COVID-19 exposes basic problems with our health care system
“Since we seek our health care from a private system, there is a lot of confusion on the cost of this care … This makes seeking treatment challenging and stressful since potential COVID-19-patients don’t know the cost to care.”
— David Torres, a Global Health Professor at Middlebury College
More than 1.8 million people have died due to COVID-19 all around the world. Although there is no question that the causative agent of this disease, the SARS-CoV-2 virus, is largely responsible for driving the loss of our loved-ones during the pandemic, the dysfunction of our health care systems has also contributed to this devastatingly high death toll.
Concerns about the costs of medical visits and a lack of health insurance coverage has led many to avoid getting tested or seeking treatment until their situation is dire.
As the incidence of COVID-19 continues to rise, we need to consider the limitations of our health care system in the United States.
Furthermore, in order that all individuals in the United States can receive care when they are in need of it, it is necessary that our communities have access to credible information on the virus, protective health behaviors, and the health care services in their area.
To better understand the health care system in the United States and Addison County, I met with two highly experienced individuals. The first is David Torres, a Global Health Professor at Middlebury College who has worked professionally in nonprofits that seek to increase access to health care services. The second is an Addison County resident, I’ll call “Jane,” who shared her experience navigating COVID-19 and the health care services that allowed her to respond to her illness (Click here to read Jane’s story). In addition, I benefitted from the expertise of Pam Berenbaum, a Global Health Professor at Middlebury College.
Foremost, it is important to broadly understand how the United States health care system operates in comparison to those of other countries. Under the U.S. Constitution, states have primary authority for the health of their populations while the federal government provides scientific guidance via the Centers for Disease Control (CDC), National Institutes of Health, National Institute of Allergy and Infectious Diseases, Food and Drug Administration, etc., along with some health-related statutes that states must adhere to.
In addition, the federal government provides funding for health insurance programs for special populations such as Medicare for people 65 and older, and Medicaid, which is intended to serve low-income populations and is administered by states with each state determining eligibility.
One limitation of our state-focused structure, Professor Torres says, is that when there is a national emergency like the COVID-19 pandemic, there are no national mandates put in place by the federal government to tell Americans how to respond. This results in conflicting messaging that can leave individuals confused on what actions they should take. In turn, Torres argues that one of the biggest limitations to the health care system in the United States during the pandemic has been the absence of any uniform messaging or approaches to the risks posed by COVID-19 — Should people wear facemasks? Is it safe to shop in a grocery store or eat in a restaurant? Which family members is it safe to see in person? There are different answers to these questions from authorities in different states.
Second, Torres highlights that the United States does not have one national health insurance program — such as a single-payer system, a social health insurance system, or other universal health insurance programs. He says that for individuals on Medicare, aspects of a national health insurance program exist, but in general, health insurance is largely privately funded in the United States, in contrast to many other countries.
In addition, Torres explained, “Not only is our health insurance privatized, but so is our health care.” This greatly complicates health care access.
“Since we seek our health care from a private system, there is a lot of confusion on the cost of this care — care being preventive care and treatment care,” Torres said. “This makes seeking treatment challenging and stressful since potential COVID-19-patients don’t know the cost to care.”
Professor Berenbaum echoed this concern.
“There is no absolute cost of anything within our health care system. Costs are negotiated between the providers and the insurance companies. Three people, each with a different insurance, might be charged three different prices for the same procedure because that is the price that their insurer negotiated with the care provider,” she said. “There is no menu for health care services — the prices are invisible unless the consumer specifically asks in advance.”
Hence, when an individual is concerned about whether they can afford care, this variability in the cost of health care can dissuade that individual from seeking out health care.
Insurance Costs & Out Of Pocket Payments
To further breakdown the complexity surrounding the cost of health care, it is important to walk through what those costs might be.
Primary care, the care that usually comes from your family physician, and secondary care, such as the care that comes from hospitals, is largely provided by private companies and requires a monetary transaction. If you do not have insurance, you have to pay the expenses out of pocket and at the full, uninsured rate. However, even if patients are insured under a health insurance company, cost-sharing (the idea that your insurance will pay for only a part of the cost of your health care) requires individuals to pay many out-of-pocket expenses. After paying a copayment, coinsurance and a deductible, as well as the monthly or annual premium, then your insurance will kick in.
In a recent survey, the Kaiser Family Foundation found that the annual premiums for employer-sponsored family health care increased by 4% this year, which causes workers to pay, on average, $5,588 for insurance. In addition, they found that the average deductible among workers is $1,644 for single coverage. This survey reveals that there is a high cost to health care for those who receive employer-sponsored health insurance.
Given that employer-sponsored health insurance can be expensive, it might come at no surprise that the cost of individual health insurance, that is health insurance that is not subsidized in a group plan (such as employer-sponsored insurance) is often prohibitively expensive. However, the Affordable Care Act (ACA) has sought to expand access.
The ACA expanded access to health insurance in two ways, Berenbaum said. Through the ACA, states can choose to do one or both of the following; “1) Expand Medicaid through more generous eligibility requirements and 2) create a marketplace where individuals choose a plan from a private insurer.”
“Some states have chosen to expand Medicaid under the ACA and some states have not,” Berenbaum continued. “Vermont has expanded Medicaid and created a state-run marketplace.”
In summary, the fragmentation of and for-profit nature of the health care system in the United States arguably allows it to be expensive and hence limits who has access to care. Although Medicare and Medicaid provide health insurance with low deductibles and sometimes with no copayments or coinsurance payments or monthly premiums, the eligibility to enroll in Medicare or Medicaid is highly restrictive.
Many would agree that the programs and funding allotted toward the ACA need to expand so that more people will seek health care services when they need of them. However, it is also important to recognize that the ACA has given people in the United States many resources for some of the potential consequences of the pandemic, such as the loss of employer-sponsored health insurance when people become unemployed. Typically, there is an enrollment period for health insurance plans. However, Berenbaum points out, “If there is a qualifying event such as job loss, then you can sign up for a marketplace-based insurance outside of the normal enrollment period.”
COVID-19 And Health Care In Vermont
Now that we have been introduced to some of the broad challenges in the health care system around the United States, we can focus on Vermont with respect to COVID-19. Specifically with respect to the pandemic, new state regulations were put in place to make it so commercial insurance companies cannot charge out-of-pocket costs for Vermonters on certain employer-sponsored insurance plans (such as copays, coinsurance, and deductibles) for COVID-19 testing performed by the CDC, the Vermont Department of Health, and approved private labs. Additionally, these regulations make it so that insurance companies cannot charge Vermonters any out-of-pocket costs for COVID-19 related treatment that is deemed medically necessary.
However, it is important to note that these regulations only apply to those individuals on fully insured employer-sponsored insurance. These regulations do not apply to those individuals who have self-insured employer-sponsored insurance or individual insurance, and for those individuals who do not have insurance.
Differentials in the cost of services based on one’s health insurance, or lack thereof, creates a financial barrier to COVID-19 health services. Furthermore, misinformation on COVID-19 symptoms and risks circulating from noncredible sources complicates our understanding as to when to get tested or seek treatment.
How To Access Health Care And Health Insurance In Vermont
Access to health care services is limited if an individual doesn’t have insurance, is unable to afford the services with insurance, or doesn’t have the time or transportation to access those services, among other reasons. These issues highlight some of the major limitations of the health care system in the United States. As described by Professor Torres, the fragmentation of the United States health care system resulting from a mix of privately and publicly funded health care programs results in a tremendous amount of variability in who has access to care. In addition, the lack of uniform messaging across the states and federal government is confusing as it prevents individuals from understanding how to be safe in a pandemic.
All things considered, I think it is important to remember that not all symptoms of COVID-19 are critical, such as is the case for Jane (see related story), and that communicating with your health care providers, your family and your friends is important in order to proactively stay safe and keep others safe. However, not everyone has a support system or is able to access health care services.
Therefore, I want to leave you with a list of resources that can help you access health care services during the pandemic:
If you are unsure of whether or not you are symptomatic for COVID-19, please click this link to refer to the symptoms outlined by the CDC. For information about protecting yourself and others from COVID-19, please click this link to see how to prevent catching the disease.
In order to find local free testing near you, click this link for the portal made available by the Vermont Department of Health that will ask you to make an account and then select a time slot for an appointment and a pop-up-testing site near you. If you are unable to book an appointment for a free, pop-up testing site because the booking is at capacity or because you do not have access to internet, you can make appointment through your health care provider. As another option, Torres recommends calling the healthline 2-1-1 or the Vermont Health Department (802-863-7240), as many of the sites are likely able to test you as a walk-in.
If you don’t have a vehicle and need a ride to a testing site, please call 833-387-7200.
If you contract the COVID-19 virus and require financial assistance to cover health services that aren’t funded by the state or do not have a primary care physician to turn to for advice, then be sure to contact the Open Door Clinic (802-388-0137), which can provide you with guidance, and can also help you obtain health insurance.
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