What is it? Medicare is a federal program that primarily serves individuals aged 65 and older, as well as some younger individuals with disabilities or certain health conditions (e.g., end-stage renal disease).
Parts of Medicare:
Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care.
Part B (Medical Insurance): Covers outpatient care, doctor visits, preventive services, and certain medical equipment.
Part C (Medicare Advantage): A private plan option that includes both Part A and Part B benefits, often with additional coverage like prescription drugs.
Part D (Prescription Drug Coverage): Provides prescription drug coverage through private plans.
Medicaid:
What is it? Medicaid is a joint federal and state program that provides health coverage to low-income individuals and families, including children, pregnant women, the elderly, and people with disabilities.
Eligibility: Varies by state but generally includes low-income individuals and families. Eligibility is based on income level, household size, and sometimes other factors like disability or pregnancy.
Expansion under the Affordable Care Act (ACA): Many states expanded Medicaid to cover more people with incomes up to 138% of the federal poverty level.
The Affordable Care Act (ACA):
What is it? The ACA, also known as Obamacare, was passed in 2010 to reduce the number of uninsured Americans and make healthcare more affordable.
Key Features:
Marketplace/Exchanges: States have established health insurance exchanges where individuals and families can shop for and compare private health insurance plans.
Subsidies: Low- and moderate-income individuals and families can receive subsidies to reduce the cost of insurance premiums and out-of-pocket expenses.
Medicaid Expansion: As mentioned, many states expanded Medicaid under the ACA, providing coverage to more low-income individuals.
Protections: The ACA includes protections like pre-existing conditions coverage, no lifetime limits, and essential health benefits.
2. Private Health Insurance:
Employer-Sponsored Insurance (ESI):
The majority of Americans (about 49%) receive health insurance through their employer. Employers typically offer several plan options with varying levels of coverage, deductibles, and premiums.
Benefits: Employers often pay a portion of the premiums, making it more affordable for employees.
Challenges: If you’re self-employed or your employer doesn’t offer insurance, you need to explore other options.
Individual Health Insurance Plans:
If you don’t have access to employer-sponsored insurance, you can purchase individual insurance through the Health Insurance Marketplace (if you’re eligible for ACA plans) or through private insurers.
These plans come with a variety of coverage options but can be expensive if you don’t qualify for subsidies under the ACA.
3. Costs of Health Insurance:
Premiums: This is the monthly amount you pay for your health insurance plan, regardless of whether you use healthcare services.
Deductibles: The amount you must pay out-of-pocket for healthcare services before your insurance starts covering the costs.
Co-pays/Co-insurance: After meeting the deductible, these are the payments you make for each service (e.g., a doctor visit) or percentage of costs for services.
Out-of-Pocket Maximums: The most you will pay for covered services in a policy period (usually a year). Once you reach this limit, the insurance company covers 100% of additional covered costs.
4. Types of Health Insurance Plans:
Health Maintenance Organization (HMO): Requires choosing a primary care physician (PCP) and getting referrals to see specialists. Lower costs, but less flexibility.
Preferred Provider Organization (PPO): Offers more flexibility in choosing healthcare providers and specialists without a referral but usually comes with higher premiums.
Exclusive Provider Organization (EPO): Similar to PPOs but requires using network providers only, except in emergencies.
Point of Service (POS): Combines features of HMO and PPO; you choose a primary care doctor but can go out of network for higher costs.
5. Major Health Insurers in the USA:
UnitedHealthcare
Blue Cross Blue Shield
Cigna
Aetna
Humana
Kaiser Permanente
Challenges in the U.S. Health Insurance System:
Cost: Health insurance premiums, deductibles, and co-pays can be expensive. Even with insurance, out-of-pocket costs can be burdensome.
Access: There are disparities in access to care based on income, location, and whether someone qualifies for government programs.
Complexity: The system is fragmented, with different insurers, programs, and regulations at the federal and state levels, which can make it difficult to navigate.
