So, before all of the massive hate on this post beings, let me preemptively state the fact that I am simply trying to learn this stuff to help me become a better doctor. Believe me when I say that - as someone in medical school - it is to my extreme embarrassment that I am not better informed on this subject. I won't make excuses for myself, but I will say but no one has ever taken the time to explain these things to me clearly. Whatever little I do comprehend about health insurance and health coverage I have picked up as dribs and drabs of information along my life. Hopefully, this post will help someone out there as clueless as I am when it comes to this stuff. Health insurance, much like taxes, were not something I really had to think about when I was growing up. Now that I find myself in the medical field, I feel incredibly ashamed not to be more learned regarding these things:
With that, please help me to understand any of these questions if you can
1) What are the various forms of health coverage one can receive (all I really understand are plans via HMOs)? What is a premium, copay, and deductible?
2) How does one buy health insurance?
3) Do companies exist that automatically give you health insurance by nature of working for them? Do hospitals provide free health insurance for their employees?
4) For what medical services and drugs are hospitals allowed to deny you service if you don't have health insurance or the ability to pay? Anything that isn't immediately life-saving (like CPR)?
5) Who qualifies for Medicare? How much of health costs does it pay?
6) Who qualifies for Medicaid? How much of health costs does it pay?
3) Does the Affordable Care Act guarantee everyone health insurance? Why do some people complain about the Affordable Care Act?
Oh my. Some good responses above but some errors tossed in throughout. Honestly, the best way to learn about insurance is to start buying your own and then try using it. I used to buy my own private insurance prior to ACA and learned most of this the hard way.
1) broadly speaking there are HMOs and PPOs. Sounds like you already know how an HMO works so I'll skip that. A PPO (preferred provider organization) is a contracted agreement between numerous doctors and hospitals (the network) and the insurance company. It will pay for all your care at a specified rate after you've met your annual deduible (typically they pay 80% and you pay 20%). Within this network you can select any doctor currently accepting new patients to be your pcp. You can get your pcp to refer you to specialists just like in an HMO, but you can also just go see the specialist yourself and the PPO will still pay for it if the doc is in your network. PPO plans will also pay for care that's outside your network but at a VERY reduced rate, typically 50-60% of "reasonable and customary charges." Who defines that? I'll give you three guesses....
Premium: this is your monthly bill. If you buy your own plan you pay all of it. If you get it through your employer you typically pay part of it and your employer pays the rest. These can vary wildly depending on the level of coverage and your age. Typically premiums start at around $150-200 a month per person for someone young and healthy, but even this can vary wildly even by zip code. Definitely check out the health insurance exchanges and see what it costs in your area.
Copay: amount you pay immediately at the time of a given service. Labs and imaging and procedures are extra. So if your copay is 30 bucks to see your pcp and you get a cold, you'll pay $30. Period. Doesn't matter if you've met your deductible or not, you pay 30 bucks for that service. The insurance company will Pay the rest. Now if the md orders a chest X-ray because your story makes him concerned for pneumonia, then you would be billed separately for your X-ray. The insurance would pay that at the agreed rate (80/20, etc) unless you hadn't met your deductible in which case you'd pay all of it at their contracted rate.
Deductible: amount, excluding copays, you must fork out every year before the insurance starts paying anything. These range from $250 for the best plans up to $5000 or more for cheaper ones. As you can imagine, these are a huge determinant of your premiums. Here's a big point I alluded to above: if you haven't met your deductible and you get a bill, you pay it at the insurance company's agreed rate. Whenever you see news reports about it costing $80,000 to get a knee replacement, they are NOT talking about any insurer's agreed rate. The only people who see that bill are the uninsured. If you have insurance, even before letting your deductible, you pay the previously contracted rate. For the X-ray, the uninsured rate may be $200; the insured agreement rate may be $75. That's what you would pay. If you'd met your deductible, you'd pay 20% or so of 75.
Out of pocket maximum: not counting your deductible, this is the most you will have to pay out of pocket in a given year. After that, the insurance pays 100% of care. Typically range from 2-10k. These can really kick in for older sicker people who aren't 65 and eligible for Medicare yet. Also have a major impact on price.
2) through the exchanges or through an employer
3) few employers pay the entire cost of health insurance anymore, but many will pay a substantial portion. They also tend to get better rates than individuals on the open market. Many companies and hospitals will self insure and pay an insurance company to administer the plan while the company is actually paying the bills. Big hospitals will frequently self insure and offer a more affordable plan where they are the in-network provider.
4) ah the emtala.... This covers any hospital with an ED that sees Medicare patients (so basically every hospital). This basically says that any patient who walks in the door must be treated and stabilized. If someone comes in with chest pain, they'll get the whole workup and, if indicated, go to the cath lab or even have a CABG regardless of their ability to pay. They will remain hospitalized until they are medically stable for discharge, even if they can't pay. Now let's say they got some stents and are started on your typical post MI/pci meds. The hospital does not have to provide their medication for life after discharge. So if the person can't afford their plavix and their other meds, the hospital doesn't have to pay. Now, if the guy thromboses his stent and comes back to the ED, you guessed it, hospital provides all that care again. For this reason, most hospitals will find ways to help patients pay for the most essential medications, but even then it's an uphill battle. And the patient will get a crazy will on the order of six figures or more. He won't pay. If he lives in one of the 45 states that allows it, he'll eventually be sued for it and likely declare bankruptcy to discharge the debt.
5) Medicare is for everyone over 65 and anyone with esrd regardless of age. Pays 100% of hospital care. Outpatient and drugs are covered under parts B and D respectively. There are some gaps in what Medicare pays and typically seniors will purchase a Medicare supplemental insurance plan to cover these.
6) Medicaid is for the poor. In states with Governors who have an IQ above room temperature, Medicaid is for everyone making under 15k a year. Typically it covers everything but doctors and hospitals hate it because it pays crap and takes forever to even pay the md the little bit it does. But it's better than nothing. Many physicians will not accept Medicaid patients for this reason, so thy can have trouble finding care. All hospitals will accept it since they're bound by emtala to provide emergency care anyhow. It does usually cover drugs too but the patients typically have a modest copay.
7) the ACA was intended to guarantee everyone insurance but has fallen far short of that. The biggest reason is the number of states that refused to expand Medicaid. Everyone else gets insurance through an employer or by purchasing a private plan on the exchange. There is no ACA network as a poster above alluded to and the ACA itself does not limit your ability to chose your doctor. There is no such thing as an ObamaCare or ACA insurance plan and nobody in the country has an insurance card that says ACA on it.
The ACA requires that everyone be allowed to purchase insurance regardless of preexisting conditions. My pre-ACA plan actually had a rider excluding coverage for anything I'd ever seen my doctor for as a child and young adult, and many more people got denied entirely. Diabetes? Nobody would sell you a policy. This was a big way that insurers kept costs down.
A lot of the ACA plans, especially the less expensive ones, have very limited networks of physicians and hospitals. Many people felt broadsided when they purchased these plans and could no longer see their regular physician. They heard the president say you could keep your doctor and assumed this applied to every plan, but failed to account for insurance companies trying to control their costs in whatever legal way they could. You can absolutely buy plans on the ACA exchanges that cover your preferred doctor, but you may have to pay more.
There are subsidies available to help people afford their insurance, but the costs for some families can be pretty high. A number of people had been going without insurance and their budgets were not able to absorb a new massive monthly bill. The subsidies are also based on the least expensive mid tier (silver) plan in your area, so most people gravitated to these cheaper plans with limited coverage networks.
If you want to get an idea of how these all play together, go on the exchange in your state and shop around for coverage for some hypothetical people. See what your parents would have to pay. See what you would have to pay.
Understanding the basics of insurance is huge and even tested now on all the usmle steps. I frequently have to think about these and other things when I'm discharging patients and arranging follow up care.
