Health Insurance Basics

Written by: Evelyn Huang, MD (NUEM ‘24) Edited by: Vytas Karalius, MD, MPH (NUEM ‘22)
Expert Commentary by: Cedric Dark, MD, MPH

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Health Insurance: The Basics Every Doctor Should Know

A Brief History of Insurance in the U.S.

• In 1929, teachers in Dallas contracted with Baylor University Hospital to have monthly payments in exchange for up to 21 days of inpatient care a year. By 1937, there were 26 similar plans that all combined to form the Blue Cross network. In the 1930s, physicians also formed a network of insurance plans known as Blue Shield [1].

• During World War II, wage controls prevented employers from raising salaries. As a result, they started to offer health insurance. The IRS added that employers and employees did not have to include these costs in their taxable income [1].

• In 1944, President Franklin Roosevelt called for an “Economic Bill of Rights” that included the right to medical care that was never passed. President Truman proposed national health insurance for all Americans that was unpopular due to anti-communist sentiment [1, 2].

• In 1965, Medicare and Medicaid were created. In 1972, Medicare was extended for people under 65 who had long-term disabilities and/or end-stage renal disease [2].

• In 2010, the Patient Protection and Affordable Care Act (ACA) was passed [2].

Medicare Basics

As of 2019, Medicare covers approximately 61.4 million people [4]. Medicare is federally-run and has four parts:

• Part A: inpatient services, nursing care, home health

• Part B: outpatient services, ED visits

• Part C: “Medicare Advantage,” enrolling in Medicare benefits through private insurers

• Part D: prescription medications

Medicaid Basics

As of 2019, Medicaid covers approximately 75.8 million people and includes low-income adults, pregnant, and children [4]. Medicaid is unique from Medicare in that it is state-run with set federal regulations. The Affordable Care Act expanded eligibility to households with income up to 138% of the federal poverty level [2]. To date, 39 states including DC have adopted this expansion and 12 states have not, as seen in the map below [5].

Medicaid also includes the Children’s Health Insurance Program (CHIP) for children living in households that are under 200% of the federal poverty level and is state-run [2]. As of 2019, CHIP covers approximately 7.2 million children [4].

Patients that come to the emergency room are also able to apply for emergency Medicaid if they are currently uninsured. The details of this vary from state to state.

The Affordable Care Act

Signed into law 2010, the Patient Protection and Affordable Care Act had three main goals: expanding healthcare coverage, decreasing health care costs, and improving health care delivery.

• Expanding healthcare coverage

  • Medicaid expansion

  • Individual mandate (discussed in “Private Insurance Basics”)

  • Requirements for employers to offer health insurance plans

  • Dependent coverage for children up to age 26

  • Removed insurance exclusions for patients with pre-existing conditions

• Decreasing health care costs

  • Tax credits for small business employers that purchase health insurance for employees

  • Creation of health insurance exchanges

  • Insurance market rules, such as limiting deductibles and prohibiting lifetime limits of coverage

  • Discounts for prescription drugs for patients covered by Medicare

• Improving health care delivery

  • National quality improvement strategies

  • Required health plans to cover preventative services

  • Bonus payments for primary care physicians

  • Grants for wellness programs

  • Required chain restaurants to disclose nutritional content

For more information on the ACA, visit this website.

Private Insurance Basics

The ACA enacted an individual mandate, which required Americans to have health insurance or face a tax fee. However, the individual mandate penalty was repealed starting in 2019. Private insurance can be purchased individually, through an exchange/marketplace (third-party markets created by the ACA) or is provided by employers [2].

The ACA also set up 10 essential health services that must be covered with insurance plans. This includes hospitalizations, ambulatory services, lab tests, prescriptions, and emergency services [7].

There are different types of private health insurances, and it is important to have a basic knowledge of this when caring for your patients [9]:

• HMO (Health Maintenance Organization): you choose a primary care physician (PCP) that is in-network, you will need a PCP referral for any specialists, no out-of-network care is covered

• PPO (Preferred Provider Organization):  you can choose in-network providers (typically lower cost) or out-of-network providers, no referral needed for specialists

• EPO (Exclusive Provider Organization): does not cover out-of-network providers, but do not need a referral for specialists

• POS (Point of Service): you have a PCP that is in-network and that must give you a referral to see a specialist, but you can also access out-of-network options for a higher cost

• Catastrophic plan: only available for people under 30 or with a hardship exemption (affordability exemption), low premium and high deductible, theoretically only used for serious illness

Insurance plans on the marketplace also have different metal tiers to their plans. As you go up in tiers, the insurance company pays more when you get healthcare, with a higher associated monthly premium. If someone utilizes a lot of health care, a higher tier choice is better [8].

• Bronze: lowest premium, higher cost that you must pay when obtaining care, high deductible

• Silver: moderate premium, moderate cost when obtaining care

• Gold: high premium, low cost when obtaining care, low deductible

• Platinum: highest premium, lowest cost when obtaining care, low deductible

Insurance Definitions You Should Know

• Premium: monthly payment to insurance company regardless of whether you use the insurance

• Deductible: how much you pay for health services before insurance starts to pay

  • Plans with lower premiums typically have higher deductibles

  • Usually, you will still need to pay copays and coinsurance if you reach your deductible until you meet your out-of-pocket maximum

• Out-of-pocket maximum: after this level, insurance will pay for 100%

  • Includes deductible, copay, and coinsurance

  • The ACA established that policies must include an out-of-pocket maximum

    • For 2020: $8,150 for an individual and $16,300 for a family [9]

• Copay(ment): fixed payment for specific service or medication

  • E.g. You pay $20 every time you see your PCP

• Coinsurance: Percentage of cost that you pay before the out-of-pocket maximum

  • E.g. You pay 20% every time you see your PCP

Part of medical care is knowing that there is an associated cost with every test and treatment that we use. Medical insurance is essential to this, and it is important to know the basic ideas and language surrounding insurance, so that we can better serve our patients.

References

1.     Moseley III GB. The U.S. Health Care Non-System, 1908-2008. AMA Journal of Ethics. 2008;10(5):324-331.

2.     Schlicher N, Haddock A. Emergency Medicine Advocacy Handbook. 5th ed. Irving: Emergency Medicine Residents’ Association; 2019:1-8.

3.     What's Medicare?. Medicare.gov. https://www.medicare.gov/what-medicare-covers/your-medicare-coverage-choices/whats-medicare. Accessed August 18, 2020.

4.     CMS Fast Facts. Cms.gov. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMS-Fast-Facts. Published 2020. Accessed August 18, 2020.

5.     Status of State Medicaid Expansion Decisions: Interactive Map. KFF. https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/. Published 2020. Accessed August 18, 2020.

6.     Summary of the Affordable Care Act. KFF. https://www.kff.org/health-reform/fact-sheet/summary-of-the-affordable-care-act/. Published 2013. Accessed November 10, 2020.

7.     Norris L. Obamacare's essential health benefits. healthinsurance.org. https://www.healthinsurance.org/obamacare/essential-health-benefits/. Published 2020. Accessed August 18, 2020.

8.     The 'metal' categories: Bronze, Silver, Gold & Platinum. HealthCare.gov. https://www.healthcare.gov/choose-a-plan/plans-categories/. Published 2020. Accessed September 8, 2020.

9.     Lalley C. Health insurance basics: The 101 guide to health insurance. Policygenius.com. https://www.policygenius.com/health-insurance/learn/health-insurance-basics-and-guide/. Published 2020. Accessed August 18, 2020.

10.  Out-of-pocket maximum/limit. HealthCare.gov. https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/. Published 2020. Accessed August 18, 2020.

Expert Commentary

Every year, I instruct our medical students and residents on the “Anatomy & Physiology of the United States Health Care System” using a historical journey from the first Blue Cross plan in Dallas crafted for schoolteachers until the modern era of the Affordable Care Act. Along the way, we have added in a piecemeal fashion to our nation’s health care system such that seniors and low-income Americans have coverage carved out for them. Everyone else is reliant upon employer insurance for coverage or must purchase for themselves. Because of our country’s surprisingly involvement in financing health care for its citizens – over 36 percent is paid by the federal government – some commentators have declared the U.S. is an “insurance company with an army.”

While national health expenditures and financing our system are big picture items everyone in the health care sector should understand, we must also understand the small details that are most relevant to patients, such as common terminology regarding their insurance types and the payments they are required to pay at the point of service.

Cedric Dark, MD, MPH

Assistant Professor

Department of Emergency Medicine

Baylor College of Medicine

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Huang, E. Karalius, V. (2022, Oct 10). Health Insurance Basics. [NUEM Blog. Expert Commentary by Dark, C]. Retrieved from http://www.nuemblog.com/blog/health-insurance-basics

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Eliminating health disparities in LGBT individuals begins in the ED

Written by: David Feiger, MD (NUEM ‘22) Edited by: Vidya Eswaran, MD (NUEM ‘20) Expert Commentary by: Will Laplant, MD, MPH '20

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Introduction

18% of lesbian, gay, bisexual, transgender, or questioning (LGBTQ) individuals avoided seeking medical attention for fear of discrimination according to a 2017 joint poll conducted by NPR, the Robert Wood Johnson Foundation, and Harvard T.H. Chan School of Public Health [1]. These fears are not unfounded—decades of anti-lesbian, gay, and bisexual (LGB) prejudice in medicine, despite greater social acceptance in the United States have tainted medicine’s perception in the LGB community.

Only in 1987 was “sexual orientation disturbance” removed from the DSM while conversion therapy, the scientifically-unfounded exercise of converting one’s sexual orientation to heterosexual, continues to be legal across much of the United States. In 2015, a pediatrician in Michigan declined to see a child of a lesbian couple which spurred a national debate of refusal of care on the basis of religious freedom [2]. Just this year the Conscience and Religious Freedom Division of the Department of Health and Human Services was established [3]. It is clear why LGB individuals may want to avoid routine medical attention.

As a disclaimer, LGBT individuals are often lumped into one category. We will focus this post on LGB individuals as we believe that the transgender experience, while occasionally overlapping with that of LGB individuals, deserves its own recognition in another post. Many studies and data grouped LGB and transgender individuals as one group and will be cited as such in this post.

Health Disparities

34% of LGBT individuals reported having been a victim of bullying, instituting a fear of discrimination and coming out that can lead to a variety of emotional and psychological consequences [4]. In the National Health Interview Study, 26% and 28% of gay men and women, respectively, and 41% and 47% of bisexual men and women, respectively, reported moderate or severe levels of mental distress compared to 17% of straight men and 22% of straight women [6]. These levels of psychological stress make LGB individuals more prone to emotional disorders leading to suicidal ideation, homelessness, depression, and substance abuse [4].

Furthermore, 18% of LGBT individuals reported having been coerced into sex and 23% sexually assaulted [4]. This victimization increases their risk of unsafe sexual behavior than their peers resulting in a twice greater likelihood of contracting sexually transmitted diseases when compared to straight-identifying men [5]. The fear of seeking medical attention only exacerbates these health disparities.

While much of the focus has been on the modern experience of LGB youth, it is important to be aware the circumstances of LGB seniors that may contribute to health disparities. Due to the social climate in which they grew up, they are less likely to be partnered, have children, or other social supports, increasing their barriers to health care. Furthermore, they often reside in senior communities where they often face continued discrimination [7].

Creating a More Welcoming Environment for All

The emergency department is often the first point of healthcare contact for the vulnerable, and is therefore a prime location to make healthcare more approachable for the LGB community.

The Waiting Room

Patients often spend hours in the waiting room, providing an opportune time to set an inviting tone for LGB patients. LGB individuals constantly seek subtle indications of acceptance in unknown environments [11]. At the most basic level, triage forms can include questions pertaining to sexual orientation and gender identity [7]. In fact, collection of this data has been recommended by the Institute of Medicine and the Joint Commission [8]. These forms can also include the hospital’s non-discrimination policy on the basis of sexual orientation and offer a contact for a patient advocate for those who have been unfairly treated. Staff can wear rainbow flag pins and waiting rooms can offer pamphlets that highlight LGB health among other health topics [7]. These small additions can make LGB individuals feel more welcome.

With the Physician
Despite 78% of emergency physicians believing that patients would refuse to reveal their sexual orientation in the emergency department, only 10% of patient respondents of all sexual orientations (n=1516) to the EQUALITY study reported that they would not answer the question [8]. As summarized by Dr. Adil Haider, the principal investigator of the study, “your patients want to be asked.”

When asking patients about their sexual orientation, it is important to use gender-neutral language. Ask “are you in a relationship?” or “do you have sex with men, women, or both?” to delve into a social history. These types of questions may comfort LGB patients to allow them to expand on details they find relevant [9]. Of course, patients who are not comfortable with their identity may continue to conceal their sexual orientation. Each individual’s coming out experience varies and it is crucial that the physician allows the patient to take his or her own time to reveal their sexual orientation, even if not on this visit. Simply asking the broad questions without judgment may begin to change the patient’s apprehensive attitude towards medicine.

Going Above and Beyond

While important to make the clinical encounter more inviting, more actions can be taken to make a hospital a leader in LGB care.

1.   Partner with local LGB organizations

Hospitals can partner with organizations that support the LGB community. Having a presence in health clinics targeting LGB individuals and other local LGB organizations will also allow the hospital to better understand and adapt to the needs specific to the community. Celebrating LGBT awareness months and having staff march in local LGB Pride events is a very public and visible way of showing support for the community [9].

2.   Actively recruiting and maintaining LGB staff

Health care providers should actively recruit LGB staff by ensuring equal employment benefits as their heterosexual colleagues by offering supplemental packages that include benefits for both married and unmarried same-sex partners. After hiring, ensure that LGB employees continue to receive support and mentoring by sponsoring LGB employee groups and functions [9].

3.   Striving for and achieving a perfect score on the Human Rights Campaign Healthcare Equality Index

The Human Rights Campaign is the largest organization supporting LGBT rights in the United States. Each year, the Human Rights Campaign scores and publishes a list of many hospitals in the United States and grades them on hospitals’ ability to provide inclusive care regardless of sexual orientation. The list evaluates a hospital’s patient and employment non-discrimination policies, visitation rights, LGBT-focused training offering, presence of patient services to LGBT individuals, employee benefits, and commitment to the community for a total score on a scale from 0 to 100.10 For healthcare institutions not achieving a perfect 100 score, this is a great tool to ensure progression to full equity of care for LGB patients.

Summing it Up

Despite rapid social acceptance of the LGB community in the United States within the past decade, remnants of fear and distrust in healthcare remain, exacerbating existing health disparities. While it may take several decades to fully eradicate the apprehension, taking the steps above will certainly make strides to achieve that goal.

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Expert Commentary

Thank you for writing about such an important topic. I think we all understand the special position of the emergency department beyond the care of emergencies; it is a point of access for many marginalized communities that have been unable to receive care through other venues. It is our duty as emergency physicians to be able to provide competent and appropriate care for all who walk through our doors.

I think it makes sense to divide the topic of LGBTQ care into two: sexual minorities (those who identify as lesbian/gay/bisexual/queer, etc) and gender minorities (those who identify as trans, genderqueer or otherwise gender nonconforming). While they have much in common, the barriers and healthcare disparities they face are unique and different, and they each warrant a lengthy discussion. I look forward to your article on the care of gender minorities!

Normalizing Care in the Emergency Department

• Identifying Those in the Room

Asking “how are the two of you related?” to figure out who else is in the room can prevent mishaps of assuming someone is with their friend, when really they are with their partner. As a major support system after discharge, it’s important to include a patient’s partner in the discussion and plan.

• Taking a Sexual History

It’s important to not conflate sexual orientation with sexual behaviors. For example, there is a well defined subsect of men who have sex with men (MSM) but do not identify as gay/bisexual. By asking “do you have sex with men, women, or both?” you ensure that you capture the data you need to treat the patient appropriately. Some people get hung up on the follow up questions to further identify how to treat a patient:

               “Do you have anal intercourse?”

               “Do you have receptive, penetrative, or both?”

The same model can be used for oral and vaginal intercourse.

• Addressing the Sexual Health of Sexual Minorities

If you are addressing sexual health needs in the emergency room, either because of chief complaint (eg. sore throat, rectal pain, vaginal discharge, abdominal pain) or exposure, try and be as comprehensive as possible. The majority of syphilis cases in the US are amongst MSM [1], making it an important consideration. I suppose this blog is also as good a place as any to highlight the recent CDC recommendations for treatment of STIs, including [2]:

1. Monotherapy with ceftriaxone for confirmed gonorrhea given increasing azithromycin resistance

2. Increased dosing of ceftriaxone (500mg from 250mg) for gonorrhea treatment, and 1g of ceftriaxone for those >150kg

3. Doxycycline 100mg BID for 7 days for chlamydia infections

   *Notably, compliance with a 7 day course of treatment should be addressed and factored into the decision (with regards to the previous standard of azithromycin 1g as a single dose).

Identifying Bias

Bias comes in two forms: explicit biases, which we are cognizant of, and implicit, which we are not. Implicit bias stems from the confluence of your life experiences and the society you are a part of. If you have been raised in a society entrenched in systemic racism, sexism, ableism and heteronormativity, you have been exposed to stereotypes and prejudices which may subconsciously shape the way you make decisions. Healthcare professionals have been shown to have a similar level of implicit bias compared to the general population [3], and this implicit bias has been correlated with significant patient outcomes. [4] What shapes your decision in who receives narcotic pain medication or who stays in the hospital for observation? I highly recommend taking at least a few tests of implicit bias which are freely available and, in my opinion, highly informative: https://implicit.harvard.edu/implicit/takeatest.html

References

1. CDC. Sexually transmitted disease surveillance 2013. Atlanta: US Department of Health and Human Services; 2014.

2. St. Cyr S, Barbee L, Workowski KA, et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1911–1916. DOI: http://dx.doi.org/10.15585/mmwr.mm6950a6external icon.

3. FitzGerald, C., Hurst, S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics 18, 19 (2017). https://doi.org/10.1186/s12910-017-0179-8

4. William J. Hall et al. “Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review”, American Journal of Public Health 105, no. 12 (December 1, 2015): pp. e60-e76.

Will Laplant MD, MPH

Emergency Medicine Physician

Good Samaritan Medical Center

Brockton, MA

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Feiger, D. Eswaran, V. (2021, May 2). Eliminating health disparities in LGBT individuals begins in the ED. [NUEM Blog. Expert Commentary by Laplant, W]. Retrieved from http://www.nuemblog.com/blog/lgbt-disparities

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References

1. “Discrimination in America: Experiences and Views of LGBTQ Americans.” www.npr.org, National Public Radio, Nov. 2017, www.npr.org.

2. Pear, Robert, and Jeremy W. Peters. “Trump Gives Health Workers New Religious Liberty Protections.” The New York Times, 18 Jan. 2018.

3. Phillip, Abby. “Pediatrician Refuses to Treat Baby with Lesbian Parents and There’s Nothing Illegal about It.” The Washington Post, 19 Feb. 2015.

4. Hafeez, Hudaisa, et al. “Health Care Disparities Among Lesbian, Gay, Bisexual, and Transgender Youth: A Literature Review.” Cureus, 2017, doi:10.7759/cureus.1184.

5. Robinson, Joseph P., and Dorothy L. Espelage. “Peer Victimization and Sexual Risk Differences Between Lesbian, Gay, Bisexual, Transgender, or Questioning and Nontransgender Heterosexual Youths in Grades 7–12.” American Journal of Public Health, vol. 103, no. 10, 2013, pp. 1810–1819., doi:10.2105/ajph.2013.301387.

6. Gonzales, Gilbert, et al. “Comparison of Health and Health Risk Factors Between Lesbian, Gay, and Bisexual Adults and Heterosexual Adults in the United States.” JAMA Internal Medicine, vol. 176, no. 9, 2016, p. 1344., doi:10.1001/jamainternmed.2016.3432.

7. Understanding the Health Needs of LGBT People. Understanding the Health Needs of LGBT People, National LGBT Health Education Center, 2016.

8. Haider, Adil H., et al. “Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity.” JAMA Internal Medicine, vol. 177, no. 6, 2017, p. 819., doi:10.1001/jamainternmed.2017.0906.

9. Ten Things: Creating Inclusive Health Care Environments for LGBT People. Ten Things: Creating Inclusive Health Care Environments for LGBT People, National LGBT Health Education Center, 2015.

10. Human Rights Campaign. “Healthcare Equality Index 2018.” Human Rights Campaign, Human Rights Campaign, 2018, www.hrc.org/hei.

11. Eliason, Michele J., and Robert Schope. “Does ‘Don't Ask Don't Tell’ Apply to Health Care? Lesbian, Gay, and Bisexual People's Disclosure to Health Care Providers.” Journal of the Gay and Lesbian Medical Association, vol. 5, no. 4, Dec. 2001.