Health insurance
From Wikipedia, the free encyclopedia
Health insurance is a type of insurance whereby the insurer pays the medical costs of the insured if the insured becomes sick due to covered causes, or due to accidents. The insurer may be a private organization or a government agency. Market-based health care systems such as that in the United States rely primarily on private health insurance.
[edit] History and evolution
The concept of health insurance was proposed in 1694 by Hugh the Elder Chamberlen from the Peter Chamberlen family. In the late 19th century, early health insurance was actually disability insurance, in the sense that it covered only the cost of emergency care for injuries that could lead to a disability[citation needed]. This payment model continued until the start of the 20th century in some jurisdictions (like California), where all laws regulating health insurance actually referred to disability insurance.[1] 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
[edit] Private health insurance
A Health insurance policy is a legal, binding contract between the insurance company and the customer. The largest difference between private sector health insurance and life insurance is that for life insurance, a person may purchase guaranteed renewable insurance for the whole of the insured's life at a constant premium rate, while health insurance is generally purchased year by year with generally no assurance of renewability and if renewable no guarantee that premium rates will not increase.
With health insurance, the policy-holder pays a deductible plus coinsurance (for instance, a $1000 deductible. Usually there is a maximum out-of-pocket payment per year, and there is usually a lifetime maximum.
Prescription drug plans are a form of insurance offered through many employer benefit plans, where the patient pays a copay and the prescription drug insurance pays the rest.
Some health care providers will agree to bill the insurance company if the patient is willing to sign an agreement that he will be responsible for the amount that the insurance company doesn't pay, as the insurance company pays according to "reasonable" or "customary" charges, which may be less than the provider's usual fee. The "reasonable" and "customary" charges vary according to the geographic location where the patient lives, but usually are determined as a multiple of the amount payable by Medicare.
Health insurance companies also often have a network of providers who agree to accept the reasonable and customary fee and waive the remainder. It will generally cost the patient less to use an in-network provider.
[edit] Inherent problems with private insurance
Any private insurance system will face two inherent challenges: adverse selection and ex-post moral hazard.
[edit] Adverse Selection
Insurance companies use the term "adverse selection" to describe the tendency for only those who will benefit from insurance to buy it. Specifically when talking about health insurance, unhealthy people are more likely to purchase health insurance because they anticipate large medical bills. On the other side, people who consider themselves to be reasonably healthy may decide that medical insurance is an unnecessary expense; if they see the doctor once a year and it costs $250, that's much better than making monthly insurance payments of $400 (example figures).
The fundamental concept of insurance is that it balances costs across a large, random sample of individuals. For instance, an insurance company has a pool of 1000 randomly selected subscribers, each paying $100/month. One of them gets really sick while the others stay healthy, which means that the insurance company can use the money paid by the healthy people to treat the sick person. Adverse selection upsets this balance between healthy and sick subscribers. It will leave an insurance company with primarily sick subscribers and no way to balance out the cost of their medical expenses with a large number of healthy subscribers.
Because of adverse selection, insurance companies use a patient's medical history to screen out persons with pre-existing medical conditions. Before buying health insurance, a person typically fills out a comprehensive medical history form that asks whether the person smokes, how much the person weighs, whether or not the person has been treated for any of a long list of diseases and so on. In general, those who look like they will be large financial burdens are denied coverage or charged high premiums to compensate. On the other side, applicants can actually get discounts if they do not smoke and are healthy.
Starting in 1976, some states started providing "health insurance" "risk pools", which allow individuals who are medically-uninsurable through private health insurance to be able to purchase a state-sponsored health insurance plan, usually at higher cost. Minnesota was the first to offer such a plan, there are now 34 states which do. Plans vary greatly from state-to-state, both in the costs and benefits to consumers and to their methods of funding and operating. They serve a very small portion of the uninsurable market -- about 183,000 people nationwide -- but in best cases do 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. Efforts to pass a national pool have as yet been unsuccessful, but some federal tax dollars have been awarded to states to innovate and improve their plans.
[edit] Moral Hazard
Moral hazard describes the state of mind and change in behavior that results from one's knowledge that if something bad were to happen, the out-of-pocket cost would be mitigated by an insurance policy--in this case, one which provides reduced prices for medical care. In the same way that people treat water with little care when it is very inexpensive, people will also tend to overuse medical care when the out-of-pocket costs are small.
However, the reverse problem also occurs. People who have no health insurance, or who are severely under-insured, may wait too long, or not seek medical care at all for conditions that could be immediately life threatening out of fear of being financially ruined by enormous medical bills.
[edit] Other factors affecting insurance price
Because of advances in medicine and medical technology, medical treatment is more expensive, and people in developed countries are living longer. The population of those countries is aging, and a larger group of senior citizens requires more medical care than a young healthier population. (A similar rise in costs is evident in Social Security in the United States.) These factors cause an increase in the price of health insurance.
Some other factors that cause an increase in health insurance prices are health related: insufficient exercise; unhealthy food choices; a shortage of doctors in impoverished or rural areas; excessive alcohol use, smoking, street drugs, obesity, among some parts of the population; and the modern sedentary lifestyle of the middle classes.
In theory, people could lower health insurance prices by doing the opposite of the above; that is, by exercising, eating healthy food, avoiding addictive substances, etc. Healthier lifestyles protect the body from some, although not all, diseases, and with fewer diseases, the expenses borne by insurance companies would likely drop. A program for addressing increasing premiums, dubbed "consumer driven health care," encourages Americans to buy high-deductible, lower-premium insurance plans in exchange for tax benefits.
[edit] Common complaints of private insurance
Some common complaints about private health insurance include:
- Insurance companies do not announce their health insurance premiums more than a year in advance.[citation needed] This means that, if one becomes ill, he or she may find that their premiums have greatly increased (however, in many states these types of rate increases are prohibited).
- If insurance companies try to charge different people different amounts based on their own personal health, people may feel they are unfairly treated.[citation needed]
- When a claim is made, particularly for a sizable amount, insureds may feel as though the insurance company is using paperwork and bureaucracy to attempt to avoid payment of the claim or, at a minimum, greatly delay it.[citation needed]
- Health insurance is often only widely available at a reasonable cost through an employer-sponsored group plan.[citation needed]
- In the United States, there are tax advantages to Employer-provided health insurance, whereas individuals must pay tax on income used to fund their own health insurance.[citation needed]
- Experimental treatments are generally not covered.[citation needed] This practice is especially criticized by those who have already tried, and not benefited from, all "standard" medical treatments for their condition.[citation needed]
- The Health Maintenance Organization (HMO) type of health insurance plan has been criticized for excessive cost-cutting policies in its attempt to offer lower premiums to consumers.[citation needed]
- As the health care recipient is not directly involved in payment of health care services and products, they are less likely to scrutinize or negotiate the costs of the health care received.[citation needed] The health care company has popular and unpopular ways of controlling this market force.[citation needed]
- Some health care providers end up with different sets of rates for the same procedure. One for people with insurance and another for those without.[citation needed]
- Unlike most publicly funded health insurance, many private insurance plans do not provide coverage of dental health care, or only offer such coverage with additional premiums.
- Insurance Companies can influence the type or amount of treatment that the insured receives by setting limits on the number of visits, types of treatment, etc., it will cover.
[edit] Publicly funded health insurance
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With publicly funded health insurance the good and the bad risks all receive coverage without regard to their health status, which eliminates the problem of adverse selection and amplifies the problem of moral hazard.
[edit] National Health Service
The National Health Service (NHS) is the "public face" of the four publicly funded health care systems of the United Kingdom. The organisations provide the majority of healthcare in the UK, from general practitioners to Accident and Emergency Departments, long-term healthcare and dentistry. They were founded in 1948 and have become an integral part of British society, culture and everyday life: the NHS was once described by Nigel Lawson, former Chancellor of the Exchequer, as 'the national religion'. Private health care has continued parallel to the NHS, paid for largely by private insurance, but it is used only by a small percentage of the population, and generally as a top-up to NHS services.
[edit] Health insurance in the United States
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According to the latest United States Census Bureau figures, approximately 85% of Americans have health insurance. Approximately 60% obtain health insurance through their place of employment or as individuals, and various government agencies provide health insurance to over 29% of Americans.[2] In 2005, there were 41.2 million people in the U.S. (14.2 percent of the population) who were without healthcare insurance for at least part of that year.(ibid) For many people, however, this does not boil down to a simple question of affordability. Part of this population might include young and healthy individuals with low risk of serious illness who don't believe that health insurance would be cost-effective. In fact, approximately one-third of these 41.2 million live in households with an income over $50,000, with half of these having an income of over $75,000.[3] Additionally, one third of these 41.2 million are eligible for public health insurance programs but have not signed up for them.[4] People living in the western and southern United States are more likely to be uninsured.[2]
[edit] Medicare
In the United States, government-funded Medicare programs help to insure the elderly and end stage renal disease patients. Some health care economists (Ewe Reinhardt of Princeton and Stuart Butler among others) assert that (the third party payment feature) these programs have 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.
Starting in 2006, Medicare Part D provides a program for the elderly to buy insurance for the purchase of prescription drugs.
[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] Medicaid
While Medicaid was instituted for the very poor, beginning in 1972, the number of individuals in the United States who lacked any form of health insurance for any period during the year increased each year, every year with the exceptions of the years 1999 and 2000.[citation needed] It has been reported that the number of physicians accepting Medicaid has decreased in recent years due to relatively high administrative costs and low reimbursements. [5]
[edit] The shift to managed care in the U.S.
Through the 1990s, managed care grew from about 25% of U.S. employees to the vast majority.
According the Centers for Medicare and Medicaid Services, nearly 100% of large firms offer health insurance to their employees.[6] 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.[7]
[edit] Health insurance in Canada
Until recently, private health insurance was illegal in all of Canada. All insurance was supplied by the government. Recently, the Supreme Court of Quebec ruled, in Chaoulli v. Quebec that private business must be allowed to offer health insurance and compete with the public program.
[edit] References
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