In 2003, according to the Heartland Institute's Merrill Matthews, association group health insurance plans offered affordable health insurance to "some 6 million Americans." Matthews responded to the criticism that said that some associations work too closely with their insurance providers. He said, "You would expect the head of AARP to have a good working relationship with the CEO of Prudential, which sells policies to AARP's seniors."
Prior to the ACA as of 2007, about 9% of Americans were covered under health insurance purchased directly, with average out-of-pocket spending is higher in the individual market, with higher deductibles, co-payments and other cost-sharing provisions. While self-employed individuals receive a tax deduction for their health insurance and can buy health insurance with additional tax benefits, most consumers in the individual market do not receive any tax benefit.
Health insurance is a benefit provided through a government agency, private business, or non-profit organization. To determine cost, a provider estimates collective medical expenses of a population, then divides that risk amongst the group of policy subscribers. In concept, insurers recognize that one person may incur large unexpected expenses, while another may incur none. The expense, then, is spread among a group of individuals to make health care more affordable for the common good of all. In addition, public health programs like Medicare, Medicaid, and SCHIP are federally-funded and state-run to provide additional medical coverage to those in vulnerable groups who qualify, such as seniors and those with disability.
The US health insurance market is highly concentrated, as leading insurers have carried out over 400 mergers from the mid-1990s to the mid-2000s (decade). In 2000, the two largest health insurers (Aetna and UnitedHealth Group) had total membership of 32 million. By 2006 the top two insurers, WellPoint (now Anthem) and UnitedHealth, had total membership of 67 million. The two companies together had more than 36% of the national market for commercial health insurance. The AMA has said that it "has long been concerned about the impact of consolidated markets on patient care." A 2007 AMA study found that in 299 of the 313 markets surveyed, one health plan accounted for at least 30% of the combined health maintenance organization (HMO)/preferred provider organization (PPO) market. In 90% of markets, the largest insurer controls at least 30% of the market, and the largest insurer controls more than 50% of the market in 54% of metropolitan areas. The US Department of Justice has recognized this percentage of market control as conferring substantial monopsony power in the relations between insurer and physicians.
^ Bump, Jesse B. (19 October 2010). "The long road to universal health coverage. A century of lessons for development strategy" (PDF). Seattle: PATH. Retrieved 10 March 2013. Carrin and James have identified 1988—105 years after Bismarck's first sickness fund laws—as the date Germany achieved universal health coverage through this series of extensions to minimum benefit packages and expansions of the enrolled population. Bärnighausen and Sauerborn have quantified this long-term progressive increase in the proportion of the German population covered by public and private insurance. Their graph is reproduced below as Figure 1: German Population Enrolled in Health Insurance (%) 1885–1995.
Bärnighausen, Till; Sauerborn, Rainer (May 2002). "One hundred and eighteen years of the German health insurance system: are there any lessons for middle- and low income countries?" (PDF). Social Science & Medicine. 54 (10): 1559–87. doi:10.1016/S0277-9536(01)00137-X. PMID 12061488. Retrieved 10 March 2013. As Germany has the world's oldest SHI [social health insurance] system, it naturally lends itself to historical analyses.
Prior to the Patient Protection and Affordable Care Act, effective from 2014, about 34 states offered guaranteed-issuance risk pools, which enabled individuals who are medically uninsurable through private health insurance to purchase a state-sponsored health insurance plan, usually at higher cost, with high deductibles and possibly lifetime maximums. Plans varied greatly from state to state, both in their costs and benefits to consumers and in their methods of funding and operations. The first such plan was implemented In 1976.
Americans are required to carry medical insurance that meets federally designated minimum standards or face a tax penalty. In certain cases, taxpayers may qualify for an exemption from the penalty if they were unable to obtain insurance due to financial hardship or other situations. Two public health insurance plans, Medicare and the Children's Health Insurance Program, target older individuals and children, respectively. Medicare also serves people with certain disabilities. The program is available to anyone age 65 or older. The CHIP plan has income limits and covers babies and children up to the age of 18.
Generally, group health insurance plans cover the cost of medical office visits for illness and checkups, hospitalization, emergency room services, ambulance transportation, operations, physical therapy, and even prescription drugs, to provide several examples of potentially covered health care services. But, every plan is different and it behooves an employee to become familiar with the details of his or her employer's plan before the benefit is needed.
Another distinction between plans that can change the rates you pay, is the type of network the plan uses. Depending on whether the plan is a PPO, HMO, EPO or POS plan, consumers will have access to the health care providers managed in different ways. HMOs tend to be the most restrictive about which doctors you can see and what you must do to see them. This usually means that the insurers save on your cost of care and thereby provide lower premiums.
The proportion of non-elderly individuals with employer-sponsored cover fell from 66% in 2000 to 56% in 2010, then stabilized following the passage of the Affordable Care Act. Employees who worked part-time (less than 30 hours a week) were less likely to be offered coverage by their employer than were employees who worked full-time (21% vs. 72%).