Health insurance in the United States
[5] Gallup issued a report in July 2014 stating that the uninsured rate for adults 18 and over declined from 18% in 2013 to 13.4% by 2014, largely because there were new coverage options and market reforms under the Affordable Care Act.
[14] The social safety net refers to those providers that organize and deliver a significant level of health care and other needed services to the uninsured, Medicaid, and other vulnerable patients.
Not only is this because the ACA does not address gaps for undocumented or homeless populations, but higher insurance premiums, political factors, failure to expand Medicaid in some states, and ineligibility for financial assistance for coverage are just some of the reasons that the social safety net is required for the uninsured.
[19] A study at Johns Hopkins Hospital found that heart transplant complications occurred most often amongst the uninsured, and that patients who had private health plans fared better than those covered by Medicaid or Medicare.
[22] Those who are insured may be underinsured such that they cannot afford full medical care, for example due to the exclusion of pre-existing conditions, or from high deductibles or co-payments.
[23] The first health coverage in the United States was established by Congress in 1798, when the Marine Hospital Fund was financed through a tax on maritime sailors' pay.
The first employer-sponsored group disability policy was issued in 1911, but this plan's primary purpose was replacing wages lost because the worker was unable to work, not medical expenses.
[25] 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.
[31] Some of the first evidence of compulsory health insurance in the United States was in 1915, through the progressive reform protecting workers against medical costs and sicknesses in industrial America.
[33] Employer-sponsored health insurance plans dramatically expanded as a direct result of wage controls imposed by the federal government during World War II.
Finally, President Lyndon B. Johnson signed the Medicare and Medicaid programs into law in 1965, creating publicly run insurance for the elderly and the poor.
The Patient Protection and Affordable Care Act was similar to the Nixon and Clinton plans, mandating coverage, penalizing employers who failed to provide it, and creating mechanisms for people to pool risk and buy insurance collectively.
However, with the Patient Protection and Affordable Care Act, effective since 2014, federal laws have created some uniformity in partnership with the existing state-based system.
Insurers are prohibited from discriminating against or charging higher rates for individuals based on pre-existing medical conditions and must offer a standard set of coverage.
[47] Services in California range from private offerings: HMOs, PPOs to public programs: Medi-Cal, Medicare, and Healthy Families (SCHIP).
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 CHIP, also a federal-state partnership that serves certain children and families who do not qualify for Medicaid but who cannot afford private coverage.
[58] With supplemental insurance, Medicare ensures that its enrollees have predictable, affordable health care costs regardless of unforeseen illness or injury.
The program now covers everyone with incomes under 133% of the federal poverty level who does not qualify for Medicare, provided this expansion of coverage has been accepted by the state where the person resides.
The federal government will fully fund the expansion of Medicaid initially, with some of the financial responsibility (10% of medical costs) gradually devolving back to the states by 2020.
[67][68] State mandates generally do not apply to the health plans offered by large employers, because of the preemption clause of the Employee Retirement Income Security Act.
[88] 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.
"[96] "[S]mall businesses in California such as dairy farmers, car dealers, and accountants created AHPs "to buy health insurance on the premise that a bigger pool of enrollees would get them a better deal.
[97] According to a 2000 Congressional Budget Office (CBO) report, Congress passed legislation creating "two new vehicles Association Health Plans (AHPs) and HealthMarts, to facilitate the sale of health insurance coverage to employees of small firms" in response to concerns about the "large and growing number of uninsured people in the United States.
1101), which established "requirements for creating a federally-certified AHP, including for certification itself, sponsors and boards of trustees, participation and coverage, nondiscrimination, contribution rates, and voluntary termination.
"[95] In November 2017, President Trump directed "the Department of Labor to investigate ways that would "allow more small businesses to avoid many of the [Affordable Care Act's] costly requirements.
[28] 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.
[25][113][121] 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.
[138] According to some experts, such as Uwe Reinhardt,[139] Sherry Glied, Megan Laugensen,[140] Michael Porter, and Elizabeth Teisberg,[141] this pricing system is highly inefficient and is a major cause of rising health care costs.
Public health insurance programs typically have more bargaining power as a result of their greater size and typically pay less for medical services than private plans, leading to slower cost growth, but the overall trend in health care prices have led public programs' costs to grow at a rapid pace as well.
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.
