Introduction

The health system in the United States is continually evolving. On this subject, it is known that change is the only constant. Since the passage of the Affordable Care Act (ACA), the American health system has faced more significant change than at any other time since the approval of Medicare and Medicaid during the 1960s.

Health care in the USA: Medicare and Medicaid

In the USA, they operate exclusively public, other mixed and private health systems. In relation to public systems, the two largest are Medicaid and Medicare. Thus, the elderly are offered Medicare, a social insurance system created in 1965, funded by the federal government, which provides health care to the population over 65 years old, as well as for people under 65 years old with some disability and those of any age with chronic renal failure. Medicare includes hospital insurance, medical insurance, and coverage for certain medications.

Regarding Medicaid, the focus of health care is focused on people and low-income families. It is an insurance administered by the State that must provide health care to American citizens or citizens with permanent residence visas in the USA, which includes low-income adults, their children and people with disabilities.

Private assistance

Regarding health care in the USA, it can be understood that many citizens who do not fit the conditions of Medicare and Medicaid make use of private health plans. Thus, since there are several plans offered, they are distinguished in relation to the way the care is made, deductible amounts, co-participation and coverage.

In general, health insurance is offered by the companies in which citizens work. However, there is still the option for the citizen to directly contract a private plan, which should involve a higher cost.

Companies offer their employees a health plan as a benefit, but it is important to note that they pre-select plans with one or more health insurance companies. In this context, the employee will be able to choose between the plans they have contracted.

Some companies may offer variations of a plan of the same type by changing only coverage amounts, and other companies may offer various types of plans and coverages (some of which may be from different insurers). Thus, as part of employee benefits, companies generally must pay a portion of the plan; and the employee, the other party, or, in certain cases, the company may pay for the entire plan.

In the following box it is possible to better understand private assistance through the types of plans:

Health Maintenance Organization (HMO):
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Refers to a type of coverage that includes access to a general practitioner, emergency care, specialization and hospitalization when necessary. In addition, for “HMO”, the patient must first undergo consultation with a clinical doctor called “primary care physician”, and then be referred to a specialist physician. In HMO, there is a small payment contribution for each appointment. Exclusive Provider Organization

(EPO): EPO uses an affiliated network of physicians, hospitals, and providers of specialized physicians. In this case, the patient can go directly to the insured specialist, without first going to a general practitioner. Preferred Provider Organization

(PPO): It is a managed care organization of physicians, hospitals and other health professionals who work with an insurer or a third-party administrator to provide healthcare at reduced prices to clients. In the PPO, the patient can make an appointment with a specialist directly, which is why they will not need to go to a general practitioner first. In the PPO, the patient must pay a small amount in care provided by "in-network" doctors (those within the coverage of the plan) or pay a greater amount in the care of "out-of-network" doctors (those outside the coverage of the plan).

Point Of Service (POS): It combines characteristics of the Health Maintenance Organization (HMO) and the Preferred Provider Organization (PPO). POS offers a favorable combination of benefits and the patient consults a general practitioner who refers him/her to insured specialists.

In addition, for a better understanding of how health plans work in the US, it is essential to have knowledge about: “premium”, “deductible”, “co-pay”, “co-insurance” and “out-of-pocket maximum”:

Premium: refers to the monthly amount that the insured citizen pays for contracting the plan. In the case of business plans, all or part of it will be paid by the company.
Deductible: this is an insurance deductible amount. In this case, in order for the insurer to start to cover all or part of the expenses, the insured will need to pay the full amount of this deductible with health services. For example: for a deductible of US$3,000.00, the insured must bear health expenses up to this amount throughout the year and, when reaching the value of the deductible, the insurer must bear the other costs.
Co-pay: represents the fixed amount that is paid for medical consultations. For example: value of US$30.00 per appointment.
Co-insurance: in this case, after the deductible amount is paid, the insurance will not normally pay all other expenses; that is, the insured will be responsible for bearing a percentage of these other expenses. Thus, "co-insurance" refers to the fixed percentage that the insured pays on the cost of medical treatment after reaching the deductible.
Out-of-pocket maximum: refers to the maximum amount that the insured must pay in a given year. We may include the maximum amounts to be paid in the “deductible”, “co-pay” and “co-insurance”. This is the limit that the insured will spend within their deductible.

Summary

Throughout the studies of this first theme, it was possible to observe that the American health system is quite complex, which is why it is important that the distinctions between the different types of health care are understood.

Finally, it can be concluded that several changes in health care have occurred over the years to the present and that, certainly, the basic principles of health care will continue to evolve at the pace of the demands and needs of the population, the market and in accordance with government regulations.

Practical Application

To further deepen the theme, we will address in practice the general context of health in the USA. It is observed that public plans are directed to a specific population. In this regard, the population that does not fit the characteristics for health care by Medicare and Medicaid, for example, seeks private companies to contract health plans.

It is possible to relate, however, the great influence of the economy to the population's search for health care. In this context, at times when economic conditions improve, people have more disposable income (and, consequently, access to insurance coverage), which can be used to obtain health services. However, in times of economic crisis, there may be a reduction in disposable income, reducing spending on health by the population.

In addition, as previously seen, most health insurance for people under 65 is provided by their employers in the US. For this reason, in times of crisis and unemployment, people who have lost their jobs also end up losing their own health plan and that of their family. Such a situation should strongly shake health care organizations.

Learn More

The Affordable Care Act (ACA) greatly influenced health insurance coverage in the United States. Studies have shown that ACA has reduced inequality related to health insurance coverage, particularly as a result of the expansion of Medicaid coverage.

Learn more about it through the article “Inequality in health insurance coverage before and after the Affordable Care Act”, available at the link: https://www.bit.ly/ad98y8.

To deepen your studies on the subject, read chapters 1 and 2 of Peter R. Kongstved's book “Essentials of Managed Health Care.

Health care in the USA

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