BASICS

OF INTERPRETATION
LESSON 10

THE U.S. HEALTHCARE SYSTEM

The U.S. health care system is not a universally accessible system – it is a publicly and
privately funded patchwork of fragmented systems and programs. Insured Americans are
covered by both public and private health insurance, with a majority covered by private
insurance plans through their employers. Government funded programs, such as Medicaid
and Medicare, provide health care coverage to some vulnerable population groups. The
government also publicly funds coverage through Indian Health Services and the military.

The U.S. spends far more public and private money combined on health care than any other
developed country. Unfortunately, this higher spending does not translate into better health
outcomes. The U.S. consistently ranks lower in some measures when compared to its peers
around the world, such as in infant mortality rate and life expectancy. The lack of universal
coverage for its population is the major challenge, resulting in inequality among different
population groups regarding healthcare access, resources, and outcomes. The fragmented
financing and delivery system also lag behind other countries in the introduction of health
information technology.

However, the amount spent on the system produces some positive outcomes and benefits
for those well insured. The U.S. healthcare system has a large and well-trained workforce,
high-quality medical specialists, excellent healthcare facilities, and research programs;
however, it also has too few primary care generalists to meet demand.

Publicly Funded Insurances

Only about 30 percent of the population is covered by three publicly funded insurance
programs: Medicare, Medicaid, and the Children’s Health Insurance programs.

Medicare is a national social insurance program administered by the federal government,

accessed primarily by seniors aged 65 and older, and by some people with
disabilities. Medicaid is a state-based insurance program accessed by some poor and near-
poor individuals. The State-based Children’s Health Insurance Program (CHIP) insures
children up to age 19 from families with incomes too high to qualify for Medicaid.

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Medicare

Medicare consists of four “parts,” which cover different services. It is largely publicly funded
but with increasing cost sharing for end users since its inception. Medicare Part A provides
hospital insurance, funded through payroll taxes. Medicare Part B provides medical
insurance, for which individuals pay monthly premiums.

Medicare Part C, the Medicare Advantage Plans, is a voucher program offered through
private commercial insurers who contract with Medicare to provide Part A and Part B
benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred
Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare
Medical Savings Account Plans.

Medicare Part D is an outpatient prescription drug program offered through private

insurers funded by the federal government to delivery Part D benefits. In 2015, the Medicare
program covered over 55 million Americans.

Medicaid

Although the federal government provides broad guidelines and partial funding for
Medicaid, the program is managed and partially funded by individual states. It is means-
tested, with states having ultimate control over eligibility. State participation in Medicaid is
voluntary and the services covered vary widely, but all states have been part of the program
since 1982 covering millions of American children and adults.

Children’s Health Insurance Program (CHIP)

Some children are eligible to be covered under the CHIP program, which is regulated by the
federal government but administered at the state level. This program provides low-cost
health coverage to children whose families earn too much money to qualify for Medicaid, but
not enough to pay for private insurance. Under certain circumstances, pregnant women are
also eligible for coverage in some states. Because CHIP works closely with Medicaid, some
states use their CHIP funds to expand Medicaid, and some others use it to run a CHIP program
alone or a combination of both: Medicaid and CHIP.

Private Insurance

The majority of privately insured Americans are in group plans that are subsidized, at least
partially, by their employers. The remaining insured population not covered by employer-
sponsored plans purchase individual private insurance, with premiums varying by age and
deductibles, co-payments and co-insurance much higher (average three times higher) than
in the employer-sponsored market.

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The 13.4 percent of Americans (42 million) who are uninsured often make use of non-profit
community health centers or hospital emergency rooms for their health care needs, though
many go without care. Uninsured Americans, undocumented immigrants included, can
access emergency rooms through the Emergency Medical Treatment and Active Labor Act
(EMTALA) of 1986, which legislates participating hospitals to accept all patients but only for
a medical assessment and stabilization. It remains unfunded, though non-profit hospitals
receive large tax deductions for providing uncompensated care.

Most Americans who are part of group insurance plans, either through their employer or
arranged individually, are enrolled in some type of managed care plan. These plans contract
with a network of health service providers, such as doctors, hospitals, clinics and other
health care providers such as pharmacies, labs, x-ray centers, and medical equipment
vendors, to provide services to their clients.

In 2003 Congress passed new legislation to create a new plan called the Health Savings
Accounts (HSAs), This is a type of savings account that allows a person to put aside tax-
exempt money to pay for qualified medical expenses incurred by the holder, thereby
providing tax benefits and lower health costs for those enrolled.

A Healthcare Savings Account can be used only if a person has a High Deductible Health Plan
(HDHP). The IRS defines an HDHP as any plan with an average of $1,400 deductible for
Individuals or $2,700 for a family. Premium contributions to these accounts are tax-
deductible and can be rolled over year to year if not spent. These funds can earn non-taxable
interest and can be withdrawn to pay for medical expenses at any time.

HSAs are often combined with High Deductible Health Plans (HDHPs). The monthly
premium payments for these plans are generally low, but the insurance does not kick in until
after the insured has paid out several thousands of dollars in out-of-pocket costs. Some
health insurance companies offer Health Savings Accounts to their customers with High
Deductible Health Plans; however, HSAs can also be opened at some banks and other
financial institutions.

Private Delivery

Private insurances deliver health care by way of managed care plans. These plans are divided
into three major types.

Health maintenance organizations (HMOs) are a type plan that require the insured party
to receive most or all of their health care from a single network of providers who have agreed
to supply care to its members. Primary care physicians (PCPs) are the first point of contact,
and only they can provide referrals to other services, but again only within the HMO network.
Individuals enrolled in an HMO must have an in-network PCP, as HMOs will not provide
coverage without one.

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Preferred provider organizations (PPOs) also contract with a network of providers. They
pay providers on a fee-for-service basis, and although it is easier to seek care from providers
outside of the PPO network than it is with HMOs, this means the patient pays more to see an
out-of-network provider. Insured individuals can choose their own PCPs, and do not need a
referral from their PCP to see a specialist if that is allowed by the specialist.

PPOs have grown in popularity over the past decade and in 2012 accounted for 56 percent
of employees insured, while 25 percent were enrolled in HMOs or point-of-service (POS)
plans.

Point-of-service (POS) plans are a hybrid between PPOs and HMOs. Like an HMO, enrollees
must have an in-network PCP to coordinate their care, but like a PPO, it is easier, albeit more
expensive, to go out of the provider network for health care services.

The Process of Receiving Health Care

Most insured patients get medical services in the following fashion.

• If the patient feels sick, s/he will make an appointment with their primary care
physician, commonly known as PCP.
• The doctor will examine the patient and run tests if necessary.
• If the patient’s ailment is a common disease, the PCP will usually treat it. A
prescription may be written and sent to the patient’s local pharmacy for pick up.
• If the patient’s ailment requires the attention of a specialist. The primary doctor will
then make a referral to see a specialist.
• The patient is seen and treated by the specialist.
• The patient will go back to the PCP for supervision of treatment and general care.

Copayments

Insurance companies usually require that the patient make a copayment to the healthcare
provider or pharmacy before receiving the services. The copay may vary depending on the
services. For example, the copayment to see a specialist may be higher than the copay to see
a primary doctor.

Urgent Care

Medical clinics that welcome walk-in patients (without an appointment) are known as
urgent care centers. Patients who need immediate treatment for non-emergency or non-life-
threating conditions can be seen at these clinics.

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Emergency Care

The emergency room (ER) provides medical care 24 hours a day to patients who are suffering
from a life-threating or severe medical condition that needs the assistance of a medical team and
hospital equipment.

Patient Protection and Affordable Care Act (ACA) of 2010 (Obamacare)

With one in six Americans uninsured, the Patient Protection and Affordable Care Act of 2010,
colloquially known as Obamacare, was introduced in 2010 in an attempt to help improve
health insurance coverage through insurance regulatory reform and individual/employer
mandates to purchase insurance. It eventually passed after a vociferous debate in Congress
and has four main goals: 1) to expand insurance coverage for Americans; 2) to improve
under-insurance; 3) to improve quality of health care, and 4) to control expenses. Despite
the implementation of the Affordable Care Act (“Obamacare”), about 10.4 percent of
Americans remain uninsured; this is about 33 million people.

One of the key features, and also one of the most controversial, is a mandate requiring that
all uninsured individuals and families in America must purchase at least a basic form of
health care insurance – known as the minimum essential coverage – or they will
be fined. There are exceptions to this financial penalty based on religious objections or
financial hardship, and for Native Americans, those without coverage for less than three
months, undocumented immigrants, incarcerated individuals, those for whom the lowest
cost plan option exceeds 8 percent of an individual’s income and those with incomes below
the tax filing threshold.

To help ensure buying insurance will not become an undue financial burden, subsidies are
available for some individuals and families who have incomes under 400 percent of the
federal poverty level.

Insurance exchanges or marketplaces have been established by some state governments,

as well as by the federal government, to help individuals find appropriate insurance plans.
They only accept applications for a certain period each year, known as the Open Enrollment
Period, and must cover essential health services. To tackle under-insurance, private insurers
cannot deny insurance to people with pre-existing medical conditions, nor can they cancel
policies if patients become ill, a practice known as rescindment.

Health Care for Undocumented Immigrants

Although the ACA provides benefits to U.S. citizens and lawfully present immigrants, this law
prohibits undocumented immigrants from enrolling through the marketplaces.

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Some states like Oregon, New York, and California, have implemented programs to cover
undocumented immigrants, particularly children and pregnant women. They can be covered
for certain emergencies regardless of income and immigration status.

Nonetheless, studies have shown that about half of the undocumented immigrant population
has some form of health insurance coverage. Some of the options that undocumented
immigrants have to obtain coverage include student health plans, employer-sponsored
coverage, and individual plans purchased off-exchange.

Because treating low-income, uninsured, and undocumented patients at the emergency

rooms is very expensive, many local officials have created less expensive alternative
programs to fund primary care regardless of the patients’ immigration status.

Workers’ Compensation

Workers’ comp is a type of insurance that helps protect businesses and employees from the
potentially devastating costs of work-related injuries, illnesses, and lawsuits. Employers are
legally required to carry this form of insurance for two main reasons: (1) to ensure that the
injured worker gets medical attention and compensation for lost income. (2) to protect the
business from being sued by their employees; for that reason, employees are required to
relinquish their right to sue their employer when accepting workers’ compensation.

In the U.S., a large number of interpreters work in the workers’ compensation field. Even
though these appointments usually take place in a medical setting between a medical
provider and the injured patient, it’s important to point out that not all appointments are
focused on healthcare delivery. Some medical encounters have legal purposes. For example,
the occupational doctor may evaluate the injured worker to determine if this injury or illness
is, in fact, work-related and the extent of the damage in order to recommend services.

Regardless of the outcome of these med-legal evaluations, many workers’ compensation

cases may end up being disputed in hearings before a judge and lawyers. For this reason, it
is important that the interpreter understands the legal consequences of each appointment.

Because this branch of interpreting requires knowledge of legal, insurance, and medical
terms exclusive to the worker’s compensation field, specialized training is advised. Also,
medical interpreters working in this sector are recommended to adhere to the legal ethics
and standards of practice more than to the healthcare ones.

For example, one major difference in legal interpreting is that the role of cultural mediator
and patient advocate is strongly discouraged.

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As mentioned above, this type of interpreting requires specialized training and it is

recommended that interpreters who anticipate working in this area get well acquainted with
the terminology, protocols, and challenges usually found in this field.

Conclusion

The U.S. healthcare system is one of the most convoluted systems in the world. It can become
very confusing and overwhelming for patients and interpreters. Being able to understand
and navigate the system will help the interpreter be aware of the patients’ needs and possible
healthcare options. It will also help improve your professionalism and enhance your
interaction with patients, healthcare providers, and the medical settings where your services
are requested.

Adapted by MITS from Evidence Network: Making sense of the U.S. Healthcare System by Lee Tunstall.

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