Health Insurance in America

What is unique in the world about the U.S. health care system is the dominance of the private element over the public element. In public programs, the United States offers Medicare and Medicaid services. The private element offers employer-sponsored and private non-group insurance. Employment-based health insurance continues to be the predominant source of coverage for the non-elderly population. Almost two-thirds (62.7%) of the non-elderly population had employment-based health insurance in 2005. Of the total population of people with health insurance, 7% of the population purchases individual plans. The services available through privately owned insurance are similar to those provided through employers; average premiums are generally somewhat higher than those for employer-sponsored coverage but vary by age and occupations. Deductibles and other cost-sharing (a portion of service cost not covered by the plan) are also higher, on average. Musicians and artists are usually generalized as an “at-risk” population. The “at risk” assessment is based on legitimate occupational health risks mentioned before. Another reason insurance companies do not insure artists is because of biases created by the hypothesized decadence of art culture.

Private health insurance plans vary greatly in their benefits to customers. More expensive plans will give the customer the more choice. Being able to choose your doctors is vital with regards to one’s health. One of the major initiatives of ROCK FOR HEALTH is giving the musicians a choice. ROCK FOR HEALTH customers deserves top medical care for the dangerous health risks on tour.

A private health insurance policy is a basic agreement between a customer and the insurance company. The insurance companies manage the customer’s care and act as an intermediary between them and the medical doctor. The more a customer pays the better insurance he or she will have. America’s Health Insurance Plans (AHIP) –a national association representing nearly 1,300 member companies providing health insurance coverage – claims that managed care is nearly everywhere in America. Nearly 90% of insured Americans are now enrolled in plans with some form of managed care.

Two major Managed Care Organizations (MCOs) are Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). Both of the major MCOs have advantages and disadvantages over each other.

The basic difference between HMOs and PPOs is the cost. HMOs prevent large out-of-pocket expenses for its customers, while with PPOs, the customers will have to pay higher deductibles and will pay a lot of out-of-pocket expenses. The concept of ‘you get what you pay for’ applies to the difference between HMOs and PPOs. In the HMO system, customers are restricted within a certain network of doctors stated within the insurance agreement. The HMO customer is given a primary physician, who is responsible to act as a general doctor for most injuries and diseases. If the primary doctor cannot treat their patient then the doctors will refer their patient to other doctors within a limited network. The customer cannot step outside the network unless approved by the primary physician and it is sometimes difficult finding certain speciality doctors within the network. In a PPO, the customer has access to a bigger network of doctors and they do not need the authorization to seek other doctors outside the larger network. In the PPO system, doctors have agreements with the insurance companies for providing discounted services to insurance companies clients. Customers are not limited to the doctors within the PPO network and have the ability to seek the best care and top specialists in America. The ability to go directly to a specialist is beneficial to customers because they receive immediate care by specialists and do not need to wait for primary physician referrals.

The PPO system tends to have better doctors within the network because the doctors within the network do not want to accept the minimum payments that HMOs companies offer. An HMO system works by pre-paying the doctors for providing care to their clients. This idea of pre-payment is called capitation and is defined as a specified dollar amount a physician gets, for a given time period, to take care of the medical needs of a specified group of people. The amount the doctor gets for a patient is a fixed monthly payment and does not increase on the patients’ unknown visits. This means that if a patient needs a considerable amount of care, and the worth exceeds the fixed monthly amount, then the money could come from the doctor’s budget instead of the insurance companies. Instead of capitation, PPOs uses a fee-for-service method. The fee-for-service method usually attracts better doctors because the payment is guaranteed and usually more.

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