Table of Contents
Overview
Definition of Health Insurance
Health insurance is defined as a legally binding agreement between the policyholder and the insurer, which outlines the rights and obligations of both parties. This contract specifies the terms under which the insurer provides financial assistance for medical expenses in exchange for regular premium payments.[27.1] In the context of health insurance, the term "health insurance policy, contract, or agreement" encompasses various forms of coverage, including group health policies issued by health maintenance organizations, as well as individual policies.[26.1] Furthermore, health insurance is officially categorized as "accident or health and sickness" and is recognized as one of the major lines of authority defined by the National Association of Insurance Commissioners (NAIC).[5.1] The contractual nature of health insurance ensures that both insurers and policyholders have clearly defined responsibilities, which helps mitigate misunderstandings regarding coverage and claims.[27.1]How Health Insurance Works
Health insurance operates through various models and plans that determine how coverage is provided and how costs are managed. Most high-income, developed countries have implemented universal health coverage, ensuring that at least 99 percent of the population has health insurance. For instance, the National Health Service in the UK offers services free at the point of service, with no co-payments required.[7.1] In contrast, the United States is notable for being the only high-income developed nation without universal health coverage, resulting in approximately 7.6 percent of its population being uninsured.[7.1] Health insurance plans in the United States can be categorized into several types, including Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Exclusive Provider Organizations (EPOs). HMOs are known for being budget-friendly, typically featuring lower premiums and deductibles, and often include fixed copays for doctor visits, making them a suitable choice for individuals on a tight budget who do not have many health issues.[13.1] In contrast, PPOs and EPOs provide different benefits and costs, with some plans offering more flexibility in choosing healthcare providers compared to HMOs. However, these plans may also involve higher out-of-pocket costs, especially when members opt to see out-of-network providers.[14.1] Overall, understanding the distinctions between these plans is crucial for consumers to make informed decisions regarding their health insurance coverage. The introduction of high-deductible health plans (HDHPs) has also become prevalent, which can be structured as either PPOs, EPOs, HMOs, or POS plans. These plans are designed to comply with IRS rules for Health Savings Accounts (HSAs) and typically involve higher out-of-pocket costs before insurance coverage kicks in.[12.1] The introduction of Medicare in 1965 marked the most significant transformation in health insurance coverage in U.S. history, providing nearly universal public health insurance to individuals aged 65 and older.[16.1] This monumental change has led to a substantial and prolonged decline in the uninsured rate among the elderly, demonstrating Medicare's enormous impact on health insurance coverage for this demographic.[16.1] Currently, Medicare constitutes approximately 17% of all U.S. health expenditures, representing about $260 billion in annual spending, which underscores its critical role in the national health care system.[17.1] Furthermore, the establishment of Medicare has influenced ongoing discussions about health care financing in the U.S., as it has become a major component of the national approach to health insurance, despite the challenges policymakers face in ensuring comprehensive access to medical care for all Americans.[18.1] The legacy of Medicare continues to shape the interplay between public and private health care sectors, reflecting the historical debates that have emerged since its inception.[18.1]History
Early Development of Health Insurance
The early development of health insurance in the United States can be traced back to the late 19th century, when the first health insurance policies were introduced for workers in the manufacturing industry. This marked the beginning of a long and complex history characterized by significant milestones and reform efforts that have shaped the health insurance landscape over time.[43.1] The initial offerings of health insurance were primarily aimed at addressing the needs of workers, particularly in response to the economic challenges posed by events such as the Great Depression. During this period, hospital and physician providers began to create private health insurance plans to mitigate the financial consequences of healthcare costs.[44.1] As the industry evolved, various types of health insurance plans emerged, including Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). HMOs recognized a growing preference among consumers for choice in healthcare providers, while PPOs expanded the options available to their members, allowing for a wider selection of healthcare services.[44.1] The regulatory framework governing health insurance in the United States is a joint effort between federal and state governments. The McCarran-Ferguson Act established that states would primarily regulate insurance, including the content of health insurance policies. This has led to state mandates requiring coverage for specific medical services, although such mandates typically do not apply to health plans offered by large employers due to the preemption clause of the Employee Retirement Income Security Act (ERISA).[45.1] By 2018, the health insurance market in the U.S. had grown to include 953 companies, with a significant concentration of revenue among the largest providers.[45.1]Evolution of Health Insurance in the United States
The evolution of health insurance in the United States has been significantly shaped by historical events and economic challenges, particularly during the Great Depression. In the early 1930s, the nation faced a healthcare crisis as many Americans were unable to afford necessary medical care, leading to a dramatic decline in hospital patient loads and financial ruin for numerous healthcare facilities.[55.1] This dire situation prompted the emergence of private health insurance, with Blue Cross and Blue Shield plans paving the way for insurers to develop products that addressed the growing demand for healthcare coverage.[48.1] The Great Depression significantly impacted the landscape of health insurance in the United States. As the economic crisis unfolded, nearly every hospital experienced a drastic decline in patient admissions, highlighting the urgent need for health coverage among the population.[54.1] This situation contributed to a growing awareness of health insurance's importance, yet it also influenced policy decisions in a complex manner. Notably, President Franklin Roosevelt's administration chose not to include a national compulsory health insurance program in the Social Security Act of the New Deal, prioritizing other pressing issues such as unemployment insurance and old-age benefits instead.[30.1] Thus, while the Great Depression underscored the necessity for health insurance, it simultaneously complicated efforts to implement significant reforms in this area. In response to the financial challenges posed by the Great Depression, the Employee Retirement Income Security Act (ERISA) was enacted in 1974, which facilitated the growth of self-insured employer health plans and fostered competition within the conventional insurance market.[47.1] This legislative change marked a pivotal moment in the evolution of health insurance, as it allowed employers greater flexibility in designing health benefits for their employees. Furthermore, the McCarran-Ferguson Act of 1945 played a crucial role in shaping the regulatory landscape of health insurance. This act reinforced state authority over insurance, enabling states to establish their own regulations regarding licensing, rate approvals, and consumer protections.[56.1] This decentralized approach allowed for tailored regulations that could better address local market needs, although it also resulted in significant variations in health insurance policies across different states.[59.1] In recent years, the Competitive Health Insurance Reform Act of 2020 has further influenced the health insurance landscape by repealing certain antitrust protections previously afforded to health insurers under the McCarran-Ferguson Act, thereby promoting greater competition in the market.[58.1] This ongoing evolution reflects the dynamic interplay between economic conditions, legislative actions, and public perceptions that have shaped health insurance in the United States over the decades.Types Of Health Insurance Plans
Health Maintenance Organizations (HMOs)
Health Maintenance Organizations (HMOs) are a specific type of health insurance plan that emphasizes preventive care and typically limits coverage to care provided by doctors and hospitals that are part of the HMO's network. This structure requires members to select a primary care physician (PCP) who coordinates their healthcare and provides referrals to specialists within the network, thereby controlling costs and ensuring that care is managed effectively.[83.1] Health Maintenance Organizations (HMOs) are a type of health insurance plan that emphasizes preventive care and provides healthcare services through a network of designated doctors and hospitals.[83.1] One of the key characteristics of HMOs is that they often cover preventive services without requiring members to meet a deductible, which encourages early detection and management of health issues.[78.1] However, HMOs typically do not cover healthcare costs from out-of-network providers, which can limit members' choices regarding healthcare providers.[82.1] Additionally, to see a specialist, members usually need a referral from a primary care physician, further structuring the way care is accessed within the HMO model.[82.1] Health Maintenance Organizations (HMOs) are a type of health insurance plan characterized by their structured provider networks and specific coverage rules. An HMO plan does not cover healthcare costs incurred from out-of-network providers, which means that members must utilize a designated network of healthcare professionals to receive benefits. Additionally, HMOs require referrals from a primary care physician (PCP) in order to see a specialist, which can limit flexibility in accessing specialized care.[82.1] In contrast, other types of health insurance plans, such as Preferred Provider Organizations (PPOs), offer a broader range of choices and do not necessitate PCP referrals, but typically come with higher monthly premiums.[81.1] Overall, HMOs are designed to provide comprehensive care while managing costs, making them a popular choice for individuals and families seeking affordable health insurance options.Preferred Provider Organizations (PPOs)
Preferred Provider Organizations (PPOs) are a type of health insurance plan that allows members to pay less when they use providers within the plan's network. This structure is designed to offer flexibility in healthcare access, enabling members to choose from a wide range of healthcare providers. Unlike Health Maintenance Organizations (HMOs), which typically limit coverage to doctors who work for or contract with the HMO, PPOs provide a broader selection of providers. Additionally, Point of Service (POS) plans also offer reduced costs when using in-network providers, similar to PPOs, but with different operational structures. Overall, the cost-sharing mechanisms in PPOs encourage members to utilize in-network services, resulting in lower out-of-pocket expenses compared to out-of-network care.[92.1] Preferred Provider Organizations (PPOs) are one of the four main types of managed health care plans, alongside Health Maintenance Organizations (HMOs), Point of Service (POS) plans, and Exclusive Provider Organizations (EPOs).[78.1] The primary distinctions among these plans include network restrictions, cost-sharing structures, and whether referrals are required for specialist services.[79.1] PPOs typically provide greater flexibility in accessing healthcare providers, as they do not mandate referrals to see specialists.[78.1] This flexibility, however, is often accompanied by higher costs compared to other plan types, such as HMOs, which may have more restrictive networks and lower overall expenses.[79.1] Understanding these differences is crucial for consumers when navigating their healthcare options.[78.1]Recent Advancements
Changes in Coverage and Access (2021-2024)
The period from 2021 to 2024 has witnessed significant changes in health insurance coverage and access in the United States, largely influenced by the ongoing effects of the Affordable Care Act (ACA) and evolving market dynamics. The enrollment in private health insurance saw a notable increase of 1.6 percent in 2023, translating to an additional 3.3 million individuals gaining coverage, while spending per enrollee rose by 9.7 percent, marking an acceleration from previous growth rates.[123.1] This surge in enrollment is indicative of a broader trend, as nearly 16.4 million consumers selected or were automatically re-enrolled in health insurance coverage through the Federally-facilitated Marketplace and State-based Marketplaces during the 2023 open enrollment period, representing a 13% increase compared to the previous year.[129.1] The recent enrollment trends under the Affordable Care Act (ACA) have significant implications for the healthcare system in the United States. Currently, 45 million people are enrolled in Marketplace or Medicaid expansion coverage under the ACA, marking the highest total on record.[130.1] This surge in enrollment is expected to transform the dynamics of healthcare delivery and financing, as increased access to care becomes a reality for many individuals who previously lacked health insurance.[131.1] As more individuals gain access to health insurance, the overall landscape of healthcare is evolving, potentially leading to improved health outcomes across the population.[131.1] However, these advancements are juxtaposed with rising costs that have become a pressing concern for consumers and small business owners alike. Employer-sponsored family health insurance premiums have escalated by 24% since 2019, prompting 68% of small business owners to express that rising premiums are their primary concern for 2025.[132.1] The correlation between employment and health insurance remains strong, as employer-sponsored insurance continues to be the largest source of health coverage in the U.S., covering more individuals than the individual market.[133.1] In recent years, discussions regarding a public health insurance option have gained momentum among policymakers. This proposed public option aims to provide more affordable choices for individuals and businesses, operating similarly to private health insurance plans, where consumers would pay for their own coverage.[134.1] The public option is designed to foster competition in the insurance marketplace by allowing consumers to choose between this plan and other available options, including private insurance.[135.1] Furthermore, some Members of Congress have proposed introducing a federally administered health insurance plan to compete with private plans in the nongroup marketplaces established by the Affordable Care Act.[136.1] This initiative seeks to ensure that all individuals, regardless of their employment status, have access to necessary healthcare services. As the landscape of health insurance continues to evolve, the interplay between public and private options will be crucial in shaping the future of coverage and access in the United States. The anticipated rollout of public health insurance plans in state marketplaces starting in 2026, with premiums required to be at least 5% lower than benchmark premiums, underscores the ongoing efforts to enhance affordability and accessibility in the health insurance market.[137.1] Ultimately, the integration of public health insurance programs alongside existing private coverage may create a more comprehensive system of benefits, although it will require careful management to navigate the complexities involved.[138.1]Impact of the Affordable Care Act
The Affordable Care Act (ACA), enacted in 2010, has significantly transformed the landscape of health insurance in the United States, primarily by expanding access to coverage and improving health equity among underserved populations. A growing body of literature indicates that the ACA has led to notable improvements in health outcomes for nonelderly adults through insurance expansions, with an estimated 20 million previously uninsured individuals gaining coverage as a result of the legislation.[141.1] The ACA has been particularly effective in reducing social disparities in key health care outcomes, including insurance coverage, access to care, and the utilization of primary care services.[157.1] Evidence from various state-level reforms, such as those implemented in Massachusetts and the Oregon Health Insurance Experiment, illustrates the ACA's role in enhancing access to health insurance for low-income populations.[141.1] Furthermore, the ACA's provisions related to health equity are integrated throughout the legislation, aiming to address disparities among racial, ethnic, and primary language groups.[160.1] Despite these advancements, challenges remain. Newly insured patients, particularly those covered by Medicaid and low-cost private health insurance plans, often face difficulties in accessing secondary care services and establishing care with private primary care providers.[142.1] Nonetheless, the ACA has marked a pivotal shift in the U.S. healthcare system, striving to improve access to preventive care and reduce disparities among underserved populations.[158.1]Key Components Of Health Insurance
Premiums and Out-of-Pocket Costs
Premiums and out-of-pocket costs are fundamental components of health insurance that significantly influence consumer decisions regarding healthcare coverage. The premium is the amount paid monthly or annually to maintain health insurance coverage, representing a fixed cost that consumers must budget for each period.[163.1] In addition to premiums, consumers must also consider out-of-pocket costs, which include deductibles, copayments, and coinsurance. Premiums and out-of-pocket costs are essential components of health insurance that consumers must understand to manage their healthcare effectively. A deductible is defined as the amount an insured individual must pay out-of-pocket before their health insurance begins to cover expenses.[164.1] Until the deductible is met, the insured is responsible for all healthcare costs. Once the deductible is satisfied, the insurance plan typically starts to share the costs of covered services. Additionally, copayments, or copays, are fixed amounts that consumers pay for specific services, such as a doctor's visit or prescription medication.[164.1] Understanding these terms is crucial for managing healthcare expenses effectively. Understanding these components is crucial for consumers as they navigate their health insurance options. Many misconceptions exist regarding health insurance coverage, such as the belief that insurance will cover 100 percent of healthcare costs. In reality, consumers are responsible for a portion of their healthcare expenses, which can vary widely based on their specific plan's terms.[173.1] By comprehending the roles of premiums, deductibles, copayments, and coinsurance, individuals can make more informed decisions about their healthcare coverage and manage their healthcare costs effectively.[165.1]In this section:
Government Programs
Medicare and Medicaid
Medicare and Medicaid are two of the six major government health care programs in the United States, providing essential health care services to approximately one-third of the American population. Medicare primarily serves individuals aged 65 and older, as well as certain younger individuals with disabilities, while Medicaid offers coverage to low-income individuals and families, including children and pregnant women.[205.1] The establishment of Medicaid was influenced by earlier legislative efforts, such as the Kerr-Mills Act, which provided federal funds to support state programs for medical care for the poor and elderly. This act laid the groundwork for the development of Medicaid, which was officially created in 1965 as part of the Social Security Amendments.[208.1] Medicaid benefits for children were specifically established in 1967 through the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, ensuring that children enrolled in Medicaid receive comprehensive health services.[207.1] As of 2019, approximately 20% of the U.S. population relied on Medicaid for health coverage, while Medicare served about 14% of citizens.[206.1] The Affordable Care Act (ACA), enacted in March 2010, is a comprehensive health care reform law designed to enhance access to health insurance.[209.1] Despite their critical role in providing health care, both Medicare and Medicaid face significant economic challenges. In 2023, federal spending on mandatory health programs, including Medicare and Medicaid, is projected to reach over $1.6 trillion, constituting about 6.2% of the U.S. economy.[213.1] This unsustainable growth in spending raises concerns about the federal government's ability to manage its debt and maintain these programs in the long term.[210.1] The high cost of insurance continues to be a significant barrier for many individuals, with approximately 25.3 million people aged 0-64 uninsured in 2023, representing 9.5% of the population. Notably, nearly 60% of these uninsured individuals, or 14.5 million, were eligible for Medicaid or subsidized Marketplace coverage. However, over 40% (10.9 million) remained ineligible due to various factors, including their state not expanding Medicaid, immigration status, or lack of access to affordable plans.[215.1] As the insurance market enters the 2023 plan year, it faces ongoing challenges related to costs, uninsured individuals, and access to care, underscoring the need for effective reforms to address these issues.[212.1]Children's Health Insurance Program (CHIP)
The Children's Health Insurance Program (CHIP), established in 1997, was designed to expand health insurance coverage for low-income children in the United States. This program has significantly increased access to health care for children, with approximately one-quarter of all children and half of low-income children receiving their health coverage through Medicaid or CHIP.[220.1] States have considerable flexibility in designing their CHIP programs, which has led to widespread expansion of eligibility for public coverage across the nation.[221.1] The Patient Protection and Affordable Care Act (ACA) has significantly expanded access to health insurance in the United States, resulting in approximately 20 million previously uninsured individuals gaining coverage.[224.1] This expansion is crucial for enhancing access to necessary health services, particularly for vulnerable subpopulations with low income, as health insurance is generally associated with increased healthcare utilization and improved health outcomes.[223.1] The ACA's initiatives aim to reduce disparities among underserved populations, thereby playing a vital role in improving health outcomes in these communities.[224.1]Challenges And Reforms
Complexity of the Health Insurance System
The complexity of the health insurance system in the United States is deeply rooted in its historical evolution, which has been a subject of political debate since the early 20th century. The first major proposal for national health insurance was issued by reformers in 1915, marking the beginning of a long-standing discussion on health care reform.[251.1] Over the decades, various reform proposals have emerged, yet comprehensive changes have often been proposed but rarely accomplished.[250.1] This ongoing debate remains a significant political issue, as evidenced by the alternative reform proposals presented by major candidates in the 2008, 2016, and 2020 presidential elections.[248.1] Despite the challenges, landmark reforms, such as the Patient Protection and Affordable Care Act (PPACA) enacted in 2010, represent critical milestones in the evolution of the healthcare system.[250.1] Recent reforms, particularly the Patient Protection and Affordable Care Act (PPACA) enacted in 2010, represent landmark changes aimed at improving access and affordability. However, the effectiveness of these reforms remains a contentious issue, as they have not fully resolved the underlying complexities of the health insurance landscape.[250.1] The pressing need for reform is underscored by the challenges of achieving better access, affordability, and equity within the system. Recommendations for future reforms include expanding insurance coverage, transitioning to value-based care, and improving the affordability of drugs and therapeutics.[252.1] The complexity of the health insurance system is significantly shaped by economic theories, particularly the law of demand. As with other markets, when the price of health care increases, individuals tend to demand less of it; however, for those with health insurance, the price they face may be considerably lower than the actual cost of care.[253.1] This dynamic is further complicated by issues such as adverse selection and moral hazard. Adverse selection occurs when the mix of unobserved attributes among insured individuals becomes less favorable, leading to higher costs for insurers, which in turn necessitates raising premiums for consumers.[256.1] Additionally, the regulatory landscape surrounding health insurance is intricate. Recent studies indicate that state regulations may either reduce health insurance coverage or have no significant impact on it, although some regulations may alter the risk distribution among insured populations.[261.1] However, it remains uncertain whether these regulations affect the utilization of healthcare services, costs, quality of care, or patient health outcomes.[263.1] Technological advancements and new healthcare delivery models, such as telehealth and AI, are also driving changes in the regulatory environment, necessitating ongoing adaptations to ensure quality care and patient access.[262.1] The historical context of health insurance reform in the U.S. reveals that political challenges, including the emergence of private employer-sponsored insurance and opposition from various interest groups, have significantly influenced the development of health insurance policies.[264.1] As the system continues to evolve, addressing these complexities will be essential for creating a more effective and equitable health insurance framework.Proposed Reforms and Future Directions
Proposed reforms in health insurance are increasingly acknowledging the critical role of social determinants of health (SDOH) in influencing health outcomes and access to care. SDOH refer to the conditions in which individuals are born, live, learn, work, play, worship, and age, and they significantly affect a wide range of health, functioning, and quality-of-life outcomes.[257.1] Key areas of focus within SDOH include employment, education, socioeconomic status, and social support networks, all of which contribute to health inequities and disparities.[258.1] However, recent research indicates that current frameworks, such as Health in All Policies (HiAP) and Health Impact Assessments (HIAs), have not led to substantial changes in SDOH or reductions in health disparities, as they do not mandate the government to address structural discrimination—one of the root causes of these disparities.[259.1] To effectively tackle these issues, a community-driven approach that emphasizes health justice is essential for transforming governmental efforts to address SDOH and eliminate health disparities.[259.1] Proposed reforms in health insurance are increasingly focused on creating a more inclusive and equitable healthcare system by integrating social determinants of health (SDOH) into policy design.[281.1] There is a growing acknowledgment within scholarly literature of the need for a more explicit focus on health equity throughout the implementation process of health system reform initiatives.[284.1] However, the range of strategies available to promote health equity at a population level has not been comprehensively documented, particularly given the complexities of health system implementation.[284.1] Effective strategies for integrating SDOH into health insurance reform include enhancing data collection on SDOH and utilizing electronic health records (EHR) to track these determinants.[283.1] Furthermore, health justice initiatives that are community-driven are essential for transforming government efforts to address SDOH and eliminate health disparities.[259.1] Despite these efforts, recent research indicates that the adoption of Health in All Policies (HiAP) and Health Impact Assessments (HIA) has not resulted in significant changes in SDOH or reductions in health disparities, underscoring the necessity for a more robust approach to address structural discrimination, which is a root cause of these disparities.[259.1] Furthermore, the U.S. Department of Health and Human Services (HHS) has initiated various programs and policies aimed at addressing SDOH, highlighting the importance of cross-sector collaboration in these efforts.[285.1] By focusing on health equity during the design and implementation of health system reforms, policymakers can create a more inclusive healthcare system that not only expands access but also improves health outcomes for all individuals, particularly those in vulnerable populations.[284.1]References
[5] The History of Health Insurance: Past, Present, and Future — Health insurance (officially called "accident or health and sickness") is one of the major, or general, lines of authority (LOAs) defined by the National Association of Insurance Commissioners (NAIC) in its Uniform Licensing Standards (ULS). As of late 2021, there were an estimated 138,682 licensed health insurance agents working in the U.S. The Insurance Information Institute (III) also
[7] Global health care systems comparison - Statistics & Facts — Most high-income, developed countries provide or mandate universal health coverage for their people. This usually means that at least 99 percent of the population has health insurance, and some countries provide it free at point-of-service with no co-payments, like the National Health Service in the UK. Health systems ranking The Legatum Institute Foundation's most recent rating of health and health systems placed Singapore's system at the top overall out of 167 nations. The ranking is based on the Legatum health index, which assesses how well people are doing in terms of their health and access to healthcare resources that can help them stay that way, including mortality rates, sickness and risk factors, health outcomes, and health systems. It is also the only high-income developed nation without universal health coverage allowing some 7.6 percent of the U.S. population to be uninsured.
[12] HMO vs PPO vs POS vs EPO: What's the difference? - healthinsurance.org — However, an HDHP will also be either a PPO, an EPO, an HMO, or a POS plan. The HDHP designation means that the plan conforms to the IRS rules for HSA-qualified plans. And the HMO, PPO, EPO, or POS designation describes the plan's approach to managed care. Learn more about HSA-qualified high-deductible health plans (HDHPs).
[13] HMO, PPO, POS, EPO, & HDHP: What's the Difference - Aetna — HMO: A budget-friendly plan. A Health Maintenance Organization (HMO) plan is one of the most affordable types of health insurance. While it may have coinsurance, it generally has lower premiums and deductibles. It also often has fixed copays for doctor visits. It's a good choice if you're on a tight budget and don't have many health issues.
[14] HMO, PPO, and EPO: What's the Difference? | Cigna Healthcare — Explore the differences between HMO, PPO, and EPO health plans. Compare premiums, out-of-pocket costs, and out-of-network coverage for each plan. ... Cigna HealthCare of South Carolina, Inc., and Cigna HealthCare of Texas, Inc. Group health insurance and health benefit plans are insured or administered by CHLIC, Connecticut General Life
[16] PDF — We study the impact of the introduction of Medicare, which provides nearly universal public health insurance coverage to the elderly. The introduction of Medicare in 1965 was, and remains to date, the single largest change in health insurance coverage in U.S. history. Its introduction was followed by a substantial and prolonged decline in
[17] Policy Impacts Library | Medicare Introduction in 1965 — Representing $260 billion in spending annually, the US Medicare program constitutes about 17% of all US health expenditures, one-eighth of the federal budget, and 2% of GDP. Medicare was enacted in July 1965 and implemented essentially nationwide in July 1966, providing virtually universal public health insurance to individuals aged 65 and older. Finkelstein and McKnight (2008) study the
[18] Medicare and Medicaid: The Past as Prologue - PMC - PubMed Central (PMC) — As a result of such actions, a State program endures, even thrives, as a major component of the U.S. approach to national health insurance, a fact that might have surprised the creators of Medicare in 1965. Yet, a Part C that would be America's national health insurance program that assured all Americans' access to medical care continued to elude policymakers, even in periods, such as the early seventies, when the passage of such a program appeared, if not likely, then at least plausible (Berkowitz, 2006). As demonstrated in this article, such modern phenomena as State management of health care finance programs, consumer choice over the type of health care plan an individual elects to join, and collaborative efforts between the public and private sectors to provide vital services all have their antecedents in the long debate over the passage of Medicare in 1965.
[26] Health insurance policy, contract, or agreement - Law Insider — Define Health insurance policy, contract, or agreement. means a group health policy or similar coverage issued by a health maintenance organization. For purposes of this Section, such group policies or coverage shall be limited to those offered to employees of employers that employ fifty or fewer individuals. "Health insurance policy, contract, or agreement" shall also mean any individual
[27] What Is a Health Insurance Policy and How Does It Work? — Contractual Nature A health insurance policy is a legally binding agreement between the policyholder and the insurer, outlining the rights and obligations of both parties. This contract specifies the terms under which the insurer provides financial assistance for medical expenses in exchange for regular premium payments.
[30] The Evolution of Health Insurance in America: A Look at the Past ... — Great Depression is believed to be one of the causes for Franklin Roosevelt's decision to not include a national compulsory health insurance program within the Social Security Act of his New Deal. Other issues such as unemployment insurance and old age benefits had taken precedence (Palmer). Health Insurance in America: The Birth of the Blues
[43] Health Insurance History in the US: A Comprehensive Timeline - CGAA — The history of health insurance in the US is a long and complex one, marked by key milestones and reform efforts that have shaped the industry into what it is today. The concept of health insurance dates back to the late 19th century, when the first health insurance policies were offered to workers in the manufacturing industry.
[44] PDF — Both types of plans provided Chapter 1: History of Health Insurance in the United States 9 indemnity coverage. POS plans are hybrids of HMOs and PPOs. HMOs observed that people seem to prefer choice, and PPOs allow their members a wider choice Chapter 1: History of Health Insurance in the United States 19 of providers. Summary • Private health insurance in the United States began as efforts by hospital and physician providers to deal with the revenue consequences of the Great Depression. Health Insurance, Second Edition 24 • The passage of the Employee Retirement Income Security Act (ERISA) in 1974 led to the growth of self-insured employer health plans and all but ensured competition in the risk-bearing segment of the conventional insurance market.
[45] Health insurance in the United States - Wikipedia — The US has a joint federal and state system for regulating insurance, with the federal government ceding primary responsibility to the states under the McCarran-Ferguson Act. States regulate the content of health insurance policies and often require coverage of specific types of medical services or health care providers. State mandates generally do not apply to the health plans offered by large employers, because of the preemption clause of the Employee Retirement Income Security Act. As of 2018, there were 953 health insurance companies in the United States, although the top 10 account for about 53% of revenue and the top 100 account for 95% of revenue.: 70
[47] PDF — Both types of plans provided Chapter 1: History of Health Insurance in the United States 9 indemnity coverage. POS plans are hybrids of HMOs and PPOs. HMOs observed that people seem to prefer choice, and PPOs allow their members a wider choice Chapter 1: History of Health Insurance in the United States 19 of providers. Summary • Private health insurance in the United States began as efforts by hospital and physician providers to deal with the revenue consequences of the Great Depression. Health Insurance, Second Edition 24 • The passage of the Employee Retirement Income Security Act (ERISA) in 1974 led to the growth of self-insured employer health plans and all but ensured competition in the risk-bearing segment of the conventional insurance market.
[48] A Brief History of Employer-Sponsored Healthcare [From the 1930s to Now] — The '30s: The Great Depression. ... Into this environment came the beginnings of private health insurance. Blue Cross and Blue Shield plans paved the way for private insurers to begin crafting plans to meet the needs of the growing market. ... However, Watergate derailed that plan, and healthcare reform took a back seat to other national policy
[54] Accidents Of History Created U.S. Health System - NPR — The First Health Insurance. ... When the Great Depression hit, almost every hospital in the country saw its patient load disappear. ... Thomasson cites the huge impact of those measures on plan
[55] Born from the Great Depression, a continued promise to protect the ... — In the early 1930s, health care in the United States was in crisis. The Great Depression had taken hold and many Americans were unable to afford the care they desperately needed. Insurance policies for health care coverage were practically non-existent. As a result, many hospitals across the country were thrown into financial ruin and were
[56] To What Degree Does the McCarran-Ferguson Act Exempt the Insurance ... — The McCarran-Ferguson Act reinforces state authority over insurance, allowing each state to establish its own rules on licensing, rate approvals, policy forms, and consumer protections. This decentralized approach enables states to tailor regulations to local markets, ensuring insurers operate within guidelines designed to maintain solvency and
[58] New Legislation Eliminates Long-Standing Antitrust Immunity for Health ... — Yesterday, the Competitive Health Insurance Reform Act of 2020 (CHIRA) was signed into law, eliminating the longstanding federal antitrust exemption for health insurers provided under the McCarran-Ferguson Act. According to AAG Delrahim, head of the DOJ Antitrust Division, by "[l]imiting the scope of conduct exempt from the antitrust laws …
[59] McCarran-Ferguson Act of 1945 - Encyclopedia.com — The McCarran-Ferguson Act provides that state law shall govern the regulation of insurance and that no act of Congress shall invalidate any state law unless the federal law specifically relates to insurance.
[78] Types of Health Insurance Plans: HMO, PPO, HSA, Fee for Service, POS — Types of Health Insurance Plans: HMO, PPO, HSA, Fee for Service, POS In addition, deductibles -- the amount you pay before your plan pays any of your health care costs -- vary according to plan, generally with the least expensive carrying the highest deductible. Deductible: Your plan may require you to pay the amount before it covers care except for preventive care. Deductible: Your plan may require you to pay the amount of a deductible before it covers care beyond preventive services. After you reach that deductible, the plan will pay 100% of your medical costs for covered benefits. Similar to a catastrophic plan, you may be able to pay less for your insurance with a high-deductible health plan (HDHP).
[79] Understanding different types of healthcare insurance plans — Navigating the complex landscape of healthcare insurance can be challenging, yet it is crucial for ensuring you and your family have the necessary coverage. This guide aims to provide a detailed overview of the various types of insurance plans available in the market, distinguishing their features, benefits, and cost structures.
[81] Types of Health Insurance Plans | Anthem — Types of Health Insurance Plans | Anthem Types of Health Insurance Plans The Three Basic Types Of Health Insurance Plans Health insurance plans vary in coverage, cost, and availability of doctors in your network. A PPO is a health plan with a “preferred” network of providers in your area and does not require a primary care provider (PCP) referral to see a specialist. A PPO health plan provides more choices but typically has higher monthly premiums. You are looking for a health plan that offers the coverage you need with costs that fall between a PPO and an HMO We can help you choose a health insurance plan with Anthem and guide you through the process. Learn more about choosing a health plan ### Balancing Health Insurance Costs
[82] What Are the Main Types of Health Insurance? - Policygenius — The next most common way to categorize a health insurance coverage is plan type — how its structured and how its provider network is run. For example, an HMO plan doesn't cover health care costs from out-of-network providers and requires referral from a primary care physician to see a specialist. ... Here is a brief overview: An HMO, or
[83] Health Insurance 101: A Comprehensive Guide — There are several different types of insurance plans you can buy to get coverage for health and other care like routine vision or dental. Plan TypeSnapshotDo you have to stay in-network to get coverage?Do procedures & specialists require a referral?HMO: health maintenance organization This is a type of health insurance plan that emphasizes preventive care and offers healthcare services through a network of designated doctors and hospitals. Availability: If your employer does not offer health insurance, you’ll need to explore alternative options such as purchasing individual coverage through the Health Insurance Marketplace, where you may qualify for subsidies based on your income, or investigating state-specific programs and private insurance providers to find a plan that meets your healthcare needs and budget.
[92] Health insurance plan & network types: HMOs, PPOs, and more — Health insurance plan & network types: HMOs, PPOs, and more | HealthCare.gov Health insurance plan & network types: HMOs, PPOs, and more Health insurance plan & network types: HMOs, PPOs, and more Health Maintenance Organization (HMO): A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. Point of Service (POS): A type of plan where you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. Preferred Provider Organization (PPO): A type of health plan where you pay less if you use providers in the plan’s network.
[123] National Health Expenditures In 2023: Faster Growth As Insurance ... — In 2023, enrollment in private health insurance increased 1.6 percent, or by 3.3 million people, and spending per enrollee grew 9.7 percent, which was an acceleration from growth of 5.1 percent in
[129] Health Insurance Marketplaces 2023 Open Enrollment Report — Nearly 16.4 million consumers selected or were automatically re-enrolled in health insurance coverage through the Federally-facilitated Marketplace (FFM) and State-based Marketplaces (SBMs) during the 2023 open enrollment. Enrollment has increased year-over-year, with 1.8 million more consumers signing up for coverage during the 2023 open enrollment compared to the 2022 open enrollment, a 13%
[130] PDF — Health Coverage Under the Affordable Care Act: Current Enrollment Trends and State Estimates Based on 2023 and early 2024 enrollment data 45 million people are currently enrolled in Marketplace or Medicaid expansion coverage under provisions of the Affordable Care Act (ACA), the highest total on record.
[131] ACA Enrollment Hits New Record Highs in 2025 — The Impact of Record Enrollment on the Healthcare System. The surge in ACA enrollment has far-reaching implications for the healthcare system in the United States. As more individuals gain access to health insurance, the dynamics of healthcare delivery and financing are changing. Increased Access to Care
[132] Health insurance industry trends and statistics for 2025 | Thatch Blog — Rising premiums concerns: Employer-sponsored family health insurance premiums have climbed 24% since 2019, which explains why 68% of small business owners say rising premiums are their biggest concern in 2025. Thatch survey findings revealed that 83% of small business owners are concerned about U.S. political turmoil impacting their health insurance offerings in 2025. As healthcare costs continue to rise and regulations evolve, small businesses face unique challenges in providing their employees affordable and comprehensive health insurance. ICHRAs can help businesses reduce costs and offer more comprehensive coverage options by providing employees with funds to purchase individual health insurance plans. Health Insurance ### How small businesses can set themselves up for success with healthcare benefits in 2025
[133] What the Data Say About Offering Public Option Plans to Workers with ... — Employer-sponsored insurance is the largest source of health coverage in the U.S., covering more than nine times the number of people than in the individual market. But the employer market's historic status as the "backbone" of the U.S. health care system is imperiled by rising health care costs. A public health insurance option—frequently floated as a policy to improve coverage access
[134] PDF — • A public health insurance option would provide more affordable choices to individuals and businesses. • State-level public options that have been considered to-date have not cost taxpayers. • Instead, the public option operates like a private health insurance plan: people and businesses pay for their own
[135] Expanding Health Insurance through a Public Option—Choices and Trade ... — At its core, a public option is an insurance plan. The term public generally refers to public financing, usually through taxes and premiums determined by the government, akin to the Medicare program.Option refers to the choice that consumers have between selecting this plan or other options, such as private insurance. Because of this choice, the public option may compete for enrollees with
[136] A Public Option for Health Insurance in the Nongroup Marketplaces: Key ... — Some Members of Congress have proposed introducing a federally administered health insurance plan, or "public option," to compete with private plans in the nongroup marketplaces established by the Affordable Care Act. In this report, the Congressional Budget Office describes the key design considerations of such a public option and some of
[137] PDF — Health and Human Services to contract with Medicaid managed care organizations as well as commercial plans to offer a public option plan on the state's health insurance marketplace starting in 2026. Premiums for the public option are required to be at least 5% lower than the benchmark premium in each zip code and are prohibited from increasing by
[138] What Are Public Health Insurance Programs and How Do They Work? — Public health insurance programs sometimes work alongside private coverage, creating a complex system of benefits that must be carefully managed. Individuals who qualify for Medicaid, Medicare, or CHIP may also have employer-sponsored insurance or individual marketplace plans.
[141] The Affordable Care Act's Impacts on Access to Insurance and Health ... — The Patient Protection and Affordable Care Act (ACA) expands access to health insurance in the United States, and, to date, an estimated 20 million previously uninsured individuals have gained coverage. In particular, we discuss evidence from (a) Massachusetts, which implemented reforms in 2006 that served as the blueprint for the ACA; (b) the Oregon Health Insurance Experiment (OHIE), which expanded Medicaid eligibility to a random sample of a low-income eligible population in 2008; and (c) California’s Low-Income Health Program (LIHP), a Medicaid Section 1115 waiver demonstration project that provided expanded coverage in county programs to low-income adults from 2011 to 2013 prior to their becoming eligible for the state’s Medicaid expansion in 2014.
[142] The impact of the Affordable Care Act on patient coverage and access to ... — The Patient Protection and Affordable Care Act (ACA) of 2010 was a comprehensive national health care reform aimed to expand health insurance coverage and improve access to care in the United States (US). Furthermore, there is limited understanding of the ACA’s coverage expansion effect on newly insured low-income patients’ access to care served by Federally Qualified Health Centers (FQHCs). Besides the challenges with establishing care with private PCPs, administrators believed newly insured patients with Medicaid and the most affordable PHI plan experienced difficulties in accessing secondary care services. While gaining coverage from Medicaid and the most affordable PHI plan enabled newly insured patients to experience an improvement in accessing care, gaps remained in the depth of covered services and willingness of all providers to accept them.
[157] The Potential and Realized Impact of the Affordable Care Act on Health ... — The Potential and Realized Impact of the Affordable Care Act on Health Equity - PubMed The Potential and Realized Impact of the Affordable Care Act on Health Equity The Potential and Realized Impact of the Affordable Care Act on Health Equity Arriving at its 10th anniversary, there is significant evidence that the ACA has reduced social disparities in key health care outcomes, including insurance coverage, health care access, and the use of primary care. Keywords: Affordable Care Act; Medicaid expansion; clinical preventive services; community health centers; discrimination; health disparities; health equity; health policy. Addressing reproductive health disparities as a healthcare management priority: pursuing equity in the era of the Affordable Care Act. Mehta P.
[158] Reducing Disparities In Health Care Coverage And Access Under The ACA — The Affordable Care Act (ACA) has dramatically improved health insurance coverage across the U.S. and reduced disparities in who can access that coverage.
[160] Achieving Health Equity via the Affordable Care Act: Promises ... — Provisions of the ACA related to health equity are woven throughout the act. Three speakers at the workshop discussed various aspects of these provisions and their potential to reduce differences in health outcomes among racial, ethnic, and primary language groups. This chapter integrates the presentations and the responses to questions in order to provide an overview of the ACA and a more
[163] Understanding the Basics of How Health Insurance Works — Key Components of Health Insurance Plans. Every health insurance plan consists of several key components that determine how it functions. These components include premiums, deductibles, copayments, and coinsurance. The premium is the amount you pay monthly or annually to maintain your insurance coverage. A deductible is the amount you must pay
[164] How Does Health Insurance Work And What Is It? — Deductibles and copays are key components of how health insurance works. A deductible is the amount you pay out-of-pocket before your insurance starts to cover expenses. Copays are fixed amounts you pay for specific services, like a doctor's visit or prescription medication. Understanding these terms is crucial for managing your healthcare
[165] Health Insurance Basics: Key Terms & Choosing a Plan | Homebody — Understanding the basics of medical insurance is essential for making informed decisions about your health care. From knowing the different types of insurance plans to understanding key components like premiums, deductibles, and copayments, this knowledge empowers you to choose the right plan and manage your health care costs effectively.
[173] 10 Myths—and Facts—about Health Insurance - BCBSAL — Myth: Health insurance will cover 100 percent of my healthcare visits and healthcare costs. Fact: Different plans have different deductibles, co-pays and co-insurance rates. Whatever the plan, you will pay a portion of healthcare costs and the health insurance provider—known as a "payer"—will pay the rest. However, if you reach your
[205] Overview of the Government Health Care Programs — The six major government health care programs—Medicare, Medicaid, the State Children's Health Insurance Program (SCHIP), the Department of Defense TRICARE and TRICARE for Life programs (DOD TRICARE), the Veterans Health Administration (VHA) program, and the Indian Health Service (IHS) program—provide health care services to about one-third of Americans.
[206] ISPOR - US Healthcare System Overview-Background — ISPOR - US Healthcare System Overview-Background ISPOR 2025 ISPOR 2024 ISPOR Patient-Centered Research Summit 2024 ISPOR 2023 ISPOR 2022 ISPOR Education Center Health Science Policy Council Health Science Policy Council Leadership Health Technology Assessment Council Out-of-pocket payments and market provision of coverage predominate as a means of financing and providing healthcare.2 As of 2019, around 50% of citizens received private insurance coverage through their employer (group insurance), 6% received private insurance through health insurance marketplaces (nongroup insurance) (discussed here), 20% of citizens relied on Medicaid, 14% on Medicare, and 1% on other public forms of insurance (eg, Veterans Health Administration [VHA] and Military Health Service [MHS]), leaving 9% of Americans uninsured.3
[207] Overview of Public Health Insurance Programs - Health Insurance is a ... — The plan will expand access to health coverage to parents with children enrolled in Arizona's Medicaid program or SCHIP with family incomes between 100 percent and 200 percent of FPL and to childless adults with family incomes up to 100 percent of FPL.
[208] A (Brief) History of Health Policy in the United States — The Kerr-Mills Act was passed, which used federal funds to support state programs providing medical care to the poor and elderly (a precursor to Medicaid).6 In 1961, the White House Conference on Aging was held, in which the task force recommended health insurance for the elderly under Social Security. The Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996, restricting the use of pre-existing conditions in health insurance coverage determinations, setting standards for the privacy of medical records, and favorably taxed long-term care insurance.8 In that same year, the Personal Responsibility and Work Opportunity Act removed the link between Medicaid and cash assistance eligibility, and allowed states to cover parents and children at higher rates.
[209] About the ACA | HHS.gov — About the ACA | HHS.gov About HHS HHS About the Affordable Care Act (ACA) The Patient Protection and Affordable Care Act, referred to as the Affordable Care Act or “ACA” for short, is the comprehensive health care reform law enacted in March 2010. Find affordable health care and compare plans at Healthcare.gov. Full Text of the Affordable Care Act and Reconciliation Act - This is not the official version, and we provide it for your convenience. Learn more about your rights & protections under the health care law. Disclaimer Policy: Links with this icon () mean that you are leaving the HHS website. The Department of Health and Human Services (HHS) cannot guarantee the accuracy of a non-federal website. For more information on HHS's web notification policies, see Website Disclaimers.
[210] PDF — The growth in spending on federal health programs is unsustainable. In this paper, I find that spending on health programs will likely compromise the federal government's ability to borrow money, as well as the sustainability of existing debt, within the next 25 to 50 years.
[212] Health and Economy Baseline Estimates - 2023 — Entering the 2023 plan year, the insurance market continues to see challenges from costs, uninsured individuals, and access to care. The Center for Health and Economy (H&E) is dedicated to assessing the impact of proposed reforms that attempt to address these issues. The following report details the most recent updates to the H&E baseline estimates […]
[213] PDF — In 2023, the federal government is expected to spend about 6.2 percent of the economy (or more than $1.6 trillion) on mandatory health programs. These programs include Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and subsidies for insurance purchased through the exchanges established by the Affordable Care Act (ACA). The
[215] Why Over 25 Million Americans Are Still Uninsured Despite ACA Coverage ... — This analysis, using American Community Survey (ACS) data, examines health coverage trends from 2022 to 2023, compares them to pre-pandemic levels in 2019, and highlights characteristics of the uninsured population ages 0-64. In 2023, pandemic-era policies such as Medicaid continuous enrollment and enhanced ACA Marketplace subsidies maintained historically low uninsured rates, with 25.3 million individuals ages 0-64 uninsured, representing 9.5% of the population. The high cost of insurance was the primary barrier, with many uninsured lacking access to employer-based coverage or remaining ineligible for Medicaid or Marketplace subsidies, particularly in non-expansion states. In 2023, nearly 60% of uninsured individuals (14.5 million) were eligible for Medicaid or subsidized Marketplace coverage, but over 40% (10.9 million) were ineligible due to factors such as their state not expanding Medicaid, immigration status, or lack of access to affordable plans as per NCBI.
[220] PDF — THE IMPACT OF MEDICAID AND SCHIP ON LOW-INCOME CHILDREN'S HEALTH Today, one-quarter of children in the U.S. and half of all low-income children receive their health coverage through Medicaid or the State Children's Health Insurance Program (SCHIP), the nation's major public coverage programs for low-income people. Medicaid covers 29
[221] The Impacts of the State Children's Health Insurance Program on ... — The State Children's Health Insurance Program (SCHIP) was created in 1997 primarily to expand insurance coverage to more low-income children. States had latitude over numerous aspects of their program design and ultimately all states expanded eligibility for public coverage under the new program (Kenney and Chang 2004).One of the yardsticks by which SCHIP is measured is the extent to which the
[223] Highly vulnerable communities and the Affordable Care Act: Health ... — Because health insurance is usually associated with increased health utilization and better health outcomes (Freeman et al., 2008; Levy and Meltzer, 2004), especially for vulnerable subpopulations with low income (Levy and Meltzer, 2008; Lucas et al., 2003), we thus explore the effects of the ACA on health insurance in not only racial and
[224] The Affordable Care Act's Impacts on Access to Insurance and Health ... — The Patient Protection and Affordable Care Act (ACA) expands access to health insurance in the United States, and, to date, an estimated 20 million previously uninsured individuals have gained coverage. In particular, we discuss evidence from (a) Massachusetts, which implemented reforms in 2006 that served as the blueprint for the ACA; (b) the Oregon Health Insurance Experiment (OHIE), which expanded Medicaid eligibility to a random sample of a low-income eligible population in 2008; and (c) California’s Low-Income Health Program (LIHP), a Medicaid Section 1115 waiver demonstration project that provided expanded coverage in county programs to low-income adults from 2011 to 2013 prior to their becoming eligible for the state’s Medicaid expansion in 2014.
[248] History of health care reform in the United States - Wikipedia — The history of health care reform in the United States has spanned many decades with health care reform having been the subject of political debate since the early part of the 20th century. Recent reforms remain an active political issue. Alternative reform proposals were offered by both of the major candidates in the 2008, 2016, and 2020 presidential elections.
[250] Healthcare reform in the United States - Wikipedia — Healthcare reform in the United States is the comprehensive change in the law and conduct of the healthcare system in the United States. Reforms have often been proposed but have rarely been accomplished. In 2010, landmark reform was passed through two federal statutes: the Patient Protection and Affordable Care Act (PPACA), signed March 23, 2010, and the Health Care and Education
[251] Unfinished Journey — A Century of Health Care Reform in the United ... — In 1915, reformers issued the first major proposal for national health insurance in the United States. Nearly a century later, Americans are still debating health care reform, the perils of
[252] Health Costs And Financing: Challenges And Strategies For A New ... — There is pressing need and opportunity for health reform that helps achieve better access, affordability, and equity. We organize our recommendations around five policy priorities: expanding insurance coverage, accelerating the transition to value-based care, advancing home-based care, improving the affordability of drugs and other therapeutics, and developing a high-value workforce. Within each priority we provide recommendations for key elected officials and political appointees that could be used as starting points for evidence-based policy making that supports a more effective, efficient, and equitable health system in the US. In this article we draw on our collective backgrounds in health financing, delivery, and innovation to offer a set of consensus-based policy recommendations focused on health care costs and financing. Policy Priorities We propose five policy priorities to advance these system goals: expand insurance coverage, accelerate the transition to value-based care, advance home-based care, improve the affordability of drugs and other therapeutics, and develop a high-value workforce.
[253] 16.2: Supply and Demand in Health-Care Markets — The law of demand applies to health care as in other markets: as the price of health care increases, you demand less of it. But we must be careful. What matters is the price of health care to you. If you have health insurance, this price may be much lower than the actual cost of providing you with care.
[256] PDF — With a sicker moral hazard the tendency of a person who is imperfectly monitored to engage in dishonest or otherwise undesirable behavior adverse selection the tendency for the mix of unobserved attributes to become undesirable from the standpoint of an uninformed party 85126_EconomicsofHealthcare Mod_rev01_001_014 cf_PP2.indd 5 8/30/17 3:17 PM 6 The Economics of Healthcare group of customers than expected, the company has higher costs and therefore has to raise the price of insurance. Buyer Good or service Access rules Financing rules (a) Model of the typical market (b) Model of a healthcare market with an insurer Payment rules Provider Patient Insurer Money Seller 85126_EconomicsofHealthcare Mod_rev01_001_014 cf_PP2.indd 7 8/30/17 3:17 PM 8 The Economics of Healthcare insurer is the government, paying for healthcare becomes part of designing the tax system.
[257] Social Determinants of Health - Healthy People 2030 | odphp.health.gov — Social Determinants of Health - Healthy People 2030 | odphp.health.gov Health Literacy in Healthy People 2030 Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Social determinants of health (SDOH) have a major impact on people’s health, well-being, and quality of life. One of Healthy People 2030’s 5 overarching goals is specifically related to SDOH: “Create social, physical, and economic environments that promote attaining the full potential for health and well-being for all.”
[258] The Role of Social Determinants of Health in Promoting Health Equality ... — Every aspect of social determinants influences the health aspects of people; hence, some areas to focus on include employment, education, socioeconomic status, social support networks, health policies, and healthcare access. Keywords: health services, health equality, health policies, social factors, social movement, health inequities, social determinants History of social determinants of health inequality Keywords used were social inequalities, social inequities, poverty, health determinants, behavior, economic status, and social movement. Studies that discussed the relationship between health inequities, the importance of social determinants, health inequities, health policies, social factors, health equality, and social movement were included. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1470525/ Am J Public Health. 13.[Epidemiology and social determinants of health inequalities] Goldberg M, Melchior M, Leclerc A, Lert F. https://www.researchgate.net/publication/9886555_Epidemiology_and_social_determinants_of_health_inequalities.
[259] The Social Determinants of Health, Health Disparities, and Health ... — Recent research has shown that the adoption of HiAP and use of HIAs has not resulted in broad changes in the SDOH or actual reductions in health disparities.4 Furthermore, neither the HiAP nor the HIA require the government to address structural discrimination, which research shows is one of the root causes of health disparities.5 For example, historical and modern-day structural discrimination in employment has limited racial and ethnic minority individuals’ economic conditions by segregating them to low wage jobs that lack benefits, such as paid sick leave and health insurance.6 This has been associated with health disparities.7 Health justice provides a community-driven approach to transform the government’s efforts to address the SDOH and eliminate health disparities.
[261] Impact of Access Regulation on Health Insurance Market Structure — Recent studies of health insurance regulation all have concluded that state regulation of insurance issue, renewal and rating in general either reduces health insurance coverage or, on net, has no impact on coverage. Some of these studies have found that regulation has no significant impact on overall coverage, but that regulation may change the risk distribution of the insured population
[262] Understanding Regulatory Changes in Health Insurance for 2025 — Regulatory changes in health insurance evolve with each new year as the federal government responds to issues and concerns from healthcare providers and patients and gains information on how current systems are working. Technological advances – New healthcare delivery models such as telehealth, health partnerships, wearable devices, and AI will continue to bring about new regulations to ensure data privacy, patient access, and overall quality of care. The special enrollment period rule was set to expire on December 31, 2025, but the new 2025 health insurance regulations would make the special enrollment period for this population permanent. The new rules give HHS the option of implementing a change to allow patients to terminate their coverage retroactively under certain circumstances if they get approved for backdated Medicare coverage. The new rule is optional for state-run health plans.
[263] Government regulation of private health insurance - PMC — This article is an update of "Government regulation of private health insurance", CD011512. Our review suggests that, from currently available evidence, it is uncertain whether policies that regulate private health insurance have an effect on utilisation of healthcare services, costs, quality of care, or patient health outcomes. The aim of this Cochrane Review was to assess the effects of government regulations of private health insurance. ‐ None of the studies looked at the effect of government regulation on the quality of care provided by private insurance companies or on people’s health.
[264] Health-Care Politics in the United States - Political Science - Oxford ... — Draws on archival research to chronicle the evolution of the health-care system in the United States. Argues that the political challenges of advancing universal health coverage in the 20th century center on the emergence of private, employer-sponsored insurance and opposition from other private interests, such as medical professionals, unions
[281] (PDF) Achieving Health Equity in the United States: Comprehensive ... — [Show full abstract] reform, which aims to create a more inclusive and equitable healthcare system by expanding insurance coverage and integrating social determinants of health into policy design
[283] Impact of hospital and health system initiatives to address Social ... — Impact of hospital and health system initiatives to address Social Determinants of Health (SDOH) in the United States: a scoping review of the peer-reviewed literature | BMC Health Services Research | Full Text Building on prior research characterizing these efforts (Part 1), this scoping review (Part 2) evaluates the effectiveness of these initiatives, with a focus on SDOH data integration, EHR utilization, and the broader scope of hospital efforts in addressing individual- and system-level determinants of health. The earlier article (Part 1) was the first systematic scoping review of hospital and health system initiatives addressing SDOH in the U.S. It made two key contributions: (1) creating a framework to identify the types of SDOH that hospitals and health systems should address and (2) developing a comprehensive model to characterize these efforts.
[284] Addressing health equity during design and implementation of health ... — We conducted a scoping review to (1) identify and characterise strategies that promote health equity during the design and implementation of health system reform initiatives; and (2) determine opportunities to strengthen health equity informed policy design and implementation processes and outcomes. While there is growing acknowledgement of the need for a more explicit focus on health equity across the implementation process within scholarly literature , the range of strategies available to promote health equity at a population level within implementation of complex reform initiatives have not been comprehensively documented, particularly recognising the multiple levels of a health system. Our proposed framework presents a process to inform and support implementation of health equity promoting reform policies and initiatives.
[285] HHS Strategic Approach to Addressing Social Determinants of Health ... — This report highlights key programs, activities, and policies of HHS' strategic approach to addressing social determinants of health, including early accomplishments to date and stories of the on-the-ground impact that these initiatives are making in people's lives. These and other actions being taken by HHS, and across the federal government, as well as cross-sector initiatives at the