Health insurance is a form of group insurance, where individuals pay premiums or taxes in order to help protect themselves from high or unexpected healthcare expenses. Health insurance works by estimating the overall “risk” of healthcare expenses and developing a routine finance structure (such as a monthly premium, or annual tax) that will ensure that money is available to pay for the healthcare benefits specified in the insurance agreement. The healthcare benefit is administered by a central organization, which is most often either a government agency, or a private or not-for-profit entity operating a health plan.
Market-based health care systems such as that in the United States rely heavily on private and not-for-profit health insurance.
The concept of health insurance was proposed in 1694 by Hugh the Elder Chamberlen from the Peter Chamberlen family. In the late 19th century, “accident insurance” began to be available, which operated much like modern disability insurance. 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. 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 most prescription drugs, but this was not always the case.
How it Works
A Health insurance policy is a contract between an insurance company and an individual. The contract can be renewable annually or monthly. The type and amount of health care costs that will be covered by the health plan are specified in advance, in the member contract or Evidence of Coverage booklet. The individual policy-holder’s payment obligations may take several forms.
Premium: The amount the policyholder pays to the health plan each month to purchase health coverage.
Deductible: The amount that the policyholder must pay out-of-pocket before the health plan pays its share. For example, a policyholder might have to pay a $500 deductible per year, before any of their health care is covered by the health plan. It may take several doctor’s visits or prescription refills before the policyholder reaches the deductible and the health plan starts to pay for care.
Copayment: The amount that the policyholder must pay out of pocket before the health plan pays for a particular visit or service. For example, a policyholder might pay a $45 copayment for a doctor’s visit, or to obtain a prescription. A copayment must be paid each time a particular service is obtained.
Coinsurance: Instead of paying a fixed amount up front (a copayment), the policyholder must pay a percentage of the total cost. For example, the member might have to pay 20% of the cost of a surgery, while the health plan pays the other %80. Because there is no upper limit on coinsurance, the policyholder can end up owing very little, or a significant amount, depending on the actual costs of the services they obtain.
Exclusions: Not all services are covered. The policyholder is generally expected to pay the full cost of non-covered services out of their own pocket.
Coverage limits: Some health plans only pay for health care up to a certain dollar amount. The policyholder may be expected to pay any charges in excess of the health plan’s maximum payment for a specific service. In addition, some plans have annual or lifetime coverage maximums. In these cases, the health plan will stop payment when they reach the benefit maximum, and the policyholder must pay all remaining costs.
Out-of-pocket maximums: Similar to coverage limits, except that in this case, the member’s payment obligation ends when they reach the out-of-pocket maximum, and the health plan pays all further covered costs. Out-of-pocket maximums can be limited to a specific benefit category (such as prescription drugs) or can apply to all coverage provided during a specific benefit year.
Prescription Drug Plans: These are plans that are a form of insurance offered through many employer benefit plans in the U.S., where the patient pays a copayment and the prescription drug insurance pays the rest.
Some health care providers will agree to bill the insurance company if patients are willing to sign an agreement that they 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.
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.
Health Insurance companies are now offering Health Incentive accounts (HIA), to reward users for living healthy and making healthy choices, like stop smoking and/or losing weight, may get you funds added into your Health Incentive Account, which may lower your out of pocket costs. The health incentive accounts also carry over from year to year but once you leave the program you lose those benefits in the HIA.
Problems with Private Insurance
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 per month. One person becomes very ill while the others stay healthy, allowing the insurance company to use the money paid by the healthy people to pay for the treatment costs of the sick person. Adverse selection upsets this balance between healthy and sick subscribers by leaving 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 the person has been treated for any of a long list of diseases and so on. In general, those who present a large financial burden are denied coverage or charged high premiums to compensate. One large U.S. industry survey found that roughly 13 percent of applicants for comprehensive, individually purchased health insurance that go through the medical underwriting process were denied coverage. Declination rates increased significantly with age, rising from 5 percent for individuals 18 and under to just under a third for individuals aged 60 to 64. On the other side, applicants can get discounts if they do not smoke and are healthy.
Starting in 1976, some states started providing guaranteed-issuance risk pools, which enable individuals who are medically uninsurable through private health insurance to purchase a state-sponsored health insurance plan, usually at higher cost. Minnesota was the first to offer such a plan; 34 states now offer them. Plans vary greatly from state to state, both in their costs and benefits to consumers and to their methods of funding and operations. They serve a very small portion of the uninsurable market — about 182,000 people in the U.S. as of 2004, but in best cases 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 money has been awarded to states to innovate and improve their plans.
Factors Affecting Insurance Prices
A recent study by Price Waterhouse Coopers examining the drivers of rising health care costs in the U.S. pointed to increased utilization created by increased consumer demand, new treatments, and more intensive diagnostic testing, as the most significant driver. 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. Advances in medicine and medical technology can also increase the cost of medical treatment. Other factors that increase utilization and therefore insurance prices are lifestyle-related: increases in obesity caused by insufficient exercise and unhealthy food choices; excessive alcohol use, smoking, and use of street drugs. Other factors noted by the PWC study included the movement to broader-access plans, higher-priced technologies, and cost-shifting from Medicaid and the uninsured to private payers.
What to Watch for with Private Insurance
Insurance companies usually only re-price their coverage annually. This means if one becomes ill, and is covered by a health insurance policy, and that illness will continue and be subject to a re-priced policy that person may find that their insurance premiums have increased to an amount they might not be able to afford. However, some states have rules and regulations which can limit price increases on certain types of health insurance coverage.
If insurance companies try to charge different people different amounts based on their own personal health, people may feel they are unfairly treated. Exceptions to this differential in pricing can be found when an individual (and their dependents) become insured under a pre-existing pool of insureds such as a group of employees insured through their employer. In that instance, the underwriter assesses the financial risk based upon the entire group (sometimes referred to as a ‘risk pool’). In these situations, a person with little or no medical expenses in their recent history will pay the same premium cost (and be subject to the same co-pays and deductibles) as someone who has had a large amount of medical expenses in their recent history.
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. One large industry survey suggests that claim processing times improved between 2002 and 2006. More claims are being submitted electronically; however, 29 percent of claims were not received by the insurer until more than a month after the date on which medical care was provided. The percentage of claims being adjudicated on an automated basis is also increasing. 14 percent of claims are “pended” by the insurer while additional information is requested or the information on the claim is verified. On average, pended claims are delayed by 9 days. Over 95 percent of the remaining “clean” claims are processed within 30 days; 57 percent are processed within one week.
Health insurance is often only widely available at a reasonable cost through an employer-sponsored group plan and online for individuals.
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, although a small number of pre-tax health plans exist.
Experimental treatments are generally not covered. This practice is especially criticized by those who have already tried, and not benefited from, all “standard” medical treatments for their condition.
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.
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. The health care company has popular and unpopular ways of controlling this market force.
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.
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 and very low dollar-amount coverages.
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.
Types of Private Insurance
Private: Employer Sponsored
Health insurance paid for by business entities generally on behalf of their employees and other immediate stakeholders. Broadly classified as “Traditional/Indemnity” and “Managed/Preferred Provider.” Most private health coverage in the U.S. is employment based, and the employer typically makes a substantial contribution towards the cost of coverage.
Costs for employer-paid health insurance are rising rapidly: since 2001, premiums for family coverage have increased 78%, while wages have risen 19% and inflation has risen 17%, according to a 2007 study by the Kaiser Family Foundation.
According the Centers for Medicare and Medicaid Services, nearly 100% of large firms offer health insurance to their employees. 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.
Many small employers provide employee health insurance, but the percentage offering is not as high as it is for larger employers. The types of coverage available to small employers are similar, but they do not have the same options for financing their benefit plans. In particular, self-insuring is not a practical option for most small employers.
Private: Individually Purchased
Policies of health insurance obtained by individuals not otherwise covered under policies or programs elsewhere classified. Generally major medical, short term medical, and student policies. Fewer Americans are covered by individually purchased medical expense insurance than by employer-sponsored coverage. The range of products available is similar, however. Average premiums are generally somewhat lower than those for employer-sponsored coverage, but vary by age. Deductibles and other cost-sharing is also higher, on average, and the individual consumer pays the entire premium without benefit of an employer contribution. Many states allow medical underwriting of applicants for individually purchased health insurance by insurance companies.
Private: Long-term Care Insurance
Long-term care (LTC) insurance is growing in popularity in the U.S. Premiums have remained relatively stable in recent years. However, the coverage is quite expensive, especially when consumers wait until retirement age to purchase it. The average age of new purchasers was 61 in 2005, and has been dropping.
Health Savings Accounts
One approach to addressing increasing premiums, dubbed “consumer driven health care,” received a boost in 2003, when President George W. Bush signed into law the Medicare Prescription Drug, Improvement, and Modernization Act. The law created tax-deductible Health Savings Accounts (HSAs). An HSA is a private bank account which is un-taxed and only penalized if spent on non-medical items or services. It must be paired with a high-deductible insurance plan. HSAs enable mostly healthy people to pay less for insurance and bank money for their own health care expenses. HSAs are one form of tax-preferrenced health care spending account. Others include Archer Medical Savings Accounts (MSAs), which have been superseded by the new HSAs (although existing MSAs are grandfathered), Flexible Spending Arrangements (FSAs) and Health Reimbursement Accounts (HRAs). FSAs and HRAs are typically used as part of an employee-benefit plan.