US healthcare/insurance question

[Splash1]

2 hours ago, YaelAldrich said:

From what I read because of his amputations, he's going to have to renovate much of his home and get a car that will allow him to drive in addition to the medical expenses that his family will incur.  I feel for him; especially since he is still a fan of the administration that helped our country to this very point.

That makes a lot of sense.  Those type of things would not be covered and very expensive.

 

[prairiewindmomma]

1 hour ago, Carolina Wren said:

Tangentially--A lot of people point out that the US education system spends more money per pupil than most, but I think that would cease to be true if the American system didn't have the cost of health insurance for teachers/staff/admins included.

It is very eye opening to look at school district budgets and see how little is spent directly on students.

[zimom]

There have been many great posts specifically about his medical costs.  Let me explain about his amputation.   First, based on what has been posted, he will NOT need a specialized car.   Modifications to his home, maybe, maybe not.    Prosthetics, that is a whole different story.   His insurance should cover one decent prosthetic for him, usually at the same benefit level as his other medical benefits (although there are still unfortunately exceptions of much lower coverage).   However, if he wants a specialized running leg, he will have to cover that 100% out of his own pocket at a cost of around $15,000.   I believe I read it was below the knee.   If it is above the knee, then much, much higher.   He will need to replace that around every 5 years.  

 

[MEmama]

2 hours ago, Carolina Wren said:

I've been coughing for months. After not getting successful treatment from other doctors, last week I contacted an ENT's office and got an appointment in only two days. I felt like I'd won a prize.

I've heard a few stories of Americans overseas being shocked at how easy it is to get health care. In one of the videos on Dr. John Campbell's youtube channel, he interviewed someone who had injured his knee and needed it looked at while somewhere in Asia (Taiwan, maybe?). So the man went in to see a doctor, who told him he'd need an MRI. The American was like, okay, how do I arrange that? Obviously he was thinking it would be a few weeks and a significant sum and a provider on the other end of town. But the doctor answered patiently, You go back down to the first floor, and they do the MRI, and then you come back up here to me. Oh.

There's a story I saw I think on Twitter of an American woman who was concerned about a breast lump while she was working temporarily in Denmark. She asked at work how to get in to see a doctor. Um, walk into the clinic across the street and tell them what's going on. But, like, what about a referral? And an appointment? And how much do I pay up front? You can get an appointment if you really need to be seen at a certain time instead of waiting your turn if someone else is being seen... but... you can just walk in there right now. Without money.

Kind of mind-blowing.

It really depends everywhere, though.

When we lived in Canada, a friend discovered a lump in her breast. She had to wait 6 months to get a biopsy (yes, 6 months). When I had the same issue in the states, it was biopsied and tested immediately. I had results within the hour and never had to leave the building.

Insurance isn’t always less expensive,either. In Canada we paid roughly the equivalent for supplemental insurance in order to have similar coverage that we had in the US. The difference came in no copays or additional costs, at least for routine stuff. We also didn’t have a doctor for our first two years because there wasn’t one available. Waiting in the ER with a 5 year old crying with an ear infection is not advisable.
 

OTOH when my mom had a heart attack in Germany, her medical care was excellent and she never paid a dime. Insurance and money weren’t even discussed (eventually somehow it went through her American provider but it was entirely taken care of). She was especially impressed with the quality of the hospital food. Lol 

We have much to learn about humane treatment in this country for sure.

[Laura Corin]

Just now, Ordinary Shoes said:

I remember the Twitter thread about the Denmark. 

Did you know that there are international insurance plans that do not provide coverage in the US? It costs too much here. Expats can buy the insurance but avoid being in the USA in case they get hurt/sick because they would have no coverage. I read a story about an American expat couple who had one of these plans and they had to arrange for their child to be born outside of the USA because of the cost. It's insane. 

 

Travel insurance that you buy in the UK has two standard costs, to include or exclude the US, Canada and the Caribbean.

[cjzimmer1]

5 hours ago, hjffkj said:

Medicaid is the only option if you want 100% coverage but then your stuck in a low paying job if you want to keep that Medicaid.  When we were growing our family dh actually asked his employer not to give him a raise once because I was pregnant and it would have disqualified us for Medicaid by $10.  Then we wouldn't have been able to afford insurance and would have had to pay for all my care out of pocket.  Even if we could have afforded the monthly premiums the deductibles would have been so high we would have still been paying a large chunk of it.

I don't know if this varies based on how individual states handle their programs for low income but in our state, if you get on state insurance when you are pregnant, they allow you (the pregnant person and the baby but not other family members) to remain on the program for one full year post birth even if your income increases past the range of eligibilty.  They want to make sure mom and baby get adequate care during that critical period so they will not cut anyone off.  I've had it happen more than once where DH had job gaps/hops that left us eligible for state insurance while I was pregnant and then once he found a job with insurance, the rest of the family was phased off but I and baby were allowed to remain on the state plan (in additional to the private plan from DH's new employer)

[hjffkj]

8 minutes ago, cjzimmer1 said:

I don't know if this varies based on how individual states handle their programs for low income but in our state, if you get on state insurance when you are pregnant, they allow you (the pregnant person and the baby but not other family members) to remain on the program for one full year post birth even if your income increases past the range of eligibilty.  They want to make sure mom and baby get adequate care during that critical period so they will not cut anyone off.  I've had it happen more than once where DH had job gaps/hops that left us eligible for state insurance while I was pregnant and then once he found a job with insurance, the rest of the family was phased off but I and baby were allowed to remain on the state plan (in additional to the private plan from DH's new employer)

I have had my medicaid cancelled while pregnant before so I don't think that is a thing in DE.  It was a paperwork error that they cancelled but if they hadn't put in the info wrong and things had actually changed they were going to cancel my coverage.  

[TechWife]

He will owe his deductible annually (max at $6000 per year right now).

After he meets his deductible, he will owe a percentage of the amount due after insurance contract pays out (it could be anywhere from 10-30%) until he meets his out of pocket maximum, after which the insurance company pays 100% according to the contract it has with the provider, but only until the end of the year, then the deductible starts all over again.

With amputations, the treatments he will need may or may not be covered by his insurance, it depends on the plan he has. He will likely need:

inpatient rehabilitation program

wound care (outpatient or inpatient, depending on where he is)

outpatient OT and PT

at home PT and OT to help him adapt to his home environment

prothesis fitting fees

prosthesis

possible additional surgeries, depending on how his legs heal

physician charges - inpatient and outpatient

hospital charges

wheelchair, walker, crutches, and/or cane

medication

bandages (for wound care from surgeries)

shower chair or bench

hand held shower nozzle

tailoring expenses for street clothes

exercise clothing to wear during rehab

anything he needs at home to make his home accessible - ramps, etc.

At some point, he will reach his lifetime out of pocket maximum (ours is $1 million per person and the insurance company will have to pay 100% according to their contract. But, keep in mind that only things that the insurance covers will go towards it - so if the insurance covers crutches but not walker, but he needs the walker, for example, he will be responsible for 100% of the price of the walker (which is set by whoever he buys it from and he may or may not get a good deal).

Also, factor work - His costs will change drastically and he will have to navigate a completely different maze if he goes on permanent or temporary disability, takes a leave of absence, or doesn't return to work.

 

 

[TechWife]

As far as the "staggaring medical expenses" part - here is a summary from a journal article. The full article is behind a paywall. It is from the Journal of Bone and Joint Surgery:

"Recent reports have suggested that functional outcomes are similar following either amputation or reconstruction of a severely injured lower extremity. The goal of this study was to compare two-year direct health-care costs and projected lifetime health-care costs associated with these two treatment pathways."

...

"When costs associated with rehospitalizations and post-acute care were added to the cost of the initial hospitalization, the two-year costs for reconstruction and amputation were similar. When prosthesis-related costs were added, there was a substantial difference between the two groups ($81,316 for patients treated with reconstruction and $91,106 for patients treated with amputation). The projected lifetime health-care cost for the patients who had undergone amputation was three times higher than that for those treated with reconstruction ($509,275 and $163,282, respectively)."

https://journals.lww.com/jbjsjournal/subjects/Rehabilitation/Abstract/2007/08000/Health_Care_Costs_Associated_with_Amputation_or.3.aspx

The report is thirteen years old and without paying for the full report, it's hard to know what costs they included. Honestly, those numbers seem really low to me. I am not sure if that's because of the time that has passed since the report was written or my own misperception.

Edited December 15, 2020 by TechWife

[mom2scouts]

We had to pick our insurance this week. We get some help through the (UN)Affordable Care Act and still only get to choose between a monthly premium that is almost half our take home pay or a lower premium with a $17,000 deductible and 50% copay (no vision or dental for either plan) and we can only use one doctor's office in the area. We just pick one because, if we ever have a major illness, we're going to be bankrupt anyway.

[EmilyGF]

3 hours ago, Laura Corin said:

Travel insurance that you buy in the UK has two standard costs, to include or exclude the US, Canada and the Caribbean.

It isn't just US health insurance that is expensive, it is anything with liability for Americans.

Our kids went to camp in Israel for 3 weeks and the cost for American citizens was $100 extra for extra liability insurance.

[mom2scouts]

Our neighbors are Indian immigrants and the wife is not yet a US citizen. Despite having what would be considered an excellent health insurance plan in the US, when she needed surgery, it was cheaper for her to fly to India to have the surgery than to have it here. 

Oh, and don't even get me started on politicians who talk about how many people have/will lose/don't have "health care" when what they are really talking about is how many people have/will lose/don't have health INSURANCE. Having insurance doesn't mean you can access health CARE.

Another thing: DH talked to the bank about a loan and was surprised by our credit rating because we still had some medical debt. The banker said they didn't even consider medical debt because, if they did, they would have to exclude just about everyone.

[mum]

https://www.usnews.com/news/best-countries/articles/2016-01-20/why-danes-happily-pay-high-rates-of-taxes

 

A discussion of health care is never complete without mentioning taxes. In Denmark, mentioned in the thread, the tax rate is 45%. Plus 7% more if you make over a certain amount. That doesn't excite me so much.  The article talks about why the Danes are happy to pay it, and maybe they are right. I just wanted to link to the article to show where I got that tax rate.

I agree that the system in the US is ridiculous. Truly and utterly stupid. Health insurance companies and pharmaceutical companies are making enormous profit. It is wrong on so many levels. 

Just don't forget, in most western countries, healthcare is either paid for up-front  or paid for at the point of service. No one is receiving free health care in Canada or Denmark or England, or any of those sort of places. Well, I guess if you live there and pay 0 income tax, you are receiving free health care. But the majority ARE paying.

This was a favorite discussion between my dad (American) and my mother-in-law (English, and a nurse). She would say "we don't pay for health care here". He would ask, "Do you work for free?" Her, "Oh no, I get paid." Him, " Who pays you?" Her, "The government." Him, "Where do they get that money." Her, "I don't know."  The answer---TAXES.

Not really sure which is better/worse. I guess the answer is they each have their pro's and con's. I have experienced both systems. I have experienced good in both, and appalling in both. Neither is perfect.

[Laura Corin]

1 hour ago, mum said:

https://www.usnews.com/news/best-countries/articles/2016-01-20/why-danes-happily-pay-high-rates-of-taxes

 

A discussion of health care is never complete without mentioning taxes. In Denmark, mentioned in the thread, the tax rate is 45%. Plus 7% more if you make over a certain amount. That doesn't excite me so much.  The article talks about why the Danes are happy to pay it, and maybe they are right. I just wanted to link to the article to show where I got that tax rate.

I agree that the system in the US is ridiculous. Truly and utterly stupid. Health insurance companies and pharmaceutical companies are making enormous profit. It is wrong on so many levels. 

Just don't forget, in most western countries, healthcare is either paid for up-front  or paid for at the point of service. No one is receiving free health care in Canada or Denmark or England, or any of those sort of places. Well, I guess if you live there and pay 0 income tax, you are receiving free health care. But the majority ARE paying.

This was a favorite discussion between my dad (American) and my mother-in-law (English, and a nurse). She would say "we don't pay for health care here". He would ask, "Do you work for free?" Her, "Oh no, I get paid." Him, " Who pays you?" Her, "The government." Him, "Where do they get that money." Her, "I don't know."  The answer---TAXES.

Not really sure which is better/worse. I guess the answer is they each have their pro's and con's. I have experienced both systems. I have experienced good in both, and appalling in both. Neither is perfect.

I think the article is right to frame tax-based health care as an investment in the feeling of security of each resident. 

For reference, as a university administrator in Scotland earning USD 33,000,   I  pay 20 per cent national income tax, with the first USD15,000 tax free. As a family, we pay around USD 3,000 in property tax. The equivalent of sales tax is 20 percent, but is not charged on food or children's clothes. There are high taxes on alcohol, cigarettes and petrol.  

Honestly,  I  think the NHS, which is funded from general taxation, is underfunded. I'd rather pay more.

Edited December 16, 2020 by Laura Corin

[wathe]

Federal taxes here are tiered:

The first $12,000 are tax-free, then

• 15% on the first $48,535 of taxable income, plus
• 20.5% on the next $48,534 of taxable income (on the portion of taxable income over 48,535 up to $97,069), plus
• 26% on the next $53,404 of taxable income (on the portion of taxable income over $97,069 up to $150,473), plus
• 29% on the next $63,895 of taxable income (on the portion of taxable income over 150,473 up to $214,368), plus
• 33% of taxable income over $214,368

To that, add provincial income tax, also tiered, and different from province to province.   Ontario, for example:

5.05% on the first $44,740 of taxable income, + 9.15% on the next $44,742, + 11.16% on the next $60,518, + 12.16% on the next $70,000, + 13.16 % on the amount over $220,000

The more you earn, the higher your tax burden.  The highest earners are paying nearly 50% on their earnings above $220k.  The lowest earners pay significantly less.

[mum]

44 minutes ago, Laura Corin said:

I think the article is right to frame tax-based health care as an investment in the feeling of security of each resident. 

For reference, as a university administrator in Scotland earning USD 33,000,   I  pay 20 per cent national income tax, with the first USD15,000 tax free. As a family, we pay around USD 3,000 in property tax. The equivalent of sales tax is 20 percent, but is not charged on food or children's clothes. There are high taxes on alcohol, cigarettes and petrol.  

Honestly,  I  think the NHS, which is funded from general taxation, is underfunded. I'd rather pay more.

I agree. I've worked for NHS, and been a patient of the NHS. Funding is always a problem. 

[EmilyGF]

9 hours ago, mum said:

https://www.usnews.com/news/best-countries/articles/2016-01-20/why-danes-happily-pay-high-rates-of-taxes

 

A discussion of health care is never complete without mentioning taxes. In Denmark, mentioned in the thread, the tax rate is 45%. Plus 7% more if you make over a certain amount. That doesn't excite me so much.  The article talks about why the Danes are happy to pay it, and maybe they are right. I just wanted to link to the article to show where I got that tax rate.

I agree that the system in the US is ridiculous. Truly and utterly stupid. Health insurance companies and pharmaceutical companies are making enormous profit. It is wrong on so many levels. 

Just don't forget, in most western countries, healthcare is either paid for up-front  or paid for at the point of service. No one is receiving free health care in Canada or Denmark or England, or any of those sort of places. Well, I guess if you live there and pay 0 income tax, you are receiving free health care. But the majority ARE paying.

This was a favorite discussion between my dad (American) and my mother-in-law (English, and a nurse). She would say "we don't pay for health care here". He would ask, "Do you work for free?" Her, "Oh no, I get paid." Him, " Who pays you?" Her, "The government." Him, "Where do they get that money." Her, "I don't know."  The answer---TAXES.

Not really sure which is better/worse. I guess the answer is they each have their pro's and con's. I have experienced both systems. I have experienced good in both, and appalling in both. Neither is perfect.

Doctors are also earning a lot. To have medical care like in Canada and Europe, we'd have to significantly decrease doctors' wages, too. 

22 High Paying Countries for Doctors in the World to Immigrate - WiseStep

From this website, the average specialist in Canada makes $70K less per year than in the USA. In Denmark a specialist would make $140K less and an GP $50K less. In Germany it would be a pay cut of $150K/years for a specialist.

From personal experience, my German friend was calling an agency in Germany to find out what her husband would have to do to work in Germany as a doctor. The agency told her they had never heard of a doctor leaving the USA to work in Germany due to the incredibly steep pay cut.

[HeartString]

Doctors in Germany may not make as much, but they aren’t graduating from medical school with the same debt load as American doctors either.  I’d imagine that mostly balances out in the end.  

[HeartString]

19 hours ago, wathe said:

Wait times can be a problem here (usually for more chronic issues), and referrals are needed for specialists (there is gatekeeping).  There is definitely griping about that.  For example, you would wait a long time for an MRI of your shoulder for rotator cuff problem, or for back pain without neurological deficit.  But, once you access the service, (MRI, specialist etc), it costs nothing out of pocket.  Cataract surgery, joint replacement surgery - those all have long waits.

Truly acute issues get handled quickly.  If you get emergency sick (appendix, ruptured aneurysm, trauma), you get very well cared for immediately, at no cost OOP.

If you get very sick sub-acutely (say, cancer) you get care, in a timely fashion, no cost OOP.

Semi-acute but not very sick (say grumbling gallbladder, but not acute cholecystitis) do tend to wait.

Preventive and primary care are also no cost OOP, and access is very good for most people (there are provider shortages in some more rural and remote communities).

My husband had to wait 8 weeks for an MRI for his neck. He was in so much pain that he was on opioids almost the entire time, which is more than enough time to have potentially created an addiction.  We had to get the MRI and then wait for results before we could wait again for an appointment at a pain clinic to start treatment.  We have good insurance through his work, it was just an issue of scheduling.
 

I have no idea what other Americans are experiencing where they think waiting for care only happens in other countries.  I guess I’m doing it wrong? And it took us a year to pay off that MRI.  

[EmilyGF]

2 hours ago, Cnew02 said:

Doctors in Germany may not make as much, but they aren’t graduating from medical school with the same debt load as American doctors either.  I’d imagine that mostly balances out in the end.  

If you look at the numbers I quoted above, it looks like it'd take about 4 years for an American doctor to get ahead of doctors in Germany, even when college and graduate school debt is taken into account.

I'm not saying that the system is *good*. Just people like to demonize insurers and health conglomerates for making oodles of money; doctors are benefitting, too, and you can't criticize the insurer for overcharging the patient without also criticizing the doctors. This gets left out of a lot of discussions of the pros and cons of other health care systems.

ETA: I'm not criticizing doctors. I think this is a systemic problem. If a child of mine were a doctor, I would encourage them to find a high paying job. The same goes for professors. My hubby is a prof and gets paid well. If he were at a UK university, he would take a huge pay cut. He can't personally change anything about higher education costs in the US by taking a lower salary, nor do I expect individual doctors or even insurance companies to make individual changes. This is definitely a systemic problem that requires coordinated changes at a higher level.

Emily

Edited December 16, 2020 by EmilyGF

[Scarlett]

2 hours ago, Cnew02 said:

My husband had to wait 8 weeks for an MRI for his neck. He was in so much pain that he was on opioids almost the entire time, which is more than enough time to have potentially created an addiction.  We had to get the MRI and then wait for results before we could wait again for an appointment at a pain clinic to start treatment.  We have good insurance through his work, it was just an issue of scheduling.
 

I have no idea what other Americans are experiencing where they think waiting for care only happens in other countries.  I guess I’m doing it wrong? And it took us a year to pay off that MRI.  

Wow that is surprising to me. Dh has had many MRIs and I don’t think has ever had to wait more than a week. They have  places that are open until 8 or 9 in the evening so he did not even have to miss work. 

[Spryte]

2 hours ago, Cnew02 said:

My husband had to wait 8 weeks for an MRI for his neck. He was in so much pain that he was on opioids almost the entire time, which is more than enough time to have potentially created an addiction.  We had to get the MRI and then wait for results before we could wait again for an appointment at a pain clinic to start treatment.  We have good insurance through his work, it was just an issue of scheduling.
 

I have no idea what other Americans are experiencing where they think waiting for care only happens in other countries.  I guess I’m doing it wrong? And it took us a year to pay off that MRI.  

I’ve never waited less than 4-6 weeks for an MRI.  And the wait to see the doc that ordered it was usually 2-3 months.  (Speaking of neurologists, in my case.)

Our family has encountered massive wait times.  6 months for the specialist I see for endocrinology, 5 mos for a psych for another family member.  I could go on and on and on.

I never understand the people who say that we don’t have wait times here.  Our lived experience has been so different.

[Bootsie]

3 hours ago, EmilyGF said:

If you look at the numbers I quoted above, it looks like it'd take about 4 years for an American doctor to get ahead of doctors in Germany, even when college and graduate school debt is taken into account.

 

What happens when you take into account the differences in liability insurance costs?  I think it takes longer to become a doctor in the US than in Germany, which is not only that US doctors are paying tuition (much higher) tuition for a longer period of time, there are more years of foregone income that a US doctor experiences.  Also, US doctors are probably more likely to be in their own practice, with the costs, hassles, and risks of running a small business that German doctors tend not to have.   I think the entire risk/reward tradeoff, not only to get through medical school, but once one is a practicing physician, that it is hard to compare just salaries.

[Frances]

14 hours ago, mum said:

https://www.usnews.com/news/best-countries/articles/2016-01-20/why-danes-happily-pay-high-rates-of-taxes

 

A discussion of health care is never complete without mentioning taxes. In Denmark, mentioned in the thread, the tax rate is 45%. Plus 7% more if you make over a certain amount. That doesn't excite me so much.  The article talks about why the Danes are happy to pay it, and maybe they are right. I just wanted to link to the article to show where I got that tax rate.

I agree that the system in the US is ridiculous. Truly and utterly stupid. Health insurance companies and pharmaceutical companies are making enormous profit. It is wrong on so many levels. 

Just don't forget, in most western countries, healthcare is either paid for up-front  or paid for at the point of service. No one is receiving free health care in Canada or Denmark or England, or any of those sort of places. Well, I guess if you live there and pay 0 income tax, you are receiving free health care. But the majority ARE paying.

This was a favorite discussion between my dad (American) and my mother-in-law (English, and a nurse). She would say "we don't pay for health care here". He would ask, "Do you work for free?" Her, "Oh no, I get paid." Him, " Who pays you?" Her, "The government." Him, "Where do they get that money." Her, "I don't know."  The answer---TAXES.

Not really sure which is better/worse. I guess the answer is they each have their pro's and con's. I have experienced both systems. I have experienced good in both, and appalling in both. Neither is perfect.

I’m sure it’s obvious to everyone on a WTM board that taxes or other payments by the citizens are covering the cost of universal healthcare in other countries. Taxpayers in Denmark are getting way more than just universal health care for those high tax rates you quoted, though. Free college (including a stipend for living expenses), subsidized childcare, pensions and help in the home for the elderly, up to two years of unemployment while looking for work, etc. etc.

In the US we actually pay more collectively for healthcare with worse outcomes, not to mention the extreme inequality in access. But the money is coming from lots of different sources (taxes, employers, employees, individual premium payments, etc.) and going to into all different pots, including insurance companies. Not to mention that we to some degree are subsidizing the often significantly lower price of some healthcare items (e.g. drugs, joints for joint replacements) in countries with universal healthcare.

Edited December 16, 2020 by Frances

[EmilyGF]

26 minutes ago, Bootsie said:

What happens when you take into account the differences in liability insurance costs?  I think it takes longer to become a doctor in the US than in Germany, which is not only that US doctors are paying tuition (much higher) tuition for a longer period of time, there are more years of foregone income that a US doctor experiences.  Also, US doctors are probably more likely to be in their own practice, with the costs, hassles, and risks of running a small business that German doctors tend not to have.   I think the entire risk/reward tradeoff, not only to get through medical school, but once one is a practicing physician, that it is hard to compare just salaries.

Still, according to the agency my friend contacted, the agency had never heard of a doctor transferring from the USA to Germany. I think if what you wrote were correct, there would be some who made that decision. 

Emily

[rebcoola]

4 hours ago, Cnew02 said:

My husband had to wait 8 weeks for an MRI for his neck. He was in so much pain that he was on opioids almost the entire time, which is more than enough time to have potentially created an addiction.  We had to get the MRI and then wait for results before we could wait again for an appointment at a pain clinic to start treatment.  We have good insurance through his work, it was just an issue of scheduling.
 

I have no idea what other Americans are experiencing where they think waiting for care only happens in other countries.  I guess I’m doing it wrong? And it took us a year to pay off that MRI.  

My dad had to wait forever to and it was no small problem 

4 minutes ago, Frances said:

I’m sure it’s obvious to everyone on a WTM board that taxes or other payments by the citizens are covering the cost of universal healthcare in other countries. Taxpayers in Denmark are getting way more than just univrersal health care for those high tax rates you quoted, though. Free college (including a stipend for living expenses), subsidized childcare, pensions and help in the home for the elderly, up to two years of unemployment while looking for work, etc. etc.

In the US we actually pay more collectively for healthcare with worse outcomes, not to mention the extreme inequality in access. But the money is coming from lots of different sources (taxes, employers, employees, individual premium payments, etc.) and going to into all different pots, including insurance companies. Not to mention that we to some degree are subsidizing the often significantly lower price of some healthcare items (e.g. drugs, joints for joint replacements) in countries with universal healthcare.

I haven't but I know my brother did the math his family would have like $15,000 more to use freely using the Denmark system.  

[Frances]

38 minutes ago, Bootsie said:

What happens when you take into account the differences in liability insurance costs?  I think it takes longer to become a doctor in the US than in Germany, which is not only that US doctors are paying tuition (much higher) tuition for a longer period of time, there are more years of foregone income that a US doctor experiences.  Also, US doctors are probably more likely to be in their own practice, with the costs, hassles, and risks of running a small business that German doctors tend not to have.   I think the entire risk/reward tradeoff, not only to get through medical school, but once one is a practicing physician, that it is hard to compare just salaries.

I think liability insurance costs in is actually one of the biggest differences. Private practices in the US are declining very steadily. More and more physicians are employees, as opposed to employers. Some students in the US can graduate medical school with very high debt, others with none. Just like virtually everything else in the US, the differences can be extreme. I don’t know if medical school in Germany is basically free except for a small fee as their college is but I would agree their doctors probably generally finish with little or no debt.

Given the high number of doctors from all over the world who apply for medical residencies in the US in order to some day practice here, I do think the higher base pay drives much if it. Of course most of those coming from other countries paid little or nothing for their medical degree. Here in the US we can’t even manage to provide enough medical school slots to fill all of our residency slots, let alone do much subsidizing of the costs of medical school (some states do better than others).

Edited December 16, 2020 by Frances

[EmilyGF]

My sister had appendicitis in Africa at a great hospital. She got laproscopic (sp?) surgery at the hospital and full treatment for $1500.

The issue was that she had to pay before they admitted her! She said the care was wonderful, though. DH had appendicitis the same month and the "sticker" price was $10K. The insurance paid something like $3K. Our co-pay was $150.

Emily

[Frances]

13 hours ago, wathe said:

Federal taxes here are tiered:

The first $12,000 are tax-free, then

• 15% on the first $48,535 of taxable income, plus
• 20.5% on the next $48,534 of taxable income (on the portion of taxable income over 48,535 up to $97,069), plus
• 26% on the next $53,404 of taxable income (on the portion of taxable income over $97,069 up to $150,473), plus
• 29% on the next $63,895 of taxable income (on the portion of taxable income over 150,473 up to $214,368), plus
• 33% of taxable income over $214,368

To that, add provincial income tax, also tiered, and different from province to province.   Ontario, for example:

5.05% on the first $44,740 of taxable income, + 9.15% on the next $44,742, + 11.16% on the next $60,518, + 12.16% on the next $70,000, + 13.16 % on the amount over $220,000

The more you earn, the higher your tax burden.  The highest earners are paying nearly 50% on their earnings above $220k.  The lowest earners pay significantly less.

While our federal taxes here are tiered (progressive), most state tax systems in the US are actually regressive (lower income people pay a higher share of their income in taxes).

[Arctic Bunny]

On 12/15/2020 at 12:03 PM, wathe said:

Wait times can be a problem here (usually for more chronic issues), and referrals are needed for specialists (there is gatekeeping).  There is definitely griping about that.  For example, you would wait a long time for an MRI of your shoulder for rotator cuff problem, or for back pain without neurological deficit.  But, once you access the service, (MRI, specialist etc), it costs nothing out of pocket.  Cataract surgery, joint replacement surgery - those all have long waits.

Truly acute issues get handled quickly.  If you get emergency sick (appendix, ruptured aneurysm, trauma), you get very well cared for immediately, at no cost OOP.

If you get very sick sub-acutely (say, cancer) you get care, in a timely fashion, no cost OOP.

Semi-acute but not very sick (say grumbling gallbladder, but not acute cholecystitis) do tend to wait.

Preventive and primary care are also no cost OOP, and access is very good for most people (there are provider shortages in some more rural and remote communities).

Or here in Sask you can pay for the MRI, and it pays for one out of the public waitlist as well, essentially decreasing the waitlist by two.

[Frances]

4 hours ago, Cnew02 said:

Doctors in Germany may not make as much, but they aren’t graduating from medical school with the same debt load as American doctors either.  I’d imagine that mostly balances out in the end.  

Maybe in some cases, but there are also doctors in the US that graduate with no little or no debt. The variance is going to be much greater in the US than in Germany.

[Frances]

Another difference in the US is the facility arms race among competing healthcare systems in the US, much like we see with colleges constantly adding new and improved dorms, gyms, etc. In my neck of the woods, it’s hospital birthing centers trying to one up each other to attract patients.

[Bootsie]

14 minutes ago, Frances said:

While our federal taxes here are tiered (progressive), most state tax systems in the US are actually regressive (lower income people pay a higher share of their income in taxes).

Most states do not have regressive income tax structures, do they?  Most states have some type of sales tax and property or wealth tax which can be regressive. 

[Frances]

4 hours ago, Cnew02 said:

My husband had to wait 8 weeks for an MRI for his neck. He was in so much pain that he was on opioids almost the entire time, which is more than enough time to have potentially created an addiction.  We had to get the MRI and then wait for results before we could wait again for an appointment at a pain clinic to start treatment.  We have good insurance through his work, it was just an issue of scheduling.
 

I have no idea what other Americans are experiencing where they think waiting for care only happens in other countries.  I guess I’m doing it wrong? And it took us a year to pay off that MRI.  

I think it varies greatly by location, insurance plan, and what specialist or test you need. I think countries with centralized healthcare can track all different health metrics quite easily, making comparisons with other countries with universal healthcare meaningful. In the US, getting any meaningful data is going to be difficult, so we mostly here about personal experiences, often at the extremes.

An exception here is things like the VA where we do see reports of wait times, etc. compared across different VA facilities.

[Frances]

4 minutes ago, Bootsie said:

Most states do not have regressive income tax structures, do they?  Most states have some type of sales tax and property or wealth tax which can be regressive. 

Some states don’t even have income taxes, so I think it matters more whether or not the overall tax system of a state is regressive or progressive. There are also states where they have an income tax, but it represents only a small portion of the taxes collected. The tax money has to come from somewhere.

https://itep.org/whopays/

[Bootsie]

27 minutes ago, Frances said:

I think liability insurance costs in is actually one of the biggest differences. Private practices in the US are declining very steadily. More and more physicians are employees, as opposed to employers. Some students in the US can graduate medical school with very high debt, others with none. Just like virtually everything else in the US, the differences can be extreme. I don’t know if medical school in Germany is basically free except for a small fee as their college is but I would agree their doctors probably generally finish with little or no debt.

Given the high number of doctors from all over the world who apply for medical residencies in the US in order to some day practice here, I do think the higher base pay drives much if it. Of course most of those coming from other countries paid little or nothing for their medical degree. Here in the US we can’t even manage to provide enough medical school slots to fill all of our residency slots, let alone do much subsidizing of the costs of medical school (some states do better than others).

In Germany, students study medicine when entering university rather than doing an undergraduate degree, then applying for medical school, then doing medical school.  The entire medical program can be done in just over six years, with very low fees.   Most people I have known in the US who have applied for medical school recently have had a four year undergraduate degree with excellent grades and often must wait a year or more before getting into medical school.  By the time a US student is starting medical school, the Germany student could be just about completed with schooling.  I was speaking with a physician in Austria recently and she was appalled that my cousin who is a nurse practitioner is able to write prescriptions in the US--she just couldn't believe that someone with less training/schooling would have the same privilege that she as a doctor had; but then I went through all of the training/education my cousin has had and it actually surpassed what she has a physician in Austria. 

[Bootsie]

24 minutes ago, Frances said:

Some states don’t even have income taxes, so I think it matters more whether or not the overall tax system of a state is regressive or progressive. There are also states where they have an income tax, but it represents only a small portion of the taxes collected. The tax money has to come from somewhere.

https://itep.org/whopays/

Yes, most of the regressive nature at the state and local level come from sales tax.  When comparing to European countries, one must remember that most have a Value Added Tax that taxes consumption, as does a sales tax, and is therefore regressive.  To compare progressivity/regressivity of the different tax structures, the VAT must also be considered.  

[Frances]

6 minutes ago, Bootsie said:

Yes, most of the regressive nature at the state and local level come from sales tax.  When comparing to European countries, one must remember that most have a Value Added Tax that taxes consumption, as does a sales tax, and is therefore regressive.  To compare progressivity/regressivity of the different tax structures, the VAT must also be considered.  

Agreed. For the best comparison, all taxes would need to be considered. My state is one of the rare ones with no sales tax.

[Frances]

28 minutes ago, Bootsie said:

In Germany, students study medicine when entering university rather than doing an undergraduate degree, then applying for medical school, then doing medical school.  The entire medical program can be done in just over six years, with very low fees.   Most people I have known in the US who have applied for medical school recently have had a four year undergraduate degree with excellent grades and often must wait a year or more before getting into medical school.  By the time a US student is starting medical school, the Germany student could be just about completed with schooling.  I was speaking with a physician in Austria recently and she was appalled that my cousin who is a nurse practitioner is able to write prescriptions in the US--she just couldn't believe that someone with less training/schooling would have the same privilege that she as a doctor had; but then I went through all of the training/education my cousin has had and it actually surpassed what she has a physician in Austria. 

Yes, I’m very familiar with the differences in the systems as I have a friend who is a doctor here and grew up in and went to medical school in Germany and my husband was accepted to medical school here twice, but chose a different path each time. We also have lots of friends and neighbors who are doctors here. I realize they can practice sooner in Germany, but I still think the significantly higher US salaries generally more than make up for the difference in the delayed career start. Of course there will always be exceptions such as those in the US who choose to work as general practitioners for low salaries in high need areas. And there is great variation in the US. I know people who graduated from undergrad and medical school with no debt for a variety of reasons (scholarships, military, parent support, work, spousal support) and others with significant debt. I think the variation in Germany would be much lower.

Edited December 16, 2020 by Frances

[Bootsie]

41 minutes ago, Frances said:

Yes, I’m very familiar with the differences in the systems as I have a friend who is a doctor here and grew up in and went to medical school in Germany and my husband was accepted to medical school here twice, but chose a different path each time. We also have lots of friends and neighbors who are doctors here. I realize they can practice sooner in Germany, but I still think the significantly higher US salaries generally more than make up for the difference in the delayed career start. Of course there will always be exceptions such as those in the US who choose to work as general practitioners for low salaries in high need areas. And there is great variation in the US. I know people who graduated from undergrad and medical school with no debt for a variety of reasons (scholarships, military, parent support, work, spousal support) and others with significant debt. I think the variation in Germany would be much lower.

Yes, the variation in the US is probably much greater.  The average debt on leaving medical school in the US is $251,000  Average Student Loan Debt for Medical School for 2020 (credible.com).  If you assume that a US doctor starts practicing 3 years later than a German doctor, if a German doctor makes $70,000 per year, that is another $210,000 that the US doctor is behind.  That means the average US doctor starts a career at a $461,000 deficit relative to the German doctor.  If you apply a 8% discount rate, a US doctor would have to earn $41,000 per year more than a German doctor to break even (assuming that all of their future expenses like medical malpractice insurance are the same).  

The differential when comparing also is heavily influenced by the exchange rate used to compare the wages.  If you are assuming $1.1/euro verses $1.25/euro, you get a significant difference and the exchange rates are likely to vary that much within a year--much less over the work-life of a physician.

[Frances]

57 minutes ago, Bootsie said:

Yes, the variation in the US is probably much greater.  The average debt on leaving medical school in the US is $251,000  Average Student Loan Debt for Medical School for 2020 (credible.com).  If you assume that a US doctor starts practicing 3 years later than a German doctor, if a German doctor makes $70,000 per year, that is another $210,000 that the US doctor is behind.  That means the average US doctor starts a career at a $461,000 deficit relative to the German doctor.  If you apply a 8% discount rate, a US doctor would have to earn $41,000 per year more than a German doctor to break even (assuming that all of their future expenses like medical malpractice insurance are the same).  

The differential when comparing also is heavily influenced by the exchange rate used to compare the wages.  If you are assuming $1.1/euro verses $1.25/euro, you get a significant difference and the exchange rates are likely to vary that much within a year--much less over the work-life of a physician.

I’m not sure average is the best measure of debt, median is likely better. Plus it likely matters far more what debt is relative to area of specialization. There are also programs that forgive much or all of student debt in the US. For example, my husband had almost all of his PharmD loans paid by his employer. My state has loan forgiveness for health professionals serving in rural areas for a short period of time. The federal government has similar programs for rural and underserved areas. Many physicians are now employees of non-profit hospitals and thus qualify for the extremely generous federal loan forgiveness program.

In the end, I think it’s like virtually everything else in the US. There are going to be vary wide ranges of true debt (debt the borrower actually pays) for medical school grads and very wide range of income for doctors practicing here. While in Germany, both ranges are likely narrower, especially debt loads.

 

Edited December 16, 2020 by Frances

[TechWife]

7 hours ago, Cnew02 said:

My husband had to wait 8 weeks for an MRI for his neck. He was in so much pain that he was on opioids almost the entire time, which is more than enough time to have potentially created an addiction.  We had to get the MRI and then wait for results before we could wait again for an appointment at a pain clinic to start treatment.  We have good insurance through his work, it was just an issue of scheduling.
 

I have no idea what other Americans are experiencing where they think waiting for care only happens in other countries.  I guess I’m doing it wrong? And it took us a year to pay off that MRI.  

Yes! Waiting for care is common in many areas of the US. Many people don’t realize that and I think that they are mostly inexperienced with the system. My DS waited three months to see a rheumatologist, seven month to see a developmental pediatrician. Some specialists are hard to find and when you do find them they are booked many months in advance. 

[rebcoola]

Yeah the waits can be killer.  My mom waiting  for a neurologist right now.  She is scheduled for February. She has debilitating dizziness that's already had other causes ruled.  We are not or rural or anything.

[Bootsie]

51 minutes ago, Frances said:

I’m not sure average is the best measure of debt, median is likely better. Plus it likely matters far more what debt is relative to area of specialization. There are also programs that forgive much or all of student debt in the US. For example, my husband had almost all of his PharmD loans paid by his employer. My state has loan forgiveness for health professionals serving in rural areas for a short period of time. The federal government has similar programs for rural and underserved areas. Many physicians are now employees of non-profit hospitals and thus qualify for the extremely generous federal loan forgiveness program.

In the end, I think it’s like virtually everything else in the US. There are going to be vary wide ranges of true debt (debt the borrower actually pays) for medical school grads and very wide range of income for doctors practicing here. While in Germany, both ranges are likely narrower, especially debt loads.

 

According to this What Is the Average Medical School Debt? - NerdWallet the median level of medical school debt is $200,000 plus a median level of $25,000 of undergraduate debt--so the mean and median in the US are not that far off in this instance.  There are some loan forgiveness programs in the US, but that does not come without risk.  I know of two physicians who had medical problems after attending medical school which significantly curtailed their ability to practice medicine (which would preclude them from participating in a loan forgiveness program).  Although it will vary significantly, those who train to be a physician in the US make a much greater person investment (time and often financial resources--even if they don't have debt if they or their family are paying tuition, including the opportunity cost of the years they are in school and not earning income) than German doctors with some risk that they will not be able to recoup that investment.  

[Frances]

31 minutes ago, Bootsie said:

According to this What Is the Average Medical School Debt? - NerdWallet the median level of medical school debt is $200,000 plus a median level of $25,000 of undergraduate debt--so the mean and median in the US are not that far off in this instance.  There are some loan forgiveness programs in the US, but that does not come without risk.  I know of two physicians who had medical problems after attending medical school which significantly curtailed their ability to practice medicine (which would preclude them from participating in a loan forgiveness program).  Although it will vary significantly, those who train to be a physician in the US make a much greater person investment (time and often financial resources--even if they don't have debt if they or their family are paying tuition, including the opportunity cost of the years they are in school and not earning income) than German doctors with some risk that they will not be able to recoup that investment.  

I agree with you that the personal investment and risk is likely greater in the US. I know more than one person who left their residency before they ever became a practicing physician, but still had to payback all of their loans. I do wonder about German doctors who choose to leave the profession. In the US, our higher education system allows one to continually reinvent themselves if they desire. It’s my understanding in Germany that becoming a physician starts quite young with attending the right type of high school and being at the absolute top in order to get into medical school. While in the US we have everything from 20 to 50 year old starting medical school, sometimes after having completely different careers first.

One interesting suggestion I’ve heard to make medical education more equitable and affordable in the US is to make medical school free, but have doctors pay for their residencies instead. So general practitioners would pay for fewer years and maybe pay less than specialists who will later make significantly higher salaries. Plus, then everyone would have to pay at some point to practice in the US, including those who come from other countries for residencies here. I doubt it will ever happen for a variety of reasons, but it’s interesting to ponder.

[Tree Frog]

9 hours ago, EmilyGF said:

Still, according to the agency my friend contacted, the agency had never heard of a doctor transferring from the USA to Germany. I think if what you wrote were correct, there would be some who made that decision. 

Emily

My bil is a family practice doctor and my dd is a third year med school student. BIL has been practicing in some way since the mid '80's. He has seen the requirements to accept Medicare patients increase while the reimbursements for those visits decrease. He has said he loses money when he sees Medicare patients. He has seen record keeping requirements change so significantly he had to add 2 staff members to his clinic (BIL, an NP, 2 nurses, and an office manager) just to cover the paperwork. In order to maintain hospital privileges, he had to (sort of?) sell his practice to a larger consortium. He had to stop delivering babies because his malpractice insurance was so high. He's looking at retiring early next year and has said he would discourage anyone from entering the field.

There are some specialists that make a lot of money, like plastic surgery. My cousin is a general surgeon and makes a large amount. Unfortunately, BIL, while being comfortable, doesn't have a lot of excess income when compared to specialists.

When dd was looking at med school and thinking about a military scholarship, we talked about how much she would likely have in loans when she finished and what her monthly school loan payment would be. We talked about it again last summer and she said if she had taken loans, she calculated the total for 4 years, including living expenses because she couldn't take another job, was at least $250,000. That amount doesn't include the cost for additional schooling to become a specialist.

Before we could decrease payment to the doctors, there would need to be a way to decrease the cost of their education or some way to forgive loans. Becoming a doctor isn't inexpensive.