In the United States, health insurance helps pay for medical costs through privately purchased insurance, social insurance, or a government-funded welfare program. Synonyms for this usage include health coverage, health care coverage, and health benefits. In a more technical sense, the term health insurance is used to describe any form of insurance that provides protection against the cost of medical services. These uses include both private insurance programs and social insurance programs such as Medicare, which pools resources and spreads the financial risk associated with large medical costs across the entire population to protect everyone, as well as social welfare programs such as Medicaid and the Medicare Program. Children's Health Insurance. . , which provide assistance to people who cannot afford medical care.
In addition to health insurance, "health insurance" can also refer to insurance that covers disability or nursing or long-term care. Different health insurance plans offer different levels of financial protection and the extent of coverage can vary widely; In 2007, more than 40% of policyholders reported that their plans do not adequately meet their needs.
The share of Americans without health insurance has fallen by half since 2013. Many of the reforms introduced by the Affordable Care Act of 2010 were aimed at expanding health care coverage to those without health insurance; However, the growth of high costs continues unabated. National health care spending is expected to grow 4.7% per person per year between 2016 and 2025. Public health care spending rose to 29% of federally mandated spending in 1990 and 35% in 2000. This spending is also expected to reach approximately half by 2025.
State and federal regulation
Historically, health insurance was regulated by the states, under the McCarran-Ferguson Act. The details of which health insurance plans could be sold depended on the states, with a variety of laws and regulations. Model laws and regulations promulgated by the National Association of Insurance Commissioners (NAIC) provide a degree of uniformity from state to state. These models do not have the force of law and only come into effect when adopted by a state. However, most states use them as guidelines and some adopt them with little or no modification.
However, with the Patient Protection and Affordable Care Act, in effect since 2014, federal laws have created some uniformity when combined with the existing state system. Insurers are prohibited from discriminating against people or charging higher rates based on pre-existing medical conditions and must provide standard coverage.
California
In 2007, 87% of Californians had some form of health insurance. Services in California range from private offerings: HMO, PPO to public programs: Medi-Cal, Medicare and Healthy Families (SCHIP). Insurers can only pay providers a capitation for healthcare organizations.
California has developed a solution to help people across the state and is one of the few states that has an office that gives people tips and resources to get the best care possible. The California Office of the Patient Advocate was founded in July 2000 to publish an annual health care quality report on major healthcare organizations, PPOs and medical groups and to create and disseminate helpful tips and resources to provide Californians with the tools they need to receive the best care.
California also has a Help Center that helps Californians if they have problems with their health insurance. The Help Center is operated by the Department of Managed Health Care, the government department that oversees and regulates managed care organizations and some PPOs.
Massachusetts
The state implemented health care reform in 2006 to reduce the uninsured rate among its citizens. The federal Patient Protection and Affordable Care Act (colloquially known as "Obamacare") is largely based on healthcare reform in Massachusetts. Because of that colloquialism, Massachusetts' reform has been nicknamed "Romneycare," in honor of then-Governor Mitt Romney.
Public health care coverage
Main article: Health Insurance Coverage in the United States
Public programs are the primary source of coverage for most seniors, as well as low-income children and families who meet certain eligibility requirements. The main public programs are Medicare, a federal social insurance program for seniors (generally people age 65 and older) and certain disabled people; Medicaid, funded jointly by the federal government and the states but administered at the state level, which covers certain very low-income children and their families; and CHIP, also a federal-state partnership that serves certain children and families who do not qualify for Medicaid but cannot afford private coverage. Other public programs include military health benefits offered through TRICARE and the Veterans Health Administration and benefits offered through the Indian Health Service. Some states have additional programs for low-income people. US Census Bureau, "CPS Health Insurance Definitions", Archived May 5, 2010, at the Wayback Machine. In 2011, about 60 percent of stays were billed to Medicare and Medicaid, up from 52 percent in 1997.
State health insurance
In the United States, Medicare is a federal social insurance program that provides health insurance to people over age 65, people who become totally and permanently disabled, patients with end-stage renal disease (ESRD), and people with ALS. Recent research has found that health trends improve for previously uninsured adults, especially those with chronic illnesses, once they enter the Medicare program. Traditional Medicare requires significant cost sharing, but ninety percent of Medicare enrollees have supplemental insurance (employer-sponsored or retiree coverage, Medicaid, or a private Medigap plan) that covers some or all of their costs. With supplemental insurance, Medicare ensures that its members have predictable and affordable health care costs, regardless of unforeseen illnesses or injuries.
As the population covered by Medicare grows, its costs are expected to rise from just over 3 percent of GDP to more than 6 percent, significantly increasing the federal budget deficit. In 2011, Medicare was the primary payer for approximately 15.3 million hospital stays, accounting for 47.2 percent ($182.7 billion) of total hospital costs in the United States. The Affordable Care Act has taken some steps to reduce Medicare spending, and several other proposals are circulating to reduce it even further.
Medicare Benefit
Medicare Advantage plans expand health insurance options for people with Medicare. Medicare Advantage was created under the Balanced Budget Act of 1997, with the intention of better controlling the rapid growth of Medicare spending and giving Medicare beneficiaries more options. But, on average, Medicare Advantage plans cost 12% more than traditional Medicare. The ACA has taken steps to align payments to Medicare Advantage plans with the costs of traditional Medicare.
There is evidence that Medicare Advantage plans select patients at low risk for major medical costs to maximize profits at the expense of traditional Medicare.
Medicare Part D
Medicare Part D offers a private insurance option that allows Medicare beneficiaries to purchase subsidized coverage for prescription drug costs. It was introduced as part of the Medicare Prescription Drug Modernization, Improvement, and Improvement Act of 2003 (MMA) and went into effect on January 1, 2006.
Medicaid
Medicaid was established in 1965 for the poorest of the poor. Because enrollees must pass a means test, Medicaid is a welfare or safety net program rather than a social insurance program. Despite its creation, the percentage of U.S. residents without any form of health insurance has increased since 1994. The number of physicians accepting Medicaid has reportedly declined in recent years due to lower reimbursement.
The Affordable Care Act dramatically expanded Medicaid. The program now covers all people with incomes less than 133% of the federal poverty level who are not eligible for Medicare, as long as this expansion of coverage is accepted by the state where the person lives. Meanwhile, Medicaid benefits should be the same as the essential benefit on the newly created state exchanges. Initially, the federal government will fully fund Medicaid expansion, with some financial responsibility (10% of medical costs) gradually returning to the states by 2020.
Children's Health Insurance Program (CHIP)
The Children's Health Insurance Program (CHIP) is a joint state and federal program to provide health insurance to children in families who earn too much money to qualify for Medicaid but cannot afford private insurance to close. The legal authority for CHIP is found in Title XXI of the Social Security Act. CHIP programs are administered by individual states in accordance with requirements established by the federal Centers for Medicare and Medicaid Services, and may be structured as standalone programs separate from Medicaid (separate child health programs), as extensions of their Medicaid programs. (CHIP Medicaid Expansion Programs). ), or combine these approaches (CHIP combined programs). States receive enhanced federal funding for their CHIP programs at a rate higher than the regular Medicaid match.
Military health benefits
The Department of Defense Military Health System (MHS) provides health benefits to active duty, retired military personnel and their dependents. The GGD consists of a direct care network of military treatment centers and a purchased care network called TRICARE. Additionally, veterans may also be eligible for benefits through the Veterans Health Administration.
Indian healthcare
The Indian Health Service (IHS) provides health care to eligible American Indians in IHS facilities and helps pay the cost of some services provided by non-IHS health care providers.
Private health care coverage
Private health insurance can be purchased on a group basis (for example, by a company to cover its employees) or purchased by individual consumers. Most Americans with private health insurance receive it through an employer-sponsored program. According to the United States Census Bureau, about 60% of Americans have insurance through an employer, while about 9% purchase health insurance directly. In 2011, private insurance billed for 12.2 million hospital stays, representing approximately 29% ($112.5 billion) of total hospital costs in the United States.
The United States has a joint federal and state system for regulating insurance, with the federal government ceding primary responsibility to the states under the McCarran-Ferguson Act. States regulate the content of health insurance policies and often require coverage of specific types of medical services or health care providers. State mandates generally do not apply to health insurance plans offered by large employers due to the preemption provision of the Employee Retirement Income Security Act.
In 2018, there were 953 health insurers in the United States, although the top 10 accounted for approximately 53% of revenue and the top 100 accounted for 95% of revenue.
Employer-sponsored
Employer-sponsored health insurance is paid in part by companies on behalf of their employees as part of a benefits package. Most private (non-government) healthcare coverage in the US is employment-based. Almost all major employers in the United States offer group health insurance to their employees. The typical PPO plan for large employers is typically more generous than Medicare or the standard Federal Employee Health Benefits Program option.
The employer usually makes a significant contribution to the costs of coverage. Typically, employers pay about 85% of their employees' insurance premiums and about 75% of their employees' dependents' premiums. The employee pays the remaining portion of the premium, usually from salary before taxes/exemption. These percentages have remained stable since 1999. Employer-provided health benefits also have tax advantages: employee contributions can be made on a pre-tax basis if the employer offers the benefits through a Section 125 cafeteria plan .
Employees who receive employer-sponsored health insurance generally receive less cash wages than without the benefit, due to the cost of insurance premiums to the employer and the value of the benefit to the employee. The value to employees is generally greater than the pay reduction due to economies of scale, a reduction in negative selection pressure on the insurance pool (premiums are lower if all employees participate rather than just the sickest ) and the reduction of income taxes. Disadvantages for workers include the disruption associated with changing jobs, the regressive tax effect (high-income workers benefit from the premium tax exemption much more than low-income workers), and higher health care spending. .
The cost of employer-paid health insurance is rising rapidly: Between 2001 and 2007, premiums for family coverage rose 78%, while wages rose 19% and inflation rose 17%, according to a Kaiser study of 2007 by Family Foundation. Costs to employers have increased markedly per hour worked and vary considerably. In particular, employers' average costs for health care benefits vary depending on company size and occupation. The hourly cost of health benefits is generally higher for workers in higher-wage occupations, but represents a smaller percentage of payroll. The percentage of total compensation spent on health care benefits has increased since the 1960s. Average premiums, including the employer and employee portions, were $4,704 for individual coverage and $12,680 for family coverage in 2008.
However, in a 2007 analysis, the Employee Benefits Research Institute concluded that the availability of work-based health benefits for active workers in the U.S. is stable. The “hire rate,” or the percentage of eligible workers enrolled in employer-sponsored plans, has fallen somewhat, but not sharply. EBRI interviewed employers for the study and found that if a major employer were to eliminate health benefits, others might follow suit. Effective January 1, 2014, the Patient Protection and Affordable Care Act will impose a $2,000 per-employee tax penalty on employers with more than 50 employees who do not offer health insurance to their full-time employees. (In 2008, more than 95% of employers with at least 50 employees offered health insurance.) On the other hand, changes in public policy could also result in reduced employer support for employment-based health benefits.
Although they are much more likely to offer health benefits to retirees than small businesses, the percentage of large companies offering these benefits has fallen from 66% in 1988 to 34% in 2002.
According to Jacob Hacker, the development of employer-based health insurance during World War II contributed to the United States' difficulties in implementing health insurance reforms.
Small Employer Group Coverage
According to a 2007 survey, approximately 59% of small business employers (3 to 199 employees) in the United States offer health insurance to their employees. The percentage of small businesses offering coverage has steadily declined since 1999. The survey shows that cost remains the top reason cited by small businesses that do not offer health benefits. New small businesses are less likely to offer coverage than businesses that have been around for several years. For example, using 2005 data for businesses with fewer than ten employees, 43% of businesses that had existed for at least 20 years offered coverage, but only 24% of businesses that had existed for less than five years. The volatility of contribution rates from year to year also appears to be higher for newer small businesses.
The types of coverage available to small employers are similar to those available to large corporations, but small businesses do not have the same options for funding their benefit plans. In particular, self-funded health care (where an employer provides health or disability benefits to employees through its own resources rather than contracting with an insurance company) is not a practical option for most small employers. A RAND Corporation study published in April 2008 found that the cost of health care coverage, as a percentage of payroll, places a greater burden on small businesses than large businesses. A study published by the American Enterprise Institute in August 2008 examined the effect of government benefit mandates on self-employed workers and found that "the greater the number of mandates in a state, the less likely a self-employed person own is an important generator of employment." The costs borne by beneficiaries are on average higher for small companies than for large ones.
When small group plans have health insurance, employees are asked to provide health information about themselves and their covered dependents when applying for coverage. When determining rates, insurers use medical data from these claims. Sometimes they request additional information from the applicant's doctor or ask for clarification.
States regulate premium rates for small groups, generally by setting limits on the variation in allowable premiums between groups (rate groups). Insurers strive to recover costs across their entire portfolio of small group businesses while adhering to state rating standards.[86] Over time, the effect of initial adoption will “fade away” as a group's costs return to the average. Recent claims experiences – whether better or worse than average – are a strong predictor of future costs in the short term. But the average health status of a given small group of employers tends to decline over time until it approaches that of an average group. The process used to determine small group coverage changes when a state enacts small group reform laws.
Insurance brokers play an important role in helping small employers find health insurance, especially in more competitive markets. Average commissions for small groups range from 2 to 8 percent of premiums. Brokers provide services beyond selling insurance, such as assisting with employee enrollment and helping resolve benefits issues.
University-sponsored health insurance for students
Many colleges, universities, graduate schools, professional schools and trade schools offer school-sponsored health insurance. Many schools require you to enroll in the school-sponsored plan unless you can demonstrate comparable coverage from another source.
As for group health plan years beginning after September 23, 2010, if an employer-sponsored health plan allows the children of employees to enroll in coverage, the health plan must allow the adults of the employees' children to enroll to register, as long as the adult child is not. and yet 26 years old. Some group health insurance plans may also require that the adult child be ineligible for other group health insurance, but only before 2014.
This expansion of coverage will help cover one in three young adults, according to White House documents.
Federal Employee Health Benefit Plan (FEHBP)
In addition to public plans such as Medicare and Medicaid, the federal government also sponsors a health benefits plan for federal employees: the Federal Employees Health Benefits Program (FEHBP). FEHBP provides health benefits to full-time civilian employees. Active duty members, retired military personnel and their dependents are covered by the Department of Defense's Military Health System (MHS). FEHBP is administered by the Federal Office of Personnel Management.
COBRA coverage
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) allows certain people with employer-sponsored coverage to have their coverage expanded if certain "qualifying events" would cause them to lose it. Employers may require COBRA qualified individuals to pay the full cost of coverage, and coverage cannot be extended indefinitely. COBRA only applies to businesses with twenty or more employees, although some states also have “mini-COBRA” laws that apply to small employers.
Types of health insurance
Traditional compensation or reimbursement for services
Early medical and hospital plans offered by insurance companies paid a fixed amount for specific illnesses or medical procedures (schedule benefits) or a percentage of the provider's reimbursement. The relationship between patient and caregiver did not change. The patient received medical care and was responsible for paying the provider. If the service was covered by the policy, the insurance company was responsible for reimbursing or indemnifying the patient based on the terms of the insurance contract ("reimbursement benefits"). Health plans that are not based on a network of contracted providers, or that base payments on a percentage of the provider's charges, are still described as benefits or reimbursement for services.
Blue Cross Blue Shield Association
The Blue Cross Blue Shield Association (BCBSA) is a federation of 38 independent health companies and insurers in the United States. Combined, they provide health insurance directly or indirectly to more than 100 million Americans. BCBSA insurance companies are franchisees, independent of the association (and traditionally from each other), offering insurance plans within certain regions under one or both of the association's brands. Blue Cross Blue Shield insurers provide some form of health insurance coverage in all U.S. states and also serve as administrators of Medicare in many states or regions of the United States, providing coverage to state government employees and federal government employees under a nationwide option. of the Federal Employee Health Benefits Plan.
Health maintenance organizations.
A health care organization (HMO) is a type of managed care organization (MCO) that provides a form of health care coverage that is delivered through hospitals, doctors, and other providers with which the HMO contracts. The Health Maintenance Organization Act of 1973 required employers with 25 or more employees to offer federally certified HMO options. Unlike traditional indemnity insurance, health insurance only covers care provided by doctors and other professionals who have agreed to treat patients in accordance with the healthcare organization's guidelines and restrictions, in exchange for a steady stream of clients. . Benefits are offered through a network of providers. Providers may be employees of the HMO ("employee model"), employees of a provider group that contracts with the HMO ("group model"), or members of an independent practice association ("IPA model"). Healthcare organizations may also use a combination of these approaches ("network model").
Organized care
The term managed care is used to describe a variety of techniques aimed at reducing the cost of health benefits and improving the quality of care. It is also used to describe organizations that use these techniques ("managed care organization"). Many of these techniques were developed by healthcare organizations, but are now used in a wide variety of private health insurance programs. In the 1990s, managed care grew from about 25% of American workers with employer-sponsored coverage to the vast majority.
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