Healthcare Financing Task 3

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Weber State University *

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C489

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Jan 9, 2024

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Organizational Systems and Quality Leadership- C489 Task 3 Mary Krish Organizational Systems and Quality Leadership Task 3 May 29, 2022

Organizational Systems and Quality Leadership- C489 Task 3 Mary Krish 1. Compare the U.S. healthcare system to the German healthcare system. In 1883 the Sickness Insurance Act was passed in Germany, representing the first social insurance program. The German government has substantially invested in their healthcare costs which has helped standardize and lower the cost of healthcare. In Germany, it is obligatory to hold insurance, and having access to healthcare is viewed as a basic human right. According to an article written by Quian Callendar, a student at The University of Michigan, “We learned more about the German concept of solidarity. The young pay for the old; the rich pay for the poor; the healthy pay for the sick; singles pay for families. When we asked the German students their opinion on Germany solidarity, it was a principle that they truly believed and held as a value”. Public health in Germany is funded by national contributions. These contributions are automatically deducted from individual salaries every month. The employers offer insurance to their employees and it’s completely transparent. If you are a lower income individual in Germany, you must join one of the “Sickness funds” for health insurance. These are not-for-profit insurance companies that collect their premiums from the employers and employees. If an individual makes above the limit for the Sickness fund insurance, they may then purchase private health insurance. In Germany, you can be covered under the sickness fund and still purchase private insurance. In the U.S. private healthcare is the predominant healthcare and it usually tied directly to the individual’s employer. The individual pays a monthly premium, co-pays for doctor and specialist visits, and deductibles. The deductible must be paid before the insurance company will pay for anything outside of preventative care. If you hold private insurance through your employer or another company, preventative healthcare is covered and the individual is not required to pay for things like birth control, immunizations, and annual exams. The employer usually helps by paying a portion of the monthly premium, but the employer doesn’t help pay any of the deductible. If a person doesn’t have fulltime employment, they are self-employed, if they make over the income for Medicaid, or they do not have an employer who offers insurance, they can get “affordable” insurance through Obamacare. Unfortunately, Obamacare is still unaffordable to a lot of individuals. For those who fall through the insurance cracks or chose not to have insurance, they are self-pay and have to pay for all services out of pocket. If a person is low- income, disabled, or they are unemployed they qualify for Medicaid. Once a person reaches the age of 65, or become disabled, they qualify for Medicare. Low income and disabled individuals qualify for both. Medicaid and Medicare are government funded insurances. Medicaid varies from state to state whereas Medicare is federally mandated. Medicaid and Medicare are only offered to certain individuals who qualify. 2.) Compare access between the two healthcare systems for children, people who are unemployed, and people who are retired. In Germany, public health insurance covers children until the age of 18. If the children’s parents have private insurance, they are covered under their parents insurance until the age of 23, or if they are still in school, they’re are covered until the age of 25. Around 90% of the children in Germany are seen by a pediatrician until the age of 12. Around the age of 12, they are moved to a regular doctor. Vaccines and preventative care for children in Germany is free.

Organizational Systems and Quality Leadership- C489 Task 3 Mary Krish In the U.S. there’s a program called CHIP (Children’s Health Insurance Program) that provides low-cost healthcare coverage to children whose families earn too much to qualify for Medicaid and who don’t qualify for insurance through an employer. According to healthcare.gov “Routine “well child” doctor and dental visits are free under CHIP. But there may be copayments for other services. Some states charge a monthly premium for CHIP coverage. The costs are different in each states, but you won’t have to pay more than 5% of your family’s income for the year.” If the child’s parents have private insurance, they are covered under their parents insurance until their 26 th birthday. Unfortunately, in the U.S., if an individual loses their job, generally they’ll lose their insurance. In the U.S. if a person’s income is low, they are disabled, or they are unemployed they qualify for Medicaid. Once a person reaches the age of 65 or if they are disabled they qualify for Medicare. It doesn’t matter whether an individual is employed or not, it is mandatory for individuals to hold health insurance in Germany. The unemployed are automatically subscribed to the Public healthcare system. In Germany all citizens are insured no matter what their age is or if they’re employed or not. The German Healthcare system has three different social security systems set up for retirees, so everyone has the same access to healthcare, no matter their social status. First, is the Contributory social insurance program which covers the individuals who paid into them. Second, the noncontributory social compensation, provides welfare to those in the military or public services. The last program is the Social Welfare program, which provides aid to those who aren’t eligible for the first two programs. In the U.S. we pay into social security and Medicare our whole working lives, but we are unable to qualify for Medicare or social security until we reach the age of 65. In the U.S. If you lose your job or retire before the age of 65, they’ll lose their insurance. If someone retires before 65, there are supplemental insurance programs that they can purchase at an additional monthly cost. a. Medication coverage in the U.S and Germany In Germany, prescriptions aren’t free, but they aren’t expensive like they are in the U.S. Filling prescriptions in Germany is simpler than in the U.S as well, because the pharmacies aren’t tied to the insurance companies. There’s not wait for approval or to confirm the cost of the medication. They fill their prescriptions and go about their day. German public health insurance will cover the cost of most prescribed medications, generally the policy holder will have to pay the first 10 euros. If a person holds private insurance, they pay for the prescription themselves and then send the receipt to the insurance company for reimbursement. Public health in Germany does not cover most contraception costs. In America there is a problem with price gouging prescription medications and it’s a known issue, our medication and prescription costs are directly related to our insurance and what they cover and if they cover the generic or name brand of a medication. In the U.S you can only go to

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Organizational Systems and Quality Leadership- C489 Task 3 Mary Krish the pharmacy covered by your insurance unless you want to pay for the medication completely out of pocket. b. Requirements to get a referral to see a specialist in the U.S. and in Germany. In Germany, there are some similarities to seeing a specialist as in the United States. For example, waiting lists vary depending on the availability of the specialist and the urgency of the patient condition. In both countries, a patient can expect a wait time of a week to a couple of months to see a specialist. The difference between the two is in the U.S., the patient needs a referral to see any type of specialist, and the wait time isn’t dependent on the type of insurance held. They’d have to see their primary care physician or an emergency/urgent care provider to get a referral to see a specialist. In Germany, in most cases, the patient can call the specialty practice directly to make an appointment without a referral. Although, some specialist, like oncology, human genetics, laboratory medicine, and radiology requires a referral. In Germany there are private doctors and specialists who only see and treat the individuals who hold private insurance. These providers usually having shorter waiting times and provide alternative medicine that wouldn’t otherwise be covered under the public insurance. There are private clinics and hospitals for private insurance holders as well. Sometimes the private hospitals will take a public insurance holder. c. Coverage for preexisting conditions in the U.S. and Germany. In the U.S. Insurance now covers pre-existing conditions, According to healthcare.gov “All Marketplace plans must cover treatment for pre-existing medical conditions… No insurance plan can reject you, charge you more, or refuse to pay for essential health benefits for any condition you had before your coverage started.” There is one exception to the law and that is if an individual is grandfathered in on an insurance plan, with a pre-existing condition, the grandfathered plan does not have to cover the condition. The grandfathered plan does not have to cover preventative care either. In Germany an individual is covered even if they have a pre-existing condition. However, if they want private insurance, they will most likely have to pay a higher monthly contribution. 3.) Two financial implications for patient with regard to the healthcare delivery differences in the countries. i.e compare how the patients are financially impacted Everyone in the U.S. is supposed to be insured or else they are fined 600.00. Meeting outrageous deductibles and or paying for services out of pocket in the U.S. makes some people go bankrupt and go into significant amounts of medical debt for medical necessities because the U.S. healthcare system doesn’t have a cap on their spending and the medical and pharmaceutical company’s price gouge almost everything. The way the insurance is set up in the U.S. is for profit and not for the overall benefits of its people. Summarizing the article written in Expatica, German public health costs the insurance holder and their employer about 14% of the monthly gross income, If someone earns more than 4,800 euros a month the cost of insurance does not continue to increase, and because the employer will cover half the cost of insurance, the most anyone should pay a month is roughly

Organizational Systems and Quality Leadership- C489 Task 3 Mary Krish 439 euros per month, and there is no deductibles in Germany. If someone opts for private healthcare in Germany they must make more than 57,600 euros. The U.S. has very high healthcare costs, with overall lower quality healthcare. Co-pays are expensive. In the United States it doesn’t matter if you have government insurance or private insurance, wait times to see providers are outward of three months. The U.S. is more individualistic in our culture and that bleeds into our healthcare as well.

Organizational Systems and Quality Leadership- C489 Task 3 Mary Krish References Ridic, G., Gleason, S., & Ridic, O. (2012). Comparisons of health care systems in the United States, Germany and Canada . Materia socio-medica. Retrieved May 29, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3633404/ Brown, L. D. (2003, January). Comparing Health Systems in four countries: Lessons for the United States . American journal of public health. Retrieved May 29, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447691/ Callender, Q. (2018, April 18). Comparing the German and American Health Care Systems: The pursuit: University of Michigan School of Public Health . The Pursuit | University of Michigan School of Public Health. Retrieved May 29, 2022, from https://sph.umich.edu/pursuit/2018posts/comparing-the-german-and-american-health-care- systems.html The German Healthcare System . Expatica. (2022, March 17). Retrieved May 29, 2022, from https://www.expatica.com/de/healthcare/healthcare-basics/german-healthcare-system- 103359/ Marketplace health plans cover pre-existing conditions . HealthCare.gov. (2022). Retrieved May 29, 2022, from https://www.healthcare.gov/coverage/pre-existing-conditions/ Children's Health Insurance Program (CHIP) eligibility requirements . HealthCare.gov. (n.d.). Retrieved May 29, 2022, from https://www.healthcare.gov/medicaid-chip/childrens-health- insurance-program/ Health Insurance in Germany - the German Healthcare System . Germany Visa. (2022, April 1). Retrieved May 29, 2022, from https://www.germany-visa.org/insurances-germany/health- insurance/#:~:text=Yes%2C%20you%20will%20be%20covered,to%20pay%20higher %20monthly%20contributions.

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