Monday, March 22, 2010

Thoughts on Health Care--In Between the Extremes

I haven’t been following the recent health care debate very closely, but I’m glad that Health Care Reform has passed. I find it disingenuous that so many staunch Republicans complain about “the way it was passed” considering their tactics, since the Clinton years, of filibustering everything...and then complaining about how things are not done with more consensus.

Living abroad, I am often treated to people’s uninformed opinions about the way “they”—we Americans--all are—overweight, ignorant, gun-toting, polluting, violators of other countries’ national sovereignty--extremists. What is most amusing, or distressing is the way people have of saying these things in front of you, as if you weren’t one of Them and might be insulted or disagree with your interlocutors. It’s not that there isn’t any truth in any of these assertions, it’s that such statements often reflect uninformed (or minimally informed) truth, issued from a very smug outsider perspective.

Let’s take the least polarizing and most personal accusation: “Americans are fat.” Maybe it’s our Anglo-Saxon hypocrisy, but if we have something negative to say about other people, minimal good manners dictate not saying this until “They” are at least out of ear’s reach. I was once told by an otherwise educated-seeming, middle-class French person that “Americans do not eat vegetables.” “Really, I said, have you ever been in the PRODUCE section of a Publix or a Safeway because they happen to be loaded with vegetables, which would be surprising if there was no market for them…”

Sometimes when people do travel abroad, a very curious thing happens: they have preconceived stereotypes of the “other” place they will be visiting (preferably exotic and different from their place, otherwise what’s the interest of traveling), so the purpose of the trip is to confirm these preconceived notions. The international traveler, with such an agenda, can be surprisingly successful. The person who is convinced that the US is a violent and lawless place will inevitably walk into a random Burger King in Los Angeles and witness a shootout. Meanwhile I, the American, have been to Burger King and other fast food joints in my life (and no I don’t and didn’t eat this food on a regular basis) and have never witnessed one gun or shooting.

I don’t know where this foreign visitor went (I’m not familiar with LA), but I assume it was a bad neighborhood. It wouldn’t occur to me to wander around the rougher Parisian “banlieues” (suburbs) as a blithe tourist. And, if I did such a thing, I would be honest enough to qualify where I was instead of identifying this as the “quintessential French experience.” As for the weight issue, I do recognize and am saddened by the fact that, statistically Americans are overweight. However, the conversation is more interesting when people say something like—“weight and making healthy food choices are often a function of education and economics, and weight gain typically accompanies the rise of processed foods and the practice of working outside the house. Society-wide weight gain, while at a more advanced stage in the US, is a phenomenon currently affecting Most developed nations…”

Now back to social security and health care. I am always surprised to hear so many Americans proclaim: “We have the best health care system in the world.” Most of these people have never lived Anywhere Else in the world. They often rely on statistics and articles that support how bad it is Everywhere Else. This is no substitute for actually having lived Somewhere Else and being able to compare.

I am not a statistics person, and I don’t have any political agenda. These are some simple points that have impressed me living both in the US and abroad:


We have private health care insurance here that was very easy to sign up for. The only reason its cost is comparable to private (non-employer affiliated) PPO health insurance in the US is because it is a world-wide policy and will reimburse us 80% of any health care expenses incurred elsewhere, but what makes it expensive is the US portion of the coverage….If this policy were limited to Spain, it would be a Whole Lot cheaper. To obtain this policy, I did not have to fill out any questionnaire on pre-existing conditions or list all the medical or hospital visits my family have had in the past five years.

When my children are sick and I go to the children’s emergency room, I give the receptionist my insurance card and my child’s name—punto y basta. I do not need to call up the insurance company to get any approvals if the emergency room doctor recommends the child stay in the hospital.

My children’s pediatrician gives me his cell phone number That He Will Answer and will visit our house (non-emergency house visits by non-network providers are reimbursed up to 80% by the health insurance) when the children are sick.

I haven’t tried this, but my American friends have. You can also get a family practice doctor to visit you at your house if you are sick and don’t feel well enough to go outside. They said the cost of this was around 100 euros and also reimbursable at 80% by their insurance.

We are not eligible for Seguridad Social (social security) because we do not work for a salary in Spain. Illegal immigrants are, however, eligible for Seguridad Social. They are given a card and affiliated doctor and hospitals and can use the system for non-emergency related health-care. Most Spanish people I know, who can afford it, have private health care insurance, either through their employer or for which they pay, privately.

Yes, they all complain about Seguridad Social—the waits and the difficulty of seeing a specialist or getting very individualized attention, but the key point is that it is there. I am sympathetic to the Spaniards’ complaints about Seguridad Social, not so much to the complaints from illegal and recently legalized immigrants. I don’t say it, but what I am thinking is: “You come from a country that could care less if you die in the street like a dog. So no, I don’t give a damn if you had to wait a long time in line behind a bunch of old Spaniards to get your health care. Those people have been paying into this system for years…Suck it up and be grateful for what you get because in my country, nobody gives you shit for free.”


Most aspects of healthcare visits take place with the nurses. Any contact with the doctor is very brief. Some practices have an emergency call number where you will first talk with a call center employee or a nurse. If they deem it necessary, a doctor may call you back.

Any stay in the hospital involves and lengthy and often complex pre-approval process with the insurer. You want to make sure you correctly understood this process or you may get stuck with the bill.

If you are checking into the hospital or need to go to the emergency room and are not spewing blood on the spot (in which case the friend or family member who brought you will be doing this), expect to spend 45 minutes just filling out forms explaining who your Primary and Secondary insurers are and all their contact information and absolving the hospital and its personnel of all blame if they should accidentally feed you into a wood chipper and cut you to a million pieces. If you have insurance, expect a bill that can range from the hundreds to thousands of dollars, depending on your co-pay and deductible. If you do not have insurance and should need emergency hospitalization and advanced medical care in the US, you can wind up with a bill in the hundreds of thousands of dollars. To add insult to injury, there is one last step. You must then interact with their “patient care consultant” to “make sure that your hospital processing is going as smoothly as possible.”

Getting Health Insurance when you are self-employed

If you do not have access to insurance through an employer or professional organization, expect to fill out a very lengthy questionnaire and answer questions about every doctor’s visit, hospital-visit and surgical procedure every person in your family has had in the past five years. If they deem that you are too high-risk, they can refuse to insure you and you will find yourself without insurance in the country with the highest cost of health care in the world (see above for the hundred thousand dollar bill).

When we were just starting JBoss, we had family health coverage through my former employer’s COBRA insurance (much higher than what we paid when this was subsidized by my employer—probably about $900 a month for two adults and a child). Three months away from end of the 18-month obligatory COBRA coverage period, I decided to shop around for a health plan that would cover our small company (just my husband and myself at that point). In the meantime, I became pregnant with twins (and no, this was not the result of any fertility treatments for you crack-pots that think that this was interfering with God’s Plan). I was not just a pregnant woman, I was a pregnant woman with twins, which put me into the High Risk pregnancy category because twins are very often born early and can require very expensive NICU (newborn intensive care unit) hospitalization for a few days to several weeks. The insurance broker was doubtful about finding anybody who would cover us.

At that point, I wondered where I had gone wrong in life. I had gotten a higher education; I worked hard. I considered myself a responsible person, I hadn’t even really waited to the last minute to obtain new insurance coverage and here I was--at risk for falling through the (in the US, practically non-existent) mattress that cushions your fall to the bottom of society—potentially with no health insurance or exorbitantly priced health insurance and the possibility of tens of thousands of dollars worth of medical debt. Things worked out for the best and we did find an HMO program that would accept us and the twins were born at a healthy 8 months, with only one of them requiring a two-day stay at NICU…but there were no guarantees things would turn out this way.

I consider the US to be a very favorable place to become an entrepreneur. Until recently, this did not apply to anybody who (they or their immediate family members) may have an existing medical condition that makes you undesirable to private health care insurers. I know talented people who could not ever work for small start-ups for this reason.

The procedure

This is how the free-market health care system works. Two years ago, I had to have a medically necessary procedure. I had private PPO insurance for which we paid quite a bit, I was sure this wasn’t going to be a problem. The first thing I learned is that Those Doctors Who Can Afford It—which is often to say the good ones—do not choose to affiliate with Cigna or Aetna or Blue Cross or whoever your “premium” health insurance provider is. These doctors may not necessarily have gone to medical school and become surgeons just so they could be driving Maseratis and living in multi-million dollar houses. On the other hand, they want do not want a health insurance bureaucrat, who is not a doctor, telling them how much they can charge or dictating what kind of treatment they should be giving to their patients.

The procedure was quite expensive and Cigna paid for far less than 80% of it. When you sign a contract with a US health insurance provider, what that “80% out of network coverage” really means is that they will pay "80% of what they think your procedure should have cost” out of network. Expect to get lots of bills later down the road from the doctor and hospital when they get lesser reimbursement. What I learned? Cigna and I’m sure they are not the only health insurance company that does this, automatically doesn’t pay a chunk of your bill—on principle. I don’t know what the statistics are on this, but I’m sure 50 to 60% people will stop there and not appeal. If you are successful in your appeal, as I was, at that point they will pay half of what they didn’t pay before, but still a lot less than the 80% you were counting on. Maybe more intrepid people successfully go on to a second appeal; I stopped there.

If you think that a lot of doctors don’t want to affiliate with your health insurance carrier, guess what? Many of the good ones, or at least the ones who seemed to have taken the “bedside manner” course in medical school—Really don’t want to affiliate with Medicare…which you will find out if you happen to have parents.

If you need private health insurance and have had any surgery in the past few years for something they considered a risk, even if whatever they operated for turned out to be benign—expect to automatically be denied health coverage.

So don’t tell me that health care reform is going to “break” our marvelous system. As far as I’m concerned—it isn’t exactly that marvelous and it’s already broken….Yes, I know that other systems aren’t perfect and have their faults as well and that there are a million different technical points you can argue. However, considering that the current free-market American system does not provide all my family members with health coverage, and, for most of my life, I was in the position of this being a Major Problem, I’m going to suck it up pay for this.

For all of you people whingeing about the way this bill was passed, you know what? The rest of us are stuck paying for the Iraq war, which we entered under false pretenses, and the ongoing Afghanistan war, which looks like it’s going to be another Vietnam. We’re stuck paying for the bail-out of the financial system, when most of us had nothing to do with the abuses or obscene payouts going on there…so welcome to our world.


Elisabeth said...

Hi, I'm Carmela's friend, I think we met in Brussels once. Carmela may have told you that I tend to get absorbed in making comparisons between countries, especially concerning health care and school systems, why she sent me the link to your blog.
I can strongly recommend a book written by a professor at UCLA, married to a Swedish woman, and leading historian of comparative social policy. Its pretty much a collection of statistical results comparing USA to European countries but I think you'll find it entertaining:
The Narcissism of Minor Differences: How America and Europe are Alike by Peter Baldwin.

Nathalie said...

Hello Elisabeth, thanks for the book recommendation. I cannot say my post has any statistical background--just my own personal experience of almost falling through the cracks of the health care system in the US and how the private health insurance companies really operate. I'm sure they are as abusive as they are in the US because purely because "they can be"--hopefully the new Obama legislation will regulate them a little better...and hopefully the private insurers in Europe will not grow to be as abusive as their American counterparts.

Delora said...


You make some very sound points. I've often wondered how the insurance companies can get away with reimbursing so little. Reimbursement depends completely on how much time and energy you are willing to expend to get what is rightfully yours! I'm hopeful that with the new plan we won't have to major in "Insurance Reimbursement" to have legitimate treatments covered.