Expaticats

In daily life, I am sometimes reminded of the subtle and not so subtle differences between the United States and the Netherlands. And sometimes I don’t notice anymore.

One difference that is impossible to overlook is healthcare. Some differences are small. For example, in the Netherlands it is common to greet people when you come in to a family practice waiting room, but here that doesn’t happen (which is strange in a way, as Americans are more chatty in other ways). In the United States it is normal to get a call reminding you of your appointment, which is a service that I like.

I also noticed that it took a while to find a primary care doctor who was taking on new patients, and who had appointments available soon (and, new patients have lower priority). I’ve heard a few stories of people who had problems finding a new primary care doctor in the Netherlands, but it seems a little easier, and the waiting times for an appointment are shorter.

The same goes for specialists. Waiting times for specialists are certainly a known problem in the Dutch system, but they seem to bit longer on average here.

Another difference is overall attitude. The system in the US seems to have evolved to the point where patients are considered to be consumers, consumers who want satisfaction. Patients are expected to be more assertive. They are egged on by ads by pharmaceutical companies who urge people to “ask your doctor about X”. Ads by those companies are certainly not unheard of in the Netherlands, but they are much more common here. People also seem to go see a doctor a bit sooner in the US than in the Netherlands.

Of course, the main difference is health insurance. Currently, some 16% of Americans (about 47 million people) are uninsured, and this number goes up every year. They often aren’t insured because they simply can’t afford it. This is a tragedy; in a rich Western country like the US, millions of people run the risk of having very high medical bills if something goes wrong, and then won’t be able to pay for them. It is not uncommon for people to have to declare bankruptcy because of medical bills. What also happens is that people postpone going to the doctor as long as possible, because they know they can’t afford it, causing whatever they have to become a very serious problem.

Let’s compare insurance costs for a minute. In the Netherlands, a basic health insurance package for one person costs of about 90 euro (125 dollars) per month. The items in this package are determined by the government, but you get it from private health insurance companies. Most items in the package are covered 100%, and they include primary care, specialists and hospital visits. Children under 18 ride along on their parents’ insurance, at no extra cost. Health insurance companies are required by law provide this basic insurance for any patient. Age or pre-existing conditions don’t matter. The government provides a pool of money that is used to cover some excess costs for health insurance companies (chronically ill, and the free healthcare for children). This pool is paid out of money that is paid by employers, per employee. Employers pay 6.5% of an employee’s gross income, with a maximum of some 2000 euro per year. If you’re self-employed, it’s 4.5%, with a maxium of 1400 euro per year. The Wikipedia entry on Dutch Healthcare gives a pretty decent overview of the system.

In the United States, the best position to be in is to work at a larger company. Most of these will provide health insurance to their employees. Not all, and noto all employees; about 60% of working people are insured this way. Companies that provide insurance have a contract with a health insurance company. The cost per employee was on average about $4700 for a single employee, and $13,000 to cover the family of an employee. The employee him/herself pays about $65 average per month, and some $275 to cover their family. For a good set of data on employer-provided healthcare, see this 2008 study by the Kaiser Family Foundation (PDF)

For people who have to pay for health insurance all by themselves, the costs varies. It depends on where you live, your age, and your medical history. If you’re young and healthy, and live in, say, North Dakota, you can get an individual plan for $70. If you’re older, have had some serious health problems, and live in New York state, you can easily pay $600 per month. For a family you start at about $275 per month in the cheapest state (and no prior conditions, etc). But on average, is much more, and can easily get up to $1200 per month in a state with a higher cost of living (a cost of living that is more comparable to the Netherlands).

The employer-provided coverage may seem better in the US at first, since it’s a little cheaper for the employee on average. But, it is important to keep several things in mind when making comparisons like this. Only 60% of working people have this insurance; getting health insurance for yourself is much more expensive. Employers have a much higher cost than in the Netherlands. Coverage is much better for the standard Dutch plan. The standard deductible for Dutch health insurance is 155 euro ($225), for US plans it’s much more (up to $2000 for an individual plan, and bringing this number down gets you an even higher premium, obviously). The basic package in the Netherlands will cover most things 100%, insurance in the US will cover basic things 80-90%. So you’ll end up paying a lot more, even if your premium isn’t that high.

There are more differences. Like I mentioned earlier, your medical history is not considered in the Netherlands. In the United States, it will lead to much higher premiums for individual plans, or being refused insurance altogether. I have also heard several stories about people actually being dropped by their insurance. There is no co-pay for most items in the Dutch plans, there usually is in the US, even for something simple like a visit to your primary care doctor. If you lose your job in the US, you will also lose your health insurance. This can lead to very bad situations, e.g. you can’t get to work in a new job because you’re ill, but you can’t get insurance, or can’t afford it, because you don’t have a job. A recent study showed that a lot of people are unwilling to change jobs or start up their own business because they know they’ll lose their health insurance.

In other words, the Dutch system wins out easily. I am not saying that the Dutch system is perfect. It has its flaws, and I am worried about the increasing influence of health insurance companies. But the differences are striking.

Back to my own experiences. I’ve had a hard time getting used to having to get out my wallet when arriving at our family care practice, at the pharmacy, or at the hospital. “People pay for basic medical things here?” I’m also not used to having to worry about whether a doctor will accept your health insurance. Lastly, I was somewhat surprised when they had to get pre-approval from the health insurance company for something as simple (and in my case very necessary) as a colonoscopy. It seems that the health insurance companies have a large role in running the show. That’s strange. If you’re a licensed doctor, you can be expected to know what to do to treat a patient, right? Apparently not according to US health insurance companies. Lastly, when you see the bills, you wonder where all the money goes. The medical staff doesn’t seem to be getting the money.

There is much more to be said about this issue. Currently, the Obama administration and the Democrats are trying to pass a healthcare reform bill. I am pessimistic about the possibility of meaningful reform. It would be sad if it didn’t happen. The health insurance situation in the United States is unworthy of a modern Western state.