Healthcare Financing Questions and Answers
A1. Compare the U.S. healthcare system with the healthcare system of Great Britain, Japan, Germany, or Switzerland
- I shall compare the healthcare system in the U.S with that in Germany.
A2. Compare access between the two healthcare systems for children, unemployed people, and people who are retired.
In both Germany and the United States, access to healthcare is compulsory. Nonprofit insurance companies in Germany cover a large chunk of the population in what is dubbed “sickness funds” (Berghöfer et al., 2020). In these programs, the insurance premiums are catered for by the government making the costs quite low and affordable to the insured persons. This insurance option is available to any citizen regardless of their age or employment status. This does not however restrict anyone from pursuing other health insurance options. For instance, individuals earning over 30,000 Euros may decide to seek private health insurance covers.
The difference between private insurance and the “sickness fund” is that the former has age and health as determinants (Roman-Urrestarazu et al., 2018). Contrary, in the United States, a large proportion of the insurance covers are through private companies. Employers are obligated to provide the covers to their employees. One may decide to pursue their insurance coverage through the Federal Marketplace that has been facilitated by the Obamacare that was enacted in 2010.
The option is made available for persons who are not satisfied with the cover provided by their employers or whose employers do not provide any insurance covers. There is yet another alternative in the United States for the unemployed or low-income groups-Medicaid. This is run by the state and is dependent on state and federal taxes. The United States has diversified as it also has the Children’s Health Insurance Program and Medicare to cover individuals that are over 65 years (Garfield et al., 2021).
A.2.a. Discuss coverage for medications in the two healthcare systems
In Germany, the prescriptions are covered by the “sickness fund”. The only costs that one incurs for medication when covered by the sickness fund are 10% of the cost of the drug. This makes it quite affordable. However, for those on private covers, they have to pay in advance and get a refund later on. This system bears some resemblance with the situation in the United States. One thing that strikes the difference is that in Germany, prescription drugs are less costly due to collective bargaining with the buyer and seller.
This is possible as the model in Germany has only one buyer; the “sickness fund” thus drug companies do not hike their prices. The individual’s insurance cover caters to the prescriptions in the US. The pricing is done under various levels. The first level comprises generic drugs that are less costly as compared to level three that is comprised of brand-name drugs. Despite the relief of the insurance cover, brand-name drugs still are expensive. Drug prices in the United States are not controlled by the government thus the prices are unreasonably high.
A.2.b Determine the requirements to get a referral to see a specialist in the two healthcare systems.
The referral system in Germany is initiated by a General Practitioner or the patient directly to the consultant without making prior consultations with their general doctor. One can opt for the “sickness fund” or private insurance covers. Owing to long waiting times, one should check early enough. The case is somewhat different in the States. Having private insurance with a preferred provider organization allows one to seek the services of a specialist without a referral.
For health maintenance organizations, a referral is needed for one to see a specialist. A specialist may choose whether to accept public or private insurance. This implies that one’s insurance provider may bar them from accessing some specialists. Some specialists shun publicly insured patients since the reimbursement rates are low.
A.2c. Discuss coverage for preexisting conditions in the two healthcare systems
An individual with a preexisting condition in Germany is covered by insurance companies. Individuals on the “sickness fund” enjoy low costs regardless of whether they have preexisting conditions. Individuals on private plans can access health services at higher premiums in the event they have preexisting conditions. In the United States, denial of coverage or providing cover at higher premiums by an insurance company based on preexisting conditions is illegal (Huguet et al., 2019). This came into action after the Affordable Care Act of 2010. It however doesn’t apply to covers taken before the enactment.
A.3. Explain two financial implications for patients about the healthcare delivery differences between the two countries (i.e. how the patients are financially impacted)
In Germany, the sickness fund plays a major role in lowering medication costs for patients. This allows negotiations between the insurance provider and the pharmaceuticals making it a lot easier for patients. Contrary to this, there are no regulations against drug companies overshooting drug prices making it extremely expensive for the patients. One big reason why policies are not formulated is that the pharmaceutical sponsor politicians’ activities thus they enjoy their protection (Kathryn Hayes, 2021).
Another financial implication is the effect of the insurance covers on the costs of seeing specialists. As explained above, it is quite affordable to visit a specialist in Germany owing to the sickness fund. The cost is the same as that of a General Practitioner. The cost of seeing a specialist in Germany per quarter is much less as compared to the costs of seeing a general doctor in the US. In the United States, the cost of seeking health services is generally strenuous to the citizens. Much as the healthcare system in the United States has evolved over the years to be one of the world’s best, there is still room to make healthcare more affordable to its citizens.
- Berghöfer, A., Göckler, D., Sydow, J., Auschra, C., Wessel, L., & Gersch, M. (2020). The German health care Innovation Fund – An incentive for innovations to promote the integration of health care. Journal Of Health Organization And Management, 34(8), 915-923. https://doi.org/10.1108/jhom-05-2020-0180
- Garfield, R., Orgera, K., & Damico, A. (2021). The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid. KFF. Retrieved 10 July 2021, from https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/#:~:text=Nationally%2C%20more%20than%20two%20million,for%20Marketplace%20premium%20tax%20credits.
- Huguet, N., Angier, H., Hoopes, M., Marino, M., Heintzman, J., Schmidt, T., & DeVoe, J. (2019). Prevalence of Pre-existing Conditions Among Community Health Center Patients Before and After the Affordable Care Act. The Journal Of The American Board Of Family Medicine, 32(6), 883-889. https://doi.org/10.3122/jabfm.2019.06.190087
- Kathryn Hayes, B. (2021). Politics and Healthcare: Drug Pricing Dynamics Leading Up to the 2020 Election. American Health & Drug Benefits. Retrieved 10 July 2021, from https://www.ahdbonline.com/issues/2020/october-november-2020-vol-13-no-5/3063-politics-and-healthcare-drug-pricing-dynamics-leading-up-to-the-2020-election.
- Roman-Urrestarazu, A., Yang, J., Ettelt, S., Thalmann, I., Seguel Ravest, V., & Brayne, C. (2018). Private health insurance in Germany and Chile: two stories of co-existence, segmentation, and conflict. International Journal For Equity In Health, 17(1). https://doi.org/10.1186/s12939-018-0831-