It refers toinsurance that aims at covering part or the whole risk of an individual who is incurring medical expenseswithout spreading the risk to a more significant number of persons. By estimation, the overall health care risk and costs on the health system expenses over a risk pool can develop from the insurer routine finance structure which includes payroll tax and monthly premiums which provide enough cash to cater for the health care benefits as specified in the insurance agreement(Cohen & Martinez, 2015). Notably, the profit from the insurance body is administered by central organisations such as private business enterprises, government agencies and nonprofit entities in the health sector.
According to the American Health Insurance Association, health insurance can be defined as coverage that aims at providing benefits payments due to injury or sickness. It also includes medical expenses, loss from accident, accidental death, disability and dismemberment. Similarly, health insurance is often in the benefit packages of the employers as a way of luring quality employees. The cost of all health insurances is deductible based on the payer, and the accumulated benefits are tax-free. The paper focuses on discussing the existing federal health insurance policy the roles of research information in reshaping the available details on public laws. It also captures the proposed changes in the current law to deal with federal issues in the health insurance policy.
Breaking Down the Health Insurance
Health insurance is tricky to navigate and managing because it directly has contact with parties concerned. Operating plans for care insurance require policyholders to maintain a flow of information and connection between the health care designated networks and the care providers into a broader range of coverage (Uberoi, Finegold& Gee, 2016). However, if the patients get care from other networks which are different from the current one, the percentage cost is always higher. Similarly, in rare cases, most health insurance agencies don’t pay for outright services which are obtained outside the recommended network.
According to Klecun(2016), many care management plans requires the patientsto make choices against the primary care physicians who controls all the care practices about their patients before making recommendations for the treatment actions (Klecun, 2016). Most Insurance companies may deny full coverage for services which were obtained without preauthorization. Conversely, insurers may also refuse any payments which are being made towards the name brand drug especially if the comparable medication or generic version is below the total cost.
Additionally, all Insurance plans which have higher out-of-pocket costs usually have smaller premiums per month as opposed to other projects which have low destructible. If an individual is shopping for ideas, he or she must weigh all the options and lower monthly benefit costs which are against the significant out-of-pocket expenses potential risks like accidents or significant illness(Cohen & Martinez, 2015).Other cousins of Health insurance includecatastrophic illness insurance, disability insurance, as well as long-term care insurance.
This refers to the plans, decisions, and actions which are undertaken to realise a specific goal in health care set up within society. Health policies help in achieving several things in health insurance as well as Medicare provisions. For example, it helps in defining an explicit vision for the future stability of health care provisions which in turn assists in establishing coherent targets and reference points for both the short and long term investments. Similarly, health policy outlines all priorities and the roles which are expected from different groups to build builds consensus and create awareness among people.
Health policy has several categories such as public health policy, global health policy, mental health policy, insurance health policy, health care health policy as well as personal health policy among others. All these health policies cover topics of access to proper care, delivery and financing of healthcare, health equity and quality of care. However, the existence of federal policies plays a vital role in creating hegemony in health care fraternity.
Health Insurance Policy
Health insurance policy refers to a standard form of contract between the person issuing the insurance, the insurer and the person being insured, the policyholder. The policyholder determines all the claims which are legally needed to be satisfied by the insurer before payment is made. In exchange, a premium is paid as the insurer commits to pay for all the losses which are caused by the perils covered in the policy language(Klecun, 2016). Promises to pay for damage caused by hazards covered under the policy language. Insurance contracts are also designed to meet several specific needs thereby unique from all other contract types. Although most insurance policies have standard forms, the existence of boilerplate in the language makes it accepted in various ways of the systems across the health care setup.
Moreover, most health insurance policies are generally an integrated contract which includes various forms that are associated with the existing agreement that was made between the insurer and the policyholder(Uberoi, Finegold& Gee, 2016). These agreements have federal government support that makes the meet the threshold of the required care. Similarly, the use of additional forms of writings such as final agreement letters can make the health insurance policy assume a non-integrated contract.
Existing federal policy problems in Health Insurance
Affordable Care Act
After the assignation of the Affordable Care Act into law by the U.S president to protect the rights of the patients, several insurance companies were prohibited from denying their patients with different pre-existing condition cover to allow children remain under the coverage of their parents before reaching an age of 26 years. In other participating states, the new act expanded Medicaid which provides medical care and attention for persons with meagre incomes.
Also, the ACA also developed a federal Healthcare Marketplace to help business and individual shops with quality insurance plans which are affordable and cost-effective. Interestingly, low-income individuals may qualify for subsidies if they sign their insurance premiums through the market. They also realise a reduced cost in their overall summations.
According to the federal law, all Americans must have medical insurances that meet the designated minimum standards of federal jurisdiction, or they face a tax penalty. However, in some cases, taxpayers may be exempted from insurance penalties if they fail to obtain the premiums due to financial constraints or other issues(Cohen & Martinez, 2015). Medicare, Children’s Health Insurance Program and Two public health insurance plans aimed at providing quality insurance services among the children and older individuals. On the other hand, Medicare serves all people with different disabilities whereas the CHIP covers children and babies between age 0-18 years old.
The program is designed as a joint federal-state and aims at providing health insurance to children below 18 years old and the poor without relying on other caregivers support. The program supports approximately four million children who were enrolled at the beginning of the fiscal year. The program also targets children whose medical expenses are beyond the Medicaid eligibility requirements. However, under legal regulations from the federal policies, this program always faces several setbacks as the poor and the children fail to get the best prescriptions from their health care services(Aanestad et al., 2017).Similarly, the program also operates as a unified grant to the federal making them capable of creating better options for significant Medicaid expansions.
VHA policy was established as a separate entity within the Veterans Administration to help in meeting the needs of U.S veteran health care. This veteran group constitutes approximately 20% of the total population of the nation although the minority receives their insurance services from the VTA programs.As a result, eligibility is triaged with the available budget such as service-connected disabilities and the compensable services from the federal government.
The Health care services from this program are delivered through several local health care avenues which are integrated within the policy itself.Notably, each VISN 10 hospitals, seven nursing homes and more than 25 ambulatory care clinics plus other several care delivery units which are controlled by the federal government(Klecun, 2016). Most of the administrative and clinical staff are employees from VHA due to low-income, older population and chronic disease which were common before the policy was made active.
DOD TRICARE is a combination of two health care programs which are governed by the Department of Defense among several federal governments. It provides services to all active-duty military personnel, retiree below 70 years old and their dependents.
TRICARE in Health Insurance policy intends to ensure explicit “force health protection.” At the level of health consistency, all active-duty personnel of the military must meet their health demands according to the “military readiness.” The program must also be able to provide emergency and urgent care to all injured soldiers in remote areas (Uberoi, Finegold& Gee, 2016). Generally, the beneficiary population of the TRICARE tends to be healthy and young. Also, other service needs of the TRICARE beneficiaries to force health protection especially on the active duty dependents should have all the federal government regulations and policies.
When identifying methods to improve the quality of government health care programs and enhancement processes, it is prudent to understand all the expectations and needs of health insurance policy and beneficiaries that are needed for future developments. These federal policy trends that influence
The federal government assumes that epidemiology trends of medical science and technology, as well as the health and disease, have a profound impact on the health care service delivery. Chronic conditions are defined as the conditions which are never resolved amidst continual impairment which reduces the normal functioning of a person such as disability, death and illness. Result reveals that older people suffer from chronic conditions as compared to young and the middle age.
Therefore, most health care resources in the United States have been devoted to helping in treating chronic diseases. However, this trend has strongly opposed federal health policies and programs (Cohen & Martinez, 2015). For example, VHA and Medicare programs have established their beneficiaries to cater for multiple chronic conditions such as diabetes, asthma, cancer, hypertension, cognitive heart failure and disorders as well as mental retardations as major critical clinical issues in all their programs.
Additionally, the overwhelming prevalence and challenges in chronic illness systems have severe repercussions on the health insurance policy and federal regulations. Ambulatory and hospitals settings are usually designed to provide all needed care services among insurance providers with limited communication to the patients or policyholders on fossilisation and periodic visits(Klecun, 2016). Overall, chronic severe conditions require active and ongoing medical management to an emphasis on tertiary and secondary prevention without checking health insurance policy requirements.
Roles of Research Information in Reshaping the HealthInsurance Policy
The Affordable Care Act which was enacted in 2010 in the United States drastically changed the landscape in the area. The goal of the federal policies was aimed at reducing the number of people who are not insured to make the coverage large and affordable in accessing medical care. However, according to Portney (2016), to accomplish these different research methods have been designed to provide enough information concerning the workability and efficiency of the insurance policy (Portney, 2016). The federal law also expanded the Medicaid eligibility to create a new marketplace where individuals who lack the coverage from their employers could access the policies from the insurers. The new technique uses a stick and carrot approach to improve the enrollment rate.
Since the adoption of ACA, approximately 20 million people have been newly insured. The ACA provides a unified research platform where people could get all the information they need concerning the importance of insurance in the health sector are explain. Different research information is standard in the ACA making it easier to be quickly. Despite all the realised successes, the federal law experienced strong political headwinds which repealed the existing law and replaced it with an alternative health reform which only addresses other issues.
Research information in Health Insurance
Most researchers depended on the available data to further their studies concerning the chosen topic. These sources of information in health insurance help the federal government meant to fathom the most critical approach to use while dealing with health care issues. Information sources such as newsletters, journal, articles and books among others provide the health sector with all necessary information.
RAND research provides mild insights about the possible impact of revising or repealing the ACA. The estudy from RAND about ACA applies the use of new versions to compare micro-simulation models which are used to predict the effect of changing health policy at national and state levels (Sommers et al., 2017). Using different research designs,many researchers have examined many impactson the configurations of health insurance in America. The information from the research reveals:
RAND research also examines the importance of modifying key provisions while retaining the ACA, such as:
Similarly, research information helps in establishing theroot cause of why unrelated health policies have numerous consequences on the lives of people(Portney, 2016). For example, research reveals that disease such as cancer and obesity are common because of the unintended monetary costs. The analysis also indicates the importance of planning and policy decisions in public health and individual behaviour implication thereby making it easier for rapid responses to calm the situation.
Moreover, research helps in identifying all the measurable health consequences and their root cause for immediate ratification. It shows the overall impact of the federalhealth policies in both the private and public health set up. For example, some studies show that economic resources are significantly influenced by health outcomes (Proctor, 2016). The relationship between health and financial resources is more than the common assumption; poverty, instead, adequate evidence shows that an inverse relationship between morbidity and income which are associated with the chronic diseases are beyond the poverty levels.
Furthermore, research information provides abundant evident on the effects of environmental factors such as cardiovascular diseases, air pollution respiratory acceleration that has been assumed in the policy. Scientific literature shows that various aspects of the social and political environment contribute adversely to health hazards. It is therefore prudent for the health insurance to have keen internalisation of these environmental factors before making a final verdict on the finality of the policy(Portney, 2016). Similarly, federal laws should be rational enough to reduce all the complexities that may exist in the health care system.
Proposed Changes and Improvements in Public Law Dealing with Health Insurance Policy
Despite numerous court disadvantages in developing effective health policies, rapidfactors influenced the health insurance policy leading to a need for proper improvements and changes in health care service provision. Most health policy has been introduced to reduce the complexities in the older judicial law for significant future development.
First, the judiciary has displayed clear leadership in health insurance management through formulating important policy related to the right of withdrawing life-sustaining treatments across all private and public hospitals. Although this was uncommon in the U.S Supreme court because of it retard nature of extending its rights beyond reproductive decision privacy, other state courts have developed a comprehensive interpretation of the state constitutions and federal policies to stabilises the health insurance policies. For example, one court in Bouvia maintained that decisions made by the patients to forgo medical treatment are philosophical and moral that must be considered(Uberoi, Finegold& Gee, 2016). Similarly, the rights of patients of refusing medical interventions have been extended to enable them prone to exemplary decisions. Notably, the courts have uniformly adhered to the surrogate decisions, particularly family members while making proper choices to the proposed changes in health insurance.
Additionally, the courts have defined all circumstances under which health insurance policies used in treatment could be terminated without interfering with the policyholder over the years. This was made possible by mild rejections that distinguish between withdrawing or withholding treatment, between extraordinary and ordinary treatment as well as between nonterminal and ill cases to ensure that the judicial applications favour the insurance policies. Similarly, many courts have protected cases involving blood transfusion and ventilators as well as the ones involving hydration and nutrition(Proctor, 2016). This was conducted through properly designed procedures and criteria that range from federal policy to the administrative law thereby creating a meaningful platform for transactions between the insurer and the policyholder.
The mental health policy also showed a similar pattern as the ones in the administrative leadership in the legislative enactment. For example, recently the courts began a system that aims at transforming mental health policy across all nations in America. To achieve this, the court established insufficient and unconstitutional mental health statutes to protect the public from any harm. Many courts also refused to honour broad discretionary language which is used in the civil commitment statutes to describe a patient’s interest (Aanestad et al., 2017). Others did not allow the civil commitment process to deter them from getting the correct solution to their health problems as stipulated in insurance policies. This is because the constitution the standards proof for civil commitment in maintaining a healthy environment for adequate beneficiaries demands convincing evidence such as mental illness. Overall, American mental health legislation has been adversely reformed to comply with the constitutional requirements concerning health insurance policy.
Moreover, Medicare reimbursement in federal deficit-reduction and ACA proposals assisted in rewarding value and quality over quantity services which are provided by the health care systems. For instances, Medicare reimbursementreduced all payments that were made under the ACA act to the Medicare Advantage Planto make accessibility to insurance policies more accessible and affordable.The new federal system also rescheduled all value-based purchasing payments for easy availability of acute-care services in hospitals according to the available support from the insurance firms(Proctor, 2016). Similarly, in infancy stages, the physician payment plans will be made after the patient has attained a quality and defined treatment.This was enhanced by the provisions of Medicare Modernization Act (MMA) whose goal was to establish medication therapy management (MTM) initiatives and to boost Medicare Part D. Again, health practitioners and insurers got significant opportunities in the health care setting to support their reimbursement and success on a demonstrated value.
In conclusion, a health insurance policy is a federal issue that helps in protecting the welfare of people in America. However, national topics such as the Veterans Health Administration Policy and DOD TRICARE have a significant influence on the disbursement of funds to support the patients. As a result, ACA provides substantial spillover effects on the pharmaceutical industry as well as the accessibility and costof drug products in several ways. As a result, the FDA proposed rules and regulations for a comprehensive pathway in biosimilarsapproval from the ACA. The provision was to ensure exclusivity in the innovator biologics period before other alternatives could be made.
Aanestad, M., Grisot, M., Hanseth, O., &Vassilakopoulou, P. (2017).Information Infrastructures for eHealth.Information Infrastructures within European Health Care (pp. 11-23).Springer, Cham.
Cohen, R. A., & Martinez, M. E. (2015). Health insurance coverage: Early release of estimates from the National Health Interview Survey, 2014. National centre for health statistics.
Klecun, E. (2016). Transforming healthcare: policy discourses of IT and patient-centred care. European Journal of Information Systems, 25(1), 64-76.
Portney, P. R. (Ed.). (2016). Public policies for environmental protection.Routledge.
Proctor, B. D. (2016). Income, poverty, and health insurance coverage in the united states: 2010. Report P60-256. September.Census Bureau.
Sommers, B. D., Gawande, A. A., &Baicker, K. (2017). Health insurance coverage and health—what the recent evidence tells us.
Uberoi, N., Finegold, K., & Gee, E. (2016). Health insurance coverage and the Affordable Care Act, 2010-2016. Washington (DC): Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation.
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