Health Care Insurance
In the United States, health care insurance is one of the most significant factors in facilitating access to health care services. Recently, the number of people covered by insurance as well as the breadth and depth of health insurance coverage has decreased. According to data from the Kaiser Family Foundation‐Health Research and Educational Trust Annual Employer Survey (2018), the average yearly costs for employer‐sponsored health insurance in 2018 are $6,896 for single coverage and $19,616 for family coverage. The average single premium increased by 3% and the average family premium increased by 5% in the last year. Workers' wages increased by 2.6% and inflation increased by 2.5% over the past year. The average insurance premium for family coverage has increased by 20% since 2013 and by 55% since 2008.
In the past, American health insurance companies have routinely rejected applicants with a preexisting condition. The insurance companies often denied claims. If a customer was hit by a truck and faced big medical bills, the insurance company dug through the records looking for grounds to cancel the policy, often while the victim was still in the hospital (Reid, 2009). Foreign health insurance companies, in contrast, must accept all applicants, and they can't cancel insurance as long as premiums are paid. Everyone is mandated to buy insurance to give the plans an adequate pool of rate payers. The key difference is that foreign health insurance plans exist only to pay people's medical bills, not to make a profit. The United States is the only developed country that lets insurance companies profit from basic health coverage. In many ways, foreign health care models are not really foreign to America, because our health care system uses elements of all of them. In Britain, the government provides health care, funding it through general taxes, and patients get no bills. In Germany, premiums are split between workers and employers, and private insurance plans pay private doctors and hospitals. In Canada; everyone pays premiums for an insurance plan run by the government, and the public plan pays private doctors and hospitals according to a set fee schedule. In the world's poor nation, sick people pay out of pocket for medical care; those who can't pay, stay sick or die. Seven hundred thousand Americans are forced into bankruptcy each year because of medical bills. In France, the number of medical bankruptcies is zero; Britain, zero; Japan, zero; and Germany, zero (Reid, 2009).
Real World Interview
I was admitted to the hospital in December for what was later diagnosed as angina. After being stabilized in the emergency room, I was admitted to the cardiac care unit. A series of tests were ordered by my cardiologist to determine enzyme levels in my blood. This would show if I had suffered a heart attack. Blood was drawn every 8 hr for 24 hr. The news was good—no heart attack—until I received the bill. My insurance company said the enzyme tests for angina were frivolous and not necessary, and they would not pay. I had my cardiologist write a letter of explanation, saying the tests he ordered were routine for determining a diagnosis. After this second appeal, the insurance company rejected my payment claim again. After several more appeals, my insurance company ultimately paid the laboratory bill for these tests but would not pay the pathologist for his interpretation of the blood tests. It has now been six months since I received my initial bill, and the hospital and pathologist's office have turned my case over to a collection agency. They did not take into consideration the fact that I was appealing the bill. They wanted me to pay upfront and then appeal. That was not going to happen.
Kathleen A. Milch
Patient
Whiting, Indiana
Canadians have their choice of health care providers. In Austria and Germany, if a doctor diagnoses a person as stressed, medical insurance pays for weekends at a health spa. Canada does make patients wait weeks or months for nonemergency care, as a way to keep costs down. But studies by the Commonwealth Fund and others report that many nations—Germany, Britain, Austria—outperform the United States on measures such as waiting times for appointments and for elective surgeries (Reid, 2009).
Many gaps have existed in insurance programs in the United States, including incomplete health care coverage, need for copayments and deductibles, lack of provider choice, need for preauthorization, and other difficulties in maneuvering through the insurance company requirements. Copayments are a fixed health care fee paid by the patient to the health care provider at the time of service; this amount is paid in addition to the money the health care provider will receive from the insurance company. Deductibles are a predetermined out‐of‐pocket fee paid by a patient for health care services before reimbursement through health insurance begins to be paid. For example, if an insurance plan has a $50 copayment and a $1,000 deductible, the patient is responsible for paying the $50 at each health care visit plus paying the first $1,000 of health care costs, after which costs will be reimbursed as allowed by the patients' health insurance plan. Preauthorization requires that approval be obtained from the insurance company before care or treatment, such as hospitalization or diagnostic testing, is initiated if such services are to be reimbursed by the patients' health insurance plan.
Medicare and Medicaid
Because the United States does not have a national/UHC program, public health care programs are intended to help fill the gap. Beginning in 1965 under Titles XVIII (Medicare) and XIX (Medicaid) of the Social Security Act, eligibility for public insurance has been based on age (Medicare for those age 65 and older) or based on having a low income and/or having a disability (Medicaid). Medicare and Medicaid programs ensure access to many needed services for patients. Medicare is the largest federal program. Medicare Part A is an insurance plan for hospital, hospice, home health, and skilled nursing care that is paid through Social Security taxes. Nursing home care that is mainly custodial is not covered. Medicare Part B is an optional insurance that covers physician services, medical equipment, and diagnostic tests. Part B is funded through federal taxes and monthly premiums paid by the recipients. Part D is optional coverage for outpatient medications.
Medicaid, a state program financed by federal and state funds, pays for services provided to persons who are medically indigent, blind, or disabled and to children with disabilities. The federal government pays between 50% and 83% of total Medicaid costs based on the per capita income of the state. Services funded by Medicaid vary from state to state but must include services provided by hospitals, physicians, laboratories, radiology, prenatal and preventive care, and nursing home and home health care services.
Other Public Programs
Other large public insurance programs are associated with American Indian and Alaska Native heritage, and the Military Services, that is, veteran's health and insurance for active military personnel and their families. The IHS, under the U.S. DHSS, provides health services to American Indians and Alaska natives enrolled in more than 500 tribes, villages, and pueblos (U.S. Department of Health and Human Services, 2010). The Indian Self‐Determination Act of 1975 gave many tribal organizations the responsibility for the provision of health care services. IHS maintains some hospitals and clinics, yet recent legislation has severely cut funding for these sites of care.
The Department of Defense (DOD) finances and manages TRICARE, the triple option benefit care plan available for military families, formerly called the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), for enlisted military personnel and their military dependents as well as for retirees and their dependents and survivors. The Department of Veterans Affairs, established in 1921, finances and manages the Veterans Health Administration (VHA). This program is available for U.S. veterans if they need any medical, prescription, surgical, and rehabilitation care services.
Critical Thinking 2.2
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