Health insurance in the United States

Health care in the United States
Public health care
Federal Employees Health Benefits Program Indian Health Service Medicaid Medicare Military Health System / TRICARE State Children's Health Insurance Program (SCHIP) Veterans Health Administration
Private health coverage
Health insurance in the United States Consumer-driven health care Flexible spending account (FSA) Health reimbursement account Health savings account High-deductible health plan (HDHP) Medical savings account Managed care Health maintenance organization (HMO) Preferred provider organization (PPO) Medical underwriting
Health care law
Emergency Medical Treatment and Active Labor Act (1986) Health Insurance Portability and Accountability Act (1996) Medicare Prescription Drug, Improvement, and Modernization Act (2003) Patient Safety and Quality Improvement Act (2005) Patient Protection and Affordable Care Act (2010)
State/municipal level reform
Fair Share Health Care Act Healthy Howard Healthy San Francisco Massachusetts health care reform Oregon Health Plan
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The term health insurance is commonly used in the United States to describe any program that helps pay for medical expenses, whether through privately purchased insurance, social insurance or a non-insurance social welfare program funded by the government.^[1] Synonyms for this usage 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 costs of medical services. This usage includes private insurance and social insurance programs such as Medicare, but excludes social welfare programs such as Medicaid. In addition to medical expense insurance, it also includes insurance covering disability or long-term nursing or custodial care needs.

The US health care system relies heavily on private and not-for-profit health insurance, which is the primary source of coverage for most Americans. According to the United States Census Bureau, approximately 85% of Americans have health insurance; nearly 60% obtain it through an employer, while about 9% purchase it directly.^[2] Various government agencies provide coverage to about 28% of Americans (there is some overlap in these figures).^[2]

In 2007, there were nearly 46 million people in the US (over 15% of the population) who were without health insurance for at least part of that year.^[2] Over 1 million workers lost their health care coverage in January, February and March of 2009. Approximately, 268,400 more workers lost health care coverage in March 2009 than in March 2008. Proving that today, that number is markedly higher as many workers who have lost their jobs have also lost their employer-provided health insurance. ^[3] The percentage of the non-elderly population who are uninsured has been generally increasing since the year 2000.^[4] There is considerable debate in the US on the causes of and possible remedies for this level of uninsurance as well as the impact it has on the overall US health care system. (see Health care reform in the United States).

Contents 1 History 2 Public health care coverage 2.1 Medicare 2.1.1 Medicare Advantage 2.1.2 Medicare Part D (Prescription Drugs) 2.2 Medicaid 2.3 State Children's Health Insurance Program (SCHIP) 2.4 Military health benefits 2.5 Indian health service 2.6 State risk pools 3 Private health care coverage 3.1 Employer-sponsored 3.1.1 Small employer group coverage 3.1.2 College-sponsored health insurance for students 3.1.3 Federal employees health benefit plan (FEHBP) 3.1.4 "Portability" of group coverage 3.2 Association group health insurance 3.3 Individually purchased 3.4 Types of medical insurance 3.4.1 Traditional indemnity or fee-for-service 3.4.2 Blue Cross & Blue Shield plans 3.4.3 Health Maintenance Organizations 3.4.4 Managed care 3.4.4.1 Network-based managed care 3.4.4.2 Other managed care techniques 3.4.5 Blurring lines 3.4.6 New types of medical plans 3.5 Health insurance market concentration 4 Other types of health insurance (non-medical) 4.1 Disability income insurance 4.2 Long-term care insurance 5 Supplemental coverage 5.1 Medicare Supplement Coverage (Medigap) 5.2 Hospital indemnity insurance 5.2.1 Scheduled health insurance plans 5.3 Dental insurance 5.4 Vision care insurance 5.5 Specified disease 5.6 Accidental Death and Dismemberment (AD&D) insurance 6 Status of the uninsured 7 Criticism of Health Insurance in the United States 8 See also 9 References 10 External links

[edit] History

Accident insurance was first offered in the United States by the Franklin Health Assurance Company of Massachusetts. This firm, founded in 1850, offered insurance against injuries arising from railroad and steamboat accidents. Sixty organizations were offering accident insurance in the US by 1866, but the industry consolidated rapidly soon thereafter. While there were earlier experiments, the origins of sickness coverage in the US effectively date from 1890. The first employer-sponsored group disability policy was issued in 1911, but this plan's primary purpose was replacing wages lost due to an inability to work, not medical expenses.^[5]

Before the development of medical expense insurance, patients were expected to pay all other health care costs out of their own pockets, under what is known as the fee-for-service business model. During the middle to late 20th century, traditional disability insurance evolved into modern health insurance programs. Today, most comprehensive private health insurance programs cover the cost of routine, preventive, and emergency health care procedures, and also most prescription drugs, but this was not always the case.

Hospital and medical expense policies were introduced during the first half of the 20th century. During the 1920s, individual hospitals began offering services to individuals on a pre-paid basis, eventually leading to the development of Blue Cross organizations in the 1930s.^[5] The first employer-sponsored hospitalization plan was created by teachers in Dallas, Texas in 1929.^[6] Because the plan only covered members' expenses at a single hospital, it is also the forerunner of today's health maintenance organizations (HMOs).^[6][7][8]

Employer-sponsored health insurance plans dramatically expanded as a result of wage controls during World War II.^[6] The labor market was tight because of the increased demand for goods and decreased supply of workers during the war. Federally imposed wage and price controls prohibited manufacturers and other employers raising wages high enough to attract sufficient workers. When the War Labor Board declared that fringe benefits, such as sick leave and health insurance, did not count as wages for the purpose of wage controls, employers responded with significantly increased benefits.^[6]

Employer-sponsored health insurance was considered taxable income until 1954.^[6]

In 1965, President Lyndon B. Johnson signs the Medicare and Medicaid legislation into effect. Since their inception, the greatest challenge to the programs has been “spiraling healthcare costs, stemming largely from innovations in medical technology and pharmaceuticals." ^[9] Now, as baby boomers advance toward senior citizenry, concerns about the financial sustainability of the programs frame any discussion about Medicare and Medicaid.

The debate for a public health care system in the United States has gone on for about 70 years. President Harry S. Truman was the first United States president to propose a system of public health insurance in his November 19, 1945 address. This fund would be open to all Americans, but it would remain optional. Participants would pay monthly fees into the plan, which would cover the cost of any and all medical expenses that arose in a time of need. The government would pay for the cost of services rendered by any doctor who chose to join the program. In addition, the insurance plan would give a cash balance to the policy holder to replace wages lost due to illness or injury. This program was denounced as a socialist approach to medicine by the American Medical Association (AMA) and did not pass.

[edit] Public health care coverage

Public programs provide the primary source of coverage for most seniors and for low-income children and families who meet certain eligibility requirements. The primary public programs are Medicare, a federal social insurance program for seniors (generally persons aged 65 and over) and certain disabled individuals; Medicaid, funded jointly by the federal government and states but administered at the state level, which covers certain very low income children and their families; and SCHIP, also a federal-state partnership that serves certain children and families who do not qualify for Medicaid but who cannot afford private coverage. Other public programs include military health benefits provided through TRICARE and the Veterans Health Administration and benefits provided through the Indian Health Service. Some states have additional programs for low-income individuals.^[10]

Health care costs have risen more rapidly than the general economic growth and continue to do so, with the consequence that Medicare and Medicaid constitute an increasing economic burden in federal spending. ^[11]

[edit] Medicare

In the United States, Medicare is a federal social insurance program that provides health insurance to elderly workers and their dependents, individuals who become totally and permanently disabled, and end stage renal disease (ESRD) patients. Some health care economists (Uwe Reinhardt of Princeton and Stuart Butler among others) assert that the third-party payment feature of this program has had the unintended consequence of distorting the price of medical procedures. As a result, the Health Care Financing Administration has set up a list of procedures and corresponding prices under the Resource-Based Relative Value Scale. Recent research has found that the health trends of previously uninsured adults, especially those with chronic health problems, improves once they enter the Medicare program.^[12]

[edit] Medicare Advantage

Medicare Advantage plans expand the health care options for Medicare beneficiaries. The option for Medicare Advantage plans is a result of the Balanced Budget Act of 1997, with the intent to better control the rapid growth in Medicare spending, as well as to provide Medicare beneficiaries more choices.

[edit] Medicare Part D (Prescription Drugs)

Medicare Part D provides a private insurance option to allow Medicare beneficiaries to purchase subsidized coverage for the costs of prescription drugs. It was enacted as part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) and went into effect on January 1, 2006.^[13]

[edit] Medicaid

Medicaid was instituted for the very poor in 1965. Despite its establishment, the percentage of US residents who lack any form of health insurance has increased since 1994.^[14] It has been reported that the number of physicians accepting Medicaid has decreased in recent years due to lower reimbursement rates.^[15] Medicaid is a social welfare or social protection program rather than a social insurance program.

[edit] State Children's Health Insurance Program (SCHIP)

The State Children’s Health Insurance Program (SCHIP) is a joint state/federal program to provide health insurance to children in families who earn too much money to qualify for Medicaid, yet cannot afford to buy private insurance. The statutory authority for SCHIP is under title XXI of the Social Security Act. SCHIP programs are run by the individual states according to requirements set by the federal Centers for Medicare and Medicaid Services, and may be structured as independent programs separate from Medicaid (separate child health programs), as expansions of their Medicaid programs (SCHIP Medicaid expansion programs), or combine these approaches (SCHIP combination programs). States receive enhanced federal funds for their SCHIP programs at a rate above the regular Medicaid match.

[edit] Military health benefits

Health benefits are provided to active duty service members, retired service members and their dependents by the Department of Defense Military Health System (MHS). The MHS consists of a direct care network of Military Treatment Facilities and a purchased care network known as TRICARE. Additionally, veterans may also be eligible for benefits through the Veterans Health Administration.

[edit] Indian health service

The Indian Health Service (IHS) provides medical assistance to eligible American Indians at IHS facilities, and helps pay the cost of some services provided by non-IHS health care providers.^[10]

[edit] State risk pools

In 1976, some states began providing guaranteed-issuance risk pools, which enable individuals who are medically uninsurable through private health insurance to purchase a state-sponsored health insurance plan, usually at higher cost. Minnesota was the first to offer such a plan; 34 states^[which?] now offer them. Plans vary greatly from state to state, both in their costs and benefits to consumers and in their methods of funding and operations. They serve a very small portion of the uninsurable market—about 182,000 people in the U.S. as of 2004,^[16] and about 200,000 in 2008.^[17]

These risk pools allow people with pre-existing conditions such as cancer, diabetes, heart disease or other chronic illnesses to be able to switch jobs or seek self-employment without fear of being without health care benefits.^[18] However, the plans are expensive, with premiums that can be double the average policy, and the pools currently cover only 1 in 25 of the so-called "uninsurable" population.^[19] Additionally, even plans which are not expensive can leave those enrolled with little real health insurance beyond "catastrophic" insurance; for example, one insurance plan through Minnesota's high-risk pool, while costing only $215 per quarter, includes a $10,000 deductible with no preventative or other health care covered unless and until the enrollee has spent $10,000 of their own money during the year on health care.^[20] Very sick people can accumulate large medical bills during mandatory waiting periods before their medical expenses are covered, and there are often lifetime expenditure caps (maximums), after which the risk pool no longer pays for any medical expenses.^[21]

Efforts to pass a national pool have been unsuccessful, but some federal tax money has been awarded to states to innovate and improve their plans. With the Patient Protection and Affordable Care Act, effective by 2014, it will be easier for people with pre-existing conditions to afford regular insurances, since all insurers will be fully prohibited from discriminating against or charging higher rates for any individuals based on pre-existing medical conditions.^[22][23]

[edit] Private health care coverage

Private health insurance may be purchased on a group basis (e.g., by a firm 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, some 60% of Americans are covered through an employer, while about 9% purchase health insurance directly.^[2]

The US has a joint federal/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.^[24][25] State mandates generally do not apply to the health plans offered by large employers, due to the preemption clause of the Employee Retirement Income Security Act.

[edit] Employer-sponsored

Employer-sponsored health insurance is paid for by businesses on behalf of their employees as part of an employee benefit package. Most private (non-government) health coverage in the US is employment-based. Nearly all large employers in America offer group health insurance to their employees.^[26] The typical large-employer PPO plan is typically more generous than either Medicare or the Federal Employees Health Benefits Program Standard Option.^[27]

The employer typically makes a substantial contribution towards the cost of coverage.^[28] Typically, employers pay about 85% of the insurance premium for their employees, and about 75% of the premium for their employees' dependents. The employee pays the remaining fraction of the premium, usually with pre-tax/tax-exempt earnings. These percentages have been stable since 1999.^[29] Health benefits provided by employers are also tax-favored: Employee contributions can be made on a pre-tax basis if the employer offers the benefits through a section 125 cafeteria plan.

Although workers are effectively paid less than they would be, because of the cost of insurance premiums to the employer, employer-sponsored health insurance offers several benefits to workers, including economies of scale, a reduction in adverse selection pressures on the insurance pool (premiums are lower when all employees participate rather than just the sickest), and reduced income taxes.^[6] The disadvantages include disruptions related to changing jobs, the unfair regressive tax effect (high-income workers benefit far more from the tax exemption for premiums than low-income workers), and possibly increased spending on healthcare.^[6]

Costs for employer-paid health insurance are rising rapidly: since 2001, premiums for family coverage have increased 78%, while wages have risen 19% and inflation has risen 17%, according to a 2007 study by the Kaiser Family Foundation.^[30] Employer costs have risen noticeably per hour worked, and vary significantly. In particular, average employer costs for health benefits vary by firm size and occupation. The cost per hour of health benefits is generally higher for workers in higher-wage occupations, but represent a smaller percentage of payroll.^[31] The percentage of total compensation devoted to health benefits has been rising since the 1960s.^[32] Average premiums, including both the employer and employee portions, were $4,704 for single coverage and $12,680 for family coverage in 2008.^[29][33]

However, in a 2007 analysis, the Employee Benefit Research Institute concluded that the availability of employment-based health benefits for active workers in the US is stable. The "take-up rate," or percentage of eligible workers participating in employer-sponsored plans, has fallen somewhat, but not sharply. EBRI interviewed employers for the study, and found that others might follow if a major employer discontinued health benefits. Effective by January 1, 2014, the Patient Protection and Affordable Care Act will impose a $2000 per employee tax penalty on employers with over 50 employees who do not offer health insurance to their full-time workers. (In 2008, over 95% of employers with at least 50 employees offered health insurance.^[34])^[35]On the other hand, public policy changes could also result in a reduction in employer support for employment-based health benefits.^[36]

Although much more likely to offer retiree health benefits than small firms, the percentage of large firms offering these benefits fell from 66% in 1988 to 34% in 2002.^[26]

[edit] Small employer group coverage

According to a 2007 study, about 59% of employers at small firms (3-199 workers) in the US provide employee health insurance. The percentage of small firms offering coverage has been dropping steadily since 1999. The study notes that cost remains the main reason cited by small firms who do not offer health benefits.^[37] Small firms that are new are less likely to offer coverage than ones that have been in existence for a number of years. For example, using 2005 data for firms with fewer than 10 employees, 43% of those that had been in existence at least 20 years offered coverage, but only 24% of those that had been in existence less than 5 years did. The volatility of offer rates from year to year also appears to be higher for newer small businesses.^[38]

The types of coverage available to small employers are similar to those offered by large firms, but small businesses do not have the same options for financing their benefit plans. In particular, self-funded health care (whereby an employer provides health or disability benefits to employees with its own funds rather than contracting an insurance company^[39]) is not a practical option for most small employers.^[40] A RAND Corporation study published in April 2008 found that the cost of health care coverage places a greater burden on small firms, as a percentage of payroll, than on larger firms.^[41] A study published by the American Enterprise Institute in August 2008 examined the effect of state benefit mandates on self-employed individuals, and found that "the larger the number of mandates in a state, the lower the probability that a self-employed person will be a significant employment generator."^[42] Beneficiary cost sharing is, on average, higher among small firms than large firms.^[43]

When small group plans are medically underwritten, employees are asked to provide health information about themselves and their covered family members when they apply for coverage. When determining rates, insurance companies use the medical information on these applications. Sometimes they will request additional information from an applicant's physician or ask the applicants for clarification. [2]

States regulate small group premium rates, typically by placing limits on the premium variation allowable between groups (rate bands). Insurers price to recover their costs over their entire book of small group business while abiding by state rating rules.^[44] Over time, the effect of initial underwriting "wears off" as the cost of a group regresses towards the mean. Recent claim experience - whether better or worse than average - is a strong predictor of future costs in the near term. But the average health status of a particular small employer group tends to regress over time towards that of an average group.^[45] The process used to price small group coverage changes when a state enacts small group reform laws.^[46]

Insurance brokers play a significant role in helping small employers find health insurance, particularly in more competitive markets. Average small group commissions range from 2 percent to 8 percent of premiums. Brokers provide services beyond insurance sales, such as assisting with employee enrollment and helping to resolve benefits issues.^[47]

[edit] College-sponsored health insurance for students

Many colleges, universities, graduate schools, professional schools and trade schools offer a school-sponsored health insurance plan. Many schools require that you enroll in the school-sponsored plan unless you are able to show that you have comparable coverage from another source.

Effective group health plan years beginning after September 23, 2010, if an employer-sponsored health plan allows employees' children to enroll in coverage, then the health plan must allow employees' adult children to enroll as well as long as the adult child is not yet age 26. Some group health insurance plans may also require that the adult child not be eligible for other group health insurance coverage, but only before 2014.^[48]

This extension of coverage will help cover one in three young adults, according to White House documents.

[edit] Federal employees health benefit plan (FEHBP)

In addition to such public plans as Medicare and Medicaid, the federal government also sponsors a health benefit plan for federal employees—the Federal Employees Health Benefits Program (FEHBP). FEHBP provides health benefits to full-time civilian employees. Active-duty service members, retired service members and their dependents are covered through the Department of Defense Military Health System (MHS). FEHBP is managed by the federal Office of Personnel Management.

[edit] "Portability" of group coverage

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) enables certain individuals with employer-sponsored coverage to extend their coverage if certain "qualifying events" would otherwise 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 firms with 20 or more employees, although some states also have "mini-COBRA" laws that apply to small employers.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides for forms of both "group-to-group" and "group-to-individual" portability. When an individual moves from one employer's benefit plan to another's, the new plan must count coverage under the old plan against any waiting period for pre-existing conditions, as long as there is not a break in coverage of more than 63 days between the two plans. When certain qualified individuals lose group coverage altogether, they must be guaranteed access to some form of individual coverage. To qualify, they must have at least 18 months of prior continuous coverage. The details of access and the price of coverage are determined on a state-by-state basis.

[edit] Association group health insurance

Regular health insurance is sometimes available to members of associations. Associations such as the American Bar Association and IEEE offer health insurance to their members, using an established insurance company to write the policies for a group plan. ^[49]

[edit] Individually purchased

According to the US Census Bureau, about 9% of Americans are covered under health insurance purchased directly.^[2] The range of products available is similar to those provided through employers. However, average out-of-pocket spending is higher in the individual market, with higher deductibles, co-payments and other cost-sharing provisions.^[43][50] Major medical is the most commonly purchased form of individual health insurance.^[51]

In the individual market, the consumer pays the entire premium without benefit of an employer contribution.^[50][52] While self-employed individuals receive a tax deduction for their health insurance and can buy health insurance with additional tax benefits, most consumers in the individual market do not receive any tax benefit.^[53]

Premiums vary significantly by age.^[50][54][55] In states that allow individual medical plan underwriting, premiums also vary by health status.^[50] However, with the Patient Protection and Affordable Care Act, effective by 2014, all insurers will be fully prohibited from discriminating against or charging higher rates for any individuals based on pre-existing medical conditions.^[22][23]

In August 2008, the Hartford Courant reported that competition was increasing in the individual health insurance market, with more insurers entering the market, an increased variety of products, and a broader spread of prices.^[56]

Individual health insurance is primarily regulated at the state level, consistent with the McCarran-Ferguson Act. Model acts and regulations promulgated by the National Association of Insurance Commissioners (NAIC) provide some degree of uniformity state to state. These models do not have the force of law and have no effect unless they are adopted by a state. They are, however, used as guides by most states, and some states adopt them with little or no change.

[edit] Types of medical insurance

[edit] Traditional indemnity or fee-for-service

Early hospital and medical plans offered by insurance companies paid either a fixed amount for specific diseases or medical procedures (schedule benefits) or a percentage of the provider's fee. The relationship between the patient and the medical provider was not changed. 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 provisions of the insurance contract ("reimbursement benefits"). Health insurance plans that are not based on a network of contracted providers, or that base payments on a percentage of provider charges, are still described as indemnity or fee-for-service plans.^[5]

[edit] Blue Cross & Blue Shield plans

The Blue Cross and Blue Shield Association (BCBSA) is a federation of 39 separate health insurance organizations and companies in the United States. Combined, they directly or indirectly provide health insurance to over 100 million Americans.^[57] BCBSA insurance companies are franchisees, independent of the association (and traditionally each other), offering insurance plans within defined regions under one or both of the association's brands. Blue Cross Blue Shield insurers offer some form of health insurance coverage in every U.S. state. They also act as administrators of Medicare in many states or regions of the U.S., and provide coverage to state government employees as well as to the federal government employees under a nationwide option of the Federal Employees Health Benefit Plan.^[58]

[edit] Health Maintenance Organizations

A health maintenance organization (HMO) is a type of managed care organization (MCO) that provides a form of health care coverage that is fulfilled through hospitals, doctors, and other providers with which the HMO has a contract. The Health Maintenance Organization Act of 1973 required employers with 25 or more employees to offer federally certified HMO options.^[59] Unlike traditional indemnity insurance, an HMO covers only care rendered by those doctors and other professionals who have agreed to treat patients in accordance with the HMO's guidelines and restrictions in exchange for a steady stream of customers. Benefits are provided through a network of providers. Providers may be employees of the HMO ("staff model"), employees of a provider group that has contracted with the HMO ("group model"), or members of an independent practice association ("IPA model"). HMOs may also use a combination of these approaches ("network model").^[5][60]

[edit] Managed care

The term managed care is used to describe a variety of techniques intended to reduce the cost of health benefits and improve the quality of care. It is also used to describe organizations that use these techniques ("managed care organization").^[61] Many of these techniques were pioneered by HMOs, but they are now used in a wide variety of private health insurance programs. Through the 1990s, managed care grew from about 25% US employees with employer-sponsored coverage to the vast majority.^[62]

Rise of managed care in the US

Year	Conventional plans	HMOs	PPOs	POS plans	HDHP/SOs
1998	14%	27%	35%	24%	~
1999	10%	28%	39%	24%	~
2000	8%	29%	42%	21%	~
2001	7%	24%	46%	23%	~
2002	4%	27%	52%	18%	~
2003	5%	24%	54%	17%	~
2004	5%	25%	55%	15%	~
2005	3%	21%	61%	15%	~
2006	3%	20%	60%	13%	4%
2007	3%	21%	57%	15%	5%
2008	2%	20%	58%	12%	8%

[edit] Network-based managed care

Many managed care programs are based on a panel or network of contracted health care providers. Such programs typically include:

• A set of selected providers that furnish a comprehensive array of health care services to enrollees;
• Explicit standards for selecting providers;
• Formal utilization review and quality improvement programs;
• An emphasis on preventive care; and
• Financial incentives to encourage enrollees to use care efficiently.

Provider networks can be used to reduce costs by negotiating favorable fees from providers, selecting cost effective providers, and creating financial incentives for providers to practice more efficiently.^[8] A survey issued in 2009 by America's Health Insurance Plans found that patients going to out-of-network providers are sometimes charged extremely high fees.^[63][64]

Network-based plans may be either closed or open. With a closed network, enrollees' expenses are generally only covered when they go to network providers. Only limited services are covered outside the network—typically only emergency and out-of-area care. Most traditional HMOs were closed network plans. Open network plans provide some coverage when an enrollee uses non-network provider, generally at a lower benefit level to encourage the use of network providers. Most preferred provider organization plans are open-network (those that are not are often described as exclusive provider organizations, or EPOs), as are point of service (POS) plans.

The terms "open panel" and "closed panel" are sometimes used to describe which health care providers in a community have the opportunity to participate in a plan. In a "closed panel" HMO, the network providers are either HMO employees (staff model) or members of large group practices with which the HMO has a contract. In an "open panel" plan the HMO or PPO contracts with independent practitioners, opening participation in the network to any provider in the community that meets the plan's credential requirements and is willing to accept the terms of the plan's contract.

[edit] Other managed care techniques

Other managed care techniques include such elements as disease management, case management, wellness incentives, patient education, utilization management and utilization review. These techniques can be applied to both network-based benefit programs and benefit programs that are not based on a provider network. The use of managed care techniques without a provider network is sometimes described as "managed indemnity."

[edit] Blurring lines

Over time, the operations of many Blue Cross and Blue Shield operations have become more similar to those of commercial health insurance companies.^[65] However, some Blue Cross and Blue Shield plans continue to serve as insurers of last resort.^[66] Similarly, the benefits offered by Blues plans, commercial insurers, and HMOs are converging in many respects due to market pressures. One example is the convergence of preferred provider organization (PPO) plans offered by Blues and commercial insurers and the point of service plans offered by HMOs. Historically, commercial insurers, Blue Cross and Blue Shield plans, and HMOs might be subject to different regulatory oversight in a state (e.g., the Department of Insurance for insurance companies, versus the Department of Health for HMOs). Today, it is common for commercial insurance companies to have HMOs as subsidiaries, and for HMOs to have insurers as subsidiaries (the state license for an HMO is typically different from that for an insurance company).^[5][60][67] At one time the distinctions between traditional indemnity insurance, HMOs and PPOs were very clear; today, it can be difficult to distinguish between the products offered by the various types of organization operating in the market.^[68]

The blurring of distinctions between the different types of health care coverage can be seen in the history of the industry's trade associations. The two primary HMO trade associations were the Group Health Association of America and the American Managed Care and Review Association. After merging, they were known as American Association of Health Plans (AAHP). The primary trade association for commercial health insurers was the Health Insurance Association of America (HIAA). These two have now merged, and are known as America’s Health Insurance Plans (AHIP).

[edit] New types of medical plans

One approach to addressing increasing premiums, dubbed "consumer driven health care," received a boost in 2003, when President George W. Bush signed into law the Medicare Prescription Drug, Improvement, and Modernization Act. The law created tax-deductible Health Savings Accounts (HSAs). An HSA is an untaxed private bank account; withdrawals are only penalized if the money is spent on non-medical items or services. Consumers wishing to deposit pre-tax funds in an HSA must be enrolled in a high-deductible insurance plan with a number of restrictions on benefit design; in 2007, qualifying plans must have a minimum deductible of US$1,050. HSAs enable healthier individuals to pay less for insurance and bank money for their own future health care expenses.^[69]

HSAs are one form of tax-preferenced health care spending account. Others include Archer Medical Savings Accounts (MSAs), which have been superseded by the new HSAs (although existing MSAs are grandfathered), Flexible Spending Arrangements (FSAs) and Health Reimbursement Accounts (HRAs). HSAs, FSAs and HRAs are most commonly used as part of an employee health benefit package.^[70] While there are currently no government-imposed limits to FSAs, legislation currently being reconciled between the House of Representatives and Senate would impose a cap of $2,500. While both the House and Senate bills would adjust the cap to inflation, approximately 7 million Americans who use their FSAs to cover out-of-pocket health care expenses greater than $2,500 would be forced to pay higher taxes and health care costs.

In July 2009, Save Flexible Spending Plans, a national grassroots advocacy organization, was formed to protect against the restricted use of FSAs in health care reform efforts, Save Flexible Spending Accounts is sponsored by the Employers Council on Flexible Compensation (ECFC), a non-profit organization “dedicated to the maintenance and expansion of the private employee benefits on a tax-advantaged basis”^[71]. ECFC members include companies such as WageWorks Inc., a benefits provider based in San Mateo, California.

Most FSA participants are middle income Americans, earning approximately $55,000 annually^[72]. Individuals and families with chronic illnesses typically receive the most benefit from FSAs; even when insured, they incur annual out-of-pocket expenses averaging $4,398 ^[73]. Approximately 44 percent of Americans have one or more chronic conditions ^[74].

Limited Medical Benefit Plans pay for routine care and do not pay for catastrophic care. As such, they do not provide equivalent financial security to a major medical plan. Annual benefit limits can be as low as $2,000. Lifetime maximums can be very low as well.

One option that is becoming more popular is the discount medical card. These cards are not insurance policies, but provide access to discounts from participating health care providers. While some offer a degree of value, there are serious potential drawbacks for the consumer.^[75]

[edit] Health insurance market concentration

The US health insurance market is highly concentrated, as leading insurers have carried out over 400 mergers from the mid-1990s to the mid-2000s. In 2000, the two largest health insurers (Aetna and UnitedHealth Group) had total membership of 32 million. By 2006 the top two insurers, WellPoint and UnitedHealth, had total membership of 67 million. The two companies together had more than 36% of the national market for commercial health insurance. The AMA has said that it "has long been concerned about the impact of consolidated markets on patient care." A 2007 AMA study found that in 299 of the 313 markets surveyed, one health plan accounted for at least 30% of the combined health maintenance organization (HMO)/preferred provider organization (PPO) market. The US Department of Justice has recognised this percentage of market control as conferring substantial monopsony power in the relations between insurer and physicians.^[76]

[edit] Other types of health insurance (non-medical)

While the term "health insurance" is most commonly used by the public to describe coverage for medical expenses, the insurance industry uses the term more broadly to include other related forms of coverage, such as disability income and long-term care insurance.

[edit] Disability income insurance

Disability income (DI) insurance pays benefits to individuals who lose their ability to work due to injury or illness. DI insurance replaces income lost while the policyholder is unable to work during a period of disability (in contrast to medical expense insurance, which pays for the cost of medical care).^[77] For most working age adults, the risk of disability is greater than the risk of premature death, and the resulting reduction in lifetime earnings can be significant. Private disability insurance is sold on both a group and an individual basis. Policies may be designed to cover long-term disabilities (LTD coverage) or short-term disabilities (STD coverage).^[78] Business owners can also purchase disability overhead insurance to cover the overhead expenses of their business while they are unable to work.^[79]

A basic level of disability income protection is provided through the Social Security Disability Insurance (SSDI) program for qualified workers who are totally and permanently disabled (the worker is incapable of engaging in any "substantial gainful work" and the disability is expected to last at least 12 months or result in death).

[edit] Long-term care insurance

Long-term care (LTC) insurance reimburses the policyholder for the cost of long-term or custodial care services designed to minimize or compensate for the loss of functioning due to age, disability or chronic illness.^[80] LTC has many surface similarities to long-term disability insurance. There are at least two fundamental differences, however. LTC policies cover the cost of certain types of chronic care, while long-term-disability policies replace income lost while the policyholder is unable to work. For LTC, the event triggering benefits is the need for chronic care, while the triggering event for disability insurance is the inability to work.^[77]

Private LTC insurance is growing in popularity in the US. Premiums have remained relatively stable in recent years. However, the coverage is quite expensive, especially when consumers wait until retirement age to purchase it. The average age of new purchasers was 61 in 2005, and has been dropping.^[81]

[edit] Supplemental coverage

Private insurers offer a variety of supplemental coverages in both the group and individual markets. These are not designed to provide the primary source of medical or disability protection for an individual, but can assist with unexpected expenses and provide additional peace of mind for insureds. Supplemental coverages include Medicare supplement insurance, hospital indemnity insurance, dental insurance, vision insurance, accidental death and dismemberment insurance and specified disease insurance.^[5]

Supplemental coverages are intended to:

• Supplement a primary medical expense plan by paying for expenses that are excluded or subject to the primary plan's cost-sharing requirements (e.g., co-payments, deductibles, etc.);
• Cover related expenses such as dental or vision care;
• Assist with additional expenses that may be associated with a serious illness or injury.^[5]

[edit] Medicare Supplement Coverage (Medigap)

Medicare Supplement policies are designed to cover expenses not covered (or only partially covered) by the "original Medicare" (Parts A & B) fee-for-service benefits. They are only available to individuals enrolled in Medicare Parts A & B. Medigap plans may be purchased on a guaranteed issue basis (no health questions asked) during a six-month open enrollment period when an individual first becomes eligible for Medicare. The benefits offered by Medigap plans are standardized.

[edit] Hospital indemnity insurance

Hospital indemnity insurance provides a fixed daily, weekly or monthly benefit while the insured is confined in a hospital. The payment is not dependent on actual hospital charges, and is most commonly expressed as a flat dollar amount. Hospital indemnity benefits are paid in addition to any other benefits that may be available, and are typically used to pay out-of-pocket and non-covered expenses associated with the primary medical plan, and to help with additional expenses (e.g., child care) incurred while in the hospital.^[5][60]

[edit] Scheduled health insurance plans

Scheduled health insurance plans are an expanded form of Hospital Indemnity plans. In recent years, these plans have taken the name mini-med plans or association plans. These plans may provide benefits for hospitalization, surgical, and physician services however, they are not meant to replace a traditional comprehensive health insurance plan. Scheduled health insurance plans are more of a basic policy providing access to day-to-day health care such as going to the doctor or getting a prescription drug; but these benefits will be limited and are not meant to be effective for catastrophic events. Payments are based upon the plan's "schedule of benefits" and are usually paid directly to the service provider. These plans cost much less than comprehensive health insurance. Annual benefit maximums for a typical scheduled health insurance plan may range from $1,000 to $25,000.^[82]

[edit] Dental insurance

Dental insurance helps pay for the cost of necessary dental care. Few medical expense plans include coverage for dental expenses. About 97% of dental benefits in the United States is provided through separate policies from carriers--both stand-alone and medical affiliates--that specialize in this coverage. Discount dental programs are also available. These do not constitute insurance, but provide participants with access to discounted fees for dental work.

[edit] Vision care insurance

Vision care insurance provides coverage for routine eye care and is typically written to complement other medical benefits. Vision benefits are designed to encourage routine eye examinations and ensure that appropriate treatment is provided.^[5]

[edit] Specified disease

Specified disease provides benefits for one or more specifically identified conditions. Benefits can be used to fill gaps in a primary medical plan, such as co-payments and deductibles, or to assist with additional expenses such as transportation and child care costs.^[5]

[edit] Accidental Death and Dismemberment (AD&D) insurance

AD&D insurance is offered by group insurers and provides benefits in the event of accidental death. It also provides benefits for certain specified types of bodily injuries (e.g., loss of a limb or loss of sight) when they are the direct result of an accident.^[5]

[edit] Status of the uninsured

In 2007, more than 45 million people in the US (15.3% of the population) were without health insurance for at least part of the year. The percentage of the non-elderly population who are uninsured has been generally increasing since the year 2000.^[4] Among the uninsured population, some 37 million were employment-age adults (ages 18 to 64), and more than 27 million worked at least part time. About 38% of the uninsured live in households with incomes over $50,000.^[2] According to the Census Bureau, nearly 36 million of the uninsured are legal US citizens. Another 9.7 million are non-citizens, but the Census Bureau does not distinguish in its estimate between legal non-citizens and illegal immigrants.^[2] It has been estimated that nearly one fifth of the uninsured population is able to afford insurance, almost one quarter is eligible for public coverage, and the remaining 56% need financial assistance (8.9% of all Americans).^[83] An estimated 5 million of those without health insurance are considered "uninsurable" because of pre-existing conditions.^[19]

The costs of treating the uninsured must often be absorbed by providers as charity care, passed on to the insured via cost-shifting and higher health insurance premiums, or paid by taxpayers through higher taxes.^[84]

A report published by the Kaiser Family Foundation in April 2008 found that economic downturns place a significant strain on state Medicaid and SCHIP programs. The authors estimated that a 1% increase in the unemployment rate would increase Medicaid and SCHIP enrollment by 1 million, and increase the number uninsured by 1.1 million. State spending on Medicaid and SCHIP would increase by $1.4 billion (total spending on these programs would increase by $3.4 billion). This increased spending would occur at the same time state government revenues were declining. During the last downturn, the Jobs and Growth Tax Relief Reconciliation Act of 2003 (JGTRRA) included federal assistance to states, which helped states avoid tightening their Medicaid and SCHIP eligibility rules. The authors conclude that Congress should consider similar relief for the current economic downturn.^[85]

[edit] Criticism of Health Insurance in the United States

The United States' system of using health insurance as a means of financing health care costs has been criticized. The following are examples of such criticisms

• While "[p]rivate plans are attractive because of their ability to be responsive to consumer demands for choice and their innovations resulting from both the profit motive and desire to attract a larger enrollment base," they also have disadvantages. Industry consolidation "has not led to strong insurers who are willing or able to negotiate effectively with dominant hospital systems," and "[i]nsurance markets have become dominated by a small number of large insurers" with "shadow pricing" by smaller insurers.^[86]

• Insurance companies have high administrative costs.^[87] Private health insurers are a significant portion of the U.S. economy directly employing (in 2004) almost 470,000 people at an average salary of $61,409.^[88]

• Health insurance companies are not actually providing traditional insurance, which involves the pooling of risk, because the vast majority of purchasers actually do face the harms that they are "insuring" against. Instead, as Edward Beiser and Jacob Appel have separately argued, health insurers are better thought of as low-risk money managers who pocket the interest on what are really long-term healthcare savings accounts.^[89][90]

• According to a study by a pro-health reform group published February 11, the nation's largest five health insurance companies posted a 56 percent gain in 2009 profits over 2008. The insurers (Wellpoint, UnitedHealth, Cigna, Aetna and Humana) cover the majority of Americans with health insurance.^[91]

[edit] See also

America’s Health Insurance Plans COBRA Economic capital Health care reform in the United States Healthcare reform Health economics Health insurance costs in the United States Health Insurance Portability and Accountability Act Health maintenance organization Injury cover List of healthcare reform advocacy groups in the United States National health insurance Physicians for a National Health Program

Public health Publicly-funded health care Medicare Rights Center RAND Health Insurance Experiment Self-funded health care Sicko Single-payer health care Social security Social welfare Uninsured in the United States United States National Health Care Act Universal health care

[edit] References

[edit] External links

This article's use of external links may not follow Wikipedia's policies or guidelines. Please improve this article by removing excessive and inappropriate external links or by converting links into footnote references. (March 2010)

• Employee Benefit Research Institute (EBRI)
• National Association of State Comprehensive Health Insurance Plans (NASCHIP)
• A Guide To Online Health Insurance Quotes
• National Association of Health Underwriters (NAHU)
• Kaiser Family Foundation
• Center for Studying Health System Change
• AHIP Center for Policy and Research
• U.S. Census Bureau - Health Insurance Statistics
• National Health Expenditure Data
• National Center for Health Statistics
• National Association of Insurance Commissioners
• Health Claim Appeals - A Guide to Resolving Health Insurance Disputes
• Centers for Medicare and Medicaid Services
• History of Health Insurance in the United States
• healthcare4every1 Campaign
• "Healthcare 2015 and U.S. health plans: How U.S. health plans can succeed in the changing healthcare environment," from the IBM Institute for Business Value
• Small Businesses for Health Care Reform
• Glossary of managed care terms
• Georgetown University Consumer Guides to Health Insurance
• Universal Health Care Foundation of Connecticut
• Paying More, Getting Less from Dollars & Sense
• Government Health Insurance Programs Nationwide
• Family medical insurance
• Medicare Interactive — Online Medicare reference guide created by the
• Gallup Poll: Health Insurance Coverage Varies Widely By Age, Income
• Blue cross CA:Dealing with a broker agent

Medicare Rights Center.

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