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Two-Tiered U.S. Healthcare System Looming

Philip Betbeze, for HealthLeaders Media, October 21, 2011

Perhaps you're familiar with a two-tiered healthcare system. It's what they have in England, to name just one example. Under this model, the government provides a basic level of medically necessary healthcare, for which timeliness, and, some say, quality, are not guaranteed.

But back to whether two tiers are in our country's future. I don't know if I completely agree with the assessments I've been hearing from leadership. I have to admit, however, that given what we know about healthcare reform, and about disturbing trends among independent physicians, it looks like we're headed that way, unless there is a change in direction.

The penalty for not obtaining health insurance is currently insignificant and Medicare, at around 90% of costs, and Medicaid, at much less than that, are poor payers. The information I'm relying here is all anecdotal, but in Texas, many independent physicians have already closed their rolls to new Medicare patients, to say nothing of Medicaid. This is happening in other states as well.

Because just about everyone over 65 is on Medicare, and hospitals need that business, they're not likely to be in the vanguard of the new two-tiered health system, but smaller organizations will. How will you know it's happening? You'll know when more and more complex organizations, from physician practices to outpatient centers, begin to refuse to deal with government payers entirely.

On the balance, worse doctors, and poorer quality institutions, will want that business. That's not necessarily a bad thing for society. After all, the previously uninsured will have access to care that they theoretically didn't before (outside of the emergency room).

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7 comments on "Two-Tiered U.S. Healthcare System Looming"


Anna Cox (10/25/2011 at 3:25 PM)
"...worse doctors, and poorer quality institutions..." What a biased and poorly informed statement. I've spent most of my career as a NP working in community outpatient clinics, providing care to those without insurance, or with public health insurance. No, this is not a recipe for getting wealthy, but to suggest that the providers who work to care for these patients are incompetent and offer poor quality care, is beyond the pale. You owe the hard-working men and women of community care a big apology.

Phyllis Kritek (10/25/2011 at 12:05 PM)
I am one of the persons arguing that we have a two-tiered system now, perhaps even more than two tiers. There are hundreds of studies that document that fact, particularly those that address inequity in health care services for the indigent and for some minority populations. It is disingenuous to posit otherwise. And equally disingenuous to posit that the PPACA is going to suddenly introduce inequity in care. Health care in the US has for some time now been better for you as a patient if you are wealthy and meet an array of other less overt criteria. PPACA may simply make that fact more transparent.

Tyco Brahe (10/24/2011 at 1:47 PM)
Of course we already have a two-tiered system: Those who have insurance and those who don't. The free market will never give us an answer as economists all agree that healthcare does not follow free market principles[INVALID]everyone will have to use healthcare sometime. There is no choice. Even Adam Smith, the father of the free market, believed that healthcare may be better served by the government. America will have to do what the rest of the developed world has already done: Universal healthcare, most effectively with a Medicare-for-all single payer system. Any other system just delays the inevitable.