different health care options available to Americans before I delve into the debate over health care policy. Since the readership is pretty diverse, people who have actually experienced the myriad aspects of the American health care system can probably also answer questions folks may have
If you are over 65 or you have certain disabilities, you are eligible for Medicare, which is administered by the federal government and funded through taxpayer contributions (which scale, based on income, although they eventually max out). Medicare was brought into being in 1965, as part of the Social Security Act, and President Johnson actually had to fight really, really hard to get Medicare passed, because the idea of providing health care to older adults was repugnant to the Republicans. Medicare is what’s known as an entitlement program; you qualify automatically for the most part, rather than needing to demonstrate that you qualify.
Medicare has several components, known as “Parts.” Part A provides hospital insurance, Part B provides outpatient medical insurance, Part C/Medicare Choice allows people to keep private plans while getting Medicare benefits through them, and Part D provides prescription coverage. Needless to say, all of these parts are severely restrictive in terms of what they will/will not cover, and all have copays and limitations. (Which is why you see heart-rending stories in the news about old people eating dog food so that they can afford their prescriptions.) So, if you’re 65 or disabled and an American, the government basically provides you with a health insurance plan which covers some of your medical expenses (if they qualify under the extremely complex rules of the system).
If you are a low income American or you have certain disabilities, you are eligible for Medicaid, which is funded by the federal government and the states. Each state runs its own Medicaid plan, with different eligibility standards and benefits available. Medicaid, also established under the Social Security Act, is a means-tested program; you aren’t automatically eligible, you must demonstrate that you are eligible. Incidentally, just being below the poverty line (currently $10,830 USD in the lower 48 for a single person, $22,050 USD for a family of four, slightly higher in Alaska and Hawaii because of the high cost of living there) doesn’t automatically mean that you are eligible for Medicaid, so not all low income Americans are covered under the plan.
If you are a child from a family of low to moderate income, you may be eligible for SCHIP (State Children’s Health Insurance Program), which is supposed to cover uninsured children who don’t qualify under Medicaid. Uninsured children are a huge problem in the United States, and this was designed to help address that. Needless to say, since its passage in 1997, SCHIP has been controversial, especially among the Republicans; President Bush the Second actually specifically vetoed several attempts to expand coverage.
If you are a member of the United States Armed Forces, you get what is widely considered to be the gold standard of health care in America. Coverage for members of the armed forces is provided through a military health care program which provides an extremely high level of coverage. Some of the most advanced medicine in the United States is being practiced in military facilities (which kind of echoes the historical trend of seeing advances in military science/technology before they show up in the civilian world).
Veterans of the armed services are eligible for care under the Veterans Administration (VA, and yes, it’s “Veterans” with no apostrophe). However, you are not automatically eligible just because you are a veteran; coverage is allocated in a series of “Priority Groups” based on whether you have a service-connected disability and some other factors. VA coverage is also widely believed to be very good, if you can get it, although it is not without problems. (Not least of which is the steadfast refusal to treat vets with PTSD and problems related to TBIs.)
If you are an employee of the federal government or a state government, you are eligible for health insurance provided through the government. The situation here is a little bit complicated, but basically, the government pays for health insurance provided through a private insurer, as a general rule. The government (or a union of government employees) negotiates a group rate, and you get to pick the plan you want. The plan also covers your immediate family.
If you are a Native American*, you are eligible for care through the Indian Health Service (IHS) at IHS facilities, and the IHS will pay for some types of treatment at non-IHS facilities. The IHS has been widely criticized for providing incredibly crappy care and for having very outdated facilities.
It’s important to note that health care for members of the armed services, veterans, and Native Americans is the only form of health care provided by the government; all other government health care programs provide health insurance, not health care.
If you are none of the above, welcome to the brave new world of health care in America!
Basically, you have several options:
Option One: Pay for all of your health expenses out of pocket. Many health care providers and allied professions actually offer a discount for people who pay in cash, ranging from hospitals to pharmacies. People opt to go this route when they: are uninsurable, can’t afford health insurance, are between insurance policies, or don’t think that they need insurance (“I’m young and healthy, what could go wrong?”).
Option Two: Purchase a health insurance policy to cover medical expenses. The kinds of medical expenses covered depends on the policy. In addition to the premium, you have to pay a deductible (they won’t start paying until you’ve spent a minimum amount, which can sometimes be very high, like $5,000 or more) and co-pays (which vary in cost, with some good plans they might run $5, with others they might be a “share of cost” which may be up to half the price of the services provided), assessed at each visit/prescription purchase, etc. Most health insurance policies do not cover dental and vision; if you want insurance for these, you need to buy it separately. There are a lot of different types of individual policies available, which I don’t really want to get into right now. Suffice it to say that you must not have any “pre-existing conditions” from acne to zoonotic infections, and the insurer can engage in something called “rescission” in which they drop you because they claim you lied on your application, or because you got sick and they don’t want to pay for it. If you have insurance, you will fight every step of the way for every benefit you receive.
Option Three: Get health insurance through work. Some American employers offer health insurance plans as benefits. Most negotiate a group rate, allowing people to get insurance more cheaply than if they paid privately. Some insurers (few) cover the cost of insurance along with deductibles and copays, some pay for the insurance, some split the cost of the insurance, and some offer insurance plans which employees can buy into, but don’t defray any of the costs. In a workplace where insurance is offered and the employer pays all or part of the cost, if an employee declines it, the employer may give the employee reimbursements for health expenses, up to a certain amount.
Option Four: State risk pool. Basically, in recognition of the issues faced by people who are uninsurable, some states have created risk pools. People who are eligible can pay a (usually very high) fee for the privilege of getting insurance through the state. That insurance usually don’t cover a whole heck of a lot.
Option Five: Young adults. In some regions, people up to 25 can be carried on a parent’s policy, if they are still dependents. People in college are usually covered through mandatory health fees which provide them either with access to the college clinic, or with an insurance policy which allows them to access care.
Pretty much, no matter what plan you have, you are going to end up having a lot of out of pocket expenses for health care. You are also going to fight for coverage and benefits, and you are probably going to lose unless you have someone with clout to back you up. Every plan discussed above (except paying in cash, obviously) routinely denies benefits to which people are entitled, and even paying in cash, as I do, can have problems. For example, the pharmacy often refuses to fill my prescriptions (to the point of not ordering specialty items prescribed for me) until I demonstrate my ability to pay, because they don’t want to restock if I don’t have enough money. Basically, the default from insurers is rejection, because they hope that people will accept the rejection and not appeal. If you are a person with disabilities trying to navigate the health care system, the issue gets even more complicated than if you’re a relatively health person who just happened to break your leg. (For example, if you need prescriptions for narcotics for pain management, you will be forced to jump through an absurd number of hoops. Every month.)
So, let’s talk about the debate over health care reform in this country.
Roughly 46 million Americans have no health insurance. Many more than that are underinsured, lacking the coverage they need to access adequate health care. The leading cost of bankruptcy in America is health care expenses. Tens of thousands of Americans die every year because they have no insurance or do not have adequate insurance (I want to note that emergency rooms must provide treatment to everyone, regardless of insurance status, so people aren’t allowed to bleed out in the street, but people with chronic conditions regularly die because they can’t access the treatment they need). The cost of health care in this country is skyrocketing. At the same time, malpractice suits are exploding, public hospitals are failing, and government plans like Medicaid are running out of money. So, obviously, something needs to be changed.
The obvious solution is what Americans call a nationalized single payer system (or “socialized medicine,” said with a sneer, because “socialized” is a pejorative statement in the United States, in case you’ve been wondering). Under this system, the government would either directly provide care or payment for care to all Americans. The plan available to members of the armed forces is an obvious model; it’s already really, really good, and it works really, really well. Some Republicans have said publicly that they think members of the armed forces “deserve a higher standard of care” than civilians, though, so, you know. Uphill battle here, to say the least.
However, single payer isn’t getting much serious consideration. This is for several reasons.
The first is that the private insurance companies do not want it to happen, for obvious reasons. This might not really be an issue, because one would think that the government would override corporations to do what’s right. Unfortunately, private insurance companies have huge amounts of political and economic clout, thanks to the fact that campaign finance in the United States is largely unregulated. So, basically, the private insurance companies have bought themselves some security.
The second is that a very large faction in America fears the idea of providing basic human services to all American citizens. These are the people running around with the infuriating signs. These people are not only wrong, they’re also gravely misinformed. They believe that countries with socialized medicine leave people dying on the side of the streets, endlessly delay care, cost lots of money, cover undocumented immigrants (which, you know, separate issue, but if my tax dollars pay for health care for undocumented immigrants, I really don’t care), deny care all the time, and so forth. They think that a “public option” will be accompanied with all sorts of nastiness and be really expensive, and they haven’t even been introduced to the concept of single payer yet.
A lot of this rhetoric has been deliberately cultivated. For example, claims about the percentage of the American economy health care accounts for, provided courtesy of insurance companies; people argue that the current system must be maintained because otherwise the economy will collapse. Or, the death panels (sorry, Natalie, had to address it). The “death panel” is actually a conversation between a patient and ou doctor in which the doctor talks about various situations which could come up and treatment options, and asks the patient about what ou wants done in those situations. If the patient says “sustain life at all costs,” life must be sustained at all costs. If the patient says “I don’t want to live on a ventilator,” then the approach to treatment would be, you know, different. Incidentally, Republicans were the original sponsors of mandating this kind of doctor-patient discussion. Conservative commentators are basically pushing every button they can find to elicit the desired response, which is a “populist uprising” of people who are sadly too ignorant to realize what they are protesting about.
I don’t want to get too into the rhetoric, but, basically, conservatives in the United States are feeling very threatened right now. They lost control of Congress and the White House, and they feel like all kinds of things are going on that they don’t like, and they are lashing out in a major way. These people you see in the news carrying protest signs, for the most part, have no idea what they are talking about, they’re just parroting what they’ve been told by talking heads. Some of this rhetoric is clearly racially motivated, and it has less to do with the issue of health care reform than with their idea that society is collapsing, and they are angry and upset about it. Personally, I just eat a bowl of ice cream when I think society is collapsing, but, you know, whatever floats your boat.
So, most of the current proposals for health care reform are revolving around how to get Americans to buy health insurance, rather than how to provide health care reform to Americans. And some of these proposals are including what they are calling a “public option,” which would basically be government-sponsored health insurance for some Americans, while maintaining the current framework. In other words, instead of doing away with the myriad options discussed above and just having one plan cover all Americans, these plans advocate for creating yet another plan. I’m opposed to this because I think it’s inefficient and unwise and will ultimately cause more problems than it solves.
Some plans reject the public option altogether, instead focusing on things like forcing insurance companies to carry people, eliminating rescission, and limiting health insurance costs with the goal of making health insurance (not necessarily health care) more accessible. These plans sometimes also contain mandates: every American would be obligated to buy health insurance. If you were extremely poor, the government might help you out a little, or issue an exception (despite the fact that poor people are probably most in need of insurance). One of the biggest problems with mandates is that the limits are pretty unreasonable. Including premiums, copays, payments out of pocket for things that aren’t covered, and deductibles, some currently uninsured people would be expected to spend close to 50% of their income on insurance (supposedly, the costs would be capped at 12-15% depending on the plan, but that’s only the cost for the premium).
The argument used to defend mandates is that car insurance is mandatory in the United States, so, therefore, health insurance should be too. There are a couple of problems with this, like the fact that buying a car is a choice and being alive is not a choice (in the same sense, at any rate). Furthermore, uninsured motorists pose a threat to others, while uninsured Americans only pose a threat to themselves, so car insurance mandates are more about collective social responsibility than personal responsibility (many Americans believe that health care is a personal responsibility, not a right, although, needless to say, I do not subscribe to this view). Another problem, as pointed out by a doc, is that car insurance is designed to provide coverage for catastrophic events, while health insurance (theoretically) covers routine ones; you don’t use your car insurance policy to buy gas, you do use health insurance to pay for a checkup.
As has been pointed out, in Massachusetts, which already has a health insurance mandate and a public option, the insurers all promptly dropped everyone they didn’t like, shunting the costliest patients over to government care. This is probably what would happen if a federal law with a “public option” passed, allowing the insurers to continue making huge profit margins and forcing the government to carry the most expensive patients. Whereas, if the government was covering everyone, the risk would be more evenly distributed, and thus less costly, because everyone would be paying into the system, but people would be taking out at different levels. Studies seem to suggest that it would be cheaper to run a nationalized single payer plan than it would to continue running the current level of government care: Yes, that’s right, it would be cheaper to eliminate the current system and provide care to all Americans than it would be to continue with the status quo.
What this debate is fundamentally about is profits, not health care. Insurance companies want to protect their profits, politicians want to protect their sources of money, and all Americans want is some goddamn health care, already.
*Hey Canadians! I understand that the correct usage in Canada is “First Nations,” but here it’s Native American. You probably already knew that since the United States is a hegemonic monster, but I thought I’d mention it, just in case.