The US Health Insurance System

Abstract

The US has, perhaps, the most complicated healthcare coverage system in the world. Although it is primarily a fee-for-service system, the primary means of accessing healthcare is through either an insurance policy (public or private) or as a direct payment from client (patient) to provider (doctor). Insurance can be expensive, and even with all the various forms of coverage, there are millions of Americans without any insurance whatsoever. This means they either do not access healthcare, or they pay as they go when they can afford it. In addition to private and public insurance, there are specific government-funded programs for persons with disabilities, children, and veterans. Even with attempts at reform such as the Patient Protection and Affordable Care Act (PPACA) (2010), health insurance in the United States remains a hotly debated and complex issue.

Overview

The US Health Insurance System. The United States continues to struggle with one of the most complicated healthcare systems in the world. It is a highly complex system of private and public insurance plans. The private plans are for people whose employers partially or fully subsidize their employees’ health coverage. There are also individuals who pay for their own private plan and can choose from various plans. Whichever plan they decide to go with, there is no such thing as complete coverage without additional costs. Even with private coverage, there is always an annual deductible and copayments for many services. In the case of a serious surgery and long hospital stay, the out-of-pocket payments can cost thousands of dollars, even with "complete coverage."

There is also a complex system of public coverage for people who cannot afford private healthcare insurance or whose employers do not provide it. In addition, there is government coverage for persons with disabilities and seniors, for people in or formerly in military service, and for American Indians. The Patient Protection and Affordable Care Act (PPACA), signed into law in 2010 and also known as the Affordable Care Act (ACA) or Obamacare (after President Barack Obama), represented the most comprehensive reform of the total US healthcare system since the 1965 introduction of Medicare and Medicaid. It attempted to address the escalating costs of health insurance and the problem of the millions of Americans left uninsured under previous systems. The fierce controversy aroused by the law illustrated just how divisive the issue of health insurance had become in the partisan atmosphere of the early twenty-first century, and the debate over healthcare reform continued. The ACA also highlighted just how political an issue healthcare is in the US. While the Republican administration of President Donald Trump attempted to repeal the ACA, the Biden-Harris administration worked to strengthen the legislation.

Further Insights

Private Coverage: Blue Cross & Blue Shield Plans. The largest private health insurance provider in the United States is Kaiser Permanente followed by Elevance Health (Anthem) and the Blue Cross Blue Shield Association. These insurance companies are active in every state (Kissel, 2023). Even private health insurance can have its problems. Although coverage is offered, it does not mean it is always provided. Coverage is offered, and individuals or companies pay the premium. However, especially with big plans like Blue Cross/Blue Shield, there is a deductible, which has risen continuously. A high annual deductible can range upwards of $1,400 for an individual and $2,800 for a family, according to the US Centers for Medicare & Medicaid Services. This means that before the insurance coverage actually kicks in, the person has to pay at least that amount in healthcare costs first. Another issue is what services the insurance will and will not cover.

Blue Cross/Blue Shield is an interesting case study. Blue Cross has a long history in the US, as it was established during the Depression, before which there was no health insurance. Although the Blue plans have established themselves across the country since the early twentieth century, they are not the same from state to state: "Blues plans today differ considerably from one another in such areas as market share, management philosophy, and the types of products they offer to their three primary market segments—individual, small group, and large group" (Aronovitz, 1994, p. 5). Another issue with the Blues was that of financial solvency; they must have the money to provide payment for the services. To ensure this, state regulations are in place. However, back in the 1990s, there was real cause for concern: "The revelation that several Blues plans were in poor financial condition prompted fundamental questions about all Blues plans because of the large number of Americans they insure" (Aronovitz, 1994, p.4).

Plans such as these have often had very strict guidelines regarding who they would cover and why. For example, in the past, it was likely that anyone who wanted private coverage would have to undergo a thorough medical examination. They might not receive coverage for a prior medical condition, which could leave them paying hundreds or even thousands of dollars in out-of-pocket expenses. Insurance companies like the Blues have not been enthusiastic about healthcare reform. Reforms enacted under the 2010 Patient Protection and Affordable Care Act (PPACA) forced insurers to accept everyone, regardless of their state of health, and to cover them for prior conditions. This means insurers must pay out hundreds of thousands of dollars (possibly millions) in coverage that they formerly would never have paid. However, studies have suggested that insurance companies have, in fact, benefited from the PPACA due to the increased number of clients caused by federal mandates.

Health Maintenance Organizations (HMOs). Although these organizations cover far fewer people than Blues plans, health maintenance organizations (HMOs) gained in popularity in the final decades of the twentieth century. HMOs are not only health insurers but also healthcare providers. The HMO works by providing coverage for a specific network of providers, who may all be part of a single multispecialty practice, work in HMO-run facilities, belong to multiple individual or group practices, or be a collective of solo practitioners. Regardless of the HMO network arrangement, the providers receive a fixed fee that has been prearranged. One of the primary philosophical foundations of the HMO is preventive care. They fund routine physical examinations to ensure ongoing good health. However, like other insurance plans, they also impose copayments and out-of-pocket expenses depending on how much coverage is in the plan (Blostin & Marclay, 1983).

In the past, the HMO commonly put a cap or a ceiling on how many days of coverage could be received within the scope of the plan and also a limit on how much money would be paid out to a person within a single year. One of the real weaknesses of the HMO plan was that it often limited the number of days one could receive coverage for mental healthcare or an extended stay in a nursing facility (Blostin & Marclay, 1983).

Managed Care. Managed care was an initiative in the private sector to address the spiraling costs of medical care, created to "manage healthcare costs." Managed care has become an integral part of the American healthcare system. It rose to some prominence during the presidency of Ronald Reagan and began as a way to control the amount of money being paid out by Medicare. Managed care was considered an excellent way of combining two important aspects of healthcare—funding and providing referrals. At the time, managed care was seen as a way of bringing down the costs of healthcare in the United States. Managed care generally will not cover services that are experimental in nature, cosmetic, or for which there is no standard of medical practice. There are also limitations to services that managed care will cover.

A managed care plan may take one of many different organizational forms. Managed care plans may be HMOs, preferred provider organizations (PPOs), exclusive provider organizations (EPOs), or point-of-service plans (POSs). Traditional HMOs, PPOs, EPOs, and POSs all use an approved network of providers; the differences lie in their coverage of services rendered by out-of-network providers. Under a PPO, a patient who receives out-of-network care can be charged higher deductibles, higher coinsurance, or other out-of-pocket expenses, while an EPO will not pay for any out-of-network care except in emergencies. With a POS plan, a patient pays for out-of-network care and is reimbursed according to a fee schedule or other predetermined scale for costs.

Even if managed care is not the "be-all and end-all," it may nevertheless provide some value to consumers. Managed care is meant to be an option for consumers that provides both the options for the consumers and streamlines services by including the financing and delivery of these healthcare services. One of the primary goals of managed care is to match patients with appropriate healthcare providers in the shortest time possible. By providing these matches, managed care is meant to be a way to limit the stress on consumers. In the final analysis, managed care underscores that healthcare is a business in America. Every party in the business of healthcare (except the consumer) is out to make a profit—the insurance companies, the healthcare providers, and anyone else with a stake in the businesses. This is the most blatant way the American system differs from the socialized systems of Canada and European nations.

Health Savings Accounts. Health savings accounts represent a relatively new approach to health insurance. These accounts allow people to save money for healthcare tax-free. According to Hoffman and Tolbert (2006),

Health Savings Accounts are a type of medical savings account that allow consumers to save for medical expenses on a tax-free basis. They are linked with high deductible health plans (HDHPs), and together these insurance and savings options represent a newer approach to healthcare, commonly referred to as consumer-directed care. Health Savings Accounts (HSAs) were federally enacted as part of the Medicare Prescription Drug Improvement and Modernization Act of 2003 (p. 1).

The main problem with HSAs is that they tend to be useful for families with higher incomes since families with lower incomes tend not to have sufficient disposable income to put into the account. Another group of people who do not benefit from HSAs are people with disabilities and persons with chronic health problems or conditions. The reason for this is the high deductible set by these plans. Those with ongoing health problems tend to visit the doctor (and other healthcare providers) far more often and therefore end up paying high rates of out-of-pocket expenses. According to Hoffman and Tolbert (2006), "Health Savings Accounts and HDHPs are likely to be more attractive to healthy individuals and families who have had few major medical expenses" (p. 3).

The reason for the creation of the HSA was to provide a way for people to pay for medical expenses not covered by insurance or other reimbursements (Lyke, Peterson, & Ranade, 2005).

Public Health Coverage: Medicaid & Medicare. Medicaid is a federal program that provides health insurance coverage to qualifying very low-income Americans, particularly those over age sixty-five and children under eighteen. Medicare is the program that provides people over sixty-five with medical care. It also provides support for persons with certain disabilities and people of all ages who have end-stage renal disease (kidney failure). Medicare has become far more complicated than it was in its original form. There are four sections to Medicare: A, B, C, and D. Respectively, they cover hospital insurance, medical insurance, advantage plans, and prescription drug coverage. One of the ongoing problems for the Medicare program has been to continue to provide the health insurance required by seniors and persons with disabilities at the same time as trying to contain costs. Like Medicaid, Medicare also has variations in practice among states, which also leads to some confusion over and frustration with the program.

One of the main provisions of the PPACA intended to reduce the number of uninsured was an expansion of Medicaid to those with incomes less than or up to 133 percent of the official federal poverty line, whether a family or individual. Several states rejected this expansion after the US Supreme Court ruled they may do so in National Federation of Independent Business v. Sebelius (2012). In 2023, Wyoming, Kansas, Texas, Wisconsin, Tennessee, Mississippi, Alabama, Georgia, South Carolina, and Florida had not adopted the expansion of Medicaid, leaving millions of people with a gap in coverage in which they qualified for healthcare but could not access it (Neukam, 2023).

Disability Insurance. There are a number of ways that insurance for disability can be provided. First, there is private insurance, which may contain coverage for short- and long-term disability. These are usually group plans through an employer. Since not everyone can return to work immediately after an injury or illness, short- and long-term disability was established to support people during periods of rehabilitation. These programs were established to prevent people from losing their incomes during a long illness or after an injury.

The largest program in the country for persons with disabilities is Social Security Disability Insurance (SSDI). It consists of a monthly premium paid out to individuals who have a permanent impairment. This is administered by the Social Security Administration and provides a monthly income for individuals who are unable to work due to the nature or severity of their disability or individuals who can work but earn less than the amount SSDI determines is the substantial gainful activity level. In addition to the primary program, there is also the Supplemental Security Income (SSI). This is a "means-tested income assistance program for aged, blind, and disabled individuals (regardless of prior workforce participation)" (Social Security Advisory Board, 2001, p. 6). To qualify for the latter, a person must have a permanent impairment, be over the age of eighteen, and not own any property.

One of the primary issues with respect to SSDI and SSI is the adjudication system. There have been ongoing concerns and formal complaints that the system is unfair and even somewhat arbitrary. The rules that provide for acceptance or denial of a person's disability have varied from state to state, as has the rate of allowance and denial. Therefore, depending on where one lives, it might be easier to gain supplementary income and, in other places, more difficult. Many seek legal counsel to secure benefits.

Despite these concerns, the agency long had no effective mechanism to provide the information needed to understand the degree to which the programs' own policies and procedures—including their uneven implementation—have caused inconsistent outcomes in different regions of the country and different parts of the disability system (Social Security Advisory Board, 2001, p. 4). Beginning in 2001, the Social Security Advisory Board compiled and released reports containing data on the disability program and determination process to improve transparency and increase accountability for such procedural inconsistencies (Social Security Advisory Board, 2012).

Since SSDI’s enactment in 1956, our ideas and perceptions of what a person with a disability can and cannot do have radically changed. There have been significant technological advances that some say enable persons with even more complicated conditions to work full-time or part-time. The SSDI program has not kept up with the times and has continued to operate in the same way since its inception. In addition to these difficulties, adjudicators are trained differently across the states, and this leads to a wide variance in the ability to understand the experience of living life with a disability. The Social Security Advisory Board (2006) has proposed a number of reforms to address such long-standing issues. Most importantly, it recognizes the need to redefine disability criteria in light of changes to the workplace and the government’s emphasis on empowering individuals of all abilities to contribute to society (Social Security Advisory Board, 2006). Reforms to the system continue. In February 2023 the “Stop the Wait” Act was introduced into Congress in an attempt to reduce the waiting time for people wishing to receive benefits (Congress.gov, 2023).

Indian Health Service. To try and rectify many of the mistakes of the past with American Indian communities, the US Department of Health and Human Services established the Indian Health Service (HIS):

Members of federally recognized tribal nations and their descendants are eligible for services provided by IHS, which operates a comprehensive health service delivery system across 12 regions for approximately 2.6 million American Indians and Alaska Natives in the United States (Indian Health Service, 2023).

One of the problems of the IHS service is familiar to all players in the arena of healthcare insurance—a lack of uniformity with respect to the establishment and maintenance of services; for example, the Navajo people of Arizona receive different services than Alaska Natives and American Indians in other states (Topor, 2006). There have also been problems with the allocation of low numbers of doctors and the lack of doctors with expertise specific to the needs of the particular Inigenous community (Topor, 2006). Even with the rising costs of healthcare in the US, the IHS has only enjoyed small increases in its budget in the mid-2010s, with appropriations of $4.8 billion, up from $4.6 billion the year before (Indian Health Service, 2016). In 2023, that number had increased to $9.3 billion, a hopeful sign (Indian Health Service, 2023).

Another disturbing problem has been that of mismanagement and even the misappropriation of funds. Inappropriate policies, poor internal control, and weak management infrastructure, including outdated personal property management policies, have been blamed for many of the problems inherent to IHS. The Government Accountability Office (GAO) also documents that IHS has such poor internal control that they often do not know whether property has been lost or stolen in their various clinics; in 2009, it found that IHS had approximately $3.5 million dollars worth of medical property lost or stolen since the preceding year (Kutz, 2009). As with many other social programs that were initially established to support American Indians, IHS has not really lived up to its promises to provide extended healthcare to American Indian communities.

Issues

The State of the Uninsured. There is perhaps no issue as salient and distressing as that of the millions of Americans who are uninsured. Addressing this issue was one of the major goals of the PPACA. In 2012, an estimated 48 million Americans were uninsured, 7 million of them being children under eighteen (DeNavas-Walt, Proctor & Smith, 2013). Of the uninsured in 2012, 35.1 million were native-born Americans, 3.3 million were naturalized citizens, and 9.5 million were foreign-born noncitizen residents. Among adults aged eighteen to sixty-four, 15.3 million full-time workers were uninsured as compared to 13.1 million part-time workers who were uninsured—together representing 28.4 million, or more than half, of the uninsured that year (DeNavas-Walt, Proctor & Smith, 2013). This strongly suggested that a high percentage of employers were not providing healthcare insurance to their employees. In 2022, the number of uninsured Americans declined to 27.5 million (Tolbert, 2022).

In 2015 analysts began to chart the effect of the PPACA on the uninsured rate, and most signs were positive such as the above-mentioned decline in the number of uninsured Americans. The Kaiser Family Foundation reported that the uninsured rate for non-elderly Americans had dropped significantly from 2013 to 2015, reaching 10.5 percent after a peak of 20.4 percent. Critically, the poll noted that the largest declines came among minorities and those with low incomes.

Smith (2008) suggested there was a strong correlation between lack of insurance and poor health: "While it is difficult to separate the consequences of being uninsured from the factors that contribute to being uninsured (e.g., lack of employment, lower income), evidence indicates a strong correlation between not having insurance and not receiving regular healthcare and thus having poor health" (p. 147).

The problem of being uninsured creates a cycle of social problems. An uninsured person tends to avoid going to the doctor because of the inability to pay. As a result, any nascent condition the individual may have will likely be far worse by the time he or she does see a doctor. This creates the necessity for complicated testing and treatment that is far more expensive than if it had been dealt with at the beginning. Thus, the patient ends up in a vicious cycle in which he or she cannot pay for insurance but ends up owing hundreds and possibly thousands of dollars for medical care. He or she may be put on a public plan, supplemented by private insurance company premiums, a pattern that ultimately contributes to rates increasing.

As mentioned earlier, one of the reasons many go uninsured is due to a decline in employers providing healthcare benefits. "The recent drop in ESI coverage was due partly to a decline in health benefit offers by small employers, but also to fewer workers being 'eligible' for coverage or electing to participate in employers' plans" (Smith, 2008, p. 41).

Patient Protection and Affordable Care Act of 2010. The Patient Protection and Affordable Care Act (PPACA)—commonly called the Affordable Care Act (ACA) or Obamacare, after its major backer, President Barack Obama—sought to reform a number of aspects of health insurance policy, as well as improve the access to and quality of healthcare services. Since the passage of PPACA, insurers have been required to cover preventive services without a deductible, copayment, or other out-of-pocket expense; extend coverage to children with existing medical conditions; cover young adult children up to age twenty-six on their parents’ plans; spend most of their premiums on benefits to consumers, rather than administrative costs; and provide justification for rate increases. Starting in 2014, insurers were no longer allowed to set annual dollar limits on coverage, reject anyone based on preexisting medical conditions, discriminate against women, or restrict or deny coverage to those who participate in clinical trials. PPACA also expands Medicare coverage through the state governments (US Department of Health & Human Services, 2013).

The PPACA was intended to address the rising costs of health insurance in the United States, and most experts forecasted that it would eventually provide greater and more affordable coverage to the public while reducing the federal deficit. However, the law faced intense opposition even after its passage and a ruling by the US Supreme Court upholding its legality. The legislation's mandate that individuals purchase some form of health insurance was heavily criticized by many conservatives, including the mainstream Republican party, and several movements were made to repeal the law or strip it of many of its central components. The PPACA and the general state of partisan politics contributed greatly to the politicization of the health insurance debate in the United States, with many arguments fueled by emotion rather than fact. For example, many opponents of the PPACA fostered a belief that the law would create "death panels" to judge whether senior citizens would receive care and that illegal immigrants would be granted healthcare coverage, despite both being false.

As the PPACA was implemented, debate continued regarding its effectiveness. Several states chose not to accept the law's expansion of Medicaid coverage. Republican efforts to prevent the funding of the law led to the 2013 shutdown of the federal government, illustrating just how controversial and divisive health insurance policy can be in the United States. The PPACA faced challenges under the Republican administration of Donald Trump, though it was strengthened under the Democratic administration of Biden-Harris.

The insurance business remains an integral part of the US healthcare system in the twenty-first century. Even with all the changes implemented under PPACA, it will take a great deal of time and a determined effort to encourage employers to sponsor health insurance plans for their employees, to assist the uninsured in signing up for coverage, to ensure that insurers and employers comply with PPACA provisions, and to make necessary changes to SSDI and IHS.

Terms & Concepts

Blue Cross & Blue Shield Plans: As a group, one of the largest private health insurance plan in the US.

Coinsurance: The percentage of medical charges that an individual (or family) must pay for services after having paid the deductible.

Deductible: The amount an individual (or family) must pay upfront for care before benefits are paid by the insurance company.

Disability Income Insurance: Known as Social Security Disability Insurance (SSDI), it is provided to persons with permanent disabilities who cannot work and persons with disabilities who can work but earn an income below the level considered "gainful support." This category also encompasses group and individual insurance plans that provide for short- and long-term disability to prevent loss of income.

Health Maintenance Organizations (HMO): A type of managed care organization that provides healthcare coverage only through the hospitals, doctors, and other providers with which the HMO has a contract.

High Deductible Health Plan (HDHP): A health insurance plan that offers lower premiums that are compensated for through higher deductibles.

Health Savings Accounts: A savings account for medical purposes available to US employees enrolled in a high-deductible health plan. The funds deposited to the account are not subject to federal income tax at the time of deposit.

Indian Health Service (IHS): Operated by the US Department of Health and Human Services (HHS), IHS provides medical and public health services to members of federally recognized tribes and Alaska Natives.

Long-Term Care Insurance (LTC or LTCI): An insurance product that provides for the cost of long-term care beyond the predetermined and limited period covered by health insurance, Medicare, or Medicaid.

Managed Care: Medical techniques that are intended to lower the cost of providing health benefits and services and that improve the quality of care.

Medicare: The insurance program that provides health insurance coverage to people aged sixty-five and over or who meet other special criteria. It is administered by the US government.

Patient Protection and Affordable Care Act (PPACA): Also known as the Affordable Care Act (ACA) or Obamacare, a US law signed in 2010 intended to significantly overhaul the US healthcare system to provide greater and more affordable health insurance coverage.

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U.S. Bureau of Labor Statistics. (n.d). Definitions of health insurance terms. Retrieved November 13, 2013, from: http://www.bls.gov/ncs/ebs/sp/healthterms.pdf

U.S. Department of Health & Human Services. (2013). Key features of the Affordable Care Act by year. Retrieved November 13, 2013, from: http://www.hhs.gov/healthcare/facts/timeline/timeline-text.html

Warner, D. C. (2012). Access to health services for immigrants in the USA: From the Great Society to the 2010 Health Reform Act and after. Ethnic & Racial Studies, 35, 40–55. Retrieved November 13, 2013 from EBSCO online database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=69603629

Suggested Reading

Dhingra, S. S., Zack, M. M., Strine, T. W., Druss, B. G., & Simoes, E. (2013). Change in health insurance coverage in Massachusetts and other New England states by perceived health status: Potential impact of health reform. American Journal of Public Health, 103, e107–e114. Retrieved November 13, 2013 from EBSCO online database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=87069057

Gordon, C. (2004). Dead on arrival: The politics of health care in twentieth-century America. Princeton, NJ: Princeton University Press.

Herzlinger, R. (2007). Who killed health care?. Columbus, OH: McGraw-Hill.

Kim, J., Braun, B., & Williams, A. D. (2013). Understanding health insurance literacy: A literature review. Family & Consumer Sciences Research Journal, 42, 3–13. Retrieved January 8, 2015, from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=90055143&site=ehost-live&scope=site

Moisio, M. A ( 2000). A Guide to health insurance billing. Florence, KY: Thomson Delmar Learning.

Murray, J. E. (2007). Origins of American health insurance—A history of sickness funds. New Haven, CT: Yale University Press.

Niles, Nancy J. (2015). Basics of the US health care system. Burlington, MA: Jones & Bartlett Learning.

Qingyue, M., Beibei, Y., Liying, J., Jian, W., Baorong, Y., Jun, G., & Paul, G. (2011). Expanding health insurance coverage in vulnerable groups: A systematic review of options. Health Policy & Planning, 26, 93–104. Retrieved November 13, 2013 from EBSCO online database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=58614084

Stanhope, V. (2015, November). The Affordable Care Act: The good, the bad and the ugly. Affilia: Journal of Women & Social Work, 423–426. doi:10.1177/0886109915610269. Retrieved December 22, 2016, from EBSCO online database Sociology Source Ultimate. http://search.ebscohost.com/login.aspx?direct=true&db=sxi&AN=110445149&site=ehost-live&scope=site