Healthcare: Five patients, five ways to be billed

To appreciate the complexity of the U.S. healthcare system, consider the case of five hypothetical patients in the same hospital, all with the same illness, all receiving the same treatment from doctors and nurses.

Their bills could be paid in so many ways.

• The patient who has insurance on the job, like 170 million other Americans, will have the bills covered by private insurance. The fees paid to the doctors and hospitals will depend on the clout of the patient’s insurance company and its ability to negotiate fees that keep the doctor and hospital bills as low as possible.

• The patient with the individual policy, like 17 million other Americans, likely will have bigger co-payments and hospital bills than someone working for a big firm with a group policy. The individual market doesn’t offer the buying clout of the big group policies.


• The patient on Medicare, along with 47 million other Americans, will have a very big chunk of the bill paid by the federal government. Medicare is the closest thing we have to national healthcare. When you reach age 65, having worked for at least 10 years, or you are the spouse of someone who worked 10 years, you automatically move into Medicare. About 38 million people are in this group, which will grow to 78 million by the year 2030, when the youngest baby boomers reach age 65. An additional 8 million people who are disabled and have been unable to work for at least two years also are enrolled in Medicare.

• The patient who is poor, like 65 million other Americans, has the bills paid through Medicaid or theChildren’s Health Insurance Program. The fees will depend on government payment schedules.

• The patient who is uninsured, like 51 million other Americans, is in trouble. He or she will be billed at the hospital’s full sticker price, which insurance companies and the government do not pay because they negotiate lower rates. Should the bill be unpaid, the hospital administrators might cancel the bill and write it off as charity care. Otherwise, the patient will risk being sued by the hospital and harassed by collection agencies.

But wait: It gets even more complicated. These totals you just read add up to more than the U.S. population because many people may have overlapping coverage. Someone on Medicare, for example ó say, an 89-year-old woman suffering fromAlzheimer’s diseaseó might be broke and living in a room in a $70,000-a-year nursing home. That segment of her care will be paid for by Medicaid.