The system of providing medical services differs in each country and is based on its culture and economic state’s peculiarities. The modern US healthcare system is built on a variety of private providers and insurance companies funded by the government or consumers. However, this system is continually transforming and changing to offer people the most affordable and high-quality medical services, and opportunities for companies and healthcare workers to implement them. Nurses’ role in this system is also transforming and creating new tasks and opportunities for their professional development. Hence, this paper will study the history and current principles of the health insurance system to understand the characteristics of its development and opportunities offered to patients and nurses.
History of Health Insurance and Managed Care in the US
The first health insurance options appeared in the early twentieth century, although they took years to spread. In 1910, The Western Clinic in Tacoma, Washington, offered various healthcare services to mill workers and owners in exchange for a monthly fee of 50 cents (Kongstvedt, 2016). The next step for managed care can be noted by creating the Blue Cross insurance plan that was offered in 1929 at Baylor Hospital in Texas for 1,500 teachers, but then expanded to other hospitals and employees. In 1939, the Blue Shield used a similar option in California, which offered insurance for miners and lumber companies (Kongstvedt, 2016). However, later both plans gained a large scale, although in both cases, they were based on the provision of insurance by employers and included services not only for treatment but also for the prevention of diseases. The Blue Cross was distinguished by the fact that it provided hospital services through contractors, while the Blue Shield provided outpatient services (Kongstvedt, 2016). Later, these two programs merged into the system that Americans know today and became mandatory in many states.
Another stage in the development of insurance was adopting the national laws Medicaid and Medicare, since they provided most of the population with health insurance. Both programs were created in 1965, and Medicare is a federal program for providing health care for the elderly and disabled (Kongstvedt, 2016). Simultaneously, Medicaid is funded jointly by the federal and state governments to help all low-income citizens, so the conditions for obtaining insurance are very different in various states. Another significant change in the history of insurance and managed care is the signing of The Affordable Care Act (ACA) in 2010, which expanded health insurance coverage among the population. This act obliged most employers to provide insurance to workers, reduced the number of conditions under which companies can deny insurance, and changed the income level per family for receiving medical benefits. Thus, the number of uninsured US citizens has dropped significantly.
The main impact of health insurance and managed care is that it has become an impetus for improving medical services quality and shifted emphasis on disease prevention. First, it is more financially profitable for hospitals and insurance companies to provide preventive services to avoid diseases that require expensive treatment. Second, it is also more beneficial for hospitals to provide quality services to prevent patients’ re-hospitalization, since it reduced cost per patient. Third, patients can choose medical facilities for treatment, so the provision of better services is a necessity in a commercially competitive health insurance environment. Thus, medical insurance and managed care benefit insurance companies, hospitals, and patients by improving health services quality.
Federal Laws to Regulate Individual Health Insurance
Individual insurance policies vary from state to state as companies and citizens must obey state laws. However, all of these rules have standard features, since they should not violate federal laws adopted to regulate individual health insurance and ensure fair and quality service for all people. Thus, federals laws protecting individuals enrolled in the private insurance are the Public Health Service Act (PHSA), and the Employee Retirement Income Security Act of 1974 (ERISA), and the Internal Revenue Code (IRC).
These acts have many similarities but their differences complement each other to consider all the rights of individuals enrolled in private insurance. PHSA focuses more on individual private insurance and provides conditions in which companies cannot refuse coverage for different discriminatory reasons (Fernandez et al., 2018). Simultaneously, ERISA and IRC are more focused on group insurance, such as insurance provided by employers to their workers, and determines the conditions and requirements in this area (Fernandez et al., 2018). However, all of these acts have been amended many times, so it is also worth noting the importance of the ACA as the last most significant law that changed rules for the protection of individuals’ rights. For example, each person must apply for insurance or pay a fine, and the act prohibits variations in fees or denials of coverage due to different health problems. In addition, the ACA allowed employees to choose healthcare providers from the Marketplace regardless of the employer’s wishes and required all companies with more than 50 employees to provide insurance to employees (Fiedler, 2018). Consequently, federal laws ensure that all US residents receive primary healthcare.
Consumer-Driven Health Care and Empowerment of the Healthcare Consumer
Consumer-driven healthcare is a relatively new approach to health insurance and healthcare delivery to the public; however, it is already showing its positive impact. This approach is based on the fact that each insured person has a personal health account, such as a health savings account (HSA) or health reimbursement arrangement (HRA), and pays for medical expenses from it (McNair et al., 2019). In other words, an individual chooses his or her insurance program or receives one from an employer, but disposes of the money that the company spends on this at his or her discretion. Thus, employees can choose the most convenient insurance, for example, aimed at some health problems, but reducing coverage for others, or even pay the medical expenses of relatives.
This approach empowers the healthcare consumer and improves service quality, people’s engagement, and knowledge about their health, and reduces the cost of services. First, people demand information about medical services and their health state to make better choices, which increases their knowledge of the necessary procedures to maintain well-being. This knowledge, coupled with the desire to save money, reduces medical costs for hospitals and increases the healthcare system’s transparency (McNair et al., 2019). Moreover, this opportunity of patients to chose forces hospitals to provide better quality to retain clients. Thus, consumer-driven healthcare has significant advantages over the traditional insurance system.
Opportunities for Nurses Within Private Insurance Market
Consumer-driven healthcare approach and expanding the insurance market demands new skills and roles from healthcare professionals. This fact creates opportunities for nurses to develop and obtain a wider variety of jobs and decent working conditions. For example, nurses can and should be involved in developing new approaches to improve the quality of care, using modern technology in medicine, and educating patients. These responsibilities also open up new jobs as nurses play a central role in preventive medicine and patient education, as well as in the provision of outpatient services.
For example, the ability to use health insurance for elderly patient care or home care creates new vacancies in nursing homes, ambulatory care, and home health for nurses. Preventive care and patient education are also usually the responsibility of a nurse, and as the focus of consumer-driven healthcare has shifted to this area, nursing services are in high demand. In addition, the private insurance market creates a highly competitive environment in which every company and hospital values qualified employees. Consequently, employers must value nurses more, provide them with education, and decent working conditions to improve their work quality, and retain clients. Thus, the private insurance market creates conditions for nurses’ development and the provision of new roles to them, contributing to the improvement of health services.
Therefore, the health insurance market in the United States has a significant impact on the country’s healthcare system as it stimulates its development. The insurance system has gone through many changes to provide the best patient service and profit to companies. Today, the country has a developed structure and laws that protect people’s rights to receive affordable medical services. However, this transformation is not over yet, and it brings opportunities both for healthcare in general and for a nurse in particular. Empowering healthcare consumers has created new challenges and opportunities for nursing professional growth and an environment in which their services are increasingly in demand. Consequently, the primary challenge for nurses today is to use these opportunities and benefit all participants in the healthcare system.
Fernandez, B., Forsberg, V.C., & Rosso, R.J. (2018). Federal requirements on private health insurance plans. Congressional Research Service. Web.
Fiedler, M. (2018). How did the ACA’s individual mandate affect insurance coverage? Evidence from coverage decisions by higher-income people. The USC-Brookings Schaeffer Initiative for Health Policy. Web.
Kongstvedt, P. R. (2016). Health insurance and managed care: What they are and how they work. Jones & Bartlett Learning.
McNair, J., White, B., Miller, C., Ferguson, & W., Coustasse, A. (2019). Potential savings from consumer-driven health plans. Business and Health Administration Association Annual Conference. Web.