Trying to understand health care and insurance in mass. ? This explanation may help

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Health care is notoriously complicated, a fragmented system that often presents challenges for the average person to navigate. Even though most people in Massachusetts have insurance, either privately through an employer or through a government-subsidized program, the level of confidence in easy access to the system is low.

The goal of this column, informed by our foundation’s more than 20 years of experience in health care research, analysis, and thought leadership, is to reduce clutter and provide information clear and helpful to guide readers through the Massachusetts healthcare system.

Parts of the whole

First, some facts. Health care in Massachusetts is a $64 billion industry, ranging from world-renowned academic medical centers in Boston to pediatricians’ offices in small towns. Chances are you know someone who works in healthcare, because the industry accounts for nearly 1 in 5 jobs.

There are many parts of the health care system, which are similar from state to state, although a few are unique to Massachusetts. Breaking it down, the first layer of the health care system is the one closest to you: the providers or trained professionals who deliver health care services directly to you and your family members. Providers range from doctors, nurses, and dentists, to mental health therapists and physical therapists, to physician assistants and pharmacists, among others.

It’s not always obvious, but these days vendors rarely work alone, largely because of the consolidation trend of the last 30 years. Most are employed in a medical practice in the community or attached to a hospital. Group providers are usually employed by an organization that makes it easier to meet a variety of patient needs in one place.

Organizations that employ providers are paid for the services they provide to you and other patients, and for what is called “overhead”: their cost of operation. Who pays them? The next layer of the healthcare system: the insurers.

Benefits of insurance

Insurers are generally described as “health plans”, but may have more complex names that lend themselves to abbreviations that may be familiar, including Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs) ) and Responsible Care Organizations (ACOs). Some insurers are for-profit companies, but most in Massachusetts are non-profit organizations.

How do providers and insurers determine the cost of your healthcare? Simply put, they negotiate and eventually agree on how much and how they are billed and paid.

Many people have health insurance coverage through their employer. About 71% of businesses in Massachusetts offered insurance, from 2018and a majority of employees enrolled in coverage.

If you have health insurance as part of your job, your employer decides which health plans they will offer you and how much they will pay the insurance company to provide this coverage to each of their participating employees. .

Employers usually pay the majority of the premium – the monthly amount the insurance company charges to insure you. The rest of the premium is paid by the workers and is usually deducted from wages. In addition to their share of the premium, people typically pay a cost – copays or deductibles – each time they use health services.

Medicare and Medicaid

Many in Massachusetts obtain health insurance through a government-subsidized program such as Medicare or Medicaid. Medicare is a federal program that provides health coverage to people age 65 or older or people with disabilities, regardless of income. Mediboss, branded MassHealth in Massachusetts, is a health insurance program for low-income people. These programs decide how much they will pay providers – there is no negotiation – and offer a uniform set of covered services.

In addition to these private and public health insurance options, there’s a third way for those who aren’t covered by an employer and aren’t eligible for Medicare or Medicaid: buy your own. The place to go is Health Connector, the state marketplace where you can compare plans and learn more about grants. There are only a few weeks each year, called “open enrollment,” during which people can enroll in a health insurance plan for the following calendar year.

Down to the essentials

Unlike most auto insurance policies, which don’t cover maintenance like oil changes and tire rotations, health insurance is required to provide basic services to help keep you healthy. health on the road of life. Think “health visits” with your child’s pediatrician or an annual mammogram to check for breast cancer.

An additional layer in the healthcare system: regulation. Many state and federal agencies monitor the safety and quality of healthcare services in any setting. Most providers – such as doctors, nurses and therapists – must be licensed, which requires them to meet a standard of care and regularly update their education and training.

All of these parts of the health care system may seem large and complex, but they aim to work together to keep people healthy by preventing and treating illness or injury and guiding patient recovery. We’ll dig deeper into the details and challenges in the following columns.

Audrey Shelto is President and CEO of Blue Cross Blue Shield of Massachusetts Foundationa private, not-for-profit organization whose mission is to ensure equitable access to healthcare for all those in the Commonwealth who are economically, racially, culturally or socially marginalized.

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