US health care

[murf]

Would some kind American please explain your health care system especially regards dialysis patients. I know in Australia, everybody is covered for almost everything - whether PD or HD. What is the big fuss about changing your present system and why are so many people against President Obama changes to the system? Do you have to pay for dialysis and what is the score about not having health insurance?

[cariad]

There's no way any American is going to be able to fully explain this, and you wouldn't want anyone to try. Trust me. This is a huge question. I'll give you my understanding of it as briefly as possible.

We have a system of Medicare (fed gov't) that covers certain people, but only at 80% (patient would pay 20% of the costs unless they qualify for further assistance) for most services, even dialysis and transplant, and the rules for getting Medicare are a bit arbitrary. Everyone over 65 is eligible. Dialysis patients and transplant patients get it automatically thanks to some relentless advocacy in the 1970s, and people who are disabled two years can often get it, but that depends on when you become disabled. If you are over a certain age when you become disabled, you need to have work credits (you need to have earned a certain amount of income in your lifetime) in order to be eligible for Medicare. If you are someone who never worked, say a stay-at-home mother, and you become disabled at 40 with cancer, sorry. Try to hang on until you're 65.

Insurance is generally group or private. What someone like me, with a history of ESRD and transplant, wants is group. Group insurance almost always comes through work, usually what we call W-2 work (a tax form, W-2 means you are an employee, not a contractor). Laws vary from state to state, the state where we live now has no mandate that employers must offer this insurance to employees. The reason that you want group is that the employer and the insurance company must offer the same deal (with minimal exceptions) to all employees (and their families) and pre-existing conditions clauses are limited. There are no health exams.

Private insurance is an excellent way to get.... uh, hosed, is the most polite word I can think of. Some of the best insurance horror stories involve paying into private insurance faithfully for years, suffering a health crisis, and then having the insurance company pore over your application documents looking for anything they can call a pre-existing condition. There is a famous story about a woman with cancer who had her insurance rescinded because she did not declare a case of acne on her application. This is what people refer to when they say "uninsurable". Private insurance companies can and do turn applicants down all the time for not being healthy enough (preexisting conditions like ESRD, or our friend who has asthma, or our other friend with persistent migraines, or....)

Almost everything must be pre-approved by the insurance company. Anyone who calls an insurance company, regardless of whether it is group or private, will hear a recorded message saying that basically they are not responsible for whatever their own reps say, and that you must wait for formal approval. This can take forever, with all sorts of delay tactics employed. Did you know that liver transplants are considered experimental? Either did I! Until CIGNA said so, and a 17-year-old in LA died. This is what we are up against.

There are other ways to pay for health insurance, and state programs, and of course, COBRA, which is what I am dealing with now (a federal law that if you are fired or quit your job involuntarily, the company must let you continue to buy into their group insurance for a certain period of time, but you will pay much, much more than the premiums that the employees pay). I don't know all of the different rules and possibilities with health insurance, and as far as I can tell, neither does anyone else. I am sure there are exceptions to everything I just wrote. It is an incredible, self-sustaining bureaucracy.

As for why Americans fear health reform, that is an equally enormous question, and I'm not exactly sure myself, since everyone I see on a regular basis, including my GP, cannot wait for the day. The people who have the most to lose from reform (insurance companies, for example) also happen to have an awful lot of money to put toward convincing everyone that it would be the end of civilization.

Aren't you sorry you asked? 

[murf]

Thanks for the great information but all I could really say is "what a mess". I know we complain about our health system in OZ but it just does not compare.

[Malibu]

If an American's employer does not offer health insurance for whatever reason (and the reason is not always that they don't want to!) then the American would need to independantly contact an insurance co and procure their own insurance.  This would not then be 'group' insurance and it is very difficult to get.  In the case of someone with kidney disease, not even ESRD yet they simply will not give it to you at all.  So, your GFR is at 34 and dropping quick and you have no insurance.  You can pay for all the testing, lab tests, medicines (even $1000/month chemo to see if it will push your membranous gn into remission) Dr visits, hospital visits, etc out of pocket if you can afford it, or (and this scenario following is for a person who works and therefor does not qualify for gov't assistance unless everyone in the entire family stops working and becomes so destitute that they cannot feed themselves, for then and only then may you be approved for gov't assistance) you can feel awful, not pay for anythng, not get any medicine or see any Drs and sit there wasting away until you think you are ESRD, go to Dr and pay for testing.......vicious circle until you finally start dialysis and THEN you are eligible for Medicare if you or your spouse have 40 work credits.  This is what we have lived for 10 years.  Luckily we had the money to pay everything.

Ahhhhh, the USA.  But I am very thankful I live here and not in Afghanistan.  :O)

[kellyt]

Until you are a small business owner you will never understand the hardship of insurance for employers.  It's horrible and it's sad.  There is absolutely no way we could afford insurance for our employees, even if we pay 50% of the employee's premium monthly.  Plus, our employees can't, or won't, pay their 50% either, so they opt out every time.  It's so unaffordable.  We currently have Humana and it's just me and my husband.  Our employees would only accept coverage if we paid 100% of their premium and that's not possible.  We are a small business and small business makes small money overall.   I have great coverage and I'm not complaining at all about that, but the cost is outrageous and it goes up every year.  I dread Nov 2011 when I lose my Medicare.  They pick up all the difference now.   It's maddening.  But I'm not going to say we are better or worse than any other country.  They all have their problems.

[plugger]

Private insurance is an excellent way to get.... uh, hosed, is the most polite word I can think of.

I could go into my dealings with private insurance, but I'm trying to keep my blood pressure down.      However, I will leave a link to the story of a fellow I met by the name of Nathan Wilkes:

http://www.calnurse.org/media-center/in-the-news/2007/january/page.jsp?itemID=29367834

It pretty much sums up how bad private insurance can get.

[Red from Canada]

I sure don't understand the US system either.  Every country in the developed world has some type of universal health care except the US.  What are they so afraid of?

[kellyt]

Some of us don't want the Government all up in our business.

[bevvy5]

I'm so hesitant to post, as I live in Canada so don't really have a dog in this fight.  From other boards I am a part of, this is an extremely emotional issue for Americans.  I'm guessing that the majority here are in favour of some form of socialized health care, because you or a loved one needs it.

However, in another discussion that started out with a similar question, the discussion quickly degenerated to, "Why should I pay for health care for someone else?  I have good insurance."  Basically it came down to why should I have to look after my neighbour who is less fortunate than I am.  One person actually equated providing universal health care to buying new cars for everyone, which I personally found very offensive. 

And there's a huge fear of the unknown, I think.  Lots of money has been put into campaigns to scare John Q. Public.

I'm so glad I live in Canada.  For us, it's a no brainer - if you're sick and you need medical care, every person in this country is entitled to it.

[Malibu]

The fact is us Americans already pay through the wazoo for those who cannot or chose not to afford to pay for health care.  And not all of them are even Americans.  People come from Mexico and show up in our hospitals, are treated, never asked if they are a citizen, and then they go home to Mexico.  Who paid for that?  Also we pay for the people who, because they have no medical insurance and a private Dr's office will not let them in unless they pay, go to the ER for basic medical care.  This not only costs the American tax payer but also cloggs up the ER so that when we go for something real that our regular DR cannot handle we have wait hours and hours while little Jose's ear infection is treated.  (This really happened to me, I am not making it up).

One of the proposals for our health care overhaul was that if you did not carry health insurance you would be taxed extra.  Two problems with this: 1.  It implied that people who do not have insurance don't pay their medical bills.  Nothing could be farther then the truth, not EVERYONE doesn't pay.  My hubby and I have been paying medical bills for 10 years for a man with kidney disease!!! (And we don'e have insurance).  2.  No insurance co would give hubby insurance because he had kidney disease!!!  Since he was not on dialysis yet he did not qualify for Medicare.  So what in the heck are you taxing him extra for when he can't get insurance?

I am just getting started    but I will stop now.

[kellyt]

Our system is broke and it needs fixing...bad.   Why can't they just make if affordable for EVERYONE???

[Stoday]

It seems to me that history is being repeated.

In 1948 when the British National Health Service was created the politician driving it (Aneurin Bevan) had every bit as much resistance to change as Obama has. The medical profession voted something like 90% against the NHS and proposed not to cooperate with the proposals. The political opposition was against reform because of the infrastructure costs. There were not enough doctors or hospitals to cater for the increased demand resulting from free health care. World War II ended only 3 years earlier and every hospital in London had bomb damage to a greater or lesser extent. The government would have to finance the rebuilding and extension of hospitals yet the Treasury was near bankrupt because of the war.

[monrein]

Canada's health care system was implemented in 1972 and it too involved struggle, controversy and resistance to change.

http://www.dufourlaw.com/ndp/tommy.htm

[kellyt]

I'm now hoping for something similar to Canada, Monrein.  Fingers crossed.

[BASSMAN]

It really all depends on your point of view whether health care is a right or a privilege.  I believe it is a right and I am for socialized medicine.  The problem here in the states is the HUGE amount of money that is made off of health care.  Insurance companies love to take your premiums and then find every excuse they can come up with not to pay out benefits.  That applies to all types of insurance, car, home, anything that is insured.  It is disgraceful and nothing more than good ole American greed.  A government health care option would force the insurance companies to get in line and cost them MILLIONS in revenue.  The Republican party is and has always been in bed with big business and that includes insurance companies.  They could give a rats ass about a poor family with a dying child.  Their answer to every social problem is PERSONAL Responsibility.  Just another way of telling the poor people of this country to piss off. 

One stay or surgery in a hospital without insurance can mean financial ruin. 

Luckily there is socialized medicine for ESRD or we would all just die.  It is called medicare. 

Before some Repub starts to rag on me.  Did you or do you receive medicare benefits for your dialysis or transplant?  Let's not be a hypocrite now. 

[Malibu]

BASSMAN I am a Republican.  But.  I think this goes deeper than that and can be explained by the greedy or the non greedy.  And I totally agree with you, all types of insurance are a total scam and about 1 thing: the almighty dollar.  It is shameful.

Cash speaks:  EPO at Sam's wholesale pharmacy is $490 if you pay cash.  How much is it at the dialysis clinic?  I have not received a bill yet (when we do get a bill you might get a post from my hubby saying I had a cardio event) but I have had others tell me that their bills come in and the EPO is $2,000.  This is due to insurance and the convoluted way it works which results in nothing more than raising the price of absolutely everything. 

We have no insurance so everything came out of our pockets until hubby started dialysis and then Medicare kicked in.  When he had to go for the AV Graft surgery I called 4 different hospitals, just the hospital fee differed from $2350 (what we paid) to $10.150.  Why is it like this?  What if someone didn't know to call different hospitals.  Man, it is bad.

[cariad]

Oh, Kelly, I can imagine providing insurance as a small business is beyond difficult. My father owned his own business in SoCal (where employers are mandated to provide insurance) for over 25 years, and at home he had 6 kids, with 2 who were uninsurable on the individual market. I cannot even imagine the premiums that he paid, and I know he did not make a dime in income for the first four years in business.

I have always heard that if you are forced to pay cash, negotiate in advance with the hospitals and doctors (you can't usually do this with pharmacies) and try to pay what an insurance company would pay - about 40% of the asking price. Of course, in emergency situations, it is too late to negotiate. When I contracted viral meningitis, I went to the ER and ended up being admitted to the hospital for 10 days. The bill was $60,000, but by agreement the insurance company only paid $18,000, and I had to pay whatever was left on my deductible (several hundred). If I had not had insurance at all, wow. Call the bankruptcy lawyer, because there is no way I would have been able to pay them $60,000.

[rocker]

I have always heard that if you are forced to pay cash, negotiate in advance with the hospitals and doctors (you can't usually do this with pharmacies) and try to pay what an insurance company would pay - about 40% of the asking price.

I have had US doctors tell me that insurance companies have threatened to drop them if they give "cash discounts" (IOW, allowing individuals to pay the insurance rate).

The insurance system in this country is unconscionable.

[kellyt]

Yes, I have Medicare following transplant and 1) I pay over $100 a month for it and 2) I've been paying into Medicare for over 25 years (just like many, many others).  I don't feel I've been "given" anything.  So, no, I don't feel like a hypocrite.  I started working as soon as I became old enough and they've been taking it out ever since.  I'm currently paying into Medicare and I STILL have to send them over $100 a month.  They aren't even Primary, they are Secondary and they will only become Primary at 30 months, so they will only be Primary for six whole months.

In my opinion Medicaid is the problem, not Medicare, because so many people who are not eligible for it have it.  I'd be willing to bet I've spent more of my money on the uninsured and the losers who just don't pay when they have the means than I have for myself.

At this point I will listen to any kind of reform, I just don't think we should accept the first thing that's thrown out.  AFFORDABLE FOR ALL.  I'm not asking for a hand out.  Again, I pay for my Medicare.

And Cariad, you are so right.  It's disheartening to be a small business owner and not be able to help out the employees more.  If I could I'd pay them all $20 and hour and give them full coverage.  It's just not possible and it's really sad.

[BASSMAN]

My whole point is medicare IS a GOVERNMENT insurance program.  One hundred dollars a month and even the payroll deductions over the years are affordable.  Now if a person could get on medicare before 65 years old, ESRD the problem would be solved!!

I have been paying it all my life too.  I have also private insurance through my work.

I am referring to the 47 MILLION Americans with NO insurance.  They pay into the system too.

[Rerun]

What we need in The United States is "cost" reform.  The costs for health care doesn't even make sense!  We found my brother's hospital bill from when he was born in 1956.  Hospital bill was $25 and his circumcision was $8.

We would not even need insurance if costs were reasonable.  Maybe catastrophic insurance like the good old days.  Now we need catastrophic insurance for a zit.

These doctors, dialysis CEO's, Hopsital administrators etc... make too damn much money. 

I'm all for making a profit, but not off sick people and tax payers.

Go start a coffee shop!

[kellyt]

I understood your post, Bassman.  I really did.   I honestly wasn't attacking you or your post.     But I really don't feel like a hypocrite.    I'll be 42 in March and this might be my only chance to get back what I've paid into Medicare.  Actually, I feel blessed, but it has nothing whatsoever to do with the Government.

[hurlock1]

Would some kind American please explain your health care system especially regards dialysis patients. I know in Australia, everybody is covered for almost everything - whether PD or HD. What is the big fuss about changing your present system and why are so many people against President Obama changes to the system? Do you have to pay for dialysis and what is the score about not having health insurance?

In Amerika, healthcare is expensive. They have tried about twenty times since I was born to change it. The powers that be and the media system use scare tactics to make socialist medicine something to be afraid of. Something about not having enough choice. Freedom has its drawbacks. "Healthcare Providers" are the insurance companies, when in fact the basic job of insurance companies is to make money, secondary to actual healthcare. Besides employing millions of people who wouldn't have jobs otherwise, the healthcare providers spend a lot of money making sure that the people believe that healthcare is a privilege rather than a right. Obamah started out trying to change the health care system, but the powers that be used the scare tactics so strongly that the bill got watered down so much that it made him look like an idealistic idiot. The transition from the current system is so great and there are so many greedy "higher ups" that there won't be any actual change in the healthcare system. It's sad.
When the systems start breaking down, and just printing more Amerikan dollars won't fix the problems and the wretched excess rich people are really the only ones that can actually afford healthcare, can afford healthcare. . .

[dwcrawford]

I'm going to post here simply because I'd like response to show up in my "new posts" section.  The only comment I will make (since I am totally torn about the issue) is:

There are places in American where people from  countries with socialized or government health care or flocking for treatment.  Ditto with health care professions flocking to come work and to gain great comments for their resumes.

I have Medicare and a Cadilac (supplement plan and drug plan -- it does cost out the (censored).  But  you can correct me if I am wrong but I get the impression that dialysis patients are covered by medicare and provided drug help.  Is it good to have bad Kidneys? 

Again, I am torn with the issue...

Obama promised change.  We got change (the banks surely did, the auto companies surely did).  But change isn't good unless it is change for the better... is it?  and is it?

[rocker]

I'm going to post here simply because I'd like response to show up in my "new posts" section.  The only comment I will make (since I am totally torn about the issue) is:

There are places in American where people from  countries with socialized or government health care or flocking for treatment.  Ditto with health care professions flocking to come work and to gain great comments for their resumes.

Yes, the medical tourism issue has been flogged over and over again in the debate.  I do not doubt that some rich people from other countries come to the US to get the most expensive healthcare in the world.  However, the flow is also huge in the other direction.  I recall hearing about cosmetic tourism years ago.  There was an article that gushed about how you could travel to South Africa, get a facelift and a booblift and weeks of being pampered at a spa - for less than just the hospital bill for an American facelift.

I think everyone's heard stories of Americans going to Mexico for cancer treatment.

I have Medicare and a Cadilac (supplement plan and drug plan -- it does cost out the (censored).  But  you can correct me if I am wrong but I get the impression that dialysis patients are covered by medicare and provided drug help.  Is it good to have bad Kidneys? 

As I think others have pointed out, it's more complicated than that.  If you have private insurance when you are diagnosed Stage 5, then Medicare is only secondary and your private insurance remains primary for 30 months, when it flips.  And it gets more complicated from there, as Medicare pays, I believe, 80%....

What I do know is that we're paying out the ass for a private policy, on COBRA, that tries to deny payment at every turn.  We get unexplained bills from medical providers after we have a) paid our co-pay, and b) also been told we have reached our "out of pocket maximum" for the year.

Our private insurance has no out-of-pocket maximum for prescriptions, so our liability is virtually unlimited there.

Again, I am torn with the issue...

Obama promised change.  We got change (the banks surely did, the auto companies surely did).  But change isn't good unless it is change for the better... is it?  and is it?

Yes, I am quite disappointed in how the insurance cabal has once again managed to dominate the debate with ridiculous scare tactics and lies to protect their profits.  You want "death panels"?  Try to get your insurance to cover an "unapproved" treatment.