This tutorial will cover the topic of paying for health care in the U.S., through the definition and discussion of:
The system of paying for health care in the United States is a complex one. One system that exists in the U.S. is the direct-fee system, in which patients pay directly for medical services. When you're paying directly for medical care that you receive, you can also be aided by insurance providers, who pay a portion of the cost of health care under direct-fee systems. In turn, you have co-pays that help the insurance company pay for your care. Of course, you can get health care under a direct-fee system without insurance, but then you are required to pay for the value of the services directly, which is prohibitively expensive for most people.
Health care is exorbitantly expensive, which prompted the 2010 Health Care Reform. Health care costs were getting increasingly expensive and many people were getting priced out of the health care market because they couldn’t afford the treatment they needed. The 2010 Health Care Reform was an effort to bring these costs down and make health care more affordable in this country.
The U.S. has some of the best medical services in the world, but they're very expensive and not available to everyone. People wanted these medical services to be available to everyone, and make it so that insurance companies couldn't exclude you if you had a pre-existing condition.
If you have diabetes then you’re a very expensive patient for an insurance company to cover, so they might not want to take you on. How ethical is that? As a society, do we want people who are sick to be able to be excluded based upon pre-existing conditions? The 2010 Health Care Reform said, “No.”
The ultimate goal of the reform was to establish more access to health care at a lower cost for everyone. Clearly, there's been much political dispute over the reform so it has not been fully implemented for everyone as of 2012.
Health maintenance organizations, or HMOs, are systems in which patients pay a monthly fee for comprehensive care that follows a specific treatment regime. Like the direct-fee systems, you're paying for care, yet there's a pre-established plan for treatment in place. Doctors and clinics working with the HMO administrators agree to treat patients in a processed fashion, in an effort to bring costs down.
If you come into the clinic with a problem with your leg, for example--you're having trouble walking and you might need a steroid injection--then the doctors have a step by step process that they follow to treat you. Meaning, they can't give you a scan right away, for instance, because they’ve got to rule out other specific things first, according to protocol.
Before they arrive at that significantly more expensive procedure that you might need, they need to rule out all the other possibilities first. By doing so, the idea is that it will bring the cost down.
There are criticisms of this model of health care because it potentially involves the cost of running unnecessary tests, yet still arriving at the same, more expensive procedure. Hence, does it really bring costs down? Are patients really happier? This is the debate--paying for health care in the United States is a very complex process, subject to political debates.
Today you learned the basic terms necessary for understanding paying for health care in the United States, including direct-fee systems, 2010 Health Care Reform, and health maintenance organizations (HMOs).
Source: This work is adapted from Sophia author Zach Lamb.
A system which has patients pay for medical services directly.
A prepaid health care plan in which a fee is paid in advance for all necessary health care.
A health care reform in the US attempting to make health care affordable by reforming the system.