ageing, menopause and puberty; AIDS/HIV; allergies or allergic disorders; birth control, conception, sexual problems and sex changes; chronic conditions; complications from excluded or restricted conditions/ treatment; convalescence, rehabilitation and general nursing care ; cosmetic, reconstructive or weight loss treatment; deafness; dental/oral treatment (such as fillings, gum disease, jaw shrinkage, etc); dialysis; drugs and dressings for out-patient or take-home use† ; experimental drugs and treatment; eyesight; HRT and bone densitometry; learning difficulties, behavioural and developmental problems; overseas treatment and repatriation; physical aids and devices; pre-existing or special conditions; pregnancy and childbirth; screening and preventive treatment; sleep problems and disorders; speech disorders; temporary relief of symptoms.[40] († = except in exceptional circumstances)

High-quality health care affects health and wellness. A health insurance policy is a contract between an insurance company and a policy holder intended to safeguard against high and unexpected health care costs. Although policy-holders pay a monthly premium, co-payments, co-insurance, and deductibles, it is expected that the total is far less than that required if paid fully out-of-pocket.
In the late 1990s federal legislation had been proposed to "create federally-recognized Association Health Plans which was then "referred to in some bills as 'Small Business Health Plans.'[79] The National Association of Insurance Commissioners (NAIC), which is the "standard-setting and regulatory of chief insurance regulators from all states, the District of Columbia and territories, cautioned against implementing AHPs citing "plan failures like we saw The Multiple Employer Welfare Arrangements (MEWAs) in the 1990s."[80] "[S]mall businesses in California such as dairy farmers, car dealers, and accountants created AHPs "to buy health insurance on the premise that a bigger pool of enrollees would get them a better deal."[81] A November 2017 article in the Los Angeles Times described how there were only 4 remaining AHPs in California. Many of the AHPs filed for bankruptcy, "sometimes in the wake of fraud." State legislators were forced to pass "sweeping changes in the 1990s" that almost made AHPs extinct.[81]
Many Democratic politicians were publicly in favor of the public option for a variety of reasons. President Obama continued campaigning for the public option during the debate. In a public rally in Cincinnati on September 7, 2009, President Obama said: "I continue to believe that a public option within the basket of insurance choices would help improve quality and bring down costs."[23] The President also addressed a Joint Session of Congress on September 9, 2009, reiterating his call for a public insurance option, saying that he had "no interest in putting insurance companies out of business" while saying that the public option would "have to be self-sufficient" and succeed by reducing overhead costs and profit motives.[24] Democratic Representative Sheila Jackson-Lee, who represents the 18th congressional district in Houston, believed that a "vigorous public option" would be included in the final bill and would "benefit the state of Texas."[25]
Scheduled health insurance plans are an expanded form of Hospital Indemnity plans. In recent years, these plans have taken the name mini-med plans or association plans. These plans may provide benefits for hospitalization, surgical, and physician services. However, they are not meant to replace a traditional comprehensive health insurance plan. Scheduled health insurance plans are more of a basic policy providing access to day-to-day health care such as going to the doctor or getting a prescription drug, but these benefits will be limited and are not meant to be effective for catastrophic events. Payments are based upon the plan's "schedule of benefits" and are usually paid directly to the service provider. These plans cost much less than comprehensive health insurance. Annual benefit maximums for a typical scheduled health insurance plan may range from $1,000 to $25,000.

Insurance against loss by illness or bodily injury. Health insurance provides coverage for medicine, visits to the doctor or emergency room, hospital stays and other medical expenses. Policies differ in what they cover, the size of the deductible and/or co-payment, limits of coverage and the options for treatment available to the policyholder. Health insurance can be directly purchased by an individual, or it may be provided through an employer. Medicare and Medicaid are programs which provide health insurance to elderly, disabled, or un-insured individuals.
Deductible: The amount that the insured must pay out-of-pocket before the health insurer pays its share. For example, policy-holders might have to pay a $500 deductible per year, before any of their health care is covered by the health insurer. It may take several doctor's visits or prescription refills before the insured person reaches the deductible and the insurance company starts to pay for care. Furthermore, most policies do not apply co-pays for doctor's visits or prescriptions against your deductible.
Broader levels of health insurance coverage generally have higher premium costs. In many cases, the insured party is responsible for paying his/her healthcare provider an up-front, tax deductible amount called co-pay. Health insurance companies then may compensate healthcare providers directly or reimburse the policy holder based on the remaining portion of an itemized bill.
Fringe benefits are generally included in an employee’s gross income (there are some exceptions). The benefits are subject to income tax withholding and employment taxes. Fringe benefits include cars and flights on aircraft that the employer provides, free or discounted commercial flights, vacations, discounts on property or services, memberships in country clubs or other social clubs, and tickets to entertainment or sporting events.
Plans with much higher deductibles than traditional health plans—primarily providing coverage for catastrophic illness—have been introduced.[105] Because of the high deductible, these provide little coverage for everyday expenses—and thus have potentially high out-of-pocket expenses—but do cover major expenses. Couple with these are various forms of savings plans.
As the population covered by Medicare grows, its costs are projected to rise from slightly over 3 percent of GDP to over 6 percent, contributing substantially to the federal budget deficit.[47] In 2011, Medicare was the primary payer for an estimated 15.3 million inpatient stays, representing 47.2 percent ($182.7 billion) of total aggregate inpatient hospital costs in the United States.[12] The Affordable Care Act took some steps to reduce Medicare spending, and various other proposals are circulating to reduce it further.
Most provider markets (especially hospitals) are also highly concentrated—roughly 80%, according to criteria established by the FTC and Department of Justice[118]—so insurers usually have little choice about which providers to include in their networks, and consequently little leverage to control the prices they pay. Large insurers frequently negotiate most-favored nation clauses with providers, agreeing to raise rates significantly while guaranteeing that providers will charge other insurers higher rates.[119]
An alternative proposal is to subsidize private, non-profit health insurance cooperatives to get them to become large and established enough to possibly provide cost savings[27][28] Democratic politicians such as Howard Dean were critical of abandoning a public option in favor of co-ops, raising questions about the ability of the cooperatives to compete with existing private insurers.[6] Paul Krugman also questioned the ability of cooperatives to compete.[29]
In the late 1990s federal legislation had been proposed to "create federally-recognized Association Health Plans which was then "referred to in some bills as 'Small Business Health Plans.'[79] The National Association of Insurance Commissioners (NAIC), which is the "standard-setting and regulatory of chief insurance regulators from all states, the District of Columbia and territories, cautioned against implementing AHPs citing "plan failures like we saw The Multiple Employer Welfare Arrangements (MEWAs) in the 1990s."[80] "[S]mall businesses in California such as dairy farmers, car dealers, and accountants created AHPs "to buy health insurance on the premise that a bigger pool of enrollees would get them a better deal."[81] A November 2017 article in the Los Angeles Times described how there were only 4 remaining AHPs in California. Many of the AHPs filed for bankruptcy, "sometimes in the wake of fraud." State legislators were forced to pass "sweeping changes in the 1990s" that almost made AHPs extinct.[81]

Other managed care techniques include such elements as disease management, case management, wellness incentives, patient education, utilization management and utilization review. These techniques can be applied to both network-based benefit programs and benefit programs that are not based on a provider network. The use of managed care techniques without a provider network is sometimes described as "managed indemnity."
The types of coverage available to small employers are similar to those offered by large firms, but small businesses do not have the same options for financing their benefit plans. In particular, self-funded health care (whereby an employer provides health or disability benefits to employees with its own funds rather than contracting an insurance company[68]) is not a practical option for most small employers.[69] A RAND Corporation study published in April 2008 found that the cost of health care coverage places a greater burden on small firms, as a percentage of payroll, than on larger firms.[70] A study published by the American Enterprise Institute in August 2008 examined the effect of state benefit mandates on self-employed individuals, and found that "the larger the number of mandates in a state, the lower the probability that a self-employed person will be a significant employment generator."[71] Beneficiary cost sharing is, on average, higher among small firms than large firms.[72]
The public health insurance option, also known as the public insurance option or the public option, is a proposal to create a government-run health insurance agency that would compete with other private health insurance companies within the United States. The public option is not the same as publicly funded health care, but was proposed as an alternative health insurance plan offered by the government. The public option was initially proposed for the Patient Protection and Affordable Care Act, but was removed after Sen. Joe Lieberman (I-CT) threatened a filibuster.[1][2]

Employers and employees may have some choice in the details of plans, including health savings accounts, deductible, and coinsurance. As of 2015, a trend has emerged for employers to offer high-deductible plans, called consumer-driven healthcare plans which place more costs on employees; some employers will offer multiple plans to their employees.[71]
Deductible: The amount that the insured must pay out-of-pocket before the health insurer pays its share. For example, policy-holders might have to pay a $500 deductible per year, before any of their health care is covered by the health insurer. It may take several doctor's visits or prescription refills before the insured person reaches the deductible and the insurance company starts to pay for care. Furthermore, most policies do not apply co-pays for doctor's visits or prescriptions against your deductible.
The bottom line? Uninsured people tend to be sicker and are more likely to die prematurely than their peers who do have health insurance.  Even adults who are young and healthy can benefit from preventive care, annual checkups and chronic disease management – be it for allergies, depression, asthma, diabetes or another type of condition. And women, in particular, benefit from gynecological and reproductive care.

Between October 28 and November 13, 2009, Democratic Senator Dick Durbin's campaign organization polled Americans to rank their support for various forms of the "public option" currently under consideration by Congress for inclusion in the final health care reform bill. The 83,954 respondents assigned rankings of 0 to 10. A full national option had the most support, with an 8.56 average, while no public option was least favored, with a 1.10 average.[52]


The Commonwealth Fund, in its annual survey, "Mirror, Mirror on the Wall", compares the performance of the health care systems in Australia, New Zealand, the United Kingdom, Germany, Canada and the U.S. Its 2007 study found that, although the U.S. system is the most expensive, it consistently under-performs compared to the other countries.[6] One difference between the U.S. and the other countries in the study is that the U.S. is the only country without universal health insurance coverage.
Historically, health insurance has been regulated by the states, consistent with the McCarran-Ferguson Act. Details for what health insurance could be sold were up to the states, with a variety of laws and regulations. Model acts and regulations promulgated by the National Association of Insurance Commissioners (NAIC) provide some degree of uniformity state to state. These models do not have the force of law and have no effect unless they are adopted by a state. They are, however, used as guides by most states, and some states adopt them with little or no change.
While politically difficult, some politicians and observers have argued for a single-payer system.[30] A bill, the United States National Health Care Act, was first proposed by Representative John Conyers in 2003[31] and has been perennially proposed since, including during the debate on the public option and the Patient Protection and Affordable Care Act.[32] President Obama has come out against a single-payer reform at this time, stating in the joint session of Congress that "it makes more sense to build on what works and fix what doesn't, rather than try to build an entirely new system from scratch."[33] Obama had previously expressed that he is a proponent of a single payer universal health care program during an AFL-CIO conference in 2003.[34]
Medicaid was instituted for the very poor in 1965. Since enrollees must pass a means test, Medicaid is a social welfare or social protection program rather than a social insurance program. Despite its establishment, the percentage of US residents who lack any form of health insurance has increased since 1994.[51] It has been reported that the number of physicians accepting Medicaid has decreased in recent years because of lower reimbursement rates.[52]
Employer-sponsored health insurance plans dramatically expanded as a direct result of wage controls imposed by the federal government during World War II.[20] The labor market was tight because of the increased demand for goods and decreased supply of workers during the war. Federally imposed wage and price controls prohibited manufacturers and other employers from raising wages enough to attract workers. When the War Labor Board declared that fringe benefits, such as sick leave and health insurance, did not count as wages for the purpose of wage controls, employers responded with significantly increased offers of fringe benefits, especially health care coverage, to attract workers.[20]
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