WORK/LIFE BALANCE FROM A MOM AND NURSE PRACTITIONER

A Glimpse of Healthcare Outside The United States

4/21/16


As with every election season, there is often talk about healthcare reform. Anyone who has any contact with our current healthcare system in the United States can tell you it needs work. The Affordable Health Care Act has made some positive changes and increased access to healthcare; however there are  many barriers in terms of insurance companies, unnecessary spending, and lack of providers, that limit and delay quality care to many people in need. As a new provider I am still navigating all the complexities of the multi-payer system currently in place in the U.S. I am always curious on how foreign systems operate, and if their citizens are satisfied with their healthcare system. I wanted to get more insight into a true single-payer system, but as I did some research only two countries Canada and Taiwan only employee a true "single-payer" system. More information on how these systems are structured and operate are available here. Most other countries have a mix of both private and government based insurances, as in the U.S.  As I have a good friend that is an Irish Citizen, I wanted to get her take on the Irish healthcare system to be able to compare and contrast the current U.S. system. I asked her a few questions about Irish healthcare which I find are issues in the U.S., which I would like to share.

Are services for massage therapy  and other complementary treatments covered by insurance?

Yes by certain providers on certain plans.

How does this compare to U.S.?

The same. Some plans, mostly PPO will cover complementary and alternative therapies.

How long do you generally have to wait to see a specialist?

If you are uninsured you go on the public list which depending on the consultant and the area you could be on for 18 months. If you have insurance you can generally get an appointment (provably with the exact same consultant in a different clinic) within a week- a few months depending on their schedule. Your policy may only cover you in certain hospitals/clinics but generally you can shop around and find one available within a few weeks. Dermatologists have much longer waiting lists for both public and private.  If you have a slow burning issue say pain that starts small but you can't work. If it isn't life threatening you can be on a waiting list to see a consultant for 1-2 years! Even if it escalates or causes your day to day life to be a complete misery nobody gives a shit... that stuff is hard.

How does this compare to U.S.?

Generally if you have a PPO plan, which are more expensive and require more out of pocket costs, you can schedule an appointment with a specialist without a referral, which usually depends on availability, but can be as short as a few weeks. For HMO insurances, sometimes the wait can be up to six months to see a specialist, and requires referral from your primary care provider. Dermatology referrals also take some time. In my pediatric clinic rotation there were zero dermatologists in a 40 mile radius who would accept a straight MediCal plan.

How much is a typical office visit to a general practitioner (PCP)?

A gp visit is usually between 55-65€.

How does this compare to U.S.?

A typical office visit copay is between $15 - $50. This does not cover any procedures or medications given in the office.

How much would you have to pay for a hospital stay?

For an emergency you pay €100 on the front desk and all care/procedures and stay is free. The €100 is largely a deterrent for people who are clogging up the system. The issues lie in overcrowding and understaffing. There are massive issues in emergency departments with patients being on trolleys in hospital corridors for days. It's horrific. The staff are amazing but under pressure and it's a thankless job especially in Dublin where there's a sizable amount of IV drug users clogging up the triage area.

How does this compare to U.S.?

  ER overcrowding is the same in the U.S. ER copays are typically around $100.00 for most insurances, however the hospital still has to treat you regardless of the patient's ability to pay. Often people are unable to pay and the bills never are paid for expensive testing and ER services. Hospital stays generally are based on your insurance deductible, which can be $1000. If you have not already spent $1000 in a year, and are hospitalized you will be stuck paying $1,000 or more of whatever your insurance will not cover.

Do you have choice in the primary care provider you see?

 You can see any gp you like.

How does this compare to U.S.? 

Depending if your provider is in your insurance network, you can choose your primary care provider. Some insurance will automatically assign you to a provider or group of providers.

What preventative services are covered?

The last government brought in a free children under 5 scheme which is still being rolled out.

Huge problems here as they never consult gps before they announce these things and run in to big objections from health care professionals.

Other things. Immunizations are all free for children. Maternity - you get 6 free gp visits pre-natal and 2 post-natal. Long term illness is also a thing so you don't pay for meds or visits. There's a shared services diabetes program to take pressure off hospitals. Free regular blood tests and nurse/doc visits a couple of times a year.

Oh just remembered free breast check for risk groups, cervical smear tests for risk groups, bowel cancer screen for risk groups (all different age brackets).

How does this compare to U.S.? 

This is essentially the same. Almost all insurance plans cover a yearly physical, which includes most preventative health screenings based on age and risk factors. Most immunizations are covered for adults and children.

Are there private insurance companies that manage the government insurance? 

Yep we have three private companies that provide independent insurance plans.  If you are uninsured (which is common post-recession) then you are simply looked after by the state - the care that I described in the previous mail is a basic cover that's open to all citizens and residents and European citizens as far as I know.   So basic care would be - in a hospital you pay your €100 and then nothing further. You'll go on a waiting list if you need to see a specialist but when you see the specialist you don't pay for that or any subsequent operation/procedure. 

If you have private health insurance that's where the bills start to come in. Your policy may not cover your entire procedure or stay etc. 

How does this compare to U.S.?

Private insurance companies do manage state plans, such as MediCal. The multiple plans and coverage varies, and is very complex.

People that are uninsured, is that because they are unemployed or refuse to buy a health plan?

Health insurance costs keep rising here. A lot of people had health insurance as a benefit from larger employers. During the recession as people lost jobs or moved companies there was huge fall off. At one point there was 1000 a week cancelling their plans out right (population of 4 million - that's a lot).  If you're unemployed and on a government support there's little chance of you affording insurance. My generation - it would be unusual for people to have health insurance if it's not provided by their employer. Last year all insurers collectively brought in a levy so it's more expensive for you to take out insurance after the age of 33 if you've never had it before. So I have to take out insurance now this month or next to not have to pay the levy.  I think that's their way of trying to get my generation in to the loop.


How does this compare to the U.S.?
With the passage of The Affordable Healthcare Act, insurance is mandated for all U.S. citizens. If you don't qualify for a government plan or have insurance through your employer, you can purchase your own private plan. This is loosely enforced through fines based on income level.



Are mental health services covered or easily accessible? 

Mental health services can be hard to access depending. If you are suicidal you're supposed to go to the emergency room and sit with all the drug addicts & winos who clog up the system. If depressed your first port of call is your GP.  From there treatment is at the discretion of the GP. There are services to access but they are all done through your GP. There are care centers both residential and non-residential around the country but concentrated in the cities.  There's also an odd gap where by children with mental health difficulties are cared from until the age of 16 and adults are only cared for from 18 years here.  There are not for profit counselling centers which see people on a donations basis.

How does this compare to the U.S.?

 

The situation is very similar in the U.S. Mental health services are very hard to access, and the first line is usually your primary care provider. If you are suicidal you will sit in the ER for sometimes days at time until you can be placed in a facility. For children it is also very hard to come by mental health services, especially if the child requires acute psychiatric hospitalization. If you have any other chronic health condition (i.e. seizures, diabetes) and need psychiatric hospitalization, it could take even longer. Referrals to psychiatrists can take several months, and many psychological and counseling services are not covered by insurance.

Are contraceptives and abortions covered?

 Eh... this is a long question. So contraceptives under the state health care (GP card and Medical card) - Condoms no, copper coil yes, implant yes, pill - yes morning after pill - I'm not sure. 

All available privately at fairly cheap rates. Coil is €80 and €120 for GP to insert, Pill is about €15 per month, Morning after pill around €35 etc. 

Abortion is illegal in Ireland... Rant alert. Despite huge pressure no government will hold a referendum required to change a statute known here as the 8th amendment to the constitution. It’s a hangover from having the state and the Catholic Church hand in hand for so many years yet no government will commit to holding a referendum. It’s frankly horrendous as in recently (last year) the law was amended a tiny bit to allow for aborting fetuses if the life of the mother is at serious risk. An Indian woman died of septicemia due to an incomplete miscarriage a couple of years ago causing a massive back last.  It’s a source of massive outrage and shame here. For me it’s horrendous to think that in 2016 I am still subject to other people's moral stand point. 

I could go on about this at length. If you decide to have an abortion you need to travel to the UK at your own expense (you can go to Belfast or traditionally London) but this is horrendous. This is also true if your unborn baby is sick, dying or you definitely will not be able to carry to term. You still have to travel for abortion even if there is a zero per cent chance of your baby surviving.

How does this compare to the U.S.?

 

I felt this was an important question, as with any election the issues of abortion and access to contraception is being addressed. This one I had to look up, as state laws vary so much on abortion and contraception. Most insurance plans cover contraceptives, with the exception of some employers refusing for moral reasons, such as Hobby Lobby. Planned Parenthood, and other such state or federally subsidized agencies usually offer contraceptives at reduced cost or free of charge, although many politicians are trying to defund these organizations. More information about the move to defund Planned Parenthood, and their funding is available here. Currently 32 states prohibit federal funding for abortions, with the exception of cases of rape and incest, and some states rape and incest are not exceptions to federally-funded abortions.  Private insurance coverage of abortions are limited to conditions which threaten the mother's life in 11 states. 28 states require a mandatory waiting period after counseling before receiving an abortion. California not included in one of these states. More information regarding state laws on abortion is available here.

This was so interesting to compare and contrast these two systems. I would love to hear other people's experiences with health care systems outside of the U.S.  If you have comments please leave them below or send me an email.


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