US Healthcare: Understanding the Challenges of Accessibility

[Sophia]

I wanted to ask about the healthcare in the USA for a long time. From what I saw in movies and read in various articles or blogs it seems to me that many people can't afford it. Or that if you get ill and go to hospital, than you have to spend all your life savings on bills?
What happens if poor people get cancer, for example? Do they get help if they can't afford the treatment?

 

[DiracPool]

I wanted to ask about the healthcare in the USA for a long time. From what I saw in movies and read in various articles or blogs it seems to me that many people can't afford it. Or that if you get ill and go to hospital, than you have to spend all your life savings on bills?
What happens if poor people get cancer, for example? Do they get help if they can't afford the treatment?

Traditionally, poor people often qualified for a program called "medicaid" in the USA. With the recent Obama health care plan, medicaid-based coverage has expanded significantly. Prior to this, to be poor and without health coverage meant bad times. Typically, health care coverage for the severely disaffected meant frequent trips to the "ER" (emergency room), which by law everyone was allowed.

 

[fresh_42]

Typically, health care coverage for the severely disaffected meant frequent trips to the "ER" (emergency room), which by law everyone was allowed.

I've heard of a hospital - I think it was somewhere around Virginia - which opened a department for minor injuries, vaccinations and so on aside their ER which was at no costs to the public. They actually saved money by this!

 

[Sophia]

Fresh, so you normally have to pay even for vaccinations? Aren't they compulsory and a matter of something like national interest? Here, parents are visited by social workers and they have to pay fines if they refuse to have their children vaccinated for free (anti-vaccination philosophy is becoming a "first world" issue, but that's another story :) )

 

[DiracPool]

Here, parents are visited by social workers

You can help us out by specifying where "here" is. That way, we can check out and qualify your assertions and perhaps contribute supplementary data.

 

[fresh_42]

Fresh, so you normally have to pay even for vaccinations? Aren't they compulsory and a matter of something like national interest? Here, parents are visited by social workers and they have to pay fines if they refuse to have their children vaccinated for free (anti-vaccination philosophy is becoming a "first world" issue, but that's another story :) )

No, I don't think so. But - as far as I know, since I'm a "European communist" like you when it comes to American healthcare - they saved the money by release their (very expensive) ER. It was even cheaper to give away minor medical care than it was when usually all those patients flood the ER as only possibility to get health care at no costs.

 

[SteamKing]

Fresh, so you normally have to pay even for vaccinations? Aren't they compulsory and a matter of something like national interest? Here, parents are visited by social workers and they have to pay fines if they refuse to have their children vaccinated for free (anti-vaccination philosophy is becoming a "first world" issue, but that's another story :) )

Just because something is compulsory doesn't mean you get it for free.

 

[Sophia]

"here"- Slovakia

 

[Sophia]

Just because something is compulsory doesn't mean you get it for free.

well, of course, it doesn't have to mean that. But in our country everyone gets compulsory vaccinations (TBC, variola, rubeola, polio, "black cough" that have been used for decades. New generations are also vaccinated against hepatitis, and 13 pneumococcus infections- vaccine is called Prevenar13) for free. There are others, like against tick ( the insect) encephalitis you have to pay for, but those are voluntary.
I thought this was the same everywhere.

 

[SteamKing]

"here"- Slovakia

You may not be charged for getting a vaccination every time you show up at a clinic, but somewhere down the line, you pay for. Taxes, fees and other money paid to the government disguise the transaction, but it occurs regardless.

Vaccines don't grow on trees; somewhere, someone has to make the vaccine and then distribute it, paying workers to produce and deliver it. I'm sure these workers like to get paid for their efforts and are not volunteering their time.

Even in western Europe and the UK, much of the revenue derived from each country's value-added tax (VAT) goes to support various social services and health care, which the public thinks is provided without cost or at very little direct cost to them.

It still costs real money to build a hospital, furnish it with medical equipment, and hire a staff to run it and care for patients. That money must come from somewhere; just because you don't get a bill with your name on it doesn't mean you aren't paying for it.

Your government makes vaccinations compulsory because it doesn't like having raging epidemics of various diseases to deal with. It's a cost savings, because administering a vaccine is almost always cheaper than administering a cure (if one is available).

 

[Sophia]

Of course it's paid from taxes and/or insurance. Still, it somehow seems more fair if you don't have to pay for it directly because for poor people it might be too much to pay for it in cash.

 

[DiracPool]

Of course it's paid from taxes and/or insurance. Still, it somehow seems more fair if you don't have to pay for it directly because for poor people it might be too much to pay for it in cash.

I'm not really qualified to comment on this because I don't have kids, but I don't think that parents have to pay to get their kids vaccinated in the USA. Again, I'm not really sure how this works, perhaps a parent of a young child in the USA could better elaborate.

 

[SteamKing]

Of course it's paid from taxes and/or insurance. Still, it somehow seems more fair if you don't have to pay for it directly because for poor people it might be too much to pay for it in cash.

In the US, there are additional means to provide health care for the poor or the indigent. The Medicaid program is administered by the states for this type of care. In addition, some states run charity hospitals, and various religious orders operate hospitals as part of non-profit foundations set up to minister to the sick.

In addition, according to federal law, no hospital can refuse to treat someone who comes to its emergency room for care, regardless of ability to pay for that care.

 

[russ_watters]

I wanted to ask about the healthcare in the USA for a long time. From what I saw in movies and read in various articles or blogs it seems to me that many people can't afford it. Or that if you get ill and go to hospital, than you have to spend all your life savings on bills?
What happens if poor people get cancer, for example? Do they get help if they can't afford the treatment?

The poor and uninsured have already been mentioned, but in any case, most people in the US have health insurance, so they don't pay much out of pocket if they get sick/get cancer.

In the US:
About 10% are not insured (they are not all necessarily poor - some choose not to be insured)*.
About 55% are insured through their (or their partner's/parent's) jobs.
About 15% are insured in private plans.
About 37% are insured in government plans (old people, the military, government workers, the poor, etc.)
http://www.census.gov/content/dam/Census/library/publications/2015/demo/p60-253.pdf
(note, the numbers add up to greater than 100% because of overlapping plans)

*My understanding is that "not insured" is only for medical specific insurance. If you are in a car accident, that is covered under car insurance. I went several years in my 20s without health insurance, by choice, with only car insurance, since by far the most likely cause of a serious medical issue for me would have been a car accident.

 

[meBigGuy]

US health care rates poor for accessibility and not that good for plain quality. It is the clear winner for highest cost per capita. It's a travesty that US corporations make huge profits on poor health. It also incentivizes treating symptoms over curing causes. (BTW, I am in the US and have great, but expensive, health insurance)

Merely looking at insurance coverage numbers doesn't really tell the story since many plans are $5000 deductible and have limited physicians. It's a travesty that many parents can't afford to take their child to a clinic to test for strep throat.

One of many surveys:
https://www.washingtonpost.com/news...least-effective-health-care-system-in-survey/

One hidden example of corporate greed is the ultimate results of the Bayh-Dole Act in 1980 (which few know anything about) which allowed Corporations to buy University Drug Patents. The result is that instead of Universities licensing patents to many corporations, one corporation gets exclusive ownership and only pursues blockbusters. It also forces university research to focus on blockbusters. The story of the politics behind this reads like a joke, and the effects on the focus of university drug research have been devastating.

The effect of for-profit corporate control on the US health system makes it more about money, and less about health.

 

[jack476]

Fresh, so you normally have to pay even for vaccinations? Aren't they compulsory and a matter of something like national interest? Here, parents are visited by social workers and they have to pay fines if they refuse to have their children vaccinated for free (anti-vaccination philosophy is becoming a "first world" issue, but that's another story :) )

Where is this magical place you're talking about?

Yes, you do have to pay for vaccinations, though the required shots are offered by the schools if you can't afford them.

You may not be charged for getting a vaccination every time you show up at a clinic, but somewhere down the line, you pay for. Taxes, fees and other money paid to the government disguise the transaction, but it occurs regardless.

Except in the US, we pay several times what other countries pay for quality of care that isn't even close to what people in those countries are getting. Sure, either way you're still paying for it, either through taxes or through insurance payments, but in the US we have some of the most expensive healthcare in the world in terms of per capita expenditure (http://data.worldbank.org/indicator/SH.XPD.PCAP) despite vastly inferior quality of care.

Plus, if the government takes $5000 from me to run a hospital, then I'm much happier than if an insurance company takes $5000 from me just so they can turn a profit.

 

[SteamKing]

Except in the US, we pay several times what other countries pay for quality of care that isn't even close to what people in those countries are getting. Sure, either way you're still paying for it, either through taxes or through insurance payments, but in the US we have some of the most expensive healthcare in the world in terms of per capita expenditure (http://data.worldbank.org/indicator/SH.XPD.PCAP) despite vastly inferior quality of care.

Plus, if the government takes $5000 from me to run a hospital, then I'm much happier than if an insurance company takes $5000 from me just so they can turn a profit.

Maybe. In the UK, the government takes your taxes to pay for the NHS, and still, the doctors there are about to go on strike, just like any other government employee. Many drugs and treatments available in the US are not available in the UK NHS system, even with government footing the bill.

Insurance companies, being private businesses, must turn a profit in order to remain in business. The government faces no such restraint, which is why public debt in many countries has exceeded supportable levels. The government spends more each year than it takes in from taxes and other revenues. Such a state of affairs can run for a while, maybe even many years, but eventually the laws of arithmetic win out.

Someone, maybe your kids, maybe your grandkids, is going to take a big haircut financially.

 

[russ_watters]

Merely looking at insurance coverage numbers doesn't really tell the story since many plans are $5000 deductible and have limited physicians. It's a travesty that many parents can't afford to take their child to a clinic to test for strep throat.

That doesn't tell the whole story either. I had a high deductible plan when I had a choice and would now if I could. I've gone years at a time without seeing a doctor, so a high deductible plan made more sense. The money doesn't just materialize out of thin air: if the insurance company is paying for it, someone has to be funding it. So if you have (for example) no deductible, that first $5,000 is paid for by higher premiums.

One of many surveys:
https://www.washingtonpost.com/news...least-effective-health-care-system-in-survey/

I love how the title (and link) say "least effective" when the survey has a category titled "effective" in which the US ranks 3rd.

 

[WWGD]

Part of the problem in the U.S is having a disjointed system with different regulations in different states, unlike I think is the case with European and in general smaller countries, where you have more of a single, centralized system. Some of the recent trends are in Bioinformatics, the use and application of IT (Information Technology) in Healthcare, and the application in some subsystems of quality improvement methods (Six Sigma, agile methods for Project Management, etc.). Examples of this are Telehealth and Telemedicine, the remote administration of health .Some patients use PHRs, Personal Health Records, which are electronic compendiums, controlled by the individual, of a person's general healthcare information.

 

[SteamKing]

Part of the problem in the U.S is having a disjointed system with different regulations in different states, unlike I think is the case with European and in general smaller countries. Some of the recent trends are in Bioinformatics, the use and application of IT in Healthcare, and the application in some subsystems of quality improvement methods.

The regulatory problem has only gotten worse since the passage of the ACA. Premiums are charged based on where the customer lives, not at the state level, but at the county level. If the county you live in has a higher incidence of disease than another county in the same state, there will be a premium differential charged for living in the 'unhealthy' area. Health insurance companies are still not permitted to operate across state lines, which further concentrates the risk.

It's still not clear that applying more IT to medical care will generate the savings in health care costs that advocates hoped for initially. It does, however, raise the spectre that your personal medical and identity information will be at increased risk of being stolen or misused, since recent events have shown that even the US government is not immune to having the fingerprint and other personal data of its employees being stolen by hackers.

http://www.reuters.com/article/us-usa-cybersecurity-fingerprints-idUSKCN0RN1V820150923

And remember, once an IT system is installed, it's only a matter of time before it becomes obsolete. How many hospitals want to be involved in running sizable IT shops, rather than providing care to patients?

 

[MikeMardis]

Just looked up the Slovakia tax rate and compared it to the USA tax rate. Slovakia tops out at 25%. The US tops out at 39%. They have free healthcare, but we've got Obamacare. Obamacare forced my twenty something daughter to get a $200/month healthcare insurance plan which has a $6000 prepay. What a deal. She's now $200/month poorer and still can't afford to see a doctor.

 

[meBigGuy]

That doesn't tell the whole story either. I had a high deductible plan when I had a choice and would now if I could.

That misses the whole point, that people who need the better coverage can't get it and your numbers don't show that. HSA's coupled with HDP's were created for people like you, and they work well. But, try having kids, getting old, getting a serious condition, etc, and your tune will change. The corporate healthcare scam ruins lives. It is not so in nearly all western countries. I believe good healthcare is a right, not a business. And I'm not even beginning the address the travesty of US mental health care. Pray you are never in a situation where someone you care for or are responsible for needs real help.

What a deal. She's now $200/month poorer and still can't afford to see a doctor.

The insurance companies bought the ACA battle using our hard earned extorted health care dollars. Republicans and Democrats signed up for the windfall for insurance companies.

 

[russ_watters]

Just looked up the Slovakia tax rate and compared it to the USA tax rate. Slovakia tops out at 25%. The US tops out at 39%.

Highest marginal tax rate is only a small part of the story. For one thing, you are referring to the personal income tax, which is only part of the taxes people pay -- and about 40% of the US pays no personal income tax, but still pays state and local taxes and the payroll tax (Social Security and Medicare).

Anyway, in total, 29.5% of Slovakia's GDP is in taxes vs 26.9% for the US; pretty low percentages vs other developed countries.
https://en.wikipedia.org/wiki/List_of_countries_by_tax_revenue_as_percentage_of_GDP

What it means is that people in the US have extra money that they should be spending for life improving things -- like their own healthcare.

 

[russ_watters]

That misses the whole point, that people who need the better coverage can't get it and your numbers don't show that. HSA's coupled with HDP's were created for people like you, and they work well. But, try having kids, getting old, getting a serious condition, etc, and your tune will change. The corporate healthcare scam ruins lives.

It's not a scam, but unfortunately it is a business model that the public demands and the insurance companies give them. The young use less medical care, so their premiums are lower. That logic should be self-evident. Perhaps someone should set up a plan where the premiums stay the same forever, based on when you sign-up. That way they are higher when you are young than they would otherwise be and lower when you are old than they would otherwise be. That might help ease the shock.

On the other hand, the old tend to be better able to pay than the young, which means the high rates aren't as much of a burden. Of course, for that to be realistic, people need to do a better job of saving for retirement...

Sure, the government could help structure the business model better, but it has done such a terrible job with such things that I just don't trust it to.

I believe good healthcare is a right, not a business.

Unfortunately, you can believe that free tacos are a right and if you get enough votes you can make that so. But that doesn't make it a good or realistic idea or square it with the concept of what "rights" is.

 

[meBigGuy]

unfortunately it is a business model that the public demands

Wonder why the public demands what it does (what it is told to demand). If you are interested, it started with the Committee for Public Information (Creel Commission) formed by Wilson to get us into WWI. It got a BIG boost by the Telecommunications Act of 1996. Now we have Citizen's United.

I promise to rant no more on this as it is a bit off-topic.

 

[WWGD]

The regulatory problem has only gotten worse since the passage of the ACA. Premiums are charged based on where the customer lives, not at the state level, but at the county level. If the county you live in has a higher incidence of disease than another county in the same state, there will be a premium differential charged for living in the 'unhealthy' area. Health insurance companies are still not permitted to operate across state lines, which further concentrates the risk.

It's still not clear that applying more IT to medical care will generate the savings in health care costs that advocates hoped for initially. It does, however, raise the spectre that your personal medical and identity information will be at increased risk of being stolen or misused, since recent events have shown that even the US government is not immune to having the fingerprint and other personal data of its employees being stolen by hackers.

http://www.reuters.com/article/us-usa-cybersecurity-fingerprints-idUSKCN0RN1V820150923

And remember, once an IT system is installed, it's only a matter of time before it becomes obsolete. How many hospitals want to be involved in running sizable IT shops, rather than providing care to patients?

But, if implemented effectively, IT systems can help lower costs and lower the number of avoidable deaths, e.g., the CPOE. Entering data electronically instead of manually is one example where errors can be greatly reduced. And having a patients health care information across time stored and organized in an integrated way can also allow a practitioner to make better recommendations for the patient's long-term care, which can hardly be done by using flat file systems, although with the caveat you mentioned of the data being hacked, which needs to be addressed more seriously.

 

[WWGD]

Just looked up the Slovakia tax rate and compared it to the USA tax rate. Slovakia tops out at 25%. The US tops out at 39%. They have free healthcare, but we've got Obamacare. Obamacare forced my twenty something daughter to get a $200/month healthcare insurance plan which has a $6000 prepay. What a deal. She's now $200/month poorer and still can't afford to see a doctor.

39% is not the effective rate; it goes way down after the accountants find the loopholes. I don't know about Slovakia, though.

 

[SteamKing]

39% is not the effective rate; it goes way down after the accountants find the loopholes. I don't know about Slovakia, though.

It's hard to compare tax burdens across national boundaries.

The federal income tax in the US is assessed only on taxable income after deductions, personal exemptions, etc. are subtracted from gross income. The income tax is also graduated, with progressively higher rates charged for income falling into different income brackets. This means that income from an individual is often taxed at several different rates according to the income bracket structure for an individual's filing status (single, married filing jointly, etc.) The tax rate for the lowest bracket is 10%; the rate for the highest bracket is 39.6%

https://en.wikipedia.org/wiki/Taxation_in_the_United_States

For 2014, the US federal government took in a total of a little over $3 trillion in federal income taxes, excise taxes, corporate taxes, and payroll taxes for social security and Medicare. Of this total, approx. $1.4 trillion was collected as income tax, or about 47% of total tax collections at the federal level.

http://www.taxpolicycenter.org/taxfacts/displayafact.cfm?Docid=203

For 2014, US GDP was estimated to be $17.4 trillion. In 2010, the GDP was a little under $15 trillion, and the total tax burden (all federal, state, and local taxes combined) was estimated to be about 24.8% of GDP, which is relatively high for the post-WWII US economy.

http://www.tradingeconomics.com/united-states/gdp

 

[Sophia]

Wow, this got rather complicated ☺ I'll have to Google all this stuff such as premiums and various plans.
So far I just understand that the US system is very complicated and there are plenty possibities depending on your plan and even the area you live in.
Here, everyone must be insured and I don't have the exact numbers but I think about half of population is insured by state. That means children and students up to 26 years old, seniors, unemployed, mothers with children younger than 3 years.
For employees, insurance is automatically taken from their salary.
We have 3 insurance companies, but the care is basically the same for everyone. They only differ in things like paying for spa (that is traditionally highly used here as we have quite a few springs of healing mineral and thermal water) or ability to get treatment abroad.
Someone may not agree, but I think this is a very good heritage from the socialist era.
However, there are many problems as well. For example, our medicines are so cheap that pharma companies sell them to West European countries sometimes leaving our patients without treatment. There is a law that prohibits that, but it doesn't work in reality.
Also, health workers, especially nurses are poorly paid. That's why last week about 1000 nurses decided to leave their jobs. Which, in a 5 million country, is a serious problem. They earn about 660-850€/ month. That is still slightly above average, but of course for such a hard work they deserve more.
And we also get corruption that I think is everywhere, but especially in post - communistic countries.
So because we note have these problems I wanted to hear about other countries. I knew I could Google, but let's be honest, statistical data do not always tell you about real situation.

 

[DiracPool]

They only differ in things like paying for spa (that is traditionally highly used here as we have quite a few springs of healing mineral and thermal water)

Nice, I'm moving to Slovakia! You had me at "thermal water."

 

[Sophia]

As far as taxes are concerned, I am no expert so I chose to remain silent

 

[DiracPool]

They only differ in things like paying for spa (that is traditionally highly used here as we have quite a few springs of healing mineral and thermal water)

Would my Slovakian medical care coverage also cover a monthly sugar foot rub?

 

[Sophia]

I must disappoint you, DiracPool, you won't get that
But if you have heart disease, movement problems, asthma, certain serious allergies, cancer in remission, certain skin disorders or if you had a gynecological surgery in the past year, you might get 21 days in spa for 1.66- 7.3 €/day + food (price depends on diagnosis- the more serious diagnosis, the less you pay). Pool entry and therapeutic procedures prescribed by doctor are 100% covered. If your child gets spa prescription, you can go with him for 5€/ day :)
Spas have a long tradition here, some of them have been known for hundreds of years (the one in the video was first mentioned in 1247) and it is very common to visit them.
For example
(after first minute) This one is about 45 minutes by train from where I live.
My friend went there for 3 weeks when she had a cyst on her ovary and my dad's doctor told him she would send him to another spa when his heart calms down a bit. There are about 20 spas in SR, each specializes in different health problems. It depends on minerals present in the water and climate conditions. Insurance even covers treatment of children with respiratory problems in caves :)

On the other side, most of our hospitals are in the same condition as they were during socialist era. They are crowded because lot of hospitals had to be closed for economic reasons so sometimes you have to wait a long time before you are accepted and doctors and nurses simply can't manage so many patients at one time. We do have some very good doctors compared to other countries but the equipment is just too old and overall conditions are desolate.
I was wondering if it is better in countries where you pay much more for insurance and what the actual availability of healthcare is there.
Because now I am confused if the critical state of our system is a result of socialism, capitalism or just plain corruption and irresponsibility of the government. It is difficult for my generation to understand all mechanisms and influences after 1990. So I wanted to compare our situation with traditionally capitalist countries to see how it works over there.

 

[SteamKing]

On the other side, most of our hospitals are in the same condition as they were during socialist era. They are crowded because lot of hospitals had to be closed for economic reasons so sometimes you have to wait a long time before you are accepted and doctors and nurses simply can't manage so many patients at one time. We do have some very good doctors compared to other countries but the equipment is just too old and overall conditions are desolate.
I was wondering if it is better in countries where you pay much more for insurance and what the actual availability of healthcare is there.
Because now I am confused if the critical state of our system is a result of socialism, capitalism or just plain corruption and irresponsibility of the government. It is difficult for my generation to understand all mechanisms and influences after 1990. So I wanted to compare our situation with traditionally capitalist countries to see how it works over there.

Corruption and irresponsibility are twin plagues which are present in all economic systems and in all countries, unfortunately. So is the shortage of qualified personnel to staff hospitals and clinics, from doctors all the way down to the nurses and other support staff.

It's that way in the US, where medical training for doctors is expensive, and new doctors often enter the field paying off large sums borrowed to pay for medical school. The first response of the politicians is to cut costs by lowering the amount of reimbursement to physicians who treat patients receiving care paid for by government (this includes medicaid and Medicare). As a result, many physicians are reluctant to treat such patients, which means if you are on medicaid, your waiting time to see a physician or specialist can be quite lengthy. With more people being dumped into the medicaid system due to the effects of the ACA, things are only going to get worse as the level of care declines, especially since medicaid is funded only partially by the federal government (the individual states pick up the difference).

https://en.wikipedia.org/wiki/Medicaid

 

[russ_watters]

So far I just understand that the US system is very complicated and there are plenty possibities depending on your plan and even the area you live in...

That's a good start. People like to portray it as an unmitigated disaster, when the reality is much more complicated. Glad you see that now.

 

[Sophia]

Thank you for your responses, SteamKing and russ_watters. I will think about that and do some more reading.

 

[meBigGuy]

Here is a link that describes a large health insurance program. (I think regence is the largest)
Regence has group plans, family plans, individual plans, medicare advantage plans, and many other sub categories related to primary care physicians, preferred providers, contract providers, and so on.
If it asks for your location you can probably enter any US zip code. Just pick a city. (for example seattle = 98101 Los Angeles = 90001)
https://www.regence.com/web/regence_individual/understanding-health-insurance

 

[WWGD]

Ultimately, many quality-control methods (like 6-Sigma) that have been proven successful in many areas (in terms of both improving quality and saving $$ ) could be used in healthcare*, both in design and implementation, but there are still important barriers to their adoption. It seems US culture does not fit well with 6-sigma paradigm; kind of strange, given US-born Ed Demming got the ball rolling on QC methods in Japan after WW2. Companies using 6-Sugma, like Motorola, Toyota, etc. have been consistently successful. It seems like it is the future..* They actuallyhave been used successfully in small-scale implementations.