Angelika In the newsletter, we have often expressed our views on the deplorable health insurance system in the USA. It is completely overpriced, inefficient, and only produces mediocre results. A huge, complex, bureaucratic apparatus in which everything has fallen apart and no one can see through it anymore, causing grief to both doctors and patients.

We believe that the system is on the verge of collapse if reforms do not happen soon, but we have little hope that this will occur in the near future. As is the case everywhere, action is only taken when it is already far too late. I also find it downright crazy that some people now deem it acceptable that the CEO of a health insurance company is shot in the open street, and for the murderer to be glorified as a hero because the frustration with the behavior of the health insurance companies is so great.

Obamacare has indeed improved US healthcare and led to far more Americans being insured. For example, 2024 was a record year in which over 21 million Americans had health insurance with the help of Obamacare. However, Obamacare is also part of a system with rising costs and ever-increasing monthly premiums. Most notably, the insured cannot choose other health insurance options through Obamacare; only the large, well-known insurance companies offer their contracts under Obamacare. Currently, there are still tax benefits that significantly lower premiums for most people who purchase health insurance policies through the "Affordable Care Act" (i.e., Obamacare). However, these government subsidies are set to expire at the end of 2025 unless the U.S. Congress decides to extend them.

In my opinion, a significant drawback of the American health insurance system is that employees typically receive their health insurance through their employer. Depending on the size of the company one works for, the company can offer its employees corresponding health insurance contracts, called "plans." Large companies with thousands of employees, like Apple or Google, accordingly have many different plans with various health insurance providers that offer generous benefits.

The health insurance companies are, of course, very interested in offering these companies good conditions. When Michael was still at Apple, we both had a top plan with the insurance company United Healthcare. It was never a problem to receive services because Apple always had a handle on it. Now, as is well known, Michael no longer works at Apple, and our Cobra insurance (Rundbrief 12/2022) has also expired after 18 months.

What now? Obamacare is not really an option if you have the possibility to be insured through your employer, because in this case the Obamacare-insured person always pays the full expensive premiums without subsidies. However, my school also offers a health insurance plan for me and allows me to insure my partner and children for higher monthly contributions. Now, my school is not a big company like Apple and therefore cannot offer a large number of health insurance plans. Specifically, there are only two plans to choose from and only one insurance provider, namely Kaiser Permanente.

Kaiser Permanente is a very interesting health insurance provider because it operates its own network of hospitals, clinics, and doctors. Members typically receive services only at Kaiser facilities, meaning they cannot simply choose a doctor who is not part of the Kaiser network or have surgery at a non-Kaiser hospital. Exceptions are only allowed if the Kaiser-insured individual has a life-threatening emergency and there is no Kaiser hospital nearby, or if the patient has something so complicated that Kaiser is overwhelmed, such as an extremely complex brain surgery.

However, Kaiser must first approve this. Kaiser Permanente now has over 12 million members. It operates approximately 700 medical facilities such as medical offices and clinics in nine states. Kaiser has a strong presence, particularly in California, as the company's headquarters is in Oakland, right across the Bay from San Francisco.

Kaiser operates a mixed organizational model, with the Kaiser Foundation Health Plan and the Kaiser Foundation Hospitals being non-profit organizations. This means that revenues and surpluses are reinvested back into these medical facilities. Additionally, there is a third component, the for-profit "Permanente Medical Group," where Kaiser doctors are employed.

The History of Kaiser Permanente., by the way, dates back to the 1930s. A young doctor named Sidney Garfield opened a hospital in the Mojave Desert in California at that time to treat workers involved in the construction of the Los Angeles Aqueduct. The workers paid five cents daily in advance for their future medical care. The idea of modern health insurance was born. Henry J. Kaiser, an industrialist, then collaborated with Garfield in the 1940s to offer this health model to shipyard workers in Richmond, California, during World War II. After World War II, in 1945, Kaiser Permanente introduced this health insurance model, namely the integration of hospitals, clinics, and doctors under the umbrella of a health insurance plan, to the broader population. Starting in the 1950s, Kaiser expanded beyond California and opened medical facilities in Hawaii, Colorado, and other states.

Now you must know that I had always sworn to myself never to be insured with Kaiser. For a long time, that was my absolute nightmare. Coming from Germany, it was extremely important to me to have the freedom to choose my doctor and, if necessary, to go to top hospitals like the University Hospital in San Francisco (UCSF) or Stanford in Palo Alto. I knew people who were either absolutely convinced and enthusiastic about the Kaiser system or others who avoided Kaiser like the plague because they hadn't been adequately helped in more complex medical cases, with dramatic consequences. However, since my school offered nothing but Kaiser, and after intensive questioning of my colleagues, who are also well acquainted with the German system, I heard mostly positive things, and in the end, I thought to myself, let's just give it a try.

Now one must know that Kaiser has undergone a significant metamorphosis lately. Just 20 years ago, every doctor wanted to open their own practice, which sometimes meant that Kaiser couldn't always recruit the absolute best medical professionals. However, nowadays it is completely insane to run one's own medical practice. The bureaucracy is so time-consuming and absurd, and it becomes more cumbersome every year, that many doctors hardly have any time left for their patients.

In a previous issue, I had already mentioned once that it is almost impossible to find a new general practitioner in San Francisco (Rundbrief 10/2023). As a patient, you often have to wait weeks and months for an appointment, whether it's with a general practitioner or a specialist. For example, I used to go to a gynecologist at the UCSF university hospital. Getting an appointment with her required a lot of advance notice and planning. You see: it doesn't help the patient much if the doctor is an expert but the patient can't get an appointment. That's why more and more doctors are choosing to work in group practices. The Kaiser system, as a very large group practice, is particularly attractive to many doctors because they don't have to deal with various American health insurance companies with hundreds of different plans, but instead operate as employees within one system. Interestingly, Kaiser is now attracting better and better doctors.

But now back to our personal experiences at Kaiser. First of all, I sent Michael, who is known to be more flexible and has more time nowadays. He was impressed by the efficiency and a system that is relatively patient-friendly.

Michael chose a primary care doctor at the state-of-the-art Kaiser facility in the Mission Bay neighborhood. The general thread at Kaiser is that the primary care doctor is the central point of contact who takes care of all health-related matters and coordinates them, such as referring you to a specialist or for a blood test. As a new Kaiser member, you first select a primary care doctor through the patient online portal. There is also the option to receive advice on this by phone, but we did it online. The portal provides the doctors' resumes and indicates whether they are still accepting new patients.

With one click each, we selected our primary care physicians. It is very easy to change your primary care doctor later if you want, which can also be done through the portal. Women are allowed to choose a primary care doctor and a gynecologist and do not need a referral from their primary care doctor if they want to see their gynecologist. At Kaiser, the primary care doctor is not isolated in their practice; you should imagine the whole thing as a huge medical center where everything is under one roof: primary care doctors, internists, orthopedists, dermatologists, gynecologists, and ear, nose, and throat doctors. The radiology department, pharmacy, and laboratory are also all part of the same system. The doctors all work together since they are employed by Kaiser and all have access to the patient records.

Doctors aren't paid based on the individual procedures they perform on the patient, but simply receive a salary. This means that doctors have much more time for their patients and do not have to rush them through in 10-minute intervals to keep their practice running. Kaiser places great emphasis on prevention and generally has a good reputation in this area. Appointments are relatively easy to get. Patients can usually choose whether they want a video conference or an in-person visit. Video conferences are suitable for follow-up appointments to discuss results or are practical if you don't want to sit in a waiting room with the flu, although sometimes it is important for the doctor to examine you in person.

Meanwhile, I've visited with my general practitioner and it was great. In the USA, it is quite common to have an annual check-up that includes a blood test, listening to the lungs, measuring blood pressure, etc., which I signed up for to get to know the doctor. She took a lot of time for me and first chatted extensively about what I do for work and my Christmas plans. For the blood test, I simply went three floors down. I have to say that I've had to somewhat revise my prejudices about Kaiser, although I still worry about what will happen if I ever have something super complicated, because the best system only proves itself when you are really sick.

What many insured individuals particularly appreciate about Kaiser is that the hassle of dealing with unexpected bills is generally reduced, as everything takes place within the same network. In this regard, we have already experienced quite a bit with various other health insurance companies we have been insured with, and the Kaiser system is significantly less nerve-wracking.

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