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Healthcare in U.S.


Trebs

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I saw a Facebook post about a reddit discussion on "Redditors who live in a country with universal healthcare, what is it really like" - from a US posted trying to get an understanding of health care in other countries, ones that do have universal healthcare. I posted a FB reply, but thought I'd share it here since many of you know my recent health history.

My dad was retired lifer military, so growing up we had full healthcare (and dental). Anything happened - we went to the base for medical, allergy shots, dental checkups - everything with no thought of co-pay and the doctors ran the tests they thought were necessary. At 20, I had a ruptured disc and base doctors treated it. So when I turned 23 (was extended because my dad's death was service connected), it was a bit of a shock to be without coverage for first time in my life. Thankfully nothing major happened until after I got a fulltime job - and that I've kept that same job for the past 20 years and been covered through two additional ruptures of that disc, numerous bouts of bronchitis, asthma, and recently two rounds of lymphoma. I like ACA, but I'd much rather we had a single-payer full coverage system. I truly believe that it is the main reason why we have the highest healthcare costs in the civilized world.

 

Some other details - even with decent health care coverage through work, my out of pocket has usually been about $2000 per year, if not more. This year, because I had to get a lot of dental work done (chemo did a lot of damage at the gumline and could not do the bone marrow transplant until all potential decay was taken care of) - I paid $6000 just for that dental care (on top of what my dental plan additionally covered).

 

While I was still with Dan, since he was self-employed, we had him as a spouse on my health and dental plan, and my "cafeteria" payments were a little over $900/month (pre-taxes but still).

 

And then on top of this, in the middle of me fighting the lymphoma and trying to recover, there have been two incidents of the insurance company turning down payments, even though they were pre-approved. They eventually did pay the hospitals, but that was about 20 hours of my life in phone calls and follow-ups, while I was barely able to maintain myself (as in getting up, eating, not constantly curled in a ball on the bed).

 

In addition to the direct benefits of the Affordable Care Act (ie, ACA or Obamacare), such as elimination of denial of coverage for pre-existing conditions, allowance for parents to keep their kids on their insurance until they're 26, elimination of lifetime limits on health benefits, forcing insurance companies to spend at least 80% on actual health care - these are all great, but the act also has some other interesting provisions.

 

One of them, is the new disclosures. My bills now have detailed breakdowns of what the hospital or clinic charged. The US government also has been releasing data on the healthcare costs - one of the many articles about this came out in May showing such things as how two hospitals in Los Angeles, just 12 miles apart - for the same procedure (hip replacement), on hospital charged $297,000 while the other charged $84,000. And based on my own bills, I can see it happening often because no one sees how much the insurance is being charged, so hospitals add on here and there to the bill up to what they think the insurance would cover (whether it happened or not), the insurance company rubber-stamps it, the patient just pays their copay, and everyone wonders why their premiums are going up the next year.

 

One last thing I want to address - the cry of "We can't go universal coverage because the sponges in society will just have health care without working and the rest of us will pay for it." Reality - we're already paying for it, in covering emergency room visits for indigent patients who should have gone to a clinic a week earlier to have a simple round of antibiotics, but are now so sick that they require days of hospitalization. We pay for it when in the food service industry, which typically does not offer health care coverage nor sick time leave - workers are forced to come to work sick and diners go home to spread the cold/flu/whatever to the rest of their families, friends and co-workers. We pay for it when the GDP of this country is stifled because we have people working 60 hours a week, but still in poverty and with no health care coverage, and dying because of not being able to see a doctor about a tooth ache that develops into an abscess and kills them.

 

Reuters reported last year, that it's estimated that 26,000 working-age adults die prematurely in the US each year, due to lack of health insurance. If a terrorist attacked a US city and killed 26,000 people, this country would be mobilized to react instantly and effectively. Yet because of the health insurance and related industries, the lack of universal healthcare in this country kills about that number each year. In California, we're lucky to have a Governor and Legislature who have embraced and moved to implement the ACA - and have already started showing health care savings in this state. Elsewhere such as Florida and Texas, the Governors have put up as many roadblocks and obstacles to implementation, and health care costs continue to rise and citizens continue to suffer.

 

We know how to effectively manage a universal health care system - we've done it for many years for the U.S. Military. Why do we still allow so many to die?

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First, I'm very sorry to hear of your health problems, Trebs. Sounds like you've had a real shit set of cards dealt and I hope you can make a good recovery. In Britain we all pay an insurance contribution through the state taxation system. So it's an efficient system - it avoids the huge costs of individual policies and individual underwriting and money handling - but just as with any healthcare system there are problems with delivery, which have been widely reported. But we've had a comprehensive national health service - the NHS - free at the point of delivery since 1948. That's a long time. We were broke when it started - just after WWII - and we're still broke now so nothing's changed :P Alongside the NHS we also have private health which provides everything except A&E. So we can have hip replacements done through private healthcare but these would cost nothing like the figures you quoted. Maybe the existence of the NHS acts as real competition to the private healthcare sector. Or maybe our private insurance - much of which is through mutuals - keeps a tighter lid on costs. No it's not perfect and it won't ever be, though most people in Britain are pretty happy with what they get. It takes away the worry. But this year the NHS has undergone the biggest changes since it was created and much of the money will now go to private healthcare providers. The jury is out on how those changes will affect delivery and cost.
 

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Trebs, I want to offer you coverage if I could :(

 

On the flip side of things, on the hospital and insurance fronts, it's messy. While HIPAA has pushed procedures and accountability up for everyone, there's a cashflow issue within Hospitals. Of the costs a hospital actually pays out, I can tell you from experience almost 60-70% comes from doctors billable hours. They make about 2.5 times more than me on average before taxes. In the past, Hospitals and health centers used State augmented funds to offset the costs of doctors between billing and receipts of insurance premiums. That stopped 2 years after Massachusetts adopted our Health Care reform act.

 

Cash issues are compounded by our net terms from Insurers; you may see a bill for $100,000 for surgery on your details, but the Hospitals cannot collect the entire amount. For Blue Cross Blue Shield for instance, you would need to wait 90 days to see payment. The Blue Cross adjuster would fix in a rate against the billed $100,000, paying about $25,000 to the Hospital. Now that doesn't seem that bad, but if your doctor and nurse costs for those 3 months amounted to $42K (30K for a single "new" doctor with an average of 120K/annual + 12K for 3 nurse practitioners), you're talking about net loss in those 3 months of $(17)K.

 

In essence Trebs, don't think what's on your bill is actually paid to the hospital. News reports might state big numbers, but insurance industry is not stupid. They use CMA (US Center for Medicare) standards for adjusters to bring every penny billed down to the legal minimum.

 

Sometimes, if your hospital is part of a larger network, you can force a premium adjustment based on volume, i.e. while the adjusted payment is only 25K, insurers can add back in 30K due to hospitals hitting a managed care goal of 100 patients.The bigger hospital networks can make a profit, but nothing like what News stories seem to suggest. For smaller hospital like my old firm, our margins were squeezed so badly that we had to mortgage out Medicare payments to meet payroll during the HIT conversion. It's ugly.

 

From my standpoint, I wouldn't mind something simpler; I've been in health care for 5 years now from several angles of the finance side. Maybe this detail is going to go over everyone's heads, but still it is very common knowledge in the industry.

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In Canada we have OHIP  its not the greatest but it does allow us to go to the doctor's and even hospital without having to pay out of pocket.It is dwindling rapidly we now pay for more things than what we used to.  We never had to pay for Ambulance, things like that. Last year my husband and I had to drive for an hour to check on my daughter she kept calling us but we couldn't figure out what she was saying so we drove down to her apartment to find her lying on the floor she had had we called her dr. not realizing we had the dentist lol but was told to call 911 we did and in a few days we ended up getting a bill for the ambulance ride and because the hospital was extremely busy and she was kept in the hallway for hours with the ambulance crew because they couldn't sign off on her she was charged extra, thankfully the disability coverage she had covered it but that is over and above OHIP. We later found out that she had had a stroke and another the day after she was finally admitted to the hospital. So here in Canada it is a bit better because basic stuff is covered unlike in the U S but on the other hand we do suffer because we still lose doctors to the American people cause they can make more money in the states than they do Canada. So whats it really like here with OHIP yes we have the basics covered and with additional coverage taken out of pocket from employment it can be very good but having good coverage or even basic coverage doesn't really mean much when you don't have the doctors or medical personnel to help the people. The states have the people but don't have the coverage we have the coverage but a serious shortage of personnel to help not really that great of a trade off is it eh?

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