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.
Medicare Advantage plans expand the health insurance options for people with Medicare. Medicare Advantage was created under the Balanced Budget Act of 1997, with the intent to better control the rapid growth in Medicare spending, as well as to provide Medicare beneficiaries more choices. But on average, Medicare Advantage plans cost 12% more than traditional Medicare. The ACA took steps to align payments to Medicare Advantage plans with the cost of traditional Medicare.
As far as the compulsory health insurance is concerned, the insurance companies cannot set any conditions relating to age, sex or state of health for coverage. Although the level of premium can vary from one company to another, they must be identical within the same company for all insured persons of the same age group and region, regardless of sex or state of health. This does not apply to complementary insurance, where premiums are risk-based.
In July 2009, Save Flexible Spending Plans, a national grassroots advocacy organization, was formed to protect against the restricted use of FSAs in health care reform efforts, Save Flexible Spending Accounts is sponsored by the Employers Council on Flexible Compensation (ECFC), a non-profit organization "dedicated to the maintenance and expansion of the private employee benefits on a tax-advantaged basis". ECFC members include companies such as WageWorks Inc., a benefits provider based in San Mateo, California.
Today, this system is more or less intact. All citizens and legal foreign residents of France are covered by one of these mandatory programs, which continue to be funded by worker participation. However, since 1945, a number of major changes have been introduced. Firstly, the different health care funds (there are five: General, Independent, Agricultural, Student, Public Servants) now all reimburse at the same rate. Secondly, since 2000, the government now provides health care to those who are not covered by a mandatory regime (those who have never worked and who are not students, meaning the very rich or the very poor). This regime, unlike the worker-financed ones, is financed via general taxation and reimburses at a higher rate than the profession-based system for those who cannot afford to make up the difference. Finally, to counter the rise in health care costs, the government has installed two plans, (in 2004 and 2006), which require insured people to declare a referring doctor in order to be fully reimbursed for specialist visits, and which installed a mandatory co-pay of €1 for a doctor visit, €0.50 for each box of medicine prescribed, and a fee of €16–18 per day for hospital stays and for expensive procedures.
Public programs provide the primary source of coverage for most seniors and also low-income children and families who meet certain eligibility requirements. The primary public programs are Medicare, a federal social insurance program for seniors (generally persons aged 65 and over) and certain disabled individuals; Medicaid, funded jointly by the federal government and states but administered at the state level, which covers certain very low income children and their families; and CHIP, also a federal-state partnership that serves certain children and families who do not qualify for Medicaid but who cannot afford private coverage. Other public programs include military health benefits provided through TRICARE and the Veterans Health Administration and benefits provided through the Indian Health Service. Some states have additional programs for low-income individuals. In 2011, approximately 60 percent of stays were billed to Medicare and Medicaid—up from 52 percent in 1997.
Early hospital and medical plans offered by insurance companies paid either a fixed amount for specific diseases or medical procedures (schedule benefits) or a percentage of the provider's fee. The relationship between the patient and the medical provider was not changed. The patient received medical care and was responsible for paying the provider. If the service was covered by the policy, the insurance company was responsible for reimbursing or indemnifying the patient based on the provisions of the insurance contract ("reimbursement benefits"). Health insurance plans that are not based on a network of contracted providers, or that base payments on a percentage of provider charges, are still described as indemnity or fee-for-service plans.
The remaining 45% of health care funding comes from insurance premiums paid by the public, for which companies compete on price, though the variation between the various competing insurers is only about 5%. However, insurance companies are free to sell additional policies to provide coverage beyond the national minimum. These policies do not receive funding from the equalization pool, but cover additional treatments, such as dental procedures and physiotherapy, which are not paid for by the mandatory policy.
While politically difficult, some politicians and observers have argued for a single-payer system. A bill, the United States National Health Care Act, was first proposed by Representative John Conyers in 2003 and has been perennially proposed since, including during the debate on the public option and the Patient Protection and Affordable Care Act. 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." Obama had previously expressed that he is a proponent of a single payer universal health care program during an AFL-CIO conference in 2003.
An individual with Cerebral Palsy will likely require specialized medical services throughout his or her lifetime. The expense for a chronic disability can greatly exceed the expense for standard care an individual without the condition incurs. Cerebral Palsy results in a chronic, physical impairment, which typically involves routine doctor visits, extended hospital stays, a range of therapies, planned surgeries, drug therapy, and adaptive equipment. Depending on the level of impairment, Cerebral Palsy usually requires a comprehensive, multidisciplinary health care team that may include any combination of the following: pediatrician, neurologist, radiologist, orthopedic surgeon, physical therapist, occupational therapist, and vocational therapist. Some individuals also require the assistance of a registered dietician, a speech pathologist, ophthalmologist, urologist, and a cosmetic dentist, amongst others.
Co-payments were introduced in the 1980s in an attempt to prevent over utilization. The average length of hospital stay in Germany has decreased in recent years from 14 days to 9 days, still considerably longer than average stays in the United States (5 to 6 days). Part of the difference is that the chief consideration for hospital reimbursement is the number of hospital days as opposed to procedures or diagnosis. Drug costs have increased substantially, rising nearly 60% from 1991 through 2005. Despite attempts to contain costs, overall health care expenditures rose to 10.7% of GDP in 2005, comparable to other western European nations, but substantially less than that spent in the U.S. (nearly 16% of GDP).
The blurring of distinctions between the different types of health care coverage can be seen in the history of the industry's trade associations. The two primary HMO trade associations were the Group Health Association of America and the American Managed Care and Review Association. After merging, they were known as American Association of Health Plans (AAHP). The primary trade association for commercial health insurers was the Health Insurance Association of America (HIAA). These two have now merged, and are known as America's Health Insurance Plans (AHIP).
Health insurance is a type of insurance coverage that pays for medical and surgical expenses incurred by the insured. Health insurance can reimburse the insured for expenses incurred from illness or injury, or pay the care provider directly. It is often included in employer benefit packages as a means of enticing quality employees. The cost of health insurance premiums is deductible to the payer, and the benefits received are tax-free.
Over time, the operations of many Blue Cross and Blue Shield operations have become more similar to those of commercial health insurance companies. However, some Blue Cross and Blue Shield plans continue to serve as insurers of last resort. Similarly, the benefits offered by Blues plans, commercial insurers, and HMOs are converging in many respects because of market pressures. One example is the convergence of preferred provider organization (PPO) plans offered by Blues and commercial insurers and the point of service plans offered by HMOs. Historically, commercial insurers, Blue Cross and Blue Shield plans, and HMOs might be subject to different regulatory oversight in a state (e.g., the Department of Insurance for insurance companies, versus the Department of Health for HMOs). Today, it is common for commercial insurance companies to have HMOs as subsidiaries, and for HMOs to have insurers as subsidiaries (the state license for an HMO is typically different from that for an insurance company). At one time the distinctions between traditional indemnity insurance, HMOs and PPOs were very clear; today, it can be difficult to distinguish between the products offered by the various types of organization operating in the market.
Having health insurance is important for several reasons. Uninsured people receive less medical care and less timely care, they have worse health outcomes, and lack of insurance is a fiscal burden for them and their families. Moreover, the benefits of expanding coverage outweigh the costs for added services. Safety-net care from hospitals and clinics improves access to care but does not fully substitute for health insurance. These findings are supported by much research, although some cautions are appropriate in using these results.
The Australian government announced in May 2008 that it proposes to increase the thresholds, to $100,000 for singles and $150,000 for families. These changes require legislative approval. A bill to change the law has been introduced but was not passed by the Senate. An amended version was passed on 16 October 2008. There have been criticisms that the changes will cause many people to drop their private health insurance, causing a further burden on the public hospital system, and a rise in premiums for those who stay with the private system. Other commentators believe the effect will be minimal.
Germans are offered three kinds of social security insurance dealing with the physical status of a person and which are co-financed by employer and employee: health insurance, accident insurance, and long-term care insurance. Long-term care insurance (Gesetzliche Pflegeversicherung) emerged in 1994 and is mandatory. Accident insurance (gesetzliche Unfallversicherung) is covered by the employer and basically covers all risks for commuting to work and at the workplace.
Some, if not most, health care providers in the United States 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. The insurance company pays out of network providers according to "reasonable and customary" charges, which may be less than the provider's usual fee. The provider may also have a separate contract with the insurer to accept what amounts to a discounted rate or capitation to the provider's standard charges. It generally costs the patient less to use an in-network provider.
Susan Heathfield makes every effort to offer accurate, common-sense, ethical Human Resources management, employer, and workplace advice both on this website, and linked to from this website, but she is not an attorney, and the content on the site, while authoritative, is not guaranteed for accuracy and legality, and is not to be construed as legal advice.
According to a 2007 study, about 59% of employers at small firms (3–199 workers) in the US provide employee health insurance. The percentage of small firms offering coverage has been dropping steadily since 1999. The study notes that cost remains the main reason cited by small firms who do not offer health benefits. Small firms that are new are less likely to offer coverage than ones that have been in existence for a number of years. For example, using 2005 data for firms with fewer than 10 employees, 43% of those that had been in existence at least 20 years offered coverage, but only 24% of those that had been in existence less than 5 years did. The volatility of offer rates from year to year also appears to be higher for newer small businesses.