The US has a private sector and a public sector for health insurance. With private insurance companies, people can choose high deductible plans where the monthly fee is low or negligible, but the costs of going to see the doctor or to get prescriptions are higher. Or they can choose a plan where the monthly fee is higher, but a higher percentage is covered during doctor visits and when getting prescriptions by the insurance company. Other plans vary in monthly cost, prescription coverage and how much it costs to see the doctor or specialist. Many private companies have networks of doctors and specialists that must be used to in order to have coverage. This is typical of a PPO (Preferred Provider Organization) vs an HMO (Health Maintenance organizations), where a Primary Care Physician (PCP) is chosen and that doctor sees the patient for most issues but can refer them out to a specialist.
In 2012 The Affordable Care Act (ACA) was enacted by President Barack Obama and the Supreme Court with the goal of giving all Americans access to quality, low cost health care including those with pre-existing conditions. There is also Medicare (where bills are paid from a trust fund set up by the patient, which is paid into throughout their lives and starts covering medical costs after turning 65), and Medicaid (where medical bills are paid from federal, state and local tax funds -- this is common in low-income families). Insurance can be provided through a person’s employer or bought as an individual plan. Before the ACA was enacted, insurance companies could deny individual coverage to people with ‘pre-existing conditions’ such as diabetes, cancer, kidney failure, skin conditions and other autoimmune disorders. Now this is not the case.
What happens if you need to see a doctor?
Depending on the insurance the patient has, they need to see a PCP or their main doctor. A major concern in the USA is whether or not seeing the doctor will be covered by insurance. Doctor visits are very expensive if insurance does not pay for them and even if they are covered there is often a fee associated called a ‘co-pay’. Prescriptions can be written by the primary care doctor, general practitioner, Emergency Room doctor, Nurse Practitioners and specialists.
Who decides what medicines a doctor can prescribe?
All prescription drugs in the USA are regulated (manufacture, transfer, use, possession and distribution) under the Controlled Substances Act (CSA) which was made law in 1970. In 1978, the Prescription Drug and Marketing Act was passed to verify the safety and efficacy of all prescription drugs. Both acts are regulated by the USA Food and Drug Administration (FDA).
Practically, what is it like to live with type 1 diabetes in the USA?
Because the USA does not have a federally regulated or consistent insurance type or coverage, a person with Type 1 diabetes may pay anywhere from all of their diabetes supplies and devices to very little. Each insurance company decides what they will cover and they offer “tiers” of coverage depending on the contracts they have with different pharmaceutical companies. A tier one prescription will cost the patient the least, but may not be the patient’s preferred type. Insurance companies also have the right to change their tiers around so that one band of test strips or insulin may change from one tier to another.
Insulin pumps and Continuous Glucose Monitors can be fully covered or not at all, depending on insurance. Many times they are covered 100% after a person pays their deductible (which is an annual out of pocket amount the patient must pay before insurance will cover the costs). The deductible in high deductible plans is usually $2,000-5,000 per person, per year. Plans with monthly payments have lower deductibles, sometimes as low as $250 for the year.
What about getting admitted to hospital?
Patients with insurance usually have a partially covered Emergency Room visits. Hospital stays generally are very expensive in the USA, and are rarely covered completely by insurance. Some surgeries are covered once the deductible is met.
How does diabetes care vary throughout the country?
Because of the variability in health insurance and what each individual plan covers, diabetes care is generally very expensive. It is recommended that patients see an endocrinologist or diabetes specialist every 3 months. However, access to these doctors is difficult to obtain, and often supplies for basic care such as strips and insulin are incredibly expensive. For example, insurance companies will put a “cap” on the number of strips they will pay for in a month. If a patient requires more, the patient and their doctor have to provide proof of need. This is type of proof of need is also required when purchasing an insulin pump or Continuous Glucose Monitor.
Back when insurance companies could turn away patients with pre-existing conditions, patients without healthcare through work, a spouse or other family member had no other option but to pay for their supplies out of pocket. Now, there are some insurance companies that want patients to use supplies to keep healthy and avoid expensive complications, so they cover all diabetes supplies.
A huge thanks to Emily Westfall in the USA for helping with this information.
To learn more about life with type 1 in the USA, check out our blog posts: