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Private Health Insurance and the Lack of Insurance

Medicine in the United States is big business. Expenditures for health care, health research, and other health items and services have risen sharply in recent decades, having increased tenfold since 1980, and now costs the nation more than $2.6 trillion annually (see Figure 13.6 “US Health-Care Expenditure, 1980–2010 (in Billions of Dollars)”). This translates to the largest figure per capita in the industrial world. Despite this expenditure, the United States lags behind many other industrial nations in several important health indicators, as we have already seen. Why is this so?

An important reason is the US system of private health insurance. As discussed earlier, other Western nations have national systems of health care and health insurance. In stark contrast to these nations, the United States relies largely on a direct-fee system, in which patients under 65 (those 65 and older are covered by Medicare) are expected to pay for medical costs themselves, aided by private health insurance, usually through one’s employer. Table 13.4 “Health Insurance Coverage in the United States, 2010” shows the percentages of Americans who have health insurance from different sources or who are not insured at all. (All figures are from the period before the implementation of the major health-care reform package was passed by the federal government in early 2010.) Adding together the top two figures in the table, 54 percent of Americans have private insurance, either through their employers or from their own resources. About 29 percent have some form of public insurance (Medicaid, Medicare, other public), and 16 percent are uninsured. This final percentage amounts to almost 50 million Americans, including 8 million children, who lack health insurance.

Their lack of health insurance has deadly consequences because they are less likely to receive preventive health care and care for various conditions and illnesses. For example, because uninsured Americans are less likely than those with private insurance to receive cancer screenings, they are more likely to be diagnosed with more advanced cancer rather than an earlier stage of cancer (Halpern et al., 2008). It is estimated that 45,000 people die each year because they do not have health insurance (Wilper et al., 2009). The Note 13.22 “Applying Social Research” box discusses a very informative real-life experiment on the difference that health insurance makes for people’s health.

Although 29 percent of Americans do have public insurance, this percentage and the coverage provided by this insurance do not begin to match the coverage enjoyed by the rest of the industrial world. Although Medicare pays some medical costs for the elderly, we saw in Chapter 6 “Aging and Ageism” that its coverage is hardly adequate, as many people must pay hundreds or even thousands of dollars in premiums, deductibles, coinsurance, and copayments. The other government program, Medicaid, pays some health-care costs for the poor, but many low-income families are not poor enough to receive Medicaid. Eligibility standards for Medicaid vary from one state to another, and a family poor enough in one state to receive Medicaid might not be considered poor enough in another state. The State Children’s Health Insurance Program (SCHIP), begun in 1997 for children from low-income families, has helped somewhat, but it, too, fails to cover many low-income children. Largely for these reasons, about two-thirds of uninsured Americans come from low-income families.

Not surprisingly, the 16 percent uninsured rate varies by race and ethnicity (see Figure 13.7 “Race, Ethnicity, and Lack of Health Insurance, 2008 (Percentage of People under Age 65 with No Insurance)”). Among people under 65 and thus not eligible for Medicare, the uninsured rate rises to almost 22 percent of the African American population and 32 percent of the Latino population. Moreover, 45 percent of adults under 65 who live in official poverty lack health insurance, compared to only 6 percent of higher-income adults (those with incomes higher than four times the poverty level). Almost one-fifth of poor children have no health insurance, compared to only 3 percent of children in higher-income families (Kaiser Family Foundation, 2012). As discussed earlier, the lack of health insurance among the poor and people of color is a significant reason for their poorer health.

The High Cost of Health Care

As noted earlier, the United States spends much more money per capita on health care than any other industrial nation. The US per capita health expenditure was $7,960 in 2009, the latest year for which data were available at the time of this writing. This figure was about 50 percent higher than that for the next two highest-spending countries, Norway and Switzerland; 80 percent higher than Canada’s expenditure; twice as high as Frances’s expenditure; and 2.3 times higher than the United Kingdom’s expenditure (Organisation for Economic Co-operation and Development, 2011). The huge expenditure by the United States might be justified if the quality of health and of health care in this nation outranked that in its peer nations. As we have seen, however, the United States lags behind many of its peer nations in several indicators of health and health care quality. If the United States spends far more than its peer nations on health care yet still lags behind them in many indicators, an inescapable conclusion is that the United States is spending much more than it should be spending.

Why is US spending on health care so high? Although this is a complex issue, two reasons stand out (Boffey, 2012). First, administrative costs for health care in the United States are the highest in the industrial world. Because so much of US health insurance is private, billing and record-keeping tasks are immense, and “hordes of clerks and accountants [are] needed to deal with insurance paperwork,” according to one observer (Boffey, 2012, p. SR12). Billing and other administrative tasks cost about $360 billion annually, or 14 percent of all US health-care costs (Emanuel, 2011). These tasks are unnecessarily cumbersome and fail to take advantage of electronic technologies that would make them much more efficient.

Second, the United States relies on a fee for service model for private insurance. Under this model, physicians, hospitals, and health care professionals and business are relatively free to charge whatever they want for their services. In the other industrial nations, government regulations keep prices lower. This basic difference between the United States and its peer nations helps explain why the cost of health care services in the United States is so much higher than in its peer nations. Simply put, US physicians and hospitals charge much more for their services than do their counterparts in other industrial nations (Klein, 2012). And because physicians are paid for every service they perform, they have an incentive to perform more diagnostic tests and other procedures than necessary. As one economic writer recently said, “The more they do, the more they earn” (Samuelson, 2011).

A few examples illustrate the higher cost of medical procedures in the United States compared to other nations. To keep things simple, we will compare the United States with just Canada (see Figure 13.8 “Average Cost of Selected Medical Procedures and Services”). The average US appendectomy costs $13,123, compared to $3,810 in Canada; the average US hip replacement costs $34,354, compared to $10,753 in Canada; the average US normal childbirth costs $8,435, compared to $2,667 in Canada; and the average US bypass surgery costs $59,770, compared to $22,212 in Canada. The costs of diagnostic tests also differ dramatically between the two nations. For example, a head CT scan costs an average of $464 in the United States, compared to only $65 in Canada, and an MRI scan costs and average of $1,009 in the United States, compared to only $304 in Canada (International Federation of Health Plans, 2010).

Managed Care and HMOs

To many critics, a disturbing development in the US health-care system has been the establishment of health maintenance organizations, or HMOs, which typically enroll their subscribers through their workplaces. HMOs are prepaid health plans with designated providers, meaning that patients must visit a physician employed by the HMO or included on the HMO’s approved list of physicians. If their physician is not approved by the HMO, they have to either see an approved physician or see their own without insurance coverage. Popular with employers because they are less expensive than traditional private insurance, HMOs have grown rapidly in the last three decades and now enroll more than 70 million Americans (see Figure 13.9 “Growth of Health Maintenance Organizations (HMOs), 1980–2007 (Millions of Enrollees)”).

Although HMOs have become popular, their managed care is also very controversial for at least two reasons (Kronick, 2009). The first is the HMOs’ restrictions just noted on the choice of physicians and other health-care providers. Families who have long seen a family physician but whose employer now enrolls them in an HMO sometimes find they have to see another physician or risk going without coverage. In some HMOs, patients have no guarantee that they can see the same physician at every visit. Instead, they see whichever physician is assigned to them at each visit. Critics of HMOs argue that this practice prevents physicians and patients from getting to know each other, reduces patients’ trust in their physician, and may for these reasons impair patient health.

The managed care that HMOs provide is controversial for several reasons. These reasons include restrictions on the choice of physicians and especially on the types of medical exams and procedures that patients may undergo.

Pixabay – CC0 Public Domain.

The second reason for the managed-care controversy is perhaps more important. HMOs often restrict the types of medical exams and procedures patients may undergo, a problem called denial of care, and limit their choice of prescription drugs to those approved by the HMO, even if their physicians think that another, typically more expensive drug would be more effective. HMOs claim that these restrictions are necessary to keep medical costs down and do not harm patients.