Health Insurance Basics: Roles for the Market and Government in Providing, Financing, and Regulating Private Insurance Coverage

Publication Date: September 2007

Publisher: Library of Congress. Congressional Research Service

Author(s):

Research Area: Business; Health

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Abstract:

Both the market and government have important roles in ensuring the availability, affordability, and adequacy of private health insurance. These roles complement one another, but even together the market and government have limitations.

The market provides a variety of insurance products for consumers and employers with different needs and preferences. These products differ on many dimensions, including the breadth of provider networks, amount of beneficiary costsharing, and techniques for managing the use of health care services. Large employers, small employers, and individuals have different health insurance options, but all must make tradeoffs between the cost of coverage and desired features.

A strength of the market is its flexibility to adapt over time to changing circumstances. As economic conditions, consumer preferences, and government policies evolve, the market generates different products with different features. The primary limitation of the market is its failure to provide affordable options for all consumers.

The federal government helps ensure access to health coverage through public programs, such as Medicare and Medicaid, and it influences the market for private insurance through tax and regulatory policies. Some tax subsidies help people purchase insurance, and others -- including those for Health Savings Accounts -- help pay for medical expenses not covered by insurance. By far the largest subsidy is the tax exclusion for employer-provided health benefits. Because of this exclusion, most people get health insurance through work.

Tax subsidies make health insurance and health care seem more affordable for certain taxpayers, but do not provide equivalent support to everyone. In addition, subsides may increase health care spending by reducing the apparent cost of health insurance and health care services.

Regulations affect both access to insurance and the adequacy of benefits. States have primary responsibility for regulating insurance, but the federal government has sought to address selected issues regarding health coverage. For example, the Health Insurance Portability and Accountability Act of 1996 and the Consolidated Omnibus Budget Reconciliation Act of 1985 include provisions that allow certain people to obtain or continue health coverage under certain circumstances. In addition, several federal laws mandate coverage for specific health benefits.

Although regulations provide some protection for consumers, neither federal nor state rules guarantee access to coverage for everyone. In addition, even where regulations require insurers or employers to offer coverage, consumers may find this coverage unaffordable. This report will be updated.