Increase Your Knowledge
The U.S. healthcare system is expensive, can be extremely complicated to navigate, and has worse health outcomes in multiple categories compared to other high income countries. Most health insurance plans charge for:
Premiums -amount you pay each month for your insurance policy
Co-payments or co-pays -a set amount you pay for each office visit and can also include costs for medications, surgery, or emergency room visits
Deductibles -an amount you have to pay before your insurance pays for medical services
Co-insurance -a percentage amount of the allowable cost of your medical care that you are required to pay after meeting your deductible. (For example, your insurance may pay 80% and you pay 20%)
Out-of-pocket costs -the amount you pay for services not paid by your health insurance plan, typically such things as your deductible, co-insurance, and copays, or payments for services not covered by your health insurance plan
Out-of-network costs -charges for services received from providers who are outside of your insurance network
If you add all of these expenses together, the average cost in Kentucky is $468 per month or $5,617 annually.
In the United States, people are 33% less likely to have a regular doctor, 25% more likely to have unmet health needs, and over 50% more likely to not obtain needed medicines compared to their Canadian counterparts who have a universal right to healthcare. We believe YOU DESERVE BETTER.
Pre-Authoritizations, or Prior Authorizations
This is also known as pre-certification. It refers to a process imposed by health insurance carriers whereby they must grant permission before the insured person receives health care services, treatments, medications, surgeries, or durable medical equipment. Failure to obtain required pre-authorization can result in the insurance company refusing to pay for these services. However, even with pre-authorization, the insurance carrier is not guaranteed to cover the cost.
The New York Times spoke to more than 50 doctors and patients. They shared horror stories about a seemingly trivial process that inflicts enormous pain, on a daily basis. The video they produced in March 2024 also explains how a process that is supposed to save money actually inflates U.S. healthcare costs while enriching insurance companies.
How does the U.S. health care system compare to other wealthy western nations?
According to the 2021 Report from the Commonwealth Fund, compared with Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom, the United States (US) ranked last overall, and last on access to care, administrative efficiency, equity, and health care outcomes. (The one bright spot was that the U.S. ranked second on measures of care process.)
This poor performance occurs despite the U.S. spending far more on health care annually than other wealthy nation. As the percent of Gross Domestic Product (GDP) in 2019, the U.S. spent 16.8%* of GDP compared with an average of 10.63 % of GDP spent on health care by the other 10 wealthy countries studied; all the while U.S. spending is climbing faster than that of the other 10 countries. Unfortunately, overall poor health care performance delivered at a high cost has persisted since at least 2004 in the U.S.
This report provides guidance on what the U.S could change to improve its health care: “Four features distinguish top performing countries from the United States:
1) They provide for universal coverage and remove cost barriers;
2) They invest in primary care systems to ensure that high-value services are equitably available in all communities to all people;
3) They reduce administrative burdens that divert time, efforts, and spending from health improvement efforts; and
4) They invest in social services, especially for children and working-age adults.”
*By 2020, national health expenditures has risen to $4.1 trillion, or 19.7$ of GDP, according to the Centers for Medicare and Medicaid Services
Privatization of Medicare Benefits: Buyer Beware
Currently, Medicare benefits can be administered by for-profit firms that promise expanded healthcare and wellness services. These plans offer lower out-of-pocket costs to patients, compared with keeping Traditional Medicare and buying supplemental insurance to bridge gaps in coverage. There are two general models:
1. Medicare Advantage Plans take over your Medicare benefits and administer them, along with other healthcare and wellness services not typically covered by Medicare. In return, these plans can limit access to covered care by approving only a restricted panel of providers within limited geographical areas, and tightening control over medication coverages, thus limiting treatment options. Medicare Advantage Plans | Medicare
2. Under the Accountable Care Organization model or ACO, patients covered by Medicare can have their healthcare benefits managed by a for-profit company. An expanded set of benefits beyond those found in traditional Medicare may be offered. As in the Medicare Advantage Model, the ACO can limit services by using only approved healthcare providers, and exercising tighter control over medications.
Major differences between the ACO REACH model and the Medicare Advantage model are:
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ACO REACH companies enter into shared financial risk agreements with Medicare in terms of the total dollars that they spend on the patients that they cover.
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Medicare states that “beneficiaries may be aligned to an entity participating in the model if they choose (or already have) a primary care doctor who is part of an ACO participating in the model.” This means you can automatically be enrolled in an ACO REACH plan without your consent.
Medicare for All Act: Key things to understand
Introduced to the U.S. House of Representatives in 2021 and the U.S. Senate in 2022, the Medicare for All bill would "provide comprehensive health care to every man, woman and child in our country – without the expenses of monthly premiums, co-pays or coinsurance costs. With no more insurance premiums, deductibles or co-payments, adopting this plan would save middle-class families thousands of dollars a year."
Implementing a national tax-based universal health insurance plan, made available to all Americans, would mirror the way Medicare is now utilized by the elderly and disabled. Our current health care system is designed to maximize profits of health insurance companies, the pharmaceutical industry, and medical equipment suppliers, rather than to make the health of Americans a priority. By establishing a tax-based, universal health care insurance system for all Americans, the U.S. can save billions each year, and improve quality, access and the health of its citizens. According to the Congressional Budget Office, Medicare for All could save the American people and our entire health care system $650 billion each year.
The No Surprises Act Protects Against Surprise Medical Bills
This year, patients gained new protections under a law designed to prevent excessive health care billing. Typically, out-of-network providers would bill consumers for the difference between the charges the provider billed, and the amount paid (if any) by the consumer’s health plan. This is known as balance billing. An unexpected balance bill is called a Surprise Bill. These surprise bills can be so high as to result in personal bankruptcies.
The U.S. Centers for Medicare and Medicaid Services (CMS) describes this new law as follows:
"As of January 1, 2022, consumers have new billing protections when getting emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers. Through new rules aimed to protect consumers, excessive out-of-pocket costs are restricted, and emergency services must continue to be covered without any prior authorization, and regardless of whether or not a provider or facility is in-network."
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Some health insurance coverage programs already have protections against high medical bills. You’re already protected against surprise medical billing if you have coverage through Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE.
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The balance billing protections generally don’t apply to ground ambulance services. For additional FAQ's:
Preventive Care Services at Risk
Millions of people depend on the preventive care that they receive to keep them healthy. Under the Affordable Care Act (ACA), individuals who receive health insurance from private carriers, as well as some people covered under Medicare and Medicaid, are entitled to receive preventive services such as well-woman exams, immunizations, maternity care, mammograms, routine pap smears, birth control, and screening colonoscopies without being charged co-pays, co-insurance or deductibles.
Preventive care can save lives-by detecting high blood pressure, diabetes, colon polyps, pre-cancerous cervical lesions, early breast cancers, abnormal labs, and much, much more. However, these benefits are at risk if the September 2022 ruling of Judge Reed O’Connor in Texas stands. He was the same judge who decided in 2018 that the entire ACA was invalid. This 2018 ruling was overturned by the US Supreme Court (SCOTUS), and the ACA remains in effect. For now.
Repercussions of Judge Reed’s ruling have not yet been felt, pending his request to review additional information, and the case is likely to land before SCOTUS. In the meantime, the situation illustrates the vulnerability of a healthcare delivery system subject to the coverage determination whims of a for-profit insurance industry which answers to its shareholders rather than to its insureds.
The Asclepius Initiative’s 2022 study found that nearly two-thirds (64%) of insured adult Kentuckians surveyed avoided, skipped, or stopped medical care or medications secondary to cost. If this ruling is implemented, that number will undoubtedly increase, as patients face costly obstacles to preventive services. Not only that, but measures of Kentuckians’ health, already ranked at 4th most unhealthy state by World Population Review, will likely worsen as well.
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