To think it is terrible that Americans with health insurance have such high deductibles

[crunchymint]

I have been reading this article about American healthcare.

www.motherjones.com/politics/2018/01/go-fund-yourself-health-care-popularity-contest/

It says -

"With health care costs and high-deductible plans on the rise for more than a decade, medical expenses are the largest single cause of bankruptcies nationwide. Despite Obamacare’s efforts to rein in costs, the average deductible on a typical plan under the Affordable Care Act is $2,550—nearly as much as the entire monthly take-home pay of the average American worker. President Donald Trump’s efforts to destabilize Obamacare have already raised premiums, and experts predict the cost of a deductible under some versions of Republican health care legislation would rise to an average of at least $4,100."

Basically when someone has health insurance, they still have to pay a certain amount out of their own pocket. Typically they have to pay a certain amount to visit a Dr and for any treatment - with insurance covering the rest. So even someone with insurance who has a chronic or serious illness, still has to pay a substantial amount of money out on top of their insurance premiums.

Paramedics and ambulance ride bills in the US…. Don’t get me started.

I believe in capitalism but that topic will have me screaming The Internationale in my driveway like a mad woman.

@PrincessNutella not sure what you have picked up about medical training in the UK. It is longer than US systems.

5 years as undergrad (many do 6).
2 years as Foundation Doc (to get registered with GMC)
2 years as core trainee (general medicine 2 yrs, surgery 2 yrs, anaesthetics used to be 2 years)
5 years as specialty trainee (general medicine 5 years, surgery 5 years, anaesthetics 5 years)
usually an additional fellowship will be completed too to get an additional competitive edge for consultant posts
End = fully fledged hospital specialist in 14 years.

US system
1st degree - 3 yrs
2nd degree (MD) - 4 yrs
Intern - 1 year to get registered now largely abolished i understand & incorporated into residency
Residency - 3-7yrs (General medicine 3 years, 5 years surgery, 4 years anaesthesia)
Fellowships (optional) last 1-3 years.

Training times
General Medicine 14years (UK) vs 10years (US)
Surgery 14 years (UK) vs 12 years (US)
Anaesthetics 14 years (UK) vs 11 years (US).

Applications to medical school and training programmes are competitive in both countries.

I'm surprised that people are surprised by this.

I'm an anaesthetist. When I go to US conferences I'm constantly surprised by the rationing of care that goes on / lack of availability of equipment/ drugs. I think i you work somewhere swanky eg. Boston Children's this doesn't happen but in more deprived areas it definitely does.

There wasn't a huge variation when I trained between DGHs/ tertiary centres for kit/ drugs etc.

I also really really worry about the amount of over investigation/ over treatment that goes on in the US system for those with good insurance vs. the very limited care for those without. I would hate to work in that kind of system. I also like that my patients never ever have to ask how much something might cost.

My understanding is that Medicare (I might have got the wrong name - the scheme for uninsured individuals) is budgeted for at a state level and some states provide virtually no care at all.

Proving the effectiveness of treatments before implementing them is a really important tenet of healthcare and is why the UK has NICE and technology assessment etc. We don't spend money on stuff unless it works. And sometimes for oncology drugs etc. this process can feel too slow for patients but it exists for reason. My understanding is that in the US if you are insured and you want a particular treatment you will get it even if it really doesn't actually offer much of a treatment advantage. Surgeons also seem to carry out procedures that have very little to offer.

WRT surgical procedures this can cause real harm as every surgery comes with procedure and GA risks. Why take the risk if the likelihood of benefit is very low?

US system - 1st degree - 3 yrs.

I'm not sure where this bit comes from. You need a bachelor's degree to apply to medical school in the US, which takes four years, not three.

It would have been helpful to cite the source you were using.

My understanding is that Medicare (I might have got the wrong name - the scheme for uninsured individuals) is budgeted for at a state level and some states provide virtually no care at all.

There are two parts to this programme. Medicare, which is a sort of generalised care for ages 65+, and Medicaid, which is for low-income individuals. Both of these are administered at the state level through participating private insurers in each state, so the funding, the qualifiers, and the level of care varies depending on where you live.

There is no actual blanket programme for uninsured individuals, and unfortunately it is very possible to be too rich for Medicaid and too poor to purchase insurance, even with the subsidies the Affordable Care Act put into place. And again, even if one IS able to purchase insurance, there's no guarantee that it will cover what it needs to cover or that you can afford the deductible -- the cheapest plans have the highest deductibles.

@MauveMavis

You’re thinking of Medicaid. Medicare is for the elderly.

My understanding is that Medicare (I might have got the wrong name - the scheme for uninsured individuals) is budgeted for at a state level and some states provide virtually no care at all.

Medicare is the program that provides medical coverage for those age 65 and older. It is funded at the Federal level, using payroll taxes that pay into a fund.

www.medicare.gov/about-us/how-is-medicare-funded

The program you are probably thinking of is Medicaid, which is funded jointly by the Federal government and the states, and administered by the states. Federal rules require that state programs provide certain benefits and eligibility rules. States are free to make their programs more generous if they so choose.

www.medicaid.gov/medicaid/financial-management/index.html

@MauveMavis I agree about the over treatment in the US.

I had a particular condition. I saw a consultant privately through BUPA. He told me the potential treatments were a, b and c.

A may have no effect, b would be temporary, c was surgery but was the only effective permanent cure.

My friend in the US by complete coincidence had exactly the same condition several years after me. She asked me about it. She was also told about a, b and c. What she wasn’t told was the outcomes. She opted for a on her doctor’s recommendation. After suffering pain for 6 months she then opted for b. 6 months later she had surgery.

My impression was that they wanted to get as much money as possible from her before the final treatment. She suffered for a year longer than necessary if she had been given the same advice as me and opted for surgery as the first treatment.

[quote Twentypast]@MauveMavis I agree about the over treatment in the US.

I had a particular condition. I saw a consultant privately through BUPA. He told me the potential treatments were a, b and c.

A may have no effect, b would be temporary, c was surgery but was the only effective permanent cure.

My friend in the US by complete coincidence had exactly the same condition several years after me. She asked me about it. She was also told about a, b and c. What she wasn’t told was the outcomes. She opted for a on her doctor’s recommendation. After suffering pain for 6 months she then opted for b. 6 months later she had surgery.

My impression was that they wanted to get as much money as possible from her before the final treatment. She suffered for a year longer than necessary if she had been given the same advice as me and opted for surgery as the first treatment.[/quote]
It is entirely likely her insurance company, rather than the doctor, had more of a hand in the decision.

Insurance companies decide on approved pathways for treatment -- i.e., you have to try the treatments they recommend or have a specific diagnosis before you have a chance of having the next thing approved. Her doctor probably isn't the one in the office dealing with the insurance companies directly, but has probably had patients come back and say their insurance company won't approve C, what else can we do?

As far as the motives for making people suffer instead of just getting the best treatment recommended by their care team, that's certainly down to money.

It's also just general medical practice to start with more conservative treatments. Before I had my recent hip surgery (an IT band release) I had to try cortisone injections and physical therapy. For some patients, those are enough.

Yup you are right. I was thinking about medicaid.

I heard a fascinating talk at a conference from a doctor who worked for her state administering the scheme. She compared what was available in her republican state (Texas) with other states. You had to be have an extremely low income to be eligible in her state for care. Other states provided support at higher levels.

I found it very very sobering.

@MissConductUS apologies - I looked at wikipedia and some of the US medical training sites and my own knowledge from interacting with US colleagues at conference/ colleagues who have moved to work in the US.

To give an example of the difference in training time someone I was at university with - non medic -graduated and moved to the US 3 years before I completed medical school in the UK.
In the US he completed a science PhD, did medical school, his cardiology residency and a fellowship and became an attending while I was still undertaking UK anaesthetic training!

She compared what was available in her republican state (Texas) with other states. You had to be have an extremely low income to be eligible in her state for care. Other states provided support at higher levels.

One provision of the ACA (Affordable Care Act aka Obamacare) was an expansion of Medicaid eligibility. Because the states pay half the cost, the ACA offered federal money to pay for the increase in the state's share for three years. To date 39 states have adopted the expansion and 11 have not. Medicaid expansion brought more people into the insured population than any other provision of the bill. It's quite possible that the other states will elect different leaders who will accept the offer at some point in the future.

It is terrible, especially when you consider those deductible averages are on a per person basis...not a per family.

But it’s been that way for ever in the US. I lived there for a few years and our health plan had a $7500 deductible as it was a family plan. That is also per calendar year...so say I went into hospital in December and come out in January, id have to pay $15k before any costs covered....

But the Americans love it that way...most of them thought nationalised health meant dying while in wait lists or dying because a government official rejected treatment. They really do not know any other way.

But the way I see it is this. I pay considerably less tax than I did in the UK. I’m on a salary of $125,000. In the UK I think that would put me in the 40% tax bracket. My total deductions last year for tax and social security were less than 9%. My take-home pay is much bigger than someone on the same salary in the UK.

I rarely use my entire deductible each year. Even if I used up my enforce MOOP I would still be paying less than you pay in taxation in the UK.

@BritWifeInUSA

But the way I see it is this. I pay considerably less tax than I did in the UK. I’m on a salary of $125,000. In the UK I think that would put me in the 40% tax bracket. My total deductions last year for tax and social security were less than 9%. My take-home pay is much bigger than someone on the same salary in the UK.

I rarely use my entire deductible each year. Even if I used up my enforce MOOP I would still be paying less than you pay in taxation in the UK.

I guess the point is really that although this works out well for you (healthy, high earner) it doesn't work well for the unhealthy low earners in society. The reason you are paying less is that you are paying only for yourself (and your high earning job gives you access to insurance that pays most of it anyway). I would feel uncomfortable about that and I also pay 40% tax and would not mind paying more for better services. I don't think access to healthcare should be dependent on being rich because I think that is actually worse for society than a system in which we are all paying for each other. I suppose it's all down to whether you want to be part of a society that at least tries to look after everyone or one in which it's every man for himself.

@BritWifeInUSA and that mentality is what perpetuates a system that means that the person who serves you your morning coffee, or washes your car(s), or cares for your kids, cannot afford to get sick.

It's a broken system, but sadly Americans seem wedded to it.

American with high deductible plan with a health savings account.

For a couple years my daughter was on a very expensive injectable medication and I hit the deductible of $3000 by February and then pretty much everything after that was minimal. I can put up to around $6500 a year into the HSA. More now that I'm a bit older.

Deductible has since gone up but in the long run it's cheaper than the "regular" medical insurance plan.

Also I broke my finger and son broke his collarbone in same year which was excellent planning on our part. 😬

Our health savings accounts are triple tax advantaged; money taken out of paycheck before taxes, withdrawals used for medical expenses are tax free, and you can put the money in various mutual funds and that grows tax free as well. You get a debit card that's very convenient for payments.

I have managed to accumulate quite a bit in the few years I've had an HSA. If I keep adding to it I can use it during retirement as well. It's my money and it's portable if I should change jobs.

But, this is really only doable for people with good jobs who are able to save and plan and have enough to cover somewhat larger expenses, especially in the first year before you've accumulated funds.

For instance, I have nearly $15,000 right now in my HSA and I have most of it invested in a balanced fund, with some as cash. I can also use the money to buy eyeglasses and pay for the dentist. The funds have been doing very well.

Poorer people cannot really afford the "affordable care act" plans because of the high deductible and because they don't have spare income to throw into an HSA. They might also not know that they can invest HSA funds in mutual funds. Heck, even my well-educated coworkers didn't realize you could do this and I suspect they are missing out on some serious growth on their funds.

But I digress.

The reason the Republicans will never allow socialized or universal healthcare here in America is because they pretend they hate "socialism" unless they personally benefit from it, and I suspect it's because the Republicans are being paid by health care lobbyists to never ever agree to ever change our system because "health care" is too big a business.

Our EDs continue to be abused for every health care problem one can imagine because people don't have a primary doctor, and this also drives up the cost for everybody.

The insurance companies can be pretty evil, too.

I love the American system. I’ve received nothing but top notch care. I can go straight to a specialist without screwing around with a pcp ‘(gap equivalent) and don’t find it at all expensive.

They tried the gatekeeper thing for awhile, but it largely failed, because it wasn’t allowed to gatekeep gynecology services, and a lot of people (myself included) used that loophole to set my ob/gyn as my my pcp, so they were more than willing to sign off on a referral with a phone call to my foot dr, or ENT.

I pay $25-50 for a dr visit, low end pcp, high end a specialist. I pay $100 for an ER visit unless I’m admitted.

My husband had several surgeries on his knee. Average wait time for appointment is ~1week maybe 2 (again, no referral) Wait time for surgery is about the same.

I’m a relatively healthy person, so all of my dr visits are sick visits, calling and seeing a dr generally happens within 24 hours.

A lot of the horror stories are anecdotal and don’t represent the norm. I pay low taxes and moderate insurance premiums and am very happy with what I get.

Oh and when my mum called 911 2 weeks ago, the response time for an ambulance was about 3 min. Just shy of the 4 min average in the US. And that is the average for all calls, it’s not graded on the response time to the type of call. So granny needing picked up receives the same response time as a pulseless/non breathing patient.

My sister has lived in the US for decades. A few years ago she cut a finger very badly, needed an ambulance to hospital.

I said, well, at least you’ve got insurance.

She said, ‘You’re joking - there was a $2000 excess.’

I think the clearest example is that 66.5% of all bankruptcies in the US are related to medical issues. If you get sick, it doesn’t matter how much you’ve saved, if you have a house, etc. It will take everything from you. Imagine them taking your house for medical expenses. There are SO many sick people who then become homeless. It’s very, very dystopian.
www.cnbc.com/2019/02/11/this-is-the-real-reason-most-americans-file-for-bankruptcy.html

Quite normal here too. Many families pay more for health insurance than they do for their mortgage.

We 'run out' of day to day benefits by about March/April every year. We are covered for hospital visits though. So everything apart from a hospital admittance from March/April on is paid for out of our own pockets. This is dr visits, medication, physio, dentists etc etc.

The one benefit we have is that our healthcare is excellent. But we pay for the pleasure.

It's very expensive to be ill.

Indeed.
Or you can be like my dbro. Had health insurance through work, had illness, his deductible went up and up. Moved employers. He had to pay 600 dollars a month towards health insurance. Lost his job during covid. Now no health care at all.

@CraftyGin

It would be much more interesting to hear from Americans who are under-insured, rather than those who gloat.

They aren't gloating--they are saying how it is, for them. People have different experiences of the US healthcare system, just as they do of the NHS.

Who benefits the most, the hospitals or the doctors/consultants?

Insurance companies and big pharma.

Germany has a pretty good system unless you are self employed. If you are self employed then health insurance is very expensive and it isn't charged on a sliding scale of income so you'd pay the same if you were earning 10k pa or 40k pa. Tbf all taxes and insurances here are way higher if you are self employed. There's no perfect system IMO.
Interesting perhaps that results in fewer entrepreneurs - I've no idea if that is the case but I would imagine it might then be that fewer set up their own businesses.

Education in England is narrow with high standards so a doctor wouldneed (guessing here) A* Chemistry, Physics/Biology, Maths and ? English. US is broader and to lower level (different states differ).

But the UK had to change it's employment laws in the 1990s?? to be in keeping with EU regulation and the long shifts of several days and nights that trainee doctors did was reduced or done away with.