Health Insurance – health insurance is the financial platform for health care in the United States. As such, it plays a significant role in access to health-care services and in health-care treatment decisions. In 2004, about 250 million Americans had health insurance, just over two thirds through private coverage and the remainder through public programs such as Medicaid and state low-cost health plans.
Nearly all health insurance plans require participants to pay a portion of their medical expenses, typically in the form of annual deductibles and service co-payments. A deductible is payment at the front end, for example, the first $2,500.00 of medical costs each year. A co-payment shares the cost of each health-care service between the person and the insurer, either as a dollar amount or a percentage of the charge. Most plans have a cap on out-of-pocket medical expenses, after which the insurer pays the full amount for covered services. Nonetheless, people who experience serious illnesses or injuries can accumulate significant additional medical expenses for services the insurance plan does not cover. As well, most people pay a portion or all of their health insurance premiums.
Because the US health-care system intricately intertwines health-care services and health insurance, conflicts arise between care needs and insurance coverage. Doctors and hospitals coordinate with insurers to obtain approval for most nonemergency treatments before engaging in them. Most insurers have lists of approved procedures and medications to facilitate the administrative processes and issue payments directly to providers. Each state has laws and rules that regulate how these processes take place and establish procedures for handling disagreements with insurer decisions, and a state insurance commissioner oversees their enforcement.
Though 85 percent of the US population has health insurance and thus access to health-care services, 15 percent does not—about 42 million people. Those who do not have health insurance have great difficulty receiving needed health-care services. The federal government mandates that providers may not deny care to anyone for lifethreatening illness or injury and for a pregnant woman’s delivery of her child. All states have programs to provide basic health-care services for children and pregnant women. State and local programs attempt to fill in the gaps in providing other care, though the need far exceeds available services.
The intertwining of health insurance and health services that can be an advantage for people who have health insurance becomes a barrier for the 42 million Americans who do not. They frequently go without medical care for conditions that prompt treatment would remedy but that without early intervention become serious and even life-threatening. Preemptive treatment, such as medications to lower blood cholesterol levels or control BLOOD PRESSURE, as well as preventive health measures such as ROUTINE PHYSICAL EXAMINATION, often are out of reach. Many health experts and public health policy planners view the lack of health insurance as one of the most significant challenges facing the health of Americans and the stability of the US health-care system.
See also HEALTH RISK FACTORS; HEALTHY PEOPLE 2010; QUALITY OF LIFE.