Health insurance in the United States is a program that helps pay for medical expenses, either through privately purchased insurance, social insurance or government-funded social welfare programs. Synonyms for this use include "health coverage", "health care coverage" and "health benefits". In a more technical sense, the term is used to describe any form of insurance that provides protection against the cost of medical services. These uses include private insurance and social insurance programs such as Medicare, which pool resources and disseminate financial risks associated with major medical costs across the population to protect all people, as well as social welfare programs such as Medicaid and the Children's Health Insurance Program, which provides assistance to people who can not afford health insurance.
In addition to medical cost insurance, "health insurance" may also refer to insurance covering disability or long-term care or custodial care needs. Different health insurance provides different levels of financial protection and coverage coverage can vary greatly, with more than 40 percent of the insured reporting that their plans did not adequately meet their needs in 2007.
The share of Americans without health insurance has been cut in half since 2013. Many of the reforms instituted by the Affordable Care Act of 2010 are designed to expand the scope of health care for those who do not have them; However, high cost growth continues. National health expenditure is projected to grow 4.7% per person per year from 2016-2025. Public health care spending was 29% of federal mandated spending in 1990, 35% in 2000, and is projected about half by 2025.
Video Health insurance in the United States
Unregistered and uninsured
Trends in personal scope
The proportion of non-elderly individuals with company-sponsored cover fell from 66% in 2000 to 56% in 2010, then stabilized following the passage of the Affordable Care Act. Employees who work part-time (less than 30 hours per week) are less likely to be offered coverage by their employers than full-time employees (21% vs 72%).
The main trend in employer-sponsored coverage has increased premiums, deductibles, and co-payments for medical services, and increases the cost of using service providers outside the network rather than in-network providers.
Trends in public coverage
Public insurance coverage increased from 2000-2010 in part due to the aging population and the economic downturn in the latter part of the decade. Funding for Medicaid and CHIP grew significantly under the health reform legislation 2010. The proportion of individuals covered by Medicaid increased from 10.5% in 2000 to 14.5% in 2010 and 20% by 2015. The proportion covered by Medicare increased from 13.5% in 2000 to 15.9% in 2010, then decreased to 14% by 2015.
Status of the uninsured
Uninsured proportions stabilized at 14-15% from 1990 to 2008, then climbed to an 18% peak in Q3 2013 and quickly fell to 11% by 2015. Unsecured proportions have stabilized at 9%.
A 2011 study found that there were 2.1 million hospitals for uninsured patients, accounting for 4.4% ($ 17.1 billion) of total hospital admissions costs in the United States. The cost of uninsured care should often be absorbed by the service provider as a charity treatment, passed on to the insured through health insurance premiums that are switched higher and higher, or paid by taxpayers through higher taxes.
Death
Because people who do not have health insurance can not get timely medical care, they have a 40% higher risk of death in a given year than health insurance, according to a study published in the American Journal of Public Health. The study estimates that in 2005 in the United States, there were 45,000 deaths associated with a lack of health insurance. A systematic review of 2008 found consistent evidence that health insurance increased service utilization and improved health.
A Johns Hopkins Hospital study found that cardiac transplant complications occur most often among uninsured patients, and that patients with personal health plans fared better than those covered by Medicaid or Medicare. Gallup issued a report in July 2014 stating that the uninsured rate for adults aged 18 years and over declined from 18% in 2013 to 13.4% by 2014, largely due to new coverage options and market reforms under the Affordable Care Act. Rand Corporation has similar findings.
Reform
The Affordable Care Act of 2010 is designed primarily to extend health coverage to those without it by expanding Medicaid, creating financial incentives for employers to offer coverage, and requiring them without an employer or public coverage to buy insurance on a newly created health insurance exchange. This requirement for almost all individuals to retain health insurance is often referred to as "an individual's mandate." The CBO estimates that approximately 33 million, if uninsured, will receive coverage for such actions by 2022.
Revocation of Individual Mandate
The Tax Cuts and Jobs Act of 2017 effectively deprive the individual's mandate, meaning that individuals will no longer be punished for failing to maintain health coverage by 2019. CBO projects that this change will result in four million more uninsured by 2019, 13 million more by 2027.
Maps Health insurance in the United States
History
Accident insurance was first offered in the United States by the Franklin Health Assurance Company of Massachusetts. The company, founded in 1850, offers insurance against injuries arising from train and steam crashes. Sixty organizations offered accident insurance in the US in 1866, but the industry quickly dissolved. Despite previous experiments, the scope of the disease in the US effectively dates from 1890. The company's first group sponsored defect policy was issued in 1911, but the main purpose of this plan was to replace the lost wages because workers were unable to work, not medical expenses.
Prior to the development of medical cost insurance, patients were expected to pay all other health care costs from their own pockets, under what is known as a fee-for-service business model. During the mid to late 20th century, traditional disability insurance evolved into a modern health insurance program. Currently, most comprehensive private health insurance programs cover the cost of routine care, prevention and emergency health care procedures, as well as most prescription drugs, but this is not always true. The emergence of private insurance is accompanied by a gradual expansion of public insurance programs for those who can not gain coverage through the market.
Hospital and medical cost policies were introduced during the first half of the 20th century. During the 1920s, each hospital began offering individual services on a pre-paid basis, leading eventually to the development of the Blue Cross organization in the 1930s. The company-sponsored hospitalization plan was first created by teachers in Dallas, Texas in 1929. Since the plan covers only the expenditure of members in one hospital, it is also a forerunner of the current health maintenance organization (HMO).
In 1935 the decision was made by the Roosevelt Administration to exclude large-scale health insurance schemes as part of the new Social Security program. The problem is not an attack by organized opposition, such as the opposition of the American Medical Association that repealed Truman's proposal in 1949. In contrast, there is a lack of active support of popular groups, congresses, or interest. Roosevelt's strategy is to wait for requests and programs to materialize, and then if he thinks it's popular enough to throw his support behind him. Its Economic Security Committee (CES) deliberately limits the Social Security health segment to the expansion of medical care and facilities. It is considered unemployment insurance a top priority. Roosevelt convinced the medical community that drugs would be kept away from politics. Jaap Kooijman said he managed to "calm the opponents without making reformers disappointed." The exact moment never came for him to reintroduce the topic.
Increase in corporate sponsored coverage
The company-sponsored health insurance plan was dramatically expanded as a direct result of wage control imposed by the federal government during World War II. The labor market was tight due to the increasing demand for goods and the declining supply of workers during the war. The imposition of wages and prices prohibited by the government prohibits producers and other entrepreneurs from raising enough wages to attract workers. When the Employment Council states that additional benefits, such as sick leave and health insurance, are not counted as wages for wage control purposes, the employer responds with a significantly increased allowance of benefits, in particular the scope of health care, to attract workers.
President Harry S. Truman proposed a public health insurance system at his address on 19 November 1945. He envisioned a national system that would be open to all Americans, but would remain optional. Participants will pay a monthly fee into the plan, which will cover any and all medical expenses incurred when required. The government will pay the service fees provided by doctors who choose to join the program. In addition, the insurance plan will give cash to policyholders to replace wages lost due to illness or injury. The proposal was quite popular among the public, but was strongly opposed by the Chamber of Commerce, the American Hospital Association, and the AMA, which denounced it as "socialism".
Foreseeing a long and expensive political struggle, many trade unions choose to campaign for corporate-sponsored coverage, which they see as less desirable but more achievable goals, and as coverage extends the national insurance system loses political momentum and ultimately fails to qualify. Using health care and other benefits to attract the best employees, the private sector, white-collar entrepreneurs across the country are expanding the US health care system. Public sector entrepreneurs follow it in an effort to compete. Between 1940 and 1960, the total number of people enrolled in the health insurance plan grew sevenfold, from 20,662,000 to 142,334,000, and by 1958, 75% of Americans had some form of health coverage.
Kerr-Mills Act
However, private insurance remains unaffordable or simply unavailable to many, including the poor, the unemployed, and the elderly. Before 1965, only half of the elderly had health insurance coverage, and they paid three times more than younger adults, while the income was lower. As a result, interest persists in creating public health insurance for those left out of the private market.
The 1960 Kerr-Mills Act provides funds suitable for countries that assist patients with their medical bills. In the early 1960s, Congress rejected plans to subsidize private protection for people with Social Security as unworkable, and amendments to the Social Security Act that created a publicly-run alternative were proposed. Finally, President Lyndon B. Johnson signed the Medicare and Medicaid program into law in 1965, creating a public-run insurance for parents and the poor. Medicare was then expanded to include people with disabilities, end-stage renal disease, and ALS.
Towards universal coverage
The absence of continuous insurance among many American workers continues to create pressure for a comprehensive national health insurance system. In the early 1970s, there was a fierce debate between two alternative models for universal coverage. Senator Ted Kennedy proposed a single universal paying system, while President Nixon responded with his own proposal based on mandates and incentives for employers to provide coverage while extending public coverage to low-paid and unemployed workers. Compromise was never achieved, and Nixon's resignation and a series of economic problems later in the decade distract Congress from health reform.
Shortly after his inauguration, President Clinton offered a new proposal for a universal health insurance system. Like Nixon's plan, Clinton relies on mandates, both for individuals and for insurance, along with subsidies for people who can not afford insurance. The bill will also create a "health-purchase alliance" to raise risk among many businesses and large groups of individuals. The plan is strictly opposed by the insurance industry and entrepreneurial groups and receives only mild support from liberal groups, especially unions, who prefer a single paying system. Finally failed after the Republican takeover in 1994.
Finally achieving universal health coverage remains a top priority among Democrats, and passing the health reform bill is one of the Obama administration's top priorities. The Patient Protection and Affordable Care Act are similar to the Nixon and Clinton plans, which require coverage, punish employers who fail to provide them, and create mechanisms for people to collect risks and buy insurance collectively. Previous versions of the bill include an openly-run insurance company that can compete to cover those who do not have an employer-sponsored coverage (so-called public options), but this is ultimately disarmed to secure support from moderates. The bill was passed by the Senate in December 2009 with all Democratic votes in favor and the House of Representatives in March 2010 with the support of most Democrats. No Republicans support it.
Coverage of public health services
Public programs provide the ultimate 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, the federal social insurance program for seniors (generally people aged 65 years and over) and certain disabled individuals; Medicaid, funded jointly by federal and state governments but managed at the state level, which includes certain low-income children and their families; and CHIP, as well as federal state partnerships that serve certain children and families who are not eligible for Medicaid but who can not afford personal coverage. Other public programs include military health benefits provided through TRICARE and the Veterans Medical Administration and benefits provided through the Indian Health Service. Some states have additional programs for low-income individuals. In 2011, about 60 percent of the stay was billed to Medicare and Medicaid - up from 52 percent in 1997.
Medicare
In the United States, Medicare is a federal social insurance program that provides health insurance for people over the age of 65, people with total and permanent disabilities, end-stage renal disease patients, and people with ALS. Recent research has found that the health trends of previously uninsured adults, especially those with chronic health problems, increased after they entered the Medicare program. Traditional Medicare requires substantial cost sharing, but ninety percent of Medicare registrants have some type of additional insurance - coverage sponsored by employers or retirees, Medicaid, or private Medigap plans - covering part or all of their cost-sharing. With additional insurance, Medicare ensures that its registries are predictable, affordable health care costs regardless of illness or unexpected injury.
As the population covered by Medicare grows, the cost is projected to increase from slightly above 3 percent of GDP to over 6 percent, contributing substantially to the federal budget deficit. In 2011, Medicare was the primary payer for approximately 15.3 million inpatients, representing 47.2 percent ($ 182.7 billion) of total aggregate hospital care costs in the United States. The Affordable Care Act takes several steps to reduce Medicare spending, and other proposals circulate to further reduce it.
Medicare Advantage
Medicare Advantage plans to expand health insurance options for people with Medicare. Medicare Advantage was created under the Balanced Budget Act of 1997, with the intent of further controlling rapid growth in Medicare spending, as well as to provide more choices for Medicare recipients. But on average, Medicare Advantage packages cost 12% more than traditional Medicare. ACA takes steps to harmonize payments with Medicare Advantage plans with traditional Medicare costs.
There is some evidence that the Medicare Advantage plan choosing low-risk patients leads to huge medical costs to maximize profits at the expense of traditional Medicare.
Medicare Part D
Medicare Part D provides personal insurance options to enable Medicare recipients to purchase subsidized coverage for prescription drug costs. It was enacted as part of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) and entered into force on 1 January 2006.
Medicaid
Medicaid was instituted for the very poor in 1965. Because the applicant must pass a meaningful test, Medicaid is a social welfare or social protection program rather than a social insurance program. Despite its formation, the percentage of US residents who have no form of health insurance has increased since 1994. It has been reported that the number of doctors receiving Medicaid has declined in recent years due to lower replacement rates.
The Affordable Care Act dramatically expands Medicaid. The program will now cover all people with incomes below 133% of federal poverty rates not eligible for Medicare, provided that this coverage extension has been accepted by the country in which the person resides. Meanwhile, Medicaid benefits must be equal to the important benefits in a newly created state exchange. The federal government will fully fund Medicaid's expansion at first, with some financial responsibilities gradually shifting back to the state by 2020.
In 2011, there were 7.6 million hospitals billed to Medicaid, representing 15.6% (approximately $ 60.2 billion) of total aggregate hospital care costs in the United States.
Children's Health Insurance Program (CHIP)
The Child Health Insurance (CHIP) program is a state/federal joint program to provide health insurance for children in families who earn too much money to qualify for Medicaid, but can not afford private insurance. The legal authority for CHIP is under the heading XXI of the Social Security Act. The CHIP program is run by each country according to the requirements set by the federal Center for Medicare and Medicaid Services, and can be structured as an independent program separate from Medicaid (separate child health program), as an extension of their Medicaid program (Medicaid CHIP expansion program) , or combine this approach (a combination of CHIP program). The state receives enhanced federal funds for their CHIP program at rates above regular Medicaid matches.
Benefits of military health
Health benefits are given to members of active service, members of the pension service and their dependents by the Department of Defense Military Health Systems (MHS). MHS consists of a direct care network of the Military Care Facility and a network of maintenance purchases known as TRICARE. In addition, veterans are also entitled to benefit through the Veterans Health Administration.
Indian healthcare
The Indian Health Service (IHS) provides medical assistance to qualified American Indians at the IHS facility, and helps pay for the fees of some services provided by non-IHS health care providers.
Country risk set
In 1976, several states began to provide a pool of guaranteed risks, allowing individuals who could not be medically insured through private health insurance to purchase state-sponsored health insurance plans, usually at a higher cost. Minnesota was the first to offer such a plan; 34 countries (Alabama, Alaska, Arkansas, California, Colorado, Connecticut, Florida, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Dakota, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, West Virginia, Wisconsin, Wyoming) now offer them. Plans vary widely from state to state, both in cost and benefits to consumers and in their funding and operating methods. They serve a small portion of the market that can not be insured - about 182,000 people in the US in 2004, and about 200,000 in 2008.
This pool of risk allows people with pre-existing conditions such as cancer, diabetes, heart disease or other chronic diseases to be able to change jobs or seek entrepreneurship without fear of not having health benefits. However, the plan is expensive, with a premium that can double the average policy, and the pools currently only cover 1 in 25 populations called "uninsured". In addition, even inexpensive plans can leave those who are registered with little real health insurance outside of "disaster" insurance; for example, an insurance plan through Minnesota's high-risk pool, while costing only $ 215 per quarter, including $ 10,000 deductible without preventive or other preventive health care unless and until the applicant has spent $ 10,000 of their own money over the year on health care. Very sick people can collect large medical bills during mandatory waiting periods before their medical costs are closed, and there is often a lifetime (maximum) expense cap, after which the risk pool is no longer paying for medical expenses.
Attempts to pass the national pool were unsuccessful, but some federal tax dollars have been given to countries to innovate and improve their plans. With Patient Protection and Affordable Care Act, effective by 2014, it will be easier for people with pre-existing conditions to buy regular insurance, as all insurance companies will be completely prohibited from discriminating or charging higher rates for each individual based on pre-existing medical conditions.
Old Condition Insurance Plan
The pre-existing Insurance Condition Plan, or PCIP, is a transitional program created in the Patient Protection and Affordable Care Act (PPACA). Those eligible for PCIP are US citizens or those living in the US legally, who have been insured for the past 6 months and "have pre-existing conditions or have been denied health coverage because of their health condition." However, if a person has health insurance or is registered in a high-risk state pool, they are not eligible for PCIP, even if the coverage does not cover their medical condition. PCIP is run by individual states or through the US Department of Health and Human Services, which has contracts with the Government Employee Health Association, or GEHA, to manage benefits. Both will be funded by the federal government and provide three plan options. These options are standard, extended, and Health Savings Account options. PCIP only covers individual applicants and does not include family members or dependents. By 2014, the provisions of the Affordable Care Act prohibit discrimination based on pre-existing conditions to be applied and PCIP registries will be transferred to new state-based healthcare exchange.
Personal healthcare coverage
Private health insurance can be purchased by group (for example, by a company to protect its employees) or purchased by an individual consumer. Most Americans with private health insurance receive it through a company-sponsored program. According to the US Census Bureau, about 60% of Americans are covered through employers, while about 9% buy health insurance directly. Private insurance was billed for 12.2 million hospitalized patients in 2011, raising approximately 29% ($ 112.5 billion) of total aggregate hospital care costs in the United States.
The US has a federal and state system together to organize insurance, with the federal government handing over the primary responsibility to the state under the McCarran-Ferguson Act. The state governs the content of health insurance policies and often requires coverage of certain types of medical services or health care providers. State mandates generally do not apply to health plans offered by large employers, because of the preemption clause of the Employee Benefit Act.
Employer sponsored
Company-sponsored health insurance is paid for by businesses on behalf of their employees as part of an employee benefits package. Most private (non-government) health coverage in the US is job-based. Almost all big companies in America offer group health insurance to their employees. Large company PPO plans are generally cheaper than Medicare or Federal Employee Health Program Standard Options.
The employer typically contributes greatly to the insurance coverage. Typically, employers pay about 85% of the insurance premium for their employees, and about 75% of the premium for their employee's expenses. Employees pay the remaining fraction of the premium, usually with pre-tax income/tax-free. This percentage has been stable since 1999. The health benefits provided by employers also benefit the tax: Employee contributions can be made on a pre-tax basis if the employer offers benefits through section 125 cafeteria plans.
Workers who receive health insurance sponsored by employers tend to be paid less in cash wages than they would be without benefits, due to the cost of insurance premiums to employers and the value of benefits to workers. Values ​​for workers are generally greater than wage reductions due to economies of scale, reduction in inverse selection pressure in insurance pools (lower premiums when all employees participate not only the sickest), and reduced income tax. Losses for workers include job-related disruptions, regressive tax effects (high-income workers benefit far greater than tax exemptions for premiums than low-income workers), and increased spending on health care.
Costs for health insurance paid by firms increased rapidly: between 2001 and 2007, the premium for family coverage had risen 78%, while wages rose 19% and inflation had risen 17%, according to a 2007 study by the Kaiser Family Foundation. Company costs increased sharply per working hour, and varied significantly. In particular, the average employer's expenses for health benefits vary by size and occupation. The hourly cost of healthcare benefits is generally higher for workers in higher paying jobs, but represents a smaller percentage of salary. The percentage of total compensation devoted to health benefits has increased since the 1960s. Average premiums, including corporate and employee sections, were $ 4,704 for single coverage and $ 12,680 for family coverage in 2008.
However, in a 2007 analysis, the Employee Benefit Research Institute concluded that the availability of work-based health benefits for active workers in the US is stable. The "withdrawal rate," or the percentage of eligible workers participating in the company-sponsored plan, has dropped slightly, but not sharply. EBRI interviewed employers for research, and found that others may follow if large employers stop health benefits. Effective January 1, 2014, Patient Protection and Affordable Care Act will impose a tax penalty of $ 2000 per employee on an employer with more than 50 employees who do not offer health insurance to their full-time workers. (In 2008, more than 95% of employers with at least 50 employees offered health insurance.) On the other hand, public policy changes may also result in reduced employer support for job-based health benefits.
Although far more likely to offer retired health benefits than small firms, the percentage of large companies offering these benefits fell from 66% in 1988 to 34% in 2002.
Company small group coverage
According to a 2007 study, about 59% of companies in small companies (3-199 workers) in the US provide employee health insurance. The percentage of small companies offering coverage has declined since 1999. The study notes that fixed costs are the main reason cited by small companies that do not offer health benefits. The new small companies are less likely to offer coverage than they have been for a few years. For example, using 2005 data for companies with fewer than 10 employees, 43% of those who have been there for at least 20 years offer coverage, but only 24% of those who have existed for less than 5 years. The offer rate volatility from year to year also seems to be higher for newer small businesses.
The types of coverage available to small entrepreneurs are similar to those offered by large companies, but small businesses do not have the same options to finance their benefit plans. In particular, self-funded healthcare (where employers provide health or disability benefits to employees on their own rather than contracting insurance companies) is not a practical option for most small entrepreneurs. The RAND Corporation study published in April 2008 found that health care costs place a greater burden on small firms, as a percentage of payroll, than for larger firms. A study published by the American Enterprise Institute in August 2008 examined the effect of the state's mandate on individual entrepreneurs, and found that "the greater the number of mandates within a country, the lower the probability that self-employed people will be significant labor generators." Cost-sharing beneficiaries, on average, are higher among smaller firms than large companies.
When small group plans are medically covered, employees are required to provide health information about themselves and their covered family members when they apply for coverage. When determining rates, insurance companies use medical information in this application. Sometimes they will ask for additional information from the applicant's doctor or ask the applicant for clarification.
The state regulates the small group premium rate, usually by placing limits on the premium variations allowed between groups (band rate). Insurers price to recover their costs over the entire book of their small group business while obeying the state rating rules. Over time, the effects of initial underwriting "fade" as group costs are regressed against the average value. The latest claims experience - whether better or worse than average - is a strong predictor of future costs in the near future. But the average health status of certain groups of small entrepreneurs tends to retreat from time to time toward the average group. The process used to establish small group coverage changes when a country enacts small group reform laws.
Insurance brokers play an important role in helping small businesses find health insurance, especially in more competitive markets. Small group commissions on average range from 2 percent to 8 percent of the premium. Brokers provide services outside of the sale of insurance, such as assisting employee registration and helping to resolve the benefit issue.
College-sponsored health insurance for students
Many colleges, universities, graduate schools, professional schools and trade schools offer school-sponsored health insurance plans. Many schools require that you enroll in a school-sponsored plan unless you can show that you have comparable coverage from other sources.
An effective multi-year group health plan begins after September 23, 2010, if a company-sponsored health plan enables employee's children to enroll in coverage, the health plan should allow adult employees to enroll as long as the adult does but age 26 Some group health insurance plans may also require that adult children are not eligible for other group health insurance coverage, but only before 2014.
This extended coverage will help include one in three young adults, according to White House documents.
The federal employee health benefits plan (FEHBP)
In addition to public plans such as Medicare and Medicaid, the federal government also sponsors a health benefit plan for federal employees - the Federal Employee Health Benefit Program (FEHBP). FEHBP provides health benefits to full-time civilian employees. Members of active service duties, members of their retired services and dependents are protected by the Department of Defense Military Health Systems (MHS). FEHBP is managed by the Office of Federal Personnel Management.
"Portability" of group scope
Two federal laws address the ability of individuals with employment-based health insurance coverage to maintain coverage.
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) allows certain individuals with company-sponsored coverage to extend their scope if certain "qualifying events" will cause them to lose. Employers may require individuals who qualify for COBRA to pay for all coverage, and coverage can not be extended indefinitely. COBRA only applies to companies with 20 or more employees, although some states also have "mini-COBRA" laws that apply to small companies.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides "group-to-group" and "group-to-individual" portability forms. When an individual moves from one employer allowance plan to another, the new plan should calculate coverage under the old plan against each waiting period for pre-existing conditions, as long as there is no break in the scope of more than 63 days between the two. plan. When certain eligible individuals lose group coverage at all, they must be guaranteed access to some form of individual coverage. To be eligible, they must have at least 18 months of continuous coverage before. Details of access and coverage are determined by state-by-state.
Association Health Plan (AHP)
In the late 1990s, federal legislation had been proposed to "create a government-recognized Association of Health Insurance Plan which was then" referred to in several bills as 'Small Business Health Plan'. The National Association of Insurance Commissioners (NAIC), which is "the regulatory and regulatory regulatory standards and regulatory arrangements of all states, the District of Columbia and territories, warns against applying the AHP which calls" plan failures as we see The Multiple Employer Welfare Arrangements (MEWA ) in the 1990s. "[S] California mall businesses like dairy farmers, car dealers, and accountants created AHP" to buy health insurance on the premise that a larger set of enrollees will give them a better deal. " The November 2017 article in the Los Angeles Times illustrates how there are only 4 AHP left in California. Many AHPs filed for bankruptcy, "sometimes after fraud." State legislators were forced to pass the "big changes in the 1990s" that almost made the AHPs go extinct.
According to the 2000 Congressional Budget Office (CBO) report, Congress passed a law that created "two new vehicles, the Association Health Plans (AHPs) and HealthMarts, to facilitate the sale of health insurance coverage to employees of small firms" in response to concerns about " uninsured people in the United States. "
In 2003, according to Heartland Institute's Merrill Matthews, the group's health insurance plan offered affordable health coverage for "about 6 million Americans." Matthews responded to criticism that some associations work too closely with their insurance providers. He said, "You would expect AARP's head to have a good working relationship with CEO Prudential, who sells policies to AARP seniors."
In March 2017, the US House of Representatives issued the Healthcare Justice Act (HR 1101), which stipulates "the requirement to create a federal certified AHP, including for the certification itself, sponsorship and supervisory boards, participation and coverage, non-discrimination, contribution levels, and voluntary termination. "
AHP will be "exempt from most state regulatory and supervisory rules, subject only to the Employees Retirement Income Act (ERISA) and oversight by the US Department of Labor, and most proposals will also allow for interstate plans."
Critics say that "Exceptions will lead to higher market instability and higher premiums in traditional small-group markets AHPs that are excluded from state regulation and control will allow them to be more selective about who they cover • They will tend to cover higher risks. population, which would cause an imbalance in the risk group for other small business health plans that are part of a collection of risks of a small group of countries.The opposite selection is likely to be widespread and the Association's Health Plan will sell unregulated products along with small group plans, non-uniform play. "According to the Congressional Budget Office (CBO)," [p] remium will go up for those who buy in traditional small-group markets. " competing with AHPs that offer cheaper and less comprehensive plans.
The National Association of Insurance Associations (NAIC), the National Governors Association and "some insurance and consumer groups" are opposed to the AHP law. NAIC issued the Consumer Notice on AHP, as proposed under Developing the Next Generation of Small Businesses Act of 2017. H.R. 1774 . Their statement says that AHP "[t] threatens the stability of small group markets" and provides "inadequate profits and inadequate protection to consumers." Under the AHP, "[f] younger consumers will have their rights protected," AHP will also be exempt from state solvency requirements, putting consumers at serious risk of medical claims that cause unpaid by their Association's Health Plan. "
In November 2017, President Trump directed the "Department of Labor to investigate ways that would" allow more small businesses to avoid many of the high cost requirements of the Affordable Act. "Under the ACA, small companies and individual markets have" gained importance. consumer protection under the ACA and state health laws - including minimum benefit levels. "In a December 28, 2017 interview with New York Times , Trump explained that," We have made associations, millions of people join the association.... It was in Obamacare or had no insurance. Or do not have health care.... It can be as high as 50 percent of the people. So now you have an association, and people do not even talk about the association. That's probably half of the people who will join... So now you have individual associations and mandates. I believe that because of the mandate of individuals and associations ".
Purchased by individuals
According to the US Census Bureau, about 9% of Americans are covered health insurance purchased directly. The various products available are similar to those provided through the company. However, average out-of-pocket expenses are higher in individual markets, with higher deductibles, joint payments and other cost-sharing provisions. Primary medical is the most frequently purchased form of individual health insurance. Although major medical health insurance policies are primarily disaster plans, eligible prevention benefits are still covered 100% without waiting or copay.
In the individual market, the consumer pays the entire premium without the benefit of the employer's contribution. While individual entrepreneurs receive tax deductions for their health insurance and can purchase health insurance with additional tax benefits, most consumers on the individual market do not receive tax benefits.
Premiums vary significantly based on age. In states that allow individual insurance plans, premiums also vary by health status. However, with Patient Protection and Affordable Care Act, effective from 2014, insurance companies are prohibited from discriminating or charging higher rates for individuals based on pre-existing medical conditions.
In August 2008, the Hartford Courant reported that competition increased in the individual health insurance market, with more insurers entering the market, increasing product variations, and wider price spread.
Individual health insurance is primarily regulated at the state level, consistent with the McCarran-Ferguson Act. The model of action and regulation disseminated by the National Association of Insurance Commissioners (NAIC) provides several levels of uniformity of states to the state. These models have no legal force and have no effect unless they are adopted by a country. They are, however, used as a guide by most states, and some countries adopt them with little or no change.
Type of medical insurance
Traditional or cost-for-service compensation
Initial hospitals and medical plans offered by insurance companies pay either a fixed amount for a particular disease or medical procedure (benefit schedule) or a percentage of the provider fee. The relationship between patient and medical provider has not changed. The patient receives medical care and is responsible for paying the provider. If the service is covered by the policy, the insurer is liable to replace or indemnify the patient under the terms of the insurance contract ("reimbursement allowance"). Health insurance plans that are not based on the contracted provider's network, or that the base payments on a percentage of the provider's fees, are still depicted as compensation or cost-for-service plans.
Blue Cross Blue Shield Association
The Blue Cross Blue Shield Association BCBSA is a federation of 38 separate health insurance organizations and companies in the United States. Combined, they directly or indirectly provide health insurance to over 100 million Americans. The BCBSA insurance company is a franchisee, independent of the association (and traditionally one another), offering insurance packages within a certain territory under one or both of the associated brands. Blue Cross Blue Shield Insurance offers several forms of health insurance coverage in every US state, and also acts as a Medicare administrator in many states or territories of the United States, and provides coverage to state and state government employees under the national election of the Program Health Benefits of Federal Employees.
Health Maintenance Organization
A healthcare organization ( HMO ) is a type of managed care organization (MCO) that provides coverage of health services that are met through hospitals, physicians and other providers by which HMOs have contract. The Healthcare Organization Act of 1973 requires employers with 25 or more employees to offer federal certified HMO options. Unlike traditional indemnity insurers, HMOs cover only the care provided by doctors and other professionals who have agreed to treat patients according to HMO guidelines and restrictions in exchange for a steady stream of customers. Benefits are provided through the provider's network. The provider may be an HMO employee ("model staff"), an employee of a group of providers who have been contracted with HMOs ("group models"), or members of independent practice associations ("IPA models"). HMOs can also use this combination of approaches ("network models").
Managed care
The term managed care is used to describe the various techniques that are intended to reduce the cost of health benefits and improve the quality of care. It is also used to describe organizations that use this technique ("managed care organization"). Many of these techniques are pioneered by HMOs, but are now used in various private health insurance programs. Throughout the 1990s, managed care grew from about 25% of US employees with corporate-sponsored coverage to the overwhelming majority.
Network-based managed maintenance
Many of the managed care programs are based on the contracted healthcare provider's panel or network. Such programs usually include:
- A collection of selected providers that provide a full range of health care services to be enrolled;
- Explicit standards for selecting providers;
- Official use checks and quality improvement programs;
- Emphasis on preventive care; and
- Financial incentives to encourage registrants to use care efficiently.
Provider networks can be used to reduce costs by negotiating the provider's profitable costs, selecting cost-effective providers, and creating financial incentives for service providers to practice more efficiently. A survey released in 2009 by the American Health Insurance Plan found that patients who went outside the provider's network were sometimes charged very high fees.
Network-based plans can be closed or open. With closed networks, enrollee fees are generally only covered when they go to the network provider. Only limited services are covered outside the network - usually only emergency care and outside treatment area. Most traditional HMOs are closed network plans. Open network plans provide some coverage when enrollee uses non-network providers, generally at lower benefit levels to encourage the use of network providers. Most of the selected service provider organizations' plans are open networks (those not often described as exclusive provider organizations, or EPOs), as well as point service plans (POS).
The terms "open panel" and "closed panel" are sometimes used to describe which health care provider in a community has the opportunity to participate in a plan. In a "closed panel" HMO, network providers are HMO employees (staff models) or members of large group practices that HMOs have contracts. In an "open panel" plan, HMO contracts or PPOs with independent practitioners, open participation in the network to any provider in the community that meets the credential requirements of the plan and is willing to accept the contract terms of the plan.
Other managed care techniques
Other managed care techniques include elements such as disease management, case management, health incentives, patient education, utilization management and utilization reviews. These techniques can be applied to both network-based benefit programs and program benefits that are not based on provider networks. The use of managed care techniques without provider networks is sometimes described as "management of indemnity."
Blurred lines
Over time, operations of many Blue Cross and Blue Shield operations became more similar to commercial health insurance companies. However, some Blue Cross and Blue Shield plans continue to act as the last service provider. Similarly, the benefits offered by the Blues plan, commercial insurance, and HMO come together in many ways due to market pressures. One example is the convergence of the selected provider organization plans (PPOs) offered by Blues and commercial insurance companies and the point of service plans offered by HMOs. Historically, commercial insurance firms, Blue Cross, and Blue Shield are planning, and HMO may be subject to different regulatory oversight in the state (eg, Department of Insurance for insurance companies, versus the Ministry of Health for HMO). Today, it is common for commercial insurance companies to own HMOs as subsidiaries, and for HMOs having insurance as a subsidiary (state licenses for HMO usually differ from that for insurance companies). At one time the difference between traditional indemnity insurance, HMO and PPO is very clear; today, it may be difficult to distinguish between the products offered by the different types of organizations operating in the market.
The blurring of the differences between the different types of health care coverage can be seen in the history of industry trade associations. The two main HMO trade associations are the American Association of Health Groups and the Managed Nations and Managed Associations of America. After the merger, they are known as the American Association of Health Plans (AAHP). The main trade association for commercial health insurance is the American Health Insurance Association (HIAA). Both have now joined, and are known as the American Health Insurance Plan (AHIP).
Type of new medical plan
The US health insurance market is highly concentrated, as the leading insurance companies have conducted more than 400 mergers from the mid-1990s to mid-2000s (decades). In 2000, the two largest health insurance companies (Aetna and UnitedHealth Group) had a total membership of 32 million. In 2006, the two largest insurance companies, WellPoint and UnitedHealth, had a total membership of 67 million. The two companies together have over 36% of the national market for commercial health insurance. The AMA has said that "it has long been concerned about the impact of the consolidated market on patient care." An AMA 2007 study found that in 299 out of the 313 markets surveyed, one health plan accounted for at least 30% of a combined health care organization (HMO)/elective provider organization (PPO). In 90% of the market, the largest insurer controls at least 30% of the market, and the largest insurer controls more than 50% of the market in 54% of metropolitan areas. The US Department of Justice has acknowledged this market control percentage as a substantial monopsonist withdrawal power in the relationship between insurance companies and doctors.
Most market providers (especially hospitals) are also highly concentrated - about 80%, according to the criteria set by the FTC and the Department of Justice - so insurance companies usually have little choice about which providers should be included in their network, influence on controlling the price they pay. Large insurance companies often negotiate the most preferred state clauses with service providers, agreeing to raise interest rates significantly while ensuring that service providers will impose higher insurance rates.
According to some experts, such as Uwe Reinhardt, Sherry Glied, Megan Laugensen, Michael Porter, and Elizabeth Teisberg, this pricing system is extremely inefficient and a major cause of the rising cost of health care. Health care costs in the United States vary greatly between plans and geographic areas, even when input costs are almost the same, and increase very quickly. Health care costs have risen faster than economic growth since at least the 1970s. Public health insurance programs usually have greater bargaining power as a result of their larger size and usually pay less for medical services than personal plans, leading to slower cost growth, but the overall trend in health care costs has led to program costs the public is growing at a rapid pace as well.
Other types of health insurance (non-medical)
Although the term "health insurance" is most commonly used by the public to explain the cost of treatment, the insurance industry uses this term more broadly to include other related forms, such as disability income and long-term care insurance.
Disability income insurance
Disability income insurance (DI) provides benefits to individuals who can not work due to injury or illness. Insurance DI replaces lost income while policyholder can not work during period of disability (in contrast to medical cost insurance, which pays for medical treatment fee). For most working age adults, the risk of disability is greater than the risk of premature death, and lifetime income reduction can be significant. Private disability insurance is sold in both groups and individuals. Policies can be designed to cover long-term disability (LTD coverage) or short-term disability (STD coverage). Business owners can also purchase disability overhead insurance to cover their business overhead costs while they can not work.
The basic level of disability income protection is provided through a Social Security Insurance (SSDI) program for fully qualified and permanently disabled workers (workers unable to engage in "profitable big jobs" and disabilities are expected to last at least 12 months or resulting in death).
Long-term care insurance
Long-term care insurance (LTC) reimburses policyholders for long-term or custodial care services designed to minimize or compensate for loss of function due to age, disability or chronic illness. LTC has many surface similarities with long term disability insurance. There are at least two fundamental differences. The LTC policy covers the cost of certain types of chronic care, while long-term disability policies supersede lost income while policyholders can not work. For LTC, the event that triggers the benefits is the need for chronic care, while the event that triggers for disability insurance is the inability to work.
LTC private insurance is increasingly popular in the US. Premiums are relatively stable in recent years. However, the coverage is quite expensive, especially when consumers wait until retirement age to buy it. The average age of new buyers was 61 in 2005, and has declined.
Additional coverage
Private insurance companies offer additional coverage in both group and individual markets. It is not designed to provide a primary source of medical or disability protection for an individual, but can help with unexpected expenses and provide additional peace of mind for the insured. Additional coverage includes Medicare supplemental insurance, hospital compensation insurance, dental insurance, vision insurance, accidental deaths and cutting insurance and certain disease insurance.
Additional coverage is intended to:
- Complete the main medical expenditure plan by paying for the excluded expenses or subject to major plan cost-sharing requirements (e.g., co-payments, deductibles, etc.);
- Close related expenses such as dental or vision care;
- Help with additional costs that may be associated with serious illness or injury.
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Medicare Supplement Coverage (Medigap)The Medicare Supplemental Policy is designed to cover costs not covered (or only partially covered) by the original "Medicare" cost-for-service benefits (Parts A & amp; B). They are only available to individuals enrolled in Medicare Parts A & amp; B. Medigap plans can be purchased on the basis of guaranteed issues (no health questions) during the six-month open enrollment period when a first individual is eligible for Medicare. The benefits offered by Medigap's plan are standard.
Hospital indemnity insurance
Hospital compensation insurance provides a fixed daily, weekly, or monthly allowance, while the insured is limited to the hospital. Payments are not dependent on actual hospital costs, and are most often expressed as fixed dollar amounts. Hospital compensation benefits are paid in addition to other benefits that may be available, and are typically used to pay the pocket and non-enclosed expenses associated with major medical plans, and to assist with additional costs (eg, childcare) occur while in the hospital.
Scheduled health insurance plan
A scheduled health insurance plan is an expanded form of the Indemnity Hospital plan. In recent years, this plan has taken the name of a mini-med plan or an association plan. This plan can provide benefits for inpatient, surgical, and physician services. However, they are not intended to replace traditional comprehensive health insurance plans. Scheduled health insurance plans are more of a basic policy that provides access to daily health care such as going to a doctor or getting prescription drugs, but these benefits will be limited and are not intended to be effective for catastrophic events. Payments are based on the program's "allowance schedule" and are usually paid directly to pe
Source of the article : Wikipedia
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