FRAMING THE DISCUSSION ON HEALTH CARE IN THE US


I think I will start today by outlining, what could be a way of discussing Health Care in the US:

1. Currently available Health Care Options
2. Suggestions as how to improve the current delivery of care
3. The Health Care Reform Bill, passed March 21, 2010
4. Non addressed issues in the 2010 Health Care Reform Bill

CURRENTLY AVAILABLE HEALTH CARE OPTIONS

I have been practicing Medicine in the US for 41 years and the following are my impressions about the system.

At the top of the pyramid are the true self-pay patients. A small group of patients who can afford medical care out of their own pocket over a long period of time. These individuals or families have enough discretionary assets or income to pay doctors, hospital and pharmacy bills without price considerations. This group can afford the best physicians and health care institutions, in many cases with reserved luxury suites, services and amenities. They can get unlimited opinions national and/or international, as well as preventive services advice. Basically they probably get the best medical care in the world

The second group, probably the vast majority of the employed population get their health care needs from their place of employment. The differences in the level of care are very diverse. I will cite some examples:

1.The top insured tier includes mostly employees of large corporations, universities, public employees, and in a decreasing frequency, members of labor unions. Their coverage may include comprehensive coverage (medical, mental, dental and vision) with premium paid by the employer

2.The next step down is basic insurance paid by both employer and employee plus a supplemental insurance (coinsurance), usually paid by the employer which cover the deductibles, co-pays etc. This group has in and out of network physicians and/or institutions who may bill the patient for the charges above “the usual and customary fee” (the usual and customary fee is set between the insurance company and the providers and may vary for the same service from provider to provider) Some examples of mostly out of network specialties include psychiatry, dermatology etc. This group gets some preventive care services, but usually a fairly basic dental plan.

3.Probably the largest group of insured patients have a basic health insurance plan that varies from company to company. Some require a primary care physician to act as a gatekeeper for referrals to specialists, some have direct access to specialists, but a limited roster of providers in the “network” . This insurance is usually provided by small businesses. The portion of the premiums paid by the patient, the co-pays, deductibles, and access to certain services (maternity care, mental and dental health) is based on what coverage choices they make. Many of these groups have very limited access to mental health and dental care

The next group is down is Medicaid. “Medicaid is the United States health program for eligible individuals and families with low incomes and resources” The types of Medicaid eligibility, are mainly based on income. While some Medicaid coverage is comprehensive to a portion of the Medicaid eligible population, there are many other types: “Presumptive Eligibility” which pays for medical care for pregnant women before their Medicaid applications have been approved. “Pregnancy Medicaid” pays for prenatal care, labor and delivery and the first few 6 weeks postpartum for both mother and infant, and finally “Emergency Medicaid”covers stroke, ear infection, organ failure, heart attack, childbirth and other life threatening emergencies. During Pregnancy this type of Medicaid covers only deliveries, but not prenatal care or postpartum sterilizations, This program is the only maternity service available to illegal aliens

The State Children's Health Insurance Program. (SCHIP) – later known more simply as the Children's Health Insurance Program (CHIP) is a program administered by the United States Department of Health and Human Services that provides matching funds to states for the children’ Health Insurance. It is intended to cover uninsured children in families with modest income, but too high to qualify for Medicaid

Medicare. I d not have much experience in this area and expect than others guests in the blog can expand on my few comments. Medicare is the health insurance for the older population. Part A covers hospital expenses, Part B outpatient services. You have to be 65 ears of age or disable to qualify. If you continue working past 65 your employer’s insurance usually requires that you join Medicare Part A. Part B becomes effective at retirement from the work place. If you have employer insurance after retirement, Part B Medicare becomes your primary insurance and your employer’s your secondary insurance. Why “secondary insurance”: Medicare does not pay for all health care needs, so most beneficiaries that can afford to get a secondary insurance, do so. I do not know with one or both, how much the co-pays, deductibles etc are. Medicare, at least, the Medicare Part B alone is not accepted by all physicians. I can not begin to understand Medicare Prescription drug coverage. I guess I will fin out when I retire

Health Spending Accounts: This are accounts is set up to pay for un-reimbursed health expenses. There are three kinds

a)Flexible Spending Accounts. Employer established spending accounts. Contributions made to this accounts may come from the employer and/or employee. The employee contributes funds through a “salary reduction agreement” and these funds are exempt from income and social security taxes. The amount is limited (in general between $3000 and $5000) and if you do not use it you loose the contributions.

b) Medical Savings Accounts. These accounts can accumulate tax-deferred interest similar to individual retirement accounts (IRAs).The funds are controlled and owned by the account holder. Different “ceilings” exist as to how much you can set aside. The funds roll-over at the end of the year and are a portable instrument that you carry with you when you change jobs.

c) Health Reimbursement Arrangements. Funds provided by the employer. The employee can use the funds until they run out. It rolls over and you have access to the unused portions if you change employment or retire.

“Self Pay” “Uninsured” patients.Forty seven million Americans are uninsured and 20 millions of illegal aliens fall also in this category. Physicians and Hospitals bill these patients, sometimes at a discount especially if bills are paid at the time of service, others charge full price (higher than the amount billed to insurance companies, Medicare or Medicaid). Some help this group to develop a payment plan. In general the large majority of these expenditures are what is called “uncompensated care” It constitutes $26.3 billion (65% of the total amount) a year. Some states pay different amounts to hospitals for this care, but the majority is absorbed by the health care systems which passes it along to those insured, leading to increase insurance premiums. Hospitals can not deny emergency access to care to the “uninsured” Presumptive eligibility and emergency Medicaid cover some of these expenses. Finally the Federal Government pays Teaching Institutions aceratin amount for the teaching of residents.

Well. This summarizes all I can think of the current health care system in the US. I hope you feel free to add, correct or comment.

Until next time

Juan L Granados, June 7, 2010

INTRODUCTION TO THE BLOG "THE WORLD'S TERTULIA"

Let’s begin by defining the term tertulia: La Tertulia is a term originated in Spain (my birth place), which means "a gathering" "a group". Originally in Spain these groups of like minded people met in bars, or home and mostly discuss literature or art. Later it evolved to other times of discussion. In the 1960s, I belonged to such a group in Madrid name and we met in a cafe bar near of the "Gran Via “or in one of our member’s homes. The topic for discussion was announced one week prior to the meeting and the discussion lasted around 1 to 2 hours over coffee and brandy.

I do not know exactly how to start, but "the tertulia" evolves as members join and topics are discussed. I would like to pick up a topic and discuss it for a yet undetermined period of time, a week, a month... (depending on how many member join"

The first topic "The Health Care Debate in the US" to include anything related to the current health care, the "ideal health care" and the passed "Health Care Reform" While criticism is expected I would like the discussion to be imminently creational. Everyone has thoughts of what it wrong with the system, but I like to hear more about comprehensive solutions

In a few days if no one starts the discussion, I will

For the time being, I would not mind ideas as to how to conduct this blog

Juan L. Granados, June 4, 2010


PS. If you are interested in my profile you can find me in face book under Juan Granados