Health Care Financing

Market-based

(HMO, POS, PPO, etc.)

Government-financed

(Medicare, Medicaid, Tricare, etc.)

Who is provided access?

Market-based plans targets individuals who do not qualify for formed cards and are underinsured and are unable to afford either commercial insurance In the market-based approach, healthcare insurance is mainly offered by the employer of the beneficiary of the insurance and the employee access through his/her employer.

In a government-based approach, it serves low-income families who are unable to afford insurance covers. These targets include the elderly, disabled, children, native Americans, veterans, active-duty military and their dependents, and pregnant women. Some of the healthcare programs provided by the government include Medicare, Medicaid, Tricare, veteran programs among others

How much coverage is provided?

In most cases, coverage varies and it bases on the needs of the insured. Employers’ offers full coverage to their employee and in some cases; children and spouse of the employee are allowed to enjoy healthcare cover offered to that employee.

Government health insurance programs were specifically meant to cover various groups of citizens whom the healthcare market failed to cater to because of their social-economic status and vulnerabilities.

How are the services paid for?

These services are mainly paid through a healthcare plan that is deducted from the beneficiary of the cover. This service can also be paid through a fixed amount by the individuals before receiving the services.

Services provided to individuals, the government provides at least minimum essential coverage meaning that coverage that ensures it satisfying the affordable care.

How does reimbursement apply?

In a market-based approach, reimbursements apply to customers through premiums with a set once a year limit. Reimbursement in this approach is very fast and efficient as the employer doesn’t take long to repay expenses spent by the beneficiary after being covered by the insurer.

In the government-based approach, reimbursement applies after the services have been rendered to the patient. It often takes longer due to limitations placed on the care offered to patients and doctors to keep costs down.

Are there limitations of care?

The market-based approach is unable to control for the average consumer and they assume that they can make good choices.

Policies that require deep industry cooperation can be vulnerable to be destroyed. This might cause the insurer to leave the market instead of adapting to the changes that have occurred. This can cause effects to the beneficiary.

On this approach, doctors and other caregivers have limitations on the tests that they order.

What guides care decisions for patients?

Decisions for care are guided by patients themselves. That is this market-based approach base on what medical service patients chose to pay for and also on what their care provider permits. They chose from a variety of different policies that the patient is capable to finance.

The government has the responsibilities of deciding and guiding the patient's HealthCare policies as many patients are low-income earners who are unable to pay for insurance covers and the majority has no knowledge of having healthcare policies.

What is the quality of services (use the HEDIS website for answers)?

The quality of service offered by a market-based approach is good since the insurer has no worries of finance as the beneficiary pays enough money to cater for required services. Since there is no limitation of resources, doctors can offer high-quality services as they are well paid.

Government based approach doesn't provide good quality services as they lack inventiveness and they face pressure from political groups that hinders them from offering quality services. The government limits healthcare spending to keep costs down hence doctors may lack the incentive to provide quality services.

Are there competitive options?

In the market-based approach, there are

Multiple providers to choose from.

Individuals who make too much to

qualify for Medicare but still feel they

need assistance paying for insurance plan

Can go for incentives such as subsidies.

In a government-based approach, considerable services and healthcare subsidies are offered to clients depending on their healthcare needs.

How much are prevention and wellness emphasized and measured?

The wellness and preventive measures are emphasized as the clients pay a very high amount for their healthcare services. For this reason, insurance providers understood that clients require healthy preventive services hence they offer insurance services that are cheaper and can be afforded by the patients.

In the same case as a market-based approach, prevention and wellness are emphasized and measured as it’s believed that patients pay a high amount for health services. This has made insurance providers to offer cheaper insurance services.

How are health care costs managed and controlled?

Cost is managed by premiums rates to the customer. Cost-sharing and managed care controls and provides management to healthcare cost.

Healthcare cost is also managed and controlled by cost-sharing and the managed care organization that consist of physicians, specialists and the hospital negotiates for themselves to reduce the overall healthcare costs.

How are medical advances generated?

At this approach, the medical advances that are generated are cost-effective and limited to procedures and treatments.

Medical advances are generated through government and state funding. This funding is very flexible.

How is health care reform established?

Healthcare reforms happened when children were covered under their parent's employer-based plan whereby the market-based approach aimed to increase the number of insured and also to increase the quality of care by reducing health costs.

The healthcare was reformed in mid-2009 when congressional democrats crafted competing for healthcare insurance reforms. This was during Barack Obama's reign and he supported universal healthcare coverage for all citizens.