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| Angelika/Mike Schilli |
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Every time we sit down with American friends, the topic of the dismal American healthcare system inevitably comes up. The better-informed Americans know and envy the fact that almost all European countries have a single payer health insurance system for everyone. Michael immediately rolls his eyes, knowing that I could discuss this tiresome topic for hours.
Even after almost eight years, I still haven't gotten used to the pitfalls of the American healthcare system. Until now, I was firmly convinced that it would never come to the point in Germany where the American system, which is outrageously expensive and simply a disaster, would be adopted. However, when I look at developments in Germany, such as the in person visit copay, online pharmacies, and dental services, I'm not so sure anymore.
Michael and I always joke that if we ever return to Germany, we won't need to make a big adjustment. Don't get me wrong: of course Germany needs reforms, but I don't quite understand why people look to America in this regard, whose system has been up against the wall for decades. Why not look to Scandinavia? I'm very much in favor of mandating for anyone in the German health ministry proposing changes based on the American model, that they visit an American doctor and an American hospital at least once beforehand. Naturally, this would include dealing with the American health insurance system. They would never spout such nonsense again.
We have repeatedly pointed it out to you: There are millions of working Americans who have no health insurance or are not adequately insured. Currently, 45 million (or 15.6% of the American population) have no health insurance--a record-breaking number.
This army of uninsured people has always existed. However, the recent increase is primarily due to the aftermath of the economic downturn, which is only slowly subsiding. In the U.S., losing your job also means losing your employer-provided health insurance. Although employees can choose to continue paying for their health insurance voluntarily, which I will explain in more detail later, it is expensive and unaffordable for many who no longer have a steady income. Even if you receive unemployment benefits--yes, those exist in the USA as well--you are not automatically covered by health insurance.
Secondly, the number of Americans without health insurance is increasing because insurance premiums have skyrocketed in recent years. Many small and medium-sized businesses can no longer afford this "luxury" and no longer offer health insurance to their employees. Other companies are increasingly passing on the rising costs to their employees, which leads to higher monthly contributions and greater out-of-pocket expenses for them. The problem with the U.S. system, however, is that companies (except in Hawaii) are completely free to decide whether and under what conditions they offer health insurance to their employees.
This is how it happens that companies cover the cost for health insurance entirely, partially, or not at all. Yahoo!, for example, has been paying it all for both of us up to now. Starting in 2005, Michael and I will pay $20 a month together, and Yahoo! will sponsor the rest of the premium. For comparison, our monthly contribution at AOL was $180. At Yahoo!, we can choose between two health insurance companies, and with one of the companies, we can choose from three different plans that differ in terms of co-payments, deductibles, choice of doctors, etc.
In general, the better the company, the better the health insurance options and conditions. Since companies pick the health insurance and models they choose, changing jobs usually means that the employee has to switch health insurance, which can result in the doctor they used to visit no longer being affiliated with the new health insurance. This is different in Germany, where the employee decides which health insurance they want and retains it even when they change jobs.
By the way, on November 2, Californians once again voted on several propositions. Proposition 72 aimed to require companies in California to offer health insurance starting at 50 employees and to pay 80% of the premium starting at 200 employees. Unfortunately, Mr. and Mrs. Californian were lulled by Arnie, who railed against the proposition, and they voted against it. How stupid can you be! Hawaii is the only state that has had a similar law to the proposed Proposition 72 since 1974. No wonder we like it so much there.
Why is it, then, that healthcare costs are exploding in America? As in other industrialized nations, people are living longer and high-tech medicine is continually improving, leading to new and expensive treatment methods.
Then there's the fact that, as is well known, Americans like to go to court. Doctors here fear nothing more than overlooking something and getting hit with a lawsuit for damages. That's why they pay for expensive insurance policies. Naturally, the money has to be recouped somehow.
I also think that the fear of making mistakes is associated with doctors here strictly following a set pattern. If the patient complains about certain symptoms, then this and that must absolutely be done. The automatic reach for the prescription pad also always makes me quite annoyed. It's as if the motto is: The patient is only happy if I prescribe them a pill. Antibiotics are still considered a cure-all here.
Of course, the insured pay for the uninsured as well. Even in America, the medical profession swears the Hippocratic Oath and does not let anyone bleed to death or die. The so-called "Emergency Rooms" (comparable to the emergency admissions in German hospitals) are obligated to treat anyone who "arrives with their head under their arm."
Many uninsured individuals go to the emergency rooms with non-life-threatening conditions because they don't know where else to go, which, of course, ends up being more expensive for the public than a doctor's visit in an office. Naturally, even patients without insurance are billed. However, where there is nothing, nothing can be collected. Therefore, the bills for the insured are slightly increased to compensate for the loss.
The county hospitals (community hospitals), i.e., public hospitals, also do not turn away anyone who does not have health insurance. In San Francisco, the "General Hospital" falls under this category. The hospital administration then negotiates with the patient regarding what they can pay by having the patient disclose their income and financial situation.
The last significant reason for the explosion in costs is the bloated administrative apparatus of the various health insurance companies. Since there are numerous different plans, all of which vary in terms of services and patient co-payments, a large number of people are needed to oversee them. When you make an appointment with a doctor, the receptionist not only asks which health insurance you have but also which plan of the mentioned insurance it is, even though they themselves may not be familiar with it, despite dealing with it every day. Another popular question quickly follows: "And don't you need to see your primary care physician first to get a referral to a specialist?" Aaaahhhhh!!!!
So it remains an unsolvable task to explain all health insurance plans. But I will try to tackle the main models. There once was the following simple model: The patient goes to the doctor or hospital of their choice, and the health insurance pays the rate charged by the doctor or hospital, minus a deductible that the patient covers. Those were the days.
Today, health insurance companies want to cut costs and have more say, which has led to what is known as "Managed Care." Its most important principle is that the respective health insurance company negotiates fixed rates with doctors and hospitals, and the patient is generally only allowed to go to these contracted doctors and hospitals. On the statements that patients receive from their health insurance, they can see the price difference. For example, my internist charged $170 for a visit with a vaccination booster. However, he only received $116 because that was the agreed rate. Additionally, certain - usually more expensive - treatment methods, such as surgeries, must be preapproved by the health insurance company. And that's where the problem lies, because the health insurance company is not independent. After all, it wants to make a profit.
With the "Preferred Provider Organizations (PPO)" model, which we currently have, I can, in principle, visit any doctor. However, I save a lot of money if I go to a doctor who is contracted with my health insurance. Generally, doctors and hospitals enter into contracts with various health insurance companies. But how do I know if my doctor is part of the network? The major health insurance companies have an online directory of doctors and hospitals that you can check. This can also be done by phone, but it usually takes more time because you have to navigate through an annoying phone menu first.
Even if I pick a contracted doctor, an in-office visit fee (called "co-payment" in America) is due at each doctor's visit, unlike in Germany where it is once per quarter. We currently pay $15 (varies by insurance company) per visit. Additionally, there is an annual deductible, which in our case is $250 per person, and it is due when we need X-rays, surgeries, and the like. After meeting the deductible, our insurance covers 90% for those procedures. cases. We pay 10%. Paying 10% of $1,000 is manageable, but 10% of $100,000 is not so easy, which is why the plan limits how much we have to pay out of pocket per year ("out-of-pocket maximum"): $1,250 per person in our case. However, the in-office visit fee does not count towards this.
To illustrate, here's a small example. Let's assume someone gets sick and the hospital bill amounts to a total of $10,000. With the Yahoo! plan we have, we pay a $250 deductible, leaving $9,750. 10% co-insurance of that is $975, so we would have to pay $250 + $975 = $1,225 ourselves, as the maximum ($1,250) has not yet been reached.
Next, the "Point of Service (POS)" model, on the other hand, incorporates the family doctor as a coordinator, meaning the patient commits to always visiting their family doctor first, who will refer them to specialists, whether affiliated with the health insurance or not, if necessary. Here too, the patient incurs lower costs if the family doctor refers them to experts who are contracted with their own health insurance ("in network"). To my knowledge, the family doctor model is also making a comeback in Germany. The idea is that the family doctor holds the reins, knows their patient, and thus prevents unnecessary specialist examinations.
In the third variant, the "Health Maintenance Organizations (HMO)," the patient is only allowed to visit contracted doctors or hospitals; otherwise, the health insurance won't pay for it. Here too, the family doctor usually coordinates upcoming treatments. In its purest form, the HMO even goes as far as the health insurance owning its own hospitals and the doctors being employees of the health insurance, as is the case with Kaiser Permanente. Everything is under one roof. If the patient needs a specialist or lab tests, they are referred internally. Although the choice of doctors is limited, the insurance covers 100% of all costs after a small co-payment. Many patients love this model because it is quite simple in terms of billing.
Another model, the "Self-Insured Health Plans," is becoming increasingly popular, especially among larger companies. The company pays money into its own fund and covers the cost for its employees in case of illness.
The latest trend are the so-called "Health Funds," which various health insurance companies offer in conjunction with employers. The company pays a certain amount per year to the health insurance provider for the respective employee, which the employee can use for incurred costs in case of illness. If they do not use up the fund, the money is carried over to the new year. Once the annual sum is spent, the employee initially pays a higher deductible before the regular insurance covers additional costs. The idea behind this is: The patient acts as their own health manager, deciding when and for what they spend money at the doctor or pharmacy. We could also choose this plan starting in 2005: Yahoo! would pay $1,125 into the fund for both of us. The annual deductible would be $750 for the two of us after the money is used up.
In America, employees decide again at the end of each year which health insurance model they will choose for the coming year. This is also because something always changes. It should be mentioned in passing that dental or eye doctor and glasses insurances are usually separate from the health insurance.
But what does the poor soul do who loses their job and thus their health insurance? The COBRA law (= Consolidated Omnibus Budget Reconciliation Act) comes to the rescue in the USA. The law states that the employee can voluntarily remain insured in the company group insurance for 18 months if they leave the company (even if they resign themselves), as long as the company insurance covers 20 or more employees. However, ex-employees then pay the premium out of their own pocket. AOL's health insurance (without dental and glasses insurance) would have cost us both $643 monthly under COBRA.
Completing COBRA is not only sensible in order to be covered in case of illness, but also to avoid a gap in insurance coverage, for example, if you take a creative break between two jobs. This protects you from being burdened with so-called "pre-existing conditions." "Pre-existing conditions" include all illnesses that were diagnosed or treated six months before joining a new health insurance plan, which can result in no treatment being paid for these illnesses for the first 6-12 months.
The pharmacies located in supermarket chain locations like "Safeway" or drugstores like "Walgreens" and "Rite Aid" surprised me on my first trip to America. Traditional pharmacies, as they are known in Germany, are now on the verge of extinction in America.
Every tourist is amazed by the 100-tablet pack of aspirin on the supermarket shelf, which the customer can even get at a very reasonable price. However, I boldly claim that the stuff is not as strong as in Germany, because headache sufferers usually have to swallow two tablets for it to work. In contrast, prescription medications have completely astronomical prices in America.
The pharmaceutical industry takes advantage of the living with the argument that the high profits are used to develop and test new medications. Oh, really! How important it is, then, that one's health insurance covers prescription medications. To save money, health insurance usually requires the doctor to prescribe so-called "generics" whenever available. This simply means that the patient does not purchase the medication under the original brand name of the manufacturing company, but rather a non-branded product that contains the same chemical ingredients but costs only a fraction.
The drugstore chain "Walgreens" dispenses these "generics" in "stylish" orange plastic containers (see Figure 4). No original packaging or anything of that luxury. You will also search in vain for the classic, neatly folded package insert. However, Walgreens does include a similar, self-made leaflet that describes the composition of the medication, how to take it, what side effects it may cause, and how much the insurance paid for the medication.
The insured also pay the prescription fee. The amount varies depending on the health insurance provider and the specific plan you have chosen. With our new health insurance, Aetna, we pay 5 dollars out of pocket for generics and 15 dollars for brand-name drugs, which we only receive if there is no corresponding generic available.
I find the option of "refill" (refilling) quite practical and consumer-friendly. The doctor then writes on the prescription how many times a patient can refill the medication without having to present a new prescription. This saves annoying doctor visits just because the medication you take regularly is running low.
Finally, I can't help but make a few critical remarks. I am shocked every time by how the doctor's offices look here compared to those in Germany. There's nothing like stylish furniture and tasteful waiting rooms. The treatment rooms are often tiny spaces where only the doctor and the patient can fit--scratched and dented medical cabinets are not uncommon. I admit that a designer desk or the size of the waiting room doesn't say anything about the quality of the treatment. But the height of tastelessness is represented by the fabric or paper gowns that look like hospital nightgowns, which the patient puts on so they don't have to face the doctor completely naked. Long live American prudery. Wouldn't surprise me if I already have been labeled as a difficult patient by some American doctors: "Oh, here she comes again, the one who doesn't want antibiotics and hates the 'modesty gown.'
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