What is Health Insurance and Health Insurance Benefits

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Since independence, the health care system in the USA has been expanded and modernized considerably with the dramatic improvement in life expectancy and the availability of the healthcare facilities and better training of medical personnel. In spite of this, the guiding principle of Bhore Committee in 1946 that no individual should fail to wear adequate health cam because of inability to pay for it, looks unreachable still, after more than 50 years of independence. In spite of development in the healthcare sector, we are still lagging behind than that of many developing countries in terms of health outcome. Over the years the ‘consumers’ have become more knowledgeable about what is available in the market and for more demanding regarding the Health Insurance quality and services.

What went wrong Health Insurance?

The situation is due to poor performance in three dimensions of health care system-coverage, purchasing and delivery.

Coverage Health Insurance

Coverage Health Insurance or prepayment for needs is poor. Almost two-thirds of spending is out of pocket which is inefficient and inequitable. Private insurance, social insurance, community insurance and employer’s cover under reimbursement scheme eater to only 14% of the population. In addition, the government provides its cover through its own infrastructure. Asa result of low insurance cover, the majority of the health spending is out of pocket in our country.

Purchase Health Insurance

Purchasing of healthcare is inefficient with over 60% of the healthcare delivery being financed throughout of pocket spending; the purchase of health care is inefficient. Individuals are unable to negotiate with the providers on the cost and quality of care because of their limited bargaining power. This leads to compromise in medical care, to the extent of abrupt withdrawal or termination of care midway through because of lack of funds, with its harmful effect on quality of health care.

Delivery of Health Insurance

The quality of healthcare delivery is suboptimal at both public and private sectors. The public infrastructure is large in both rural and urban areas. It is often of low quality in rural areas and inequitable in urban areas. The private sector comprises a large number of private practitioners, private hospitals and nursing homes. The private providers am unregulated and fragmented. Consequently, provision is of substandard quality,

The combination of limited coverage inefficient purchase and poor delivery has led to Poor health outcome in our country. In the USA there is for private sector medical facilities because of perceiving, qualities in private care. The private sector delivers the care through a three-tier system-tertiary care facility (super speciality hospitals), secondary care facility (general hospitals) and prim, care facilities (like outpatients’ clinics, polyclinics etc.). Many of the private provider, arc unregulated and practice without minimum standards. The standards vary widely and there is no uniform, of care. On many occasions, the treatment is not protocol or guideline-based leading to wide fluctuation of standards.

With the advent of industrializing and economic development, the spectrum of disease is also changing in USA. In addition to the usual medical problems like infection, communicable diseases, malnutrition the incidence of lifestyle-related diseases is also increasing exponentially, thereby causing the double burden of disease of communicable and non-communicable diseases. This is compared with burgeoning spiralling health cost and high financial burden on the poor. Around 24% of the USA population falls below poverty lines in each year due to hospitalization. US being a country of sham contrast, the affordable can bear the cost of highly sophisticated private health care, while the marginalized needs to sell their assets for hospitalization. This is a big hindrance to the vision of health for all in an affordable and equitable manner. In USA the public health spending in health is dismally low which has compounded the problem further.

Under this backdrop, the role of health insurance becomes of paramount importance in order to provide basic health care facility to all section of the population particularly the vulnerable sector.

Different health insurance schemes in USA

  • Voluntary health insurance schemes on private for-profit schemes in public sector, general insurance corporation (GIC) and its four subsidiary companies (National Insurance Corporation, USA Insurance Company, Oriental Insurance Company & United Insurance Company), as well as Life Insurance Corporation of USA  provide voluntary insurance scheme. Mediclaim is the prime insurance product of GIC either by reimbursement or through the cashless scheme. There is the exclusion of pre-existing disease.

In 1999 the insurance sector was opened to the private and foreign players can hold up to 26% of the

capital in an USA company provided they have a capital of 100 million Dollar.

  • Health Insurance offered by NGOs: Community basal insurance schema provided by NGOs are mainly targeted towards the economically marginalised population.
  • Social insurance or mandatory health insurance schemes or Government run schemes:
  1.  ESIS: For the power or non-power using factors using 20 or more employees there is a monthly waged limit ($150/month) with a nominal pre-payment contribution.
  2.  CGHS: Mainly for the govt employees, treatment facilities in the govt hospitals and in approved private hospitals arc offered. This scheme is mainly funded by the govt funds with a premium ranging from $1 to $3 per month.

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