How many Americans have no health care

The US health care reform debate is entering the crucial phase. The government wants to finally close the gaps in a system that is sick in many areas. A visit to Washington shows how big these are.

Historic site: The decision on reform is made in the Capitol, the seat of Congress. Photo: vario images
Carrie is a cute little girl, estimated to be nine years old. She has big blue eyes, a gentle look, but no more hair on her head, probably lost due to chemotherapy. Life-size, the petite child looks at people waiting in the middle-class Washington district of Wesley Heights from a bus stop poster. Carrie is a cancer patient at St. Jude Children's Research Hospital. "Help Carrie fight cancer" is written on the poster. And "Donate now."

American clinics publicly solicit donations is not uncommon in the United States. On the contrary: for the houses that are not posh suburban clinics, it is everyday life. Be it posters at the bus stop, leaflets on the lamppost, advertisements on the Internet or a telephone donation marathon with the local radio station - almost any means is right to raise money. “It is unbelievable what is done in the clinics to get money. They are constantly looking for sponsors, they work day and night, ”reports Dr. med. Wolfgang Stehr (40). The doctor, who trained in Germany, has been working at American hospitals for eight years, and he knows that the clinics don't advertise for the money out of clumsy showmanship, but because they really need the support of donors. "Otherwise you would not be able to keep the hospital running," says the German who is married to an American.

47 million uninsured Americans require hospital emergency room treatment - that's the law. But not only these patients are a burden on the clinic's budget. In addition, there are the treatment costs for around 30 million underinsured people. Their insurance policies are so bad that they are left on their own if they have a really serious illness or if they have an accident. In addition: About 80 million Americans are insured through state programs, pensioners and the socially disadvantaged. “With these patients, the clinics' money is safe and it flows quickly. But only standard treatments are paid for, so what comes in is strictly limited, ”explains Stehr. The result: the cost apparatus of many hospitals is covered by donations from private individuals, companies or foundations. Or through money, with which the public sector has to support the supply. The Washington hospital, where Stehr currently works as a pediatric surgeon, was lucky: the half-urban, half-university facility just received a $ 150 million donation - from the Arab emirate of Abu Dhabi.

Hospital staff make financial plans for patients
In large cities like the American capital, the system's dilemma is particularly noticeable. Because they can be found in every major city in the USA, the poorer areas, the often ghetto-like districts. People live there who - if at all - only have a job now and then. Or they have a job from which they can support the family, but not an employer who pays for their insurance and that of their relatives. “The outpatient department in the hospital replaces the general practitioner in such areas. If there are problems, people simply come to the nearest clinic because we are not allowed to turn them away here, ”reports Stehr. "Some," he adds, "ultimately don't care who pays for the treatment."

Knows the major deficits of the system: Wolfgang Stehr, a doctor in the USA for eight years.
Photo: private
Regardless of whether it is a cold, an accident or leukemia: The procedure that takes place as soon as an American enters the clinic is always the same: Personal details and insurance status are checked using the Social Security Number. This is done by a so-called case worker. He only has one job in the clinics: to collect money. He quickly gets in touch with the insurer to get an idea of ​​the scope of the insurance benefits. If there are any at all. Deficits in the insurance package quickly become apparent: "After all, the case worker often knows more than the insured himself," says Stehr. In some cases, the insurance status, the patient's wallet, or the clinic's generosity determine whether or not a particular operation can be performed. Mind you: there is only time for such a consideration in non-acute cases. Emergency patients are generally cared for, regardless of their insurance status. The hunt for the money does not start until later in these cases.

The case workers also act as a kind of life coach: They provide the uninsured and underinsured with information on where and how they can apply for government grants for medical care, or they work with them to set up payment plans so that the treatment costs can be repaid in installments can. “Because the hospital bills in the USA are horrendous,” explains Stehr, who knows not only the German and US systems but also the French hospital system through work stays. “A day in the US hospital costs around $ 1,500, in the intensive care unit $ 3,000 to $ 10,000.” Stehr does not hide the fact that the high doctor's fees and a lack of willingness on the part of the hospitals are also part of the American problem. However, with such high treatment costs, it quickly becomes clear to some patients that the bill will remain unpaid in whole or in part. Because there is simply nothing to be gained from many.

For some, the question is: food or medication?
In the USA, people who are already not well-disposed towards life have hardly a chance: those who are chronically ill. In addition to the clinic and medical bills, you will also be worn down by horrendously high drug costs. These are higher in the USA than in many other countries - and again the system does not suit its citizens: In pharmacies, drugs are not dispensed in packages, but in counted individual doses. "Then the patient stands there, looks in his wallet and thinks: 'How many days can I afford pills?‘ ", Explains Stehr. "And when he then does the math and has to decide whether to buy food for his children or expensive medication, his decision is clear." He has had these experiences again and again, whether in Washington (District of Columbia) or previously in Cincinnati (Ohio) or York (Pennsylvania): “The patients just have the money to buy medication for a few days.” Sooner or later they end up in the emergency room again.

According to Stehr, people from the lower middle class and upper class are primarily affected by the system's errors: low-income taxi drivers, poor young adults, teachers at small private schools, shoe sellers or families with only one income. The way out of the health debt is long for them - if it succeeds at all. According to a recent study by Harvard University, healthcare costs are the leading cause of personal bankruptcies in the United States: they make up 60 percent. The study also shows that American middle-class families are particularly affected: 75 percent of the insolvent families had health insurance, but could not bear the treatment costs due to the many gaps in the insurance system. Harvard professor David Himmelstein put it this way: “As long as your name is not Warren Buffett, your family is only one serious illness away from bankruptcy.” Because even for those Americans who think they are well insured, a serious illness can also and especially financially have nasty consequences.

Insurers reject patients with previous illnesses
One of the biggest pitfalls is the regulation of the so-called pre-existing conditions. The insurers may reject applicants if they have a previous illness. A single visit to psychotherapy is sufficient for this, pregnancy is also one of them. Predispositions or belonging to risk groups (such as breast cancer in the family) can also be sufficient to have insurance cover denied or made unaffordable. In addition, many insurers require high deductibles for certain treatments or include a so-called donut hole when spending on medication: The medication costs are then only paid up to a certain limit, after which the patient has to pay the bills himself. These regulations also affect those who are state-insured and are particularly fatal for the chronically ill: Medicines for a person suffering from dementia or diabetes can easily cost several hundred dollars a month. That makes even high earners stumble.

Surgeon Stehr can also report on more extreme examples in which the insurers let their omnipotence play and the insured cannot be sure of support in an emergency: He knows cases in which the insurer has decided to stay in a clinic after studying the medical files only two days instead of the present three days were necessary. “The costs for the third day in the hospital are simply not paid and the hospital bill is passed on to the patient. No one is interested in whether the insurer is able to cover these costs. "

As for most Europeans, it is “intolerable” for the native of Baden-Württemberg that not everyone has access to health insurance in the USA. He, who, despite all the criticism, can also gain a lot of positive from the American system, judges clearly in this regard: “Everyone should have access to health care, regardless of their financial background. The question of whether I go to the doctor must not be a decision between health and survival. "
Nora Schmitt-Sausen


The US Health Care System Today
Companies in the United States are not required to purchase health insurance for their employees. Just under 60 percent of US citizens are insured through their employer. Even large companies are struggling with insurance premiums, which have risen steadily in recent years. Smaller companies usually shy away from the high costs entirely, and so part-time and short-term employees as well as permanent employees of small business owners usually have no health insurance. Even self-employed people are often without insurance cover. Some employees reject an insurance offer from the employer because they cannot or do not want to afford the co-payment. Insuring yourself as an individual is disproportionately expensive compared to the group contracts that an employer can conclude, and at the same time the insurance cover is usually worse. Only nine percent of Americans have such individually taken out insurance.

About 80 million Americans are uninsured for at least one month a year - for example if they change jobs and lose their insurance coverage. 47 million US citizens have persistent lack of access to health care. The state programs Medicare (for US citizens over 65 years of age and people with disabilities) and Medicaid (for US citizens on incomes below the poverty line) care for around 80 million people.

The US healthcare system is the most expensive in the world, and its costs are rising steadily: it currently devours $ 2.3 trillion annually, or 16 percent of gross domestic product. $ 7,290 is an American's per capita health care bill per year. For comparison: In Germany it is $ 3,588.


The struggle for reform
President Barack Obama wants health insurance to be affordable for all Americans. To do this, he wants to expand government aid programs and give small businesses financial incentives to insure their employees. An important part of the reform are also new guidelines for private individuals taking out insurance policies. The previous practice of insurers to reject patients due to previous illnesses or to curtail protection in the event of serious illnesses is also to be restricted. The pharmaceutical companies should undertake to sell drugs at reduced prices to those who are insured through state programs.

In the Senate, in which there are two senators per federal state, the more than 2,000-page reform draft is currently up for debate. The Democrats, who are mostly in favor of a law, have a majority there, but they need the votes of two independent senators to vote. At the same time, they cannot allow themselves to deviate. However, four Democrats are still wrestling with their approval. It is ruled out that one of the Republican senators will vote in favor of the reform.

Abortion, in particular, has heated up the debate: Conservatives are flushed with the thought that the state could help finance abortions. In addition, the elected officials divided the question of whether the reform should include state insurance (public option). This would mean that the state would actively participate in the competition between health insurers. How the employers should be obliged to protect their employees and what punishment threatens those who refuse to take out insurance is still unclear to many.

The real crux of the project, however, is the financing: The reform is expected to cost between 848 billion and around one trillion dollars over the next ten years, depending on the proposal. Part of the money is to come in through tax increases for the rich and redeployment. How the sum should be raised in detail and whether the USA, which is still badly shaken by the economic crisis, can afford such a reform, opinions differ.

The pharmaceutical industry and insurers in particular have been storming Obama's plans for months. US citizens are also rubbing against the reform. In the minds of Americans, health insurance protection is not anchored as a fundamental right of the individual, but the rejection of state interference is: many Americans forbid any form of state interference in their personal living environment. They believe more in the responsibility of the individual.

The 435 members of the House of Representatives passed a bill in a narrow vote in November. If the Senate now also agrees, both proposals must still be combined into a joint draft. Only then does the President's signature take place. It is considered possible - for the first time since 1917 - that a reform can get through. If there is a radical change in the law, between 94 and 96 percent of all Americans would have health insurance in the future.
US Health Care System: Revolution or Failure

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