Getting Health Care

Health Insurance

When you seek any kind of health care, practically the first question you hear will be “What is your insurance?” Since January 1, 2014, almost everyone in the U.S. was required by law to carry health insurance. With few exceptions (such as for those in prison or those whose income is so low they don’t have to file a tax return), eligible people who do not sign up for an insurance plan will be subject to fines.

To make health insurance more affordable, the government is expanding current programs that provide coverage to those in financial need and is starting a new program to subsidize people whose incomes may be as high as four times the federal poverty level ($62,040 for a family of two in 2013).

The law expands health insurance coverage:

Finding and getting coverage may be confusing, but all states must establish a program to assist people who are having trouble getting health insurance or getting their current insurers to pay for services. To find your state’s program, go to Consumer Assistance Program or ask at the Information Desk in your public library for a telephone contact number.

Health Insurance Options

There are several ways to get health insurance. They include:

Health Insurance Exchanges

Since 2013, each state must open a Health Insurance or Health Benefit Exchange, a center that people can contact either online or by phone if they need health coverage. The idea is to have a “one-stop” shopping system where you can fill out a form and learn:

If you are eligible for a subsidy, you must purchase your coverage through an exchange. 

All policies sold through these exchanges must offer, at a minimum:

If your present coverage doesn’t include all these services it does not have to add them, but you are free to shop for a new policy through your state’s exchange.

No matter how small or large your income, if you are a U.S. citizen or legal resident of the U.S., the Exchange should be able to help you select the best plan for you and your family.

Furthermore, not all states will run their own Health Insurance Exchanges.

To find about the situation in your state, go to Health Insurance Marketplace.

Fraud alert: Scam artists are taking advantage of persons applying for insurance. No legitimate insurer or government employee will:

Employer-sponsored Health Insurance

One of the most common sources of health insurance is employer-subsidized health coverage. The federal government does not tax employer-paid health benefits as part of your income, so this is a very popular benefit. Because the health care reforms will eventually require all large companies to provide health insurance for full-time workers, some companies are reducing employees’ hours to less than full time to avoid offering coverage.

Individual Health Insurance   

Health savings accounts (HSAs) may go with some health insurance plans that have high deductibles. 

Medicaid and CHIP/S-CHIP

Medicaid is a government health insurance program for people whose incomes are near or below the poverty level. 

Children’s Health Insurance Program, also called CHIP or S-CHIP, provides health and dental coverage for children whose families who cannot afford private insurance but who earn too much to qualify for Medicaid.

If You Have Insurance

Health care providers—doctors, clinics, hospitals, and so on—have dozens of different agreements with different health insurance companies. 

All this inconsistency is the insurers’ and providers’ headache, not yours, but it can make it harder for you to find the doctor or service you need.

You will be expected to show your health insurance card anywhere you go for medical care. The card not only contains information about your insurance company, but also can be a key to your medical records. Letting someone else use your health insurance card is illegal and also can endanger the borrower, who has a different medical history.

What will the medical treatment or service cost? Often, nobody seems to know. If you ask, you may get a blank stare or a simple refusal to state a price—or even an estimate—in advance of a procedure. This response is partly because

If You Don’t Have Health Insurance

After January 1, 2014, those who do not have health insurance, with few exceptions, will be subject to a penalty fee. The fee will be phased in, starting at $95 or 1% of taxable income in 2014 and rising to $695 or 2.5% of taxable income in 2016. You may be exempted from this fee only if you:

Even if you don’t have to pay a penalty, there could be grave financial consequences for lacking health coverage. If you must seek care, health care providers can charge you any amount they want, often much more than they would get from insurance companies for the same care. If you don’t have insurance, try to negotiate an affordable fee before you receive care. And if possible, try to get treatment at free or low-cost clinics, which are available in most cities and in many county seats. 

Free and Low-Cost Clinics

If your problem is urgent, there is another alternative.

Hospital Emergency Rooms

If you cannot wait for the appointment offered at a free clinic—if you are in pain, bleeding, or having trouble breathing, for instance, go to a hospital emergency room.

Prescription Drugs And Insurance

Generics and Brand Names

Drug makers who develop and patent a new drug have the exclusive right to manufacture and sell it for several years after introducing it to the market . This is the “brand” name drug. When this right expires, anyone can manufacture and sell an equivalent drug, or “generic.” 

Prescription Drug Costs

If your insurance includes drug coverage:

If your prescriptions are not covered by insurance or if you don’t have prescription insurance, you may find significant savings by shopping carefully before you buy:

You can check out the prices for a given drug in your area at goodrx.com and rxpricequotes.com , two online sites that compare the prices of many common prescription drugs at your local pharmacies.

Getting Good Health Care

Whether or not you have health insurance, and no matter what kind of insurance you have if you are covered, it’s important to know how to get the best possible health care. You may be able to treat most minor injuries and illnesses yourself; but for medical emergencies, routine health care, and immunizations, you will need to see medical professionals with the appropriate training and experience.

Minor Injuries and Illnesses

You can treat many minor injuries and illnesses at home. To do so, it helps to have basic first aid supplies on hand:

For information about first aid for specific types of injuries, and guidance about seeing a doctor, you can look at the Mayo Clinic's First Aid site.

Colds, coughs, sore throats, headaches, and upset stomachs usually don’t need professional attention unless they persist longer than usual, are unusually severe, or involve a fever higher than 102 degrees.

For information about specific symptoms, you can go to sites such as WebMD, or simply google “When to see a doctor.”

Emergencies

If you need immediate help—if someone is unconscious, bleeding heavily, in severe pain, has difficulty breathing, or may have broken bones—don’t delay. You can either take the person to the nearest hospital emergency room or pick up a phone, dial 911, describe the problem, and ask for an ambulance. Ambulance transportation can be expensive. If the person can manage it, your car or a taxi will be cheaper and just as fast. Some hospitals will provide taxi vouchers to reduce costs for people in need.

Problems such as dizziness, disorientation (not knowing who or where one is), and drug or alcohol intoxication may or may not be emergencies, depending on the degree and duration of the symptoms. Use your judgment, but if you are unsure, get help—don’t wait.

Routine Health Care

Whether or not you have a health complaint, it’s a good idea to schedule a visit with a primary-care physician as a new patient when you enroll in a health plan.

Because of the insurance issues described earlier, it can be hard to find a primary care physician. For instance, doctors may limit the number of patients from a given health plan. Or because the plan doesn’t reimburse them for the service, they may offer few openings for routine physicals for patients from your plan after they accept you as a patient.

Although assigned to a full-fledged doctor, you may find yourself actually seeing an intern, resident, physician assistant, or nurse practitioner. Not to worry: Interns are recently graduated doctors. Residents are doctors advancing through specialty training. Physician assistants and nurse practitioners have undergone specialized training and have passed a rigorous examination. And all are supervised by a fully qualified doctor.

Covid-19

Immunizations

Immunizations are preventive treatments that protect you from a wide range of diseases, not only measles and mumps, but even some sexually transmitted diseases. Some vaccinations, such as tetanus, need to be repeated at regular intervals to maintain effectiveness. Vaccination is the safest and most effective way to protect yourself and your children from common, serious illnesses.

Dental Care

We often neglect our teeth, perhaps because we tend to think of them as unimportant. Lose one, so what? There are lots more. But it’s not just a question of losing a tooth. Toothaches may signal major infection or other serious illness. Pain of any kind is a signal to pay attention, and pain in the teeth is no exception.

Many health plans do not cover dental services, but there are discount dental plans that will reduce the cost of care. Web sites such as dentalclinicmanager.com provide information about these plans.

If you can’t afford a dental plan, look for a free or low-cost dental clinic. If there is a local chapter of the American Dental Association, its representatives can tell you where to go.

Some people naturally have strong, healthy teeth, and if you are lucky enough to be one of them, the dentist can take a back seat until you have the time, money, and energy to think about it. But do not ignore pain in your teeth.

Counseling and Therapy

You can get counseling from a variety of professionals. Counselors or therapists can help you learn to manage the stress of adapting to your new life. They also can help if a psychological or emotional problem is affecting your functioning.

To be reimbursed by your insurer for these services, the professional must determine that you have a treatable condition. The list below describes different titles of mental health professionals, but all have similar qualifications and credentials. The following section (Finding and Evaluating a Health Care Provider) applies to all those job titles listed here.

Finding and Evaluating Health Care Providers

Finding a good health care provider may be easy if your health care plan offers a list of approved providers, or if you have friends or co-workers who can give you recommendations. But if you are on your own, or if your friends and co-workers don’t know a professional in the area you need, finding a good provider can be tough. Your insurance company’s list of approved providers may include dozens of names, but little information other than their credentials. You may want to check out medlineplus.gov, a government Web site that features a directory of health professionals by location.

Even if you have a list or a personal recommendation from someone you trust, it’s up to you, once you have seen a provider, to decide whether or not you want to go back. Following are some suggestions to help you make that decision.

Health Providers’ Credentials

A license or certificate issued by the state indicates that a provider has completed the training required for competence in the field. Health professionals who participate in insurance plans are monitored for credentials by the insurer. Hospitals and clinics are responsible for ensuring that their workers have appropriate credentials.

If you are seeing a health care provider in private practice, you should expect to see these documents—usually framed and hanging on the office wall, along with various diplomas. If you do not, ask about them. If the doctor does not produce the actual document, you can either check with your state licensing authority or find another doctor (usually the easier course of action).

Lack of credentials is a very big red flag, but a license does not tell you all you need to know.

Quality of Care

Quality of care varies widely, even among credentialed professionals. A high fee or a Harvard diploma doesn’t mean you will get the best care.  A crowded, shabby, free clinic doesn’t mean you will get inferior care.

The best source of information is a friend or family member who has had good results from that doctor, who likes the doctor and the people who work in the doctor’s office. Often, however, we don’t have that valuable kind of personal information and must decide for ourselves. 

Here are some ideas to help you with your decision. Because you may be seeing a professional other than a doctor, the generic term provider covers all the key professionals.

These criteria are not outlandishly demanding or perfectionist. Still, you may not find them all met everywhere you go, and that may or may not matter. It’s up to you to decide, upon reflection, whether or not you received good care.

Alternative or Complementary Medicine "Alternative” or “complementary” treatment refers to a variety of medications and treatments that are not science based. Most have not been shown objectively to work. Some of these alternative treatments, such as Chinese herbals, derive from long-standing practices of other cultures. Others, like faith healing, are derivatives of religious beliefs. Some others are simply inventions of people who, perhaps deliberately misleading themselves and others, make unsubstantiated claims for their “treatments.”

Many people claim to be helped by these alternative treatments, and indeed they may have improved or even been cured. But the improvement is not necessarily because of the treatment. People may benefit from a common characteristic called “the placebo effect,” which makes them not only feel better, but actually get better if they think or expect that they will. In controlled scientific tests of a treatment, an important measure is whether the number of people who improve during the treatment is significantly greater than that of the people who actually are not receiving the treatment but think they are.

There is little objective information about whether or why alternative treatments work. The National Institutes of Health (NIH), the government health research center, has been conducting evaluations of some of these treatments. Go to nih.gov and enter the search term “alternative medicine” to check out objective findings about specific treatments.

If you are using or are interested in alternative treatment, it is important to keep a few cautions in mind:

Additional Resources

Decisions about health care may be complex and difficult, but they are your decisions, not anyone else’s. Good information is critical for good decisions. Luckily, a lot of information is available about almost any health problem you may have, as well as many ideas about how to get help to treat it.

In addition to the Web sites listed in specific sections above, this section lists a few other reputable Web sites where you can go for more information.

Health Information Online

National Institutes of Health (NIH), has authoritative information about medical and mental health conditions and treatments, and many links to other sites’ information about specific conditions.

MedlinePlus, combines resources of the National Library of Medicine with those of the NIH. In addition to information about medical issues, MedlinePlus provides a directory of health care providers that you can sort by location, a medical encyclopedia and dictionary, and interactive tutorials on major health topics.

WebMD.com, a commercial Web site, has much useful information about health in general, and about many specific diseases. It also has news, feature articles, blogs, message boards, and advertisements, as well as plain old information.

Information About Specific Diseases

Many Web sites focus on specific areas of the body, or on widespread and/or chronic diseases. Such sites include the following:

American Cancer Society

American Diabetes Association

American Heart Association

American Lung Association

National Institute on Alcohol Abuse and Alcoholism,

National Institute on Drug Abuse

National Institute of Mental Health

The National Association on Mental Illness

Support

Patient Advocate Foundation, 1-800-532-5274, provides free help to people with chronic, debilitating, and life-threatening ailments, addressing such issues as access to care, maintaining employment, and preserving financial stability. The site offers chat conferences with a professional case manager for personalized attention.

You can also seek support through various hot lines and online groups devoted to particular topics. To find support groups for a specific condition, google "support group" plus the name of the condition.

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