The US is one of the countries with the best and unique healthcare systems among developed countries. Unlike other countries with a uniform health system, the US system is diverse. Moreover, America has enacted laws advocating for universal coverage. In other words, the US healthcare system is a hybrid type that does not function as a national health service or a single-payer kind of health insurance system (Department for Professional Employees, 2016). In the US, the healthcare system is divided among various groups. For instance, in 2014, private funding was estimated at 48 percent of the total care expenditure. Households and private businesses contributed 28% and 20% of healthcare spending, respectively. Department for Professional Employees (2016) estimates that federal and state and local governments contributed 28 and 17 percent, respectively. According to the Department for Professional Employees (2016), 66% of American workers have private insurance plans. Based on these statistics, it is clear that most of the US healthcare services are provided through private programs even if they are publicly financed.
The history of health insurance can be traced back to 1910 to the mid-1940s before World War II. Managed care program was conceptualized in the late 19the century when a group of physicians started to offer prepaid healthcare services. This form of medical plan was only limited to a specific group of people, workers, and union members. The program was meant to minimize health care costs. Each subscriber was to pay a small annual fee to physicians upon which they granted unlimited access to medical services. The program became popular in the 20th century, where other companies such as railroad, lumber, and mining companies contracted with healthcare providers or formed their medical schemes to cover their employees’ medical needs. This approach to healthcare became more pronounced during the great depression of 1930. In the 1970s, many companies and the federal government advised employees to subscribe to prepaid form medical covers. In the 1980s, the cost of providing healthcare insurance to workers became unbearable, forcing employers to enter into a contract with managed care. In the 1990s, every employee was familiar with the idea of managed care (Mullner & Chung, 2016). Currently, many Americans with private medical covers and government-sponsored plans are insured by some form of managed care.
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The Key Federal Laws Involved In Private Insurance
Private Health Insurance (PHI) came into existence because of three main primary reasons with the hope of delivering quality care. The program's main objective was to serve as alternative healthcare insurance for people who did not prefer state-financed covers. As a result, the program appeared to be an economically stable plan for households and those with higher incomes. Secondly, the program is considered a complementary option by many since it can act as a co-payment option for services that are partially covered by state insurance (Fernandez, Forsberg, & Rosso, 2018). Lastly, the PHI program is also viewed as a supplementary program to include services that are not covered by state insurance or by those who want instant access to some services.
From the above statement, it is apparent that the motives behind PHI expose subscribes to exploitation by service providers, requiring government intervention to cushion the consumers from such malpractices. In the void of control and regulations, PHI providers might abuse their powers by engaging in practices that aim to lower their risk of running into losses. These malpractices can include denying services to people with pre-existing terminal diseases. (Fernandez, Forsberg, & Rosso, 2018). At the same time, the government must balance the needs to protect subscribers without overburdening services providers with laws that may hinder the sustainable growth of PHI. It is essential to note that most of the federal requirements were developed under the Patient Protection and Affordable Care Act (ACA). It is for these reasons that the federal government saw the need to enact rules that govern PHI operations.
The key federal laws that protect PHI clients are categorized into different sections, such as cost-sharing limits, covered services, and keeping coverage. The individual enrolled in PHI is assured of guaranteed renewability of an individual plan or group plan at the option of the insurance holder. On the other hand, each enrollment is protected by the federal law that prohibits the act of rescissions when the holder gets sick or injured. However, this law is allowed if the holder was involved in some kind of fraud or if the individual is made an intentional misrepresentation of the involved material. Both are in regard to keeping the coverage section. In terms of covered services, the enrolled individual is protected with regards to minimum hospital stay after childbirth, where plans are warned against restricting the stay in the hospital for childbirth (Fernandez, Forsberg, & Rosso, 2018). On the other hand, plans are also required to fully ensure that they are complying with the annual limits on out-of-pocket spending law that only applies to the in-network coverage of the EHB.
Consumer-Driven Healthcare and the Empowerment of the Healthcare Consumer
When it comes to health matters, not a single individual would like their health compromised by anyone or any organization. As a result, most people willingly chose consumer-driven health care for their medical needs. This Consumer-driven health care plan (CDHP) refers to a program in which consumers are given the chance of managing and participating in the well-being of their health rather than being controlled by third parties. Through such freedom in coverage options, the consumer is empowered and able to express his or her priorities as well as preferences in terms of the care provided. Through this option, the patients are also given a chance to make trade-offs regarding healthcare and other monetary services instead of having someone else making these crucial decisions for them (Robinson, & Ginsburg, 2009). In other words, when health care is empowered through CDHP insurance plans, the patient is hence able to account for their health care spending fully. Some of the pros and cons of CDHP is that it is cost-saving for the payers and beneficiaries, but on the con side, it can impose increased patient risks in addition to not working for some specific consumer groups.
The empowerment of the healthcare consumer is easily achieved through a program like CDHP, which plays a massive role in encouraging consumers to purchase the best healthcare services that fit both their needs and effectiveness in terms of quality and accessibility for them. Therefore when an organization decides to implement the CDHP insurance option, then they would, in a significant way, reduce the cost of healthcare services for their workers (Robinson, & Ginsburg, 2009). At the same time, they will be to offer them a better platform for participating in their medical decisions. Therefore, any healthcare market that is willing to provide quality services to its clients is required to consider implementing both patient engagement and consumer empowerment strategies as the key elements to achieve that goal (Robinson, & Ginsburg, 2009). By doing so, one will be sure that the consumers are equipped with the right tools and resources, as well as the support required in making effective decisions regarding their healthcare.
Nurses Opportunities Emerged Within the Private Insurance Market
The healthcare system has been changing over time, and some of these changes are brought about by the emerging technologies, increased number of patients, and the evolving insurance programs. Nurses are vital in ensuring the well-being of a patient as well as the outcomes of the treatment process. Nowadays, nurses can coordinate care from multiple providers, aid in patient's transition from hospital to their homes or any other setting for that matter, and provide specialized services for patients with intense care needs. In other words, nurses play the role of health coaches with the primary aim of preventing illnesses and promoting the wellness of the patients. Private health insurance has, in one way or the other impacted the health care industry in a significant way. For instance, nurses have been provided with the opportunity of accessing increased medical resources and providing quality and improved care to their patients.
Conclusion
The health status of a nation is essential in ensuring economic success. Different programs in collaboration with state and local governments have been working together with hospitals and insurance providers to ensure the provision of quality and accessible services. Enrolling on a health insurance plan under public or private programs is considered a basic necessity for many Americans. They believe that health insurance coverage is the key to accessing quality healthcare and thus having better health outcomes. Additionally, most Americans believe that being covered by an insurance program is the best way of having a regular source of care that will significantly address all personal needs regarding health services. As seen throughout the essay, private health insurance is easily purchased through individual plans or employment-based groups. Finally, consumers are empowered through specific programs such as consumer-driven healthcare, which helps them manage their health.
References
Department for Professional Employees. (2016). T he U.S. health care system: An international perspective. https://www.dpeaflcio.org/factsheets/the-us-health-care-system-an-international-perspective
Fernandez, B, Forsberg C, V, & Rosso, J, R. (2018). Federal requirements on private health insurance plans. Congressional Research Service . https://fas.org/sgp/crs/misc/R45146.pdf
Mullner, M, R, & Chung, K. (2016). Managed care: Health insurance and system. Encyclopedia Britannica . https://www.britannica.com/topic/managed-care
Robinson, J. C., & Ginsburg, P. B. (2009). Consumer-driven health care: Promise and Performance. Health Affairs, 28 (Suppl2), w272-w281.
