This document provides an overview of the major types of health insurance plans in the United States. It discusses employer-based group plans that cover over half of Americans, as well as self-paid private plans for individuals. It also outlines the government programs of Medicare for seniors and disabled, Medicaid for low-income individuals, and SCHIP for children. Other sources of coverage discussed include other government programs, private charities, and Health Savings Accounts. Around 8% of the population, or 26 million people, lacked health insurance in 2019.

1. Insurance Plans
in USA
Mohammad Javad Rajabi
Ph.D. Candidate of Pharmacoeconomics and Pharma Management
SBMU
April 2021

2. 0. Background
1. Employer-Based Group Health Insurance
2. Self-Paid Private Insurance
3. Medicare
4. Medicaid
5. Other Government and Private Programs and Charity
6. The Uninsured
7. State Children’s Health Insurance Program
8. Health Savings Accounts (HSAs
Topics
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3. Background
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4. Employer-Based Group Health Insurance
More than half (56.4%) the U.S. population is covered by employer group health
insurance
An employee usually obtains insurance by choosing one of the options offered
through his or her employer, deciding whether to include children and other
dependents, and contributing to the total premium
Almost all large employers provide health insurance benefits, but fewer than one-
third of small employers (those with fewer than 10 employees) do so, and those
that do often make the employee pay a large part of the premium so that fewer
people choose to participate
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5. Employer-Based Group Health Insurance
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6. Almost 10 percent of the population, mostly people who are self-employed or who
work for small companies that don’t provide employee benefits, purchase private
health insurance individually
Individuals acting on their own behalf lack group purchasing power and often pay
significantly increased premiums, even for reduced levels of coverage.
Self-Paid Private Insurance
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7. many elderly people don’t belong to employer groups and would be subject to severe
adverse selection if they purchased insurance individually, the U.S. government created
Medicare, a federal insurance program that covers individuals over age 65 and some
people with disabilities
money for Medicare: tax of 2.9 percent on all wages, general tax revenues and
premiums
Medicare program cost $644 billion in 2019
Part A (hospital) coverage:
1. Inpatient care in a hospital
2. Skilled nursing facility care
3. Nursing home care (inpatient care in a skilled nursing facility that’s not custodial or long-term care)
4. Hospice care
5. Home health care
Medicare
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8. Part B (physician and outpatient services) coverage:
1. Medically necessary services: Services or supplies that are needed to diagnose or treat
your medical condition and that meet accepted standards of medical practice.
2. Preventive services: Health care to prevent illness (like the flu) or detect it at an early
stage, when treatment is most likely to work best.
Part D (prescription drug) coverage: provides protection for people who have
very high drug costs. Everyone who has Medicare is eligible for this coverage
Medicare
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9. People who are poor can’t pay for insurance, and many of them (10 percent of the
population) are covered under the Medicaid program
federal/state program insures people whose incomes are insufficient to pay for
health care, and it also provides supplemental coverage for a substantial number of
elderly people, including a majority of those living in nursing homes
Program design differs from state to state (80% : low-income states, 50%: wealthier states)
Budget: $613.5 billion in 2019
Although Medicaid was designed to cover mothers with low incomes and their
children, it has become the largest funding mechanism for nursing homes
Medicaid
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10. Charity paid for about $58 billion in health care in 2002
workers’ compensation, automobile accident insurance, and similar programs paid
more than $25 billion.
The Department of Veterans Affairs received $22 billion in funding
 Programs sponsored by the Maternal and Child Health Bureau Substance Abuse and
Mental Health Services Administration, Bureau of Indian Affairs, and a variety of
other programs accounted for about another $28 billion n health care
Other Government and Private Programs
and Charity
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11. The Uninsured
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12. The Uninsured
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In 2019, 8.0 percent of people, or 26.1 million, did not have health insurance at
any point during the year
While some uninsured individuals pay large sums out of pocket when they get
sick, a much greater number stay healthy and pocket the cash or, having no
resources, depend on charity when they are ill
What Do People Buy When They Don’t Buy Health Insurance?

13. The Uninsured
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14. State Children’s Health Insurance Program
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SCHIP was enacted by Congress in 1997 as Title XXI of the Social Security Act
to provide $40 billion to increase coverage for the 10million children under the
age of 18 who are uninsured
2018: 9.6 Million Children Enrolled
The program cover children whose parents make too much money to qualify for
Medicaid but too little to afford private insurance
Medicaid Expansion CHIP programs provide the same Medicaid benefit package
as provided for children under each state’s Medicaid state plan

15. State Children’s Health Insurance Program
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16. Health Savings Accounts
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Insurance provides protection against the cost of medical care. Inevitably, this
protection makes people less sensitive to costs; that is, they are more willing to use
extra services and less concerned about finding the best price for the services they
use
In an HSA, a person deposits a set amount of money each year in a tax-advantaged
account, which can then be used to purchase medical services
This is a high-powered incentive to motivate people to pay attention to costs, shop
for the lowest prices, and avoid unnecessary services

17.  Health Economics: Fundamentals and Flow of Funds, Thomas E. Getzen
 www.medicar.gov
 https://www.census.gov
References
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