Health Insurance in the US



today we're here with Nathan Moore a resident physician at Washington University in st. Louis and co-author of the healthcare handbook Nathan thanks for being here my pleasure so we have this interesting looking pie chart in front of us here so what are we going to talk about this part chart explains how people get health insurance in the u.s. so maybe the best place to start was is with a little bit of background on that yeah so the health insurance industry is one of the largest in the country over 900 billion dollars in revenues last year interesting interplay between private companies and government programs and it will be changing pretty significantly with the Affordable Care Act just take a step back for just a second we always hear about three groups when it comes to how we pay for health care we hear about the patient the provider and then something called a payor yeah it sounds confusing but it's not that complicated the patients are the ones who get care that providers the ones who give the care and the pay ORS as you might guess are the ones who pay for it so for most Americans the payor is just their health insurance plan right yeah and Americans can get their health insurance either from a private company or from the government or have no insurance at all so I think actually the easiest way to learn about this is to go through this pie chart okay what we noticed is that it's split into six different sections but the major portion of the chart almost half is taken up by one section right so about half of Americans get health insurance through their jobs it's called employer sponsored insurance and this is when you get insurance to the company that you work for that your parents work for or that your spouse works for basically what happens is that your employer will contract with a private company to offer health coverage so these are just companies like Blue Cross Blue Shield you know which is what I have or Aetna UnitedHealth things like that right yeah exactly and these companies will work with your employer to offer you and your family a choice of health insurance plans might be something like a preferred provider organization plan a point a service plan health savings account plan or several other types and based on how much coverage you want and how much you're willing to pay you can pick one okay so if you're willing to pay a higher premium you can basically get more services covered under your plan yeah exactly and the cost of the premium will be split between you and your employer typically the employer pays three core Division you'll pay a quarter okay that makes sense so let's move on to this next piece here it's still a pretty sizable portion of Americans about seventeen percent overall yeah this is Medicaid it's a government health insurance program funded by both the federal and state government but it's run by the state governments so what I remember learning is that Medicaid just takes care of low-income people right the indigent and the poor yeah there's some truth that there's a little bit more complex it covers a low income people but only in certain categories people that need the most help so children parents with dependent children pregnant women the disabled and seniors and they always say that Medicaid is a means-tested program but I've never really understood what that means yeah means-tested indicates that the government when you apply for Medicaid will check to see how much money you have and how much you make per year if you have too much money you don't qualify for Medicaid but since Medicaid is state-run does that mean the rules are different in each state yeah exactly so just because you qualify for Medicaid and once the state doesn't mean you qualify in another this is a big point of controversy currently because the Affordable Care Act was intended to expand Medicaid eligibility in all states however the Supreme Court decided that each state could decide individually whether or not to expand Medicaid okay okay so that's why there's been all that controversy with the Supreme Court exactly so let's move on to the next piece of the pie here it's similar in size to Medicaid a little bit smaller at about 13 percent right this is Medicare it's it's another government health insurance program but it's run by the federal government so it's the same in each state okay so who qualifies for Medicare u.s. citizens who are 65 and older the disabled and those with end-stage renal disease or Lou Gehrig's disease okay so just to make sure that we understand each other so Medicaid is for low-income people in certain categories and Medicare is usually for older Americans right and the other big difference is that Medicare isn't means-tested so the government isn't looking at your income when you why all American citizens 65 or older eligible and there's also four parts to Medicare yeah that's kind of a confusing point let's go over that a little bit okay so the four parts are Part A which covers inpatient care at hospitals nursing homes Part B which covers outpatient care like at a physician's clinic Part C is Medicare Advantage so this is private insurance paid for by Medicare and Part D is prescription drug coverage okay so there's big government health programs for low-income people and for seniors yeah there's two more that we should talk about which is the VA or Veterans Affairs system this covers military veterans there's also TRICARE which covers active duty personnel and their families okay so that's this little slice here right yeah that's right so whenever people talk about the Veterans of air systems these are just the VA hospitals we've all heard about right well that's a little bit more complicated than that the VA and TRICARE not only own hospitals and provide payment for the care they also employ the doctors and actually provide the care so it's different from the other systems we talked about okay so we're really just left with the people who don't get health insurance through their work at all they don't qualify from Medicare they don't qualify for Medicaid or even one of the military programs but as you can see this is still a big chunk about 6% of Americans where do they get their insurance yeah so these folks buy their insurance on the open market individually common scenarios you might see or those who are self-employed unemployed or those who work for companies that don't offer insurance so if you can just buy insurance on this market why even have something like the Affordable Care Act why doesn't everyone just do this it's a good question so it's actually pretty difficult to buy insurance on your own in the open market it's confusing it's difficult to find a good plan and it's almost always more expensive so isn't this where the new health insurance exchanges are going to come in yeah exactly so the Affordable Care Act established health insurance exchanges in each state that are supposed to make it easier and cheaper to buy health insurance on your own the government is also going to provide subsidies to people to buy insurance on their own so in the next few years we should see a lot more people in this slice of the pine okay that seems to make a lot of sense well I think everyone can guess what this last category is just by the process of elimination the elephant in the room the uninsured yeah unfortunately it's a significant piece about 13% of Americans have no health insurance and these people have a tougher time getting health care especially primary care the wait longer to get their conditions checked out and on average they've got more chronic health problems than people with insurance so how is this gonna change under the Affordable Care Act the main goal of the Affordable Care Act was to get people without insurance on insurance through a variety of ways through the health insurance exchanges through Medicaid expansion and a couple other things so hopefully in the next five to ten years we'll see this piece of the pie shrink significantly

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