How does health insurance work in the US?

Question

I am a non-US citizen and need this information to do a case.

Specifically:
1) Is health insurance compulsory for everyone?
2) What happens if someone cannot afford it?
3) In the event that a medical procedure needs to be done, does health insurance cover all the bills? Does the patient need to pay anything extra?
4) Does the patient have any say over what kind of procedure he can take? Say if 2 treatments are available for his condition, can the patient choose the more expensive treatment? And if so, is it covered by the insurance?

Thanks for reading this. Your help in answering any part of the questions would be greatly appreciated!

Thanks to those who have responded so far.

I would like to further ask:

Does a health insurance contract state that it will only cover the "normal" rates for a procedure? For eg. if there are 2 possible treatments for a disease, 1 of which is more expensive but more effective than the other, will the patient only be covered by the LESS expensive one?

Or is it a case in which the patient can opt for the more expensive one and "top-up" the difference?

This is a crucial question to my understanding the case. Thanks!

Answer 1

You've asked a very broad question. There is no simple answer.

In truth, health insurance works a little differently in each state.

To answer your specific questions:
1) No, health insurance is not compulsory for everyone. If you're lucky, you are able to join a group policy at work. (If you're really lucky, it's a good policy and the employer pays at least half of it.) Some states have recently made it compulsory, but that's such a recent change that there's no clear cut answer yet for how that's going to work.

2) What happens if someone can't afford it is... they don't get it, usually. Except if your income puts you below the "poverty level", in which case you qualify for Medicaid. (In some states there are programs that typically provide assistance with insuring children, though they are few and far between for covering adults.)

3) Health insurance rarely covers all the bills when you have a procedure done. Most plans cover 50-80% after you meet your deductible. The deductible amounts vary widely (but the trend is that the deductibles are getting higher and higher to keep the premiums down.) If you're really, REALLY lucky, you don't have a deductible (which is only an option on group plans), and you may only have to pay 10% of covered charges. (These plans are few and far between. As in, you might have them if you're in Congress.)

4) Yes, the patient has some say over procedures. However, if the patient opts for an "experimental" procedure, or one that isn't deemed "medically necessary", then health insurance may refuse to cover any charges at all.

In the end, as with most things, the middle class takes the brunt of these costs. This has become such a problem that more than 50% of all bankruptcies are as a result of medical bills (and of those, more than 75% had health insurance.)

** Edited to add:
It's not ALL about the money when a procedure is involved. If it is, the state keeps track of complaints filed on behalf of consumers with "managed care" (ie. any type of network arrangement including Preferred Provider Organizations, Health Maintenance Organizations, and Point of Service organizations -- also known as PPO, HMO, and POS) and may very well revoke a company's charter to do business in the state should the company be turning down too many legitimate claims.

However, insurance companies are sticklers for following the "standard" for medical care. This is what makes it difficult to answer your question. Because they should not deny anything that's considered standard for care in the given circumstances (should not and will not being two completely different things, of course.) And there may be several options that would be considered "standard." If the patient wants treatment that isn't yet considered "standard", they would balk. Period.

Answer 2

Wow. What a question. In the order asked.
1. No.
2. You do without.
3. Rarely do they cover all the bills. Most often, patients pay a pre-negotiated portion - either a set dollar amount of a copay or a percentage.
4. In a perfect world, only doctors and their patients would have say over what treatments are performed. But, since this is by far NOT a perfect world, the insurance companies have the say. The patient doesn't get to choose the more expensive treatment - and the ONLY way it would be covered was if the patient and their doctor(s) can prove beyond a shadow of a doubt that by the insurance shelling out more money up front (in the form of the treatment) they would, in fact, save money in the long run - by not having to pay for complications or repeat proecdures.

If the patient ops to "top up" the treatment, they better have deep pockets because they'll probably end up paying for most, if not all of it.

Answer 3

Hey guys a few follow up questions:
When does the payment for the insurance by the insurance company take place? Is it immediately after the treatment and when the patient checks out or is it that the patient pays first and is repaid by the insurance company once the company processes the claim? And in this case how long does the company take to process the claim on an average?
Thanks

Answer 4

Health insurance doesnt work in the US. If you cant afford it (it is very expensive) you dont have it. We do have programs to provide insurance to those that cant afford it, but it is primarily for children. You can choose any treatment you want as long as you are going to pay for it. If you do have insurance the insurance company pretty much tells you what they will pay for, otherwise you are on your own. Insurance companies rule in the US, and if you dont like it.....too bad.