The basics
There is no national mandatory health insurance system in the United States, due to the unique history of the country and its outlook. Free choice and individual responsibility are fiercely defended notions.
Everybody, or every family – except the elderly or the very poor – who wants health coverage must do so through a private insurer. In 55 per cent of cases, such coverage is provided through an employer who shares the cost with the employee.
The system hinges on market factors. Premiums, types of care reimbursed, levels of reimbursement, cost-sharing between employer and employee – all this depends on a variety of variables, from how big the employer is to where the employee lives. Women pay more than men, large people more than thin ones, the elderly more than young people.
For the elderly and the poor, there are two government programmes. One is Medicare for over-65s and the disabled; it covers 48 million people by paying for basic hospital care, with options available at extra cost for doctor’s visits and prescriptions. The other is Medicaid, which provides free care for the neediest, subject to their resources.
Civil servants and military veterans have their own health insurance.
In 2010, 49 million Americans under the age of 65, or 18 per cent of the population, had no health insurance.
How it works
Health insurance may pay for the whole cost of a medical bill, but more often, it covers only part of the cost, leaving the patient to “co-pay” the remainder of the bill. Patients can go to designated hospitals or doctors with whom the insurer had negotiated discounts; if they go outside that list, they have to check first if the insurer will pay. Those without insurance, most often the poorest, pay higher, non-negotiated fees out of their own pockets.
Fees are very high in general because doctors must pay back the high cost of their medical studies and insure themselves against malpractice suits, which are common in the United States and which explain why American doctors carry out so many detailed examinations. A doctor can refuse a Medicare or Medicaid patient. In case of a life-or-death emergency, by law, the patient must be treated.
The costs
For the government 47.7 per cent of overall health costs are public expenditures, due to direct or indirect assistance, such as tax deductions. The US health-care system is the most expensive in the world in terms of per centage of gross domestic product (17.4 per cent). Per capita, it costs $8,000 – twice the figure for France, for example. Some $2.6 trillion (€1.9 trillion) went towards health care in 2010, 10 times more than 30 years ago.
For individuals, premium costs vary widely, due to the many parameters involved. Last year, coverage for an employee and family, through an employer, typically cost $15,000 (€11,000), with 30 per cent paid by the employee and the rest by the employer.
Individuals can open non-taxable health savings accounts to squirrel away money in the event of a future medical need.
Health care in the US
Life expectancy in the US is 78.2 years. In that regard, it ranks 50th on a world scale, and 28th among rich nations in the Organisation for Economic Cooperation and Development (OECD).
The United States ranks 32nd among OECD member states for infant mortality (seven per 1,000), and first for medical costs imposed on patients.
Obama’s medical care law
The US law that extends health insurance coverage to most Americans, dubbed “Obamacare” by its detractors, is 2,400 pages long but only certain points have been challenged before the US Supreme Court.
• The individual mandate
Beginning in 2014, every US citizen will be obliged to take out health insurance, either individually or through their employer, or be subject to sanctions. The only exceptions are members of certain faiths, prisoners, elderly or disabled Americans covered by Medicare, and those covered by Medicaid, the insurance program for the poor.
It is the most controversial element of the law, one challenged by 28 states. Opponents argue that the Congress overstepped its constitutional prerogatives in requiring individuals to buy insurance, while the administration contends that the Congress was on solid ground by virtue of constitutional provisions on trade and taxes.
The Supreme Court has set aside two hours tomorrow to hear the arguments. But it will first spend 90 minutes today considering whether it has standing to rule on a measure that has not yet entered into force. If it decides it does not, the debate on the individual mandate provision will be put off until at least 2014.
• Pre-existing conditions
Beginning in 2014, insurance companies must extend coverage to all comers without regard to pre-existing health conditions. This point has not been challenged but it may not survive if the individual mandate is judged anti-constitutional.
The court would have to determine whether the law could survive without this key measure. The justices will spend 90 minutes on this issue on Wednesday.
• Coverage of the poor
The income levels for those eligible for coverage under Medicaid, the government insurance program for the poor, are raised to 133 per cent of the poverty level, extending the benefit to 16 million Americans. The states appealing to the court say this reform would involve a notable transformation of the federal-state partnership in the financing of Medicaid.
The Administration assures that the additional cost will be financed entirely by the federal government. The Supreme Court will spend a half hour deliberating on this aspect of the law on Wednesday.
• The markets
Each state is to create a marketplace by 2014 where individuals and employers can compare insurance policies and rates and sign up for coverage. Some part of the population and small businesses could be eligible for government assistance. Businesses with more than 50 employees who have not offered their employees coverage by 2014 must pay a fine.