[url=http://www.shroomery.org/forums/newpost.php?Cat=The US has private health insurance but no health care system.
Dateline: Friday, August 03, 2007
Reposted: Monday, August 06, 2007
by John Chuckman
The release of Michael Moore's new film, Sicko, seems an appropriate time to offer a summary view of American healthcare. Many Americans remain unaware of the regime under which they live, until hit by illness or accident. Canadians, debating needed improvements for their system, often argue with little understanding of the bizarre realities of America's.
As someone who has lived roughly half my life in the United States and half in Canada, and as an economist by profession, I think I can provide a vivid sketch of American healthcare.
There actually is no "system".
Most middle-class people have private health insurance. Traditionally, their employers pay for this as an employee benefit, although there is no legal requirement for them to do so.
Since there are about 1,500 insurance companies looking for this business, the nature and quality of the policies vary immensely.
Private health insurance provides excellent coverage for young healthy people who need it least, and expensive mediocre coverage for those who need medical care most.
For a privileged cut of the population — those working for the government and large corporations and legislators — the benefits are very good. They receive excellent medical care.
As you may imagine, the quality and quantity of the benefits diminish as you move down the prestige scale. For a more typical office worker, there will usually be many limits on the policy, such as: an annual $1500 deductible; a 15-20 percent deductible for each procedure; and, in some cases, coverage that is as low as 60 percent of costs.
Such policies are the reason that health care is the single largest cause of personal bankruptcy in the US.
Inflation in fees and costs by the health-providing industry means that a single day visit to a hospital for a relatively minor procedure as an outpatient, usually costs something like $7,000 when all the bills are in.
I say, "when all the bills are in" because for weeks after the procedure, the patient will receive endless bills: from each doctor, from the anesthetist, from the hospital, from laboratories, from the ambulance company, etc. The invoices include long computer lists, with items like $150 for the use of a scissors or $10 for some aspirins in a cup.
Under some insurance policies, the patient pays out of pocket and applies for reimbursement. This can cause a cash crunch where the bills are high. Under other policies, the practitioner or institution bills the insurance company directly and the patient receives a bill for what's left over.
In any case, if you do not pay the balance fairly promptly, your file will be turned over to a collection agency who will then hound you daily for the money.
There are invariably disagreements with the insurance company over specifics. The patient (or an advocate) usually must dial an 800-number and wait on hold a long time to talk to somebody at the call center about the issue. Because of the complexity of the terms of a given policy, patients have to be well-informed even to discuss which items are covered and to what extent.
On some policies, even pretty decent ones, patients are required to call an 800-number before going to the emergency room. Unless the insurance company gives specific permission for the visit, the patient is solely responsible for the emergency-room bill.
But even pretty good insurance policies typically have lifetime limits on benefits. Patients with chronic, catastrophic or terminal conditions often reach the end of their benefits long before they cease to need medical care.
Note the fact that very good to excellent coverage for upper-middle class and government people effectively silences those who would be active in changing the system.
This is a key reason that the healthcare chaos never becomes a burning political issue. It also provides a lever to be used if someone wants to reform things, as the Clintons did. A barrage of ads threatening upper-middle-class people that the excellent level of their care would be reduced proved to be a very effective ploy.
For many of the privately insured however, benefits range from mediocre to terrible. America has more than forty million with no benefits, but a statistic never given, and more important, is the huge number of under-insured.
Note that an individual can approach some companies to buy your own insurance if your employer provides none. Because you are not part of pool in these circumstances, your fees will be very high. The benefits are also likely to be poor to mediocre.
The industrial sector of the US has declined sadly for decades. With its decline, most working people have lost the opportunity for decent, employer-paid insurance. The growth sector of the economy is services — including the infamous McJobs — and these places typically offer poor or no insurance.
People in non-union factory or middling office jobs or much of the service industry get benefits so limited that a serious event can throw them into bankruptcy. This is how the policies, where they are available, are priced low enough for such employers to afford.
Some of the other disturbing elements in this national healthcare chaos include:
lack of privacy, because your private health records are in the hands of private insurance companies, and this is marketing information, which they trade in, for profit;
loss of opportunity, if a prospective employer finds something in your private health-care information that they don't like;
loss of negotiating power, as people with better policies desperately hang on to their jobs for fear of losing coverage in middle-age, just when they need it most;
loss of personal choice, as some private insurers will not cover procedures such as abortion;
employees' health care may be compromised if for some reason, usually cost-cutting, an employer suddenly change insurers. Employees are faced with a whole new set of qualifiers, requirements, 800-numbers, deductibles, and limits. This can happen a number of times in your career, and it is very unsettling.
companies deeply concerned about costs will gradually work their way down from excellent policies to mediocre ones. You must adjust accordingly.
Clearly, the rules are made by and for the insurers, not the insured. As an example, not many years ago, if you lost your job, in most cases, you immediately lost your insurance. Too bad if you or your child had chronic needs. Now, there is a time-limited bridging mechanism — for which you must apply, fill out forms, and pay — that allows you to be insured until you secure a new job with new insurance.
For the really poor, there are often-impoverished county hospital emergency wards — which still must try to obtain some degree of payment out of patients, according to their means. In general, the care in such places is poor. Remember the recent scandal about the level of care that Walter Reed Hospital provides for qualified ex-soldiers under the Veterans' Administration.
Retired Americans qualify for Medicare, a system whose benefits are completely inadequate to modern needs. If you retire without a supplemental insurance — either paid by your past employer in a good job or by yourself in other cases — you may face serious problems.
The Medicaid system for poor Americans is extremely complex, and the extent and nature of benefits vary considerably from state to state. If you move from one state to another you can lose coverage for the services you were using before. Again, depending on the state, you may be required to make co-payments for services.
You have to be really needy to qualify for Medicaid benefits, and your means are examined in detail. For some Medicaid services, officials are entitled to recover expenses from a beneficiary's estate.
In various US jurisdictions, private hospitals — generally the best but not always — are required to take a certain quota of non-insured patients. This quota is never generous. The cost of this sharing effectively gets dumped onto the insured, increasing the cost of insurance.
This method also leads to some bizarre results. Suppose an uninsured person is picked up on the street by an ambulance after an accident. The ambulance will call ahead to the nearest hospital to see whether they can take another uninsured. If the answer is no, the medics call another hospital. This continues until they find a taker. However, by that time, the patient may expire in the ambulance, a not uncommon event.
Imagine the horrors for an uninsured person, whether a citizen or a visitor from abroad, who gets mugged in the United States! First, there is the horror of the mugging or rape or assault, and then the horrors of dealing with the Medical Kremlin.
This brief review gives you a realistic sketch of healthcare in America. If you are young and healthy, you need not be overly concerned. Of course, it is precisely the pool of young and healthy people that insurers love, because their employers pay but the employees don't use many benefits. That is why institutions like the high-tech industry or huge multi-national corporations have such good policies. They get used comparatively little.
The entire 'system' segments the population into many different pools of insurance clients and potential patients, from low risk clients with excellent benefits, to high-risk clients with terrible benefits. It truly is medical Social Darwinism, organized by lawyers and financiers.
John Chuckman is former chief economist for a large Canadian oil company. He has many interests and is a lifelong student of history. He writes with a passionate desire for honesty, the rule of reason and concern for human decency. He is a member of no political party and takes exception to what has been called America's "culture of complaint" with its habit of reducing every important issue to an unproductive argument between two simplistically defined groups. John regards it as a badge of honor to have left the United States as a poor young man from the South Side of Chicago, when the country embarked on the pointless murder of something like three million Vietnamese in their own land because they happened to embrace the wrong economic loyalties. He lives in Canada, which he is fond of calling "the peaceable kingdom."
Chuckman’s recent book The Decline of the American Emprie and the Rise of China as a Global Power, Magpie Books, London, is available from Chapters-Indigo on-line.
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-I'd rather have a frontal lobotomy than a bottle in front of me
CANADIAN CENTER FOR POLICY ALTERNATIVES
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