Healthcare difference part II……….Rationing in the US

Anticipating the differences between the US and Canada, I focused on the rationing of healthcare. When most folks I know talk about the difference between the delivery of health care in the two nations, rationing and quality are two differences that stand tall among the potential pitfalls of a nationalized system. Rationing occurs in both systems, the prime difference is the transparency with which it occurs in each system.

Rationing in the United States
Many people are surprised to learn that rationing of healthcare resources does in fact take place within the United States, and the absence of transparency is why most American do not recognize the rationing. The rationing of healthcare in the US occurs in two forms- insured and uninsured.

Uninsured
If you are unfortunate and lack health care insurance in the United States, then by definition you ration the health care that you receive from the system. You ration your healthcare because you have no choice, it is simply too expensive to be sick, and even more expensive to purchase insurance. So like most folks when money is short, you do without things that seem to be luxuries. This means that you do not enter the healthcare complex until you have no choice, and enter the system when your health has deteriorated to such an extent that you must enter the system because you are simply too ill to do otherwise. This illness may be something seemingly innocuous such as a bad case of the flu, or something more complicated. In the end, it means a trip to the emergency room/urgent care/walk in clinic for the help. Often the choice of where to enter the system is dictated by the available cash on hand, with those who have the fewest resources shunting to the emergency department for their care. Unfortunately this means that they are entering the system at the most expensive point.

This makes little sense economically but it is one of the only ways people can be guaranteed that they will be seen and treated, and it is the Emergency Medical and Active Labor Act that makes this possible. This obliges the emergency department to make sure that the patient does not have any life threatening illnesses and that they are medically stable before sending them home. This does not mean that everyone has to be treated, but in a practical sense, everyone is. The line between diagnosis and stabilization to treatment is very small, so it makes little sense not to just finish the work. This is in part why so many people arrive for prolonged waits in the emergency departments across the US. Patients who have more discretionary spending often go to the Urgent Care or Walk In clinics to be seen for their minor ailments. These clinics are far more efficient than the Emergency Departments, but payment is expected at the time of service. In both cases, the treating provider has no obligation to care for the patient beyond their encounter, that is, they have no obligation to look after the long term chronic health care needs of the patients they treat. In essence they are rationing the care they deliver; they do not deliver the long term care.
If you need hospitalization and you lack health insurance, then this prospect is a nightmare. The EMTALA obligates the hospital to admit you to the hospital, stabilize you condition, and then look toward discharge. Hospital costs are such that even an overnight stay in the hospital may cost you over $1500 which for a family of four with two working parents earning $50,000 a year will find difficult. Additionally most folks without insurance work in jobs where there is little if any paid sick time, so there is the burden of lost income for the period of time you are hospitalized as well as any time spent recovering after you leave the hospital. In fact recent studies (prior to the economic slump) indicate that health care expenses contribute to bankruptcy in 50% of the cases and when looking at housing problems (failure to pay rent or mortgage payment), 25% are due to healthcare expenses.

The Insured
If you are one of those fortunate enough to have insurance, you are still subjected to health care rationing, but unlike the uninsured, it is often a more complex form of rationing that takes place. It is not called rationing in the usual sense; it is couched in terms such as “covered services”, “preferred provider”, “pre-existing condition”, and “denied claims”. Here is how it plays out from the perspective of a physician inside a very organized integrated health care network.

When a patient presented to be seen in the clinic everything went very well as long as I did not ask the system do more than it was prepared to accomplish. In other words, if I saw the patient, diagnosed the condition, and treated it then there was no particular problem. However, if I wanted to involve other providers, provide more than one type of service on the same day, or provide care that was outside of the usual scope the rationing began. As an example, if I a patient can to me with a mole on their skin that was concerning and I determined that the mole should come off, then proceeded to remove this mole during the same visit, it was often not paid. What this meant to the patient was inconvenience, in that I would diagnose them and have them come back on another day for the procedure that should have taken place at the same time as the initial visit. If I wanted more specific testing it often required additional paperwork to be completed in order to justify the service. Often this would involve a phone call to someone who would approve the service. These same steps were required when medications outside of the formulary were required, or when a referral to a specialist was indicated. These additional steps increased the time line for a patient to obtain the services, and each step provided an opportunity for the insurance company to decline the coverage. Often after a claim had been submitted, additional paperwork would come through that would essentially be asking if the condition being covered might have been a pre-existing condition. If you are unfortunate enough to be found to have received services for a pre-existing condition, then the claims will be denied and you will be stuck with the bill for any services that can be related to that condition, after the fact.

An additional component to the rationing of health care for the insured patient is the conditions and services covered as well as the amount of coverage for these conditions. The fact that you have insurance is not a guarantee that you will receive treatment. If you need treatment for a condition that is not covered by your plan then you are out of luck. Likewise, the type of treatment that you may be eligible to receive will depend on the terms of you plan. These terms may change without your notice, and you may be left holding the bag. Finally, if the cost of your care exceeds the threshold of the plan, then you insurance runs out and ceases to pay for any additional costs. This is in fact rationing. If you have insurance and you do not need much then you get what you want without any real trouble. If you have significant needs, then it is likely that the insurance company will ration your access until you run out of coverage or they find a link to a pre-existing condition that allows them to decline payment for the claims. If you are uninsured you really only get acute treatment and nothing more, at great cost.

In the case of the US, the rationing that occurs is done in a manner that is not transparent and is without any recourse. You cannot vote out the people who have rationed your healthcare, you cannot sue the insurance company that has decline your care, and the majority of people cannot afford to get sick. In a system where healthcare is nationalized transparency is a key element to the rationing of care…..more to come.