Health Coverage

Health Coverage, Not Health Insurance

Health Coverage Insurance 101

This is the fourth post in a multi-part series, Insurance Foundations.

Now that we’ve defined what insurance is, and taken a look at what makes something insurable, we can finally turn our attention to health insurance. Or, more properly, health coverage. I often prefer the latter term for a very simple reason: we don’t really have health insurance anymore.

That said, I still use the term “health insurance” at times because it’s the more recognizable phrase.

The reason we don’t really have health insurance anymore is simple: medical costs aren’t insurable.

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In an Emergency, Network Status Comes Second

Health Coverage

A recent Miami Herald article, as reprinted by InsuranceNewsNet, opened with a starkly written story about a South Florida mother driving nearly an hour to find in-network emergency care for her daughter after visiting an urgent care. The providers at the urgent care had warned her that the child’s appendix could rupture at any time. Unfortunately, the mother had to drive past two existing emergency rooms — both of which were close by — to find an in-network facility.

Members of Florida Blue and its affiliates can still seek emergency care at hospitals run by Broward Health and Memorial. Health insurers are required to cover emergency services at any hospital in the country as if it’s in-network, even if it’s out-of-network. But, “I don’t know what that means in real-life terms,” [the parent] said.

Questions and scenarios swirled in her head that January night: If [the child] was admitted into an out-of-network ER, would she have to fight with every doctor to get insurance coverage? Would she be forced to transfer hospitals? Would just the ER visit be covered — but the rest not?

This situation was used to highlight the choices patients faced in the wake of a provider network contract negotiation that failed — in this case, between Florida Blue and Broward Healthcare. But it’s not the best example, and for the reason that was stated in the article: health insurers are required to cover emergency services at any hospital in the country as if it’s in-network, even if it’s out of network.

That’s true; it’s based on a federal law called the Emergency Medical Treatment and Active Labor Act (EMTALA). Further, based solely on the information in this article, it appears that the mother could probably have gone to Broward Health Medical Center. Let’s take a deeper dive into why that is, and what likely would have happened had she done so.

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The ACA Succeeded at Its Intended Goals

Health Coverage

Many eyes were on Congress last Thursday as legislators grilled the CEOs of the largest health coverage payors in the country. And “grilling” was the right word — the exchanges were heated, and at times became downright brutal, a tone reflected in media coverage that didn’t pull any punches.

The message was clear: people are fed up with the way health coverage works in this country. At best, the system feels expensive, opaque, and unresponsive. At its worst? The opinions are unrepeatable in polite company — and often for good, justifiable reasons.

There are any number of ways to unpack the Congressional testimony — and any number of pundits out there unpacking it — but one thing that’s important to understand is that, when evaluated by the issues it was attempting to address, the Affordable Care Act has been successful.

Yes, I mean that seriously: premium increases were curtailed; the number of uninsured dropped dramatically; and numerous problematic practices were abolished. The problem isn’t the ACA itself; the problem is that it was never the all-purpose “fix” it was touted to be.

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Provider Networks: Everyone Suffers

Health Coverage

In my last two posts, I explained why provider networks exist (and that they’re not new), and what problems they solve. Those benefits are real, substantial, and often underappreciated — particularly in today’s contentious landscape.

At the same time, provider networks also have very real problems that are inherent to their design. It’s not because the concept itself is inappropriate, but because any system that mediates access, pricing, and payment between patients, providers, and payors must introduce friction somewhere. That friction can’t be avoided — and, just like the benefits, the problems affect more than one set of stakeholders.

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