Guest Post: Making sense of the U.S. healthcare system by Tammy Rome

This week I am very excited to participate in a “blog swap” with the wise and talented Tammy Rome of migraine.com and sevenportions.com.

To provide my Canadian readers with a taste of what it’s like to navigate chronic pain for our neighbours south of the 49th parallel, Tammy’s post is all about making sense of U.S. healthcare. To see my post on dealing with the Canadian healthcare system, visit Tammy’s comprehensive blog all about chronic pain and healing at brainstorm.tammyrome.com.


 healthcare_US

Making sense of the U.S. healthcare system

My friends who live in countries with socialized healthcare are often shocked by the complex healthcare system in the United States. It used to be a lot simpler and much more affordable. Over the decades it has become complicated by attempts to “make it better”. These efforts have all had unintended consequences that make the system more complex and difficult to access for those living in poverty, especially in rural areas.

It used to be that doctors treated generations of a single family. They made house calls, delivered babies, nursed the sick back to health, and attended the dying…all for a modest, affordable fee. Advances in science and the introduction of health insurance increased costs and red tape. Even so, growing up in the 1970s, I remember healthcare still be being relatively affordable and accessible. Most insurance plans were “indemnity plans” that covered 80% of all costs after a modest deductible. The premiums were subsidized by employers to keep the costs for low.

Things began to change in the 1980s when Managed Care and Health Maintenance Organizations offered to lower costs for both the insured and the insurer by creating pre-approval processes for expensive or elective procedures. The result was devastating. Patients were denied life-saving care and their surviving family members often sued the insurance company. On the physician side of the equation, malpractice insurance rates rose so high that many family doctors stopped performing riskier procedures, such as childbirth.

A deluge of new, pricier drugs came to market offering better relief from a variety of ailments. Then pharmaceutical companies were permitted to market direct to the patient. Television commercials and magazine ads sprung up for everything from Viagra to Rogaine. Patients were confused by all the new information.

Then high-tech medicine arrived with an even higher price tag. Doctors could now detect heart disease and cancer at early rates. Life-saving treatments prolonged our lifespan well into the 90s. You might survive that heart attack or stroke now, only to be saddled with astronomically high medical bills. Bankruptcy was often the only option. People lost their life savings, their homes, and their dignity. The price of prescriptions rose so high that senior citizens on Social Security were forced to choose between food and medicine.

We had big problems. Starting in the 90s with President Clinton, the Democratic party pushed for a nationalized healthcare program. Republicans argued that our government could barely maintain the public healthcare systems currently available (Medicare, Medicaid, and the Veterans Administration). They warned of high costs, long wait times, and more service denials. Back and forth they went for two decades and three presidents, until President Obama, aided by loyal Democrats pushed through a gigantic (and largely unread) healthcare reform bill in 2012.

Affordable Healthcare Act

This new law promised to make health insurance more affordable for all Americans. It also promised to make reproductive care available with every insurance plan, remove pre-existing condition limits, and allow parents to include adult children on their plans up to age 26. When the first phase launched in 2014, there was a lot of confusion and even more problems.

The process was based on the idea that people could visit a website to enroll, take advantage of premium subsidies, and compare available plans. But the websites didn’t work very well and people had problems just signing up to look around. The deadline to choose a healthcare plan kept getting pushed back because of the many glitches with the online enrollment system.

When people finally did gain access to the websites (each state had their own), they were shocked by the price tag. Prior to the passage of ACA, a typical premium for a family of four was $200-300 per month with an annual deductible of $1000-$2500. These were called High Deductible Plans and tax payers were permitted to save up thousands in a Health Savings Plan (bank account) for future use.

Now, typical premiums are 2-4 times higher with an average deductible of $10,000 per year. The projected average cost per household is over $20,000 per year. Lower income families may qualify for a subsidy that helps pay for your premiums. If you choose not to purchase health insurance, the Internal Revenue Service (IRS) will levy a tax penalty against you when you file your annual income tax return. The tax is small right now and there are many exemptions. However, the tax is projected to increase dramatically over the next few years.

Uninsured

Can you believe that after all of this, we still have millions of citizens without health insurance? Although supporters of ACA claim that everyone can be insured, the reality is not so positive. Many middle income families earn too much to qualify for premium subsidies, yet still cannot afford the cost of health insurance.

Just to cover my husband and son, we have two options:

  1. Employer-provided coverage at $700 a month with a $10,000 deductible
  2. ACA-sponsored plan at $500 a month with a $1500 deductible.

My husband earns just a bit too much to qualify for a subsidy, but not nearly enough to afford these rates. We’ve done the math. It’s cheaper right now to pay out of pocket for our estimated expenses. Sure, we take a chance on some emergency, but those dollars only stretch so far.

Part of the problem is that ACA requires all insurance plans to cover reproductive services. Not everyone needs these services, yet they are paying for them anyway. Prior to the implementation of ACA, individuals could choose a less expensive plan that did not cover reproductive services. Because of all the additional requirements, premiums have jumped very high.

Some employers are still able to cover a majority of the cost, while many smaller businesses simply don’t have the funds to help pay part of the premiums. That leaves many individuals weighing the cost of health insurance versus the tax penalty for not having insurance. Some, like my family, have concluded that paying the penalty is more affordable.

Getting help out of state

Most insurance plans are restricted to a small region. Patients must often seek prior authorization in order to see a specialist out of state. Travel expenses are almost never covered. They are tax-deductible if you itemize your deductions. However, ACA has increased the minimum to itemize medical expenses up to 10% of your annual income. So a typical family of 4 with a $40,000 a year income would have to spend $4000 out-of-pocket in order to take advantage of this savings.

Medicare

Medicare is the health insurance program available to retired and disabled individuals. Every U.S. worker is taxed to help pay for Medicare with every paycheck. It only covers about 70% of all costs, so most people opt to pay for a Medicare supplement plan through a private insurer. Low-income may qualify for Medicaid, too. There are also assistance programs to help defray the cost of premiums.

I recently qualified for Medicare coverage. This is a benefit that I have been paying for since I started working at age 16. Now that I am disabled and have met the mandatory 2-year waiting period, Medicare will start March 1st. Because my husband is still earning a decent paycheck, I don’t qualify for subsidies. I will pay a $140 premium plus another $25 for a supplement plan out of my monthly Social Security Disability Income (SSDI) check. It sure beats the almost $250 a month I was paying for an insurance plan with a huge deductible. Prescription medicines will be more affordable, too. Unfortunately, not all of the medically-necessary treatments are covered. There are still plenty of things I will have to pay cash for.

Medicaid

Medicaid is funded by both federal and state government. Benefits and qualifications vary by state. It is available to low-income families and individuals who might otherwise go without coverage. Fewer doctors are willing to accept Medicaid (or Medicare) patients because the reimbursement for services is insufficient to pay their costs. There are long wait times for services and many services are not covered. It’s better than nothing, and probably a lot like the socialized healthcare programs in other countries.

Shortage of headache specialists

There are over 36 million migraineurs in the U.S. and yet only 416 headache specialists. They are concentrated mostly in the northeast. Some states don’t even have one specialist! Most patients rely on their primary care physician or general neurologists to treat migraine. Obviously this means that many are subject to sub-standard care, only getting referrals to the experts when their condition is out of control. This is a sad state of affairs given that headache experts tell us that early intervention is the best way to prevent the development of the difficult-to-treat, Chronic Migraine.

The silver lining

There is one bright spot in the whole mess. Emergency rooms are still required to treat patients whether they can afford to pay or not. Not so good for hospital finances, but a relief to uninsured patients facing an urgent, life-threatening health crisis.

I am more fortunate than many to have competent care from professionals who really know my family. We have had the same family doctor for over 18 years. My headache specialists are true professionals who are experts in the field. I haven’t experienced the long delays, insurance denials, and medication shortages that many of my friends have faced. For example, Botox was approved in just three weeks without any trouble. Sure, it’s expensive, but at least I have access to what I need.

One comment

  1. thanks very informative blog

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