Their Health Insurance Coverage Through Benefits Programs example essay topic

To Health and Back To understand health care and its complexities, let's first take a look at how it is defined in the dictionary. The American Heritage Dictionary defines health care as the prevention, treatment, and management of illness and the preservation of mental and physical well-being through the services offered by the medical and allied health professions. Now that we have a definition of health care let us further explore and understand the concepts of traditional and alternative health care. To begin with, all American health care is provided to patients by a diverse array of entities. There are nonprofit hospitals, which may be operated by county governments, state governments, religious orders, or independent nonprofit organizations.

There are for-profit hospitals, which are usually operated by large private corporations. There are many outpatient clinics, which may be operated by any of the above organizations or may be a partnership of health care professionals (essentially a large medical or dental group). Finally, there are some health care professionals who individually, or in a group, practice for personal profit. Costs of medical supplies (consumables), machines, tools, and pharmaceuticals are usually passed through to the patient or their insurer. The default legal situation has always been that the patient must pay out-of-pocket in full for all services rendered, as with any other service industry; this business model is known as "fee-for-service".

But today, fee-for-service is only for the minority of people who are not covered by any kind of insurance. Most people are covered by some kind of cost-spreading insurance which distributes the risk of illness and the cost of health care among a group of people. This means that each individual or their employer pays predictable monthly premiums, so that when any given individual needs health care, they will have to pay up-front one of the following: (1) nothing (increasingly rare), (2) a minimum part of the total cost (a deductible), or (3) a small part of the cost of every single procedure (a co-payment). The entity that provides the health care is usually not the same entity that does the task of spreading the cost of it. The exceptions are health maintenance organizations like Kaiser Permanente which run their own hospital and clinic networks to control costs, and a few employers which employ an in-house physician or even operate their own outpatient clinics. Instead, most people receive their health insurance coverage through benefits programs provided by employers.

Most of the remainder is covered by government insurance programs like Medicare and Medicaid, and various state and local programs for the poor. Either way, health care providers must bill a patient's insurer for the cost of services rendered. The billing process is generally considered to be one of the most inefficient and wasteful parts of our health care system, for the following reasons: (1). The lack of a national identity card forces insurers to impose many bureaucratic procedures like pre-authorization of non-emergency procedures upon both providers and patients to guard against fraud; (2). The insurers have a financial interest in denying coverage for any reason, and providers and patients have a financial interest in fighting denials of coverage, and both end up wasting time and money in the process; (3). The extreme fragmentation of the entire industry forces all entities to waste a lot of time learning about each other's bureaucratic procedures, because of the low probability that any pair of provider and insurer will regularly encounter each other; and (4).

Much of the health care industry still operates on inefficient paper documents, because no entity outside the federal government has the market power to impose a single standard for digital transmission of health care information, and the federal government has been unable to create such a standard as of 2005. The enrollment rules for many health insurance companies result in millions of people going without health care coverage, including children. Most uninsured people are working-class persons between the ages of 2 and 65 whose employers do not provide health insurance, and who earn too much money to qualify for one of the local or state insurance programs for the poor, but do not earn enough to cover the cost of enrollment in a health insurance plan designed for individuals. Some states do offer limited insurance coverage for working-class children, but not for adults; other states do not offer such coverage at all, and so, both parent and child are caught in what is called a coverage "gap". However, such persons cannot be left to die in the street.

Since 1986, a controversial federal law, EM TALA, has required all American emergency rooms which bill federal healthcare programs to stabilize all incoming patients without regard to their ability to pay. This law was created as an un-funded mandate; the federal government and the state governments have never fully compensated both public and private hospitals for the full cost of such emergency charity care. The hospitals do attempt to bill uninsured patients directly under the fee-for-service model, but most such people cannot pay their hospital fees, and escape into bankruptcy when hospitals seek legal process against them. As a result, innumerable private hospitals have gone out of business since 1986.

Others have raised prices on those that can pay to avoid going out of business. Some physicians have vociferously questioned the ability of the remaining emergency rooms, particularly in smaller cities, to respond to very large-scale disasters like 9/11. Although it certainly keeps alive many working-class people who are badly injured, another problem is that the 1986 law neither requires the provision of preventive or rehabilitative care, nor subsidizes such care, and it certainly does nothing about the difficulties in the American mental health system. In turn, in many American cities, it is common for mentally ill homeless people to "cycle" through emergency rooms. When admitted, such patients can be suffering from numerous diseases and malnutrition; hospitals clean them up and nurse them back to health, then discharge them to the street at the first legally justifiable opportunity; and then the same patients are back in the ER in three to six months after becoming critically ill again. The hospital often ends up absorbing the full cost of care, since many homeless people are convicted drug addicts, which makes them ineligible for almost all federal and state assistance programs for the poor.

In the end, hospitals spread the cost to the patients who can pay (by raising prices on everything), which only further increases the total cost of health care for everyone. This increase in total cost may also cause additional people to become uninsured as insurance companies pass on the cost. Finally, the unavailability of preventive care and the high cost of paying out-of-pocket means that many working-class persons delay visiting an emergency room as long as possible. In turn, such persons are more vulnerable to catastrophic diseases that could have been much more easily treated if identified early through regular checkups (like cancer and heart disease). The financial cost of treating those diseases at a late stage is also much higher.