Health Care in the US

Types of Health Insurance

Private Health Insurance- policies paid for by a policy-holder to a private insurance company for healthcare coverage. HMO (Health Maintenance Organizations) –A form of private insurance, it contracts with doctors and hospitals to get lower prices to save money in exchange for sending patients only to these “contracted” doctors.

Medicare – (elderly/disabled) Insurance program provided by the federal government to provide health insurance coverage to the elderly and their dependents or individuals who become permanently disabled Medicaid – (the poor) a government provided social welfare program that provides health insurance to the very POOR.

State Children’s Health Insurance Program (SCHIP) - a joint state/federal program to provide health insurance to children in families that earn too much money to qualify for Medicaid, yet cannot afford to buy private insurance. Universal Health Care - government programs intended to ensure that ALL CITIZENS have access to most types of health care. Patients may pay for some portion of their care, but most care is subsidized by taxpayers and/or by compulsory health insurance.

Rising Costs of Insurance

The Uninsured- usually will attend emergency rooms for care if needed and cannot pay for the services. As a result, hospitals charge insured patients more money for services to cover the costs they will not be reimbursed for by the uninsured. Therefore insurance companies, that actually pay the hospitals, wind up charging the policy-holder more for the price of a policy. “Miracle” Drugs- these latest “state of the art drugs” can keep patients alive longer than in the past but cost enormous amounts of money for prescriptions.

Rising Life Expectancy- since people are living longer, insurance companies will pay for the elderly’s healthcare longer. Fee-For-Services- Doctors in the U.S. are paid for each service (tests, x- rays, etc.) provided rather than on a cases by case basis. This can encourage a doctor to perform unnecessary tests and/or services to increase their profit.

The Healthcare System

Primary Care Physicians (PCP)- a physician that provides the first contact for a person with an undiagnosed health concern. Sometimes they are referred to as GPs or general practitioners. “Gatekeepers”- refers to Primary Care Physicians that must refer a patient to a specialist before an insurance company will pay for that specialist’s services. Referrals- recommendation for a patient by a PCP to see a specialist. Specialists- doctors that are experts in a specific area of healthcare.

Health Insurance Policies

Premium- the amount a policy-holder pays to the health insurance company each month for coverage. Deductible- the amount a policy-holder must pay out of pocket before the health plan pays its share. Copayment- the amount a policy-holder must pay per visit when they obtain healthcare services.

Coverage limits: Some health plans only pay for health care up to a certain dollar amount for a specific service. The policy- holder may be expected to pay any charges in excess of the limit. Medical Necessity- services are considered needed for a patient’s healthcare. The controversy is whether the doctor or the insurance company should decide what is a necessity.

How insurance companies increase profits

Pre-existing Conditions- a medical condition that a patient may have been born with or acquired before they purchased a healthcare plan. Insurance companies in the past have denied coverage to those that have these conditions and have not disclosed it to the company or they have been denied the ability to enroll in a plan to begin with. Exclusions: Not all services are covered. The policy-holder is generally expected to pay the full cost of non-covered services out of their own pocket.

Life-time Caps- the annual or lifetime maximum amount of money an insurance plan will pay for a policy- holder’s healthcare services.   Outpatient – surgery that allows a person to return home on the same day that a surgical procedure is performed. It is also referred to as ambulatory surgery or same-day surgery.

Peoples Methods of Saving Money

Remain Uninsured- this either bankrupts a patient or it leaves the hospital with unpaid bills or both. Drug Re-importation- people ordering or purchasing drugs from Canada or Mexico where the same drugs are cheaper. This is technically illegal in the U.S. but done often. Go To the Doctor Less-this could lead to undiagnosed diseases/conditions that eventually get worse

Other Recurring and Current Issues

Affordable Healthcare and Patient Protection Act (Obamacare)-sets up specific government regulations for insurance companies and conditions that must be met by all healthcare plans. No one “goes on Obamacare”. They must find plans that meet Obamacare standards.

Euthanasia- is the practice of having a medically-assisted death Euthanasia- is the practice of having a medically-assisted death. It illegal in most states and countries and is sometimes referred to as the “Right to Die” by supporters. Tort Reform- the idea of capping the amount of money patients can sue doctors for in medical malpractice suits. This would drive down the cost of a doctor’s malpractice insurance thereby making their services cheaper.