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Several hospital chains are driving the boom – including HCA Inc., which will open its seventh ER later this year in Florida, and Wake Med Health and Hospitals, which will add its fourth next month in the Raleigh, N.C., metro area. They regard the facilities as a way to expand into new markets, generate admissions to their hospital and reduce crowding at their hospital-based ERs.

reater Houston has 150 emergency rooms — twice the number as greater Miami -- even though its population is only slightly bigger, according to a KHN analysis.

While the ERs charge insurers double or triple the amount per patient as an urgent care center or doctor's office, patients use them for routine care that could be provided in less costly settings, Ho says. That is the case with standard ERs as well. Yet, insured patients have little incentive to drive past the more expensive, freestanding ERs because their co-payment is only $50 or $100, just modestly more than what it might cost for a visit to an urgent care center or doctor’s office. Their insurers pay the balance generally.

Medicare covers all those treatment options. By law, it can't consider price when making coverage decisions. Nor can it insist that a new technology be significantly better than existing ones or encourage doctors or patients to seek less-costly alternatives. And once Medicare starts writing checks, private health plans generally follow, distorting the usual market mechanisms, says Arthur Kellermann, a physician and senior policy analyst at Rand Corp.

Another big driver of health-care costs is technology. In almost every other industry, innovation generally makes things more efficient and less costly. But in health care, it often brings higher costs with little added value.

All health plans offered on a state exchange must provide comprehensive coverage that includes doctors’ visits, lab work, hospital stays, emergency room services, maternity care, prescriptions, mental health services and children’s dental and vision care.

Policies with the most generous benefits will be “platinum” plans; they will have the highest monthly premiums but fewer out-of-pocket costs and lower deductibles. The “gold” and “silver” plans will be somewhat less generous, while those in the “bronze” category will have the cheapest premiums but may require high out-of-pocket costs and deductibles.

Be aware that the plans may have narrow provider networks — your favorite doctor or the hospital down the street may not be a participant. You’ll need to check to see if a certain provider is in the network, advised Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reform.

Premium prices are influenced by many factors, including what insurers guess their costs will be, a region’s labor costs and how much hospitals and other facilities charge. Competition between insurers is also a significant factor.

While some of the lowest cost plans are in the “bronze” tier of coverage, such plans generally have higher annual deductibles and co-payments than a silver plan.  Also, the silver plans reduce some costs for subsidy-eligible consumers, which could reduce their exposure to big bills if they fell seriously ill.

“Although premiums are generally the first and last thing discussed when comparing plans, out-of-pocket costs may be an equally or even more important consideration, particularly for those with significant health care needs.”

Companies are increasingly offering employees health plans that allow them more freedom to choose doctors and hospitals and that generally do not require referrals from primary care doctors for specialty care.

insurers generally still pay a fee for every visit and procedure, a payment system that has been blamed for driving up spending.

this movement back toward’’ fee-for-service medicine “is really going to hurt us.’’

Ryan White, a hospital consultant with Eide Bailly LLP, said one concern is that more people who buy private insurance, including through the online exchanges being set up by the federal government and some states, could opt for plans with high deductibles. He said the lowest-cost plans offered through the exchanges could have deductibles as high as $7,000. That creates a problem if they get sick.“A lot of the individuals signing up for those plans probably don’t have $7,000 sitting in a bank account to pay general hospital of Milwaukee,” White said.

Delta Airlines has reduced the generous health benefits offered to its pilots in order to avoid a new federal tax on costly health plans, known as the “Cadillac tax.” Starting in 2018, most employers must pay a 40 percent excise tax on the amount that premiums for a health plan exceed $10,200 for an individual and $27,500 for a family. “Given enough years, all plans will eventually risk being subject to the Cadillac tax and as they do, the natural reaction will be to continually reduce benefits provided,” wrote a Delta executive in a memo.

making unionized workers less competitive and potentially causing unionized employers to drop the plans that cover more than 20 million people.

To offset the expected rising costs of these "multiemployer" plans, several union groups want their lower-paid members to be able to remain on the plans wh

"will shatter not only our hard-earned health benefits, but destroy the foundation of the 40 hour work week that is the backbone of the American middle class," the union officials wrote.

Medicare patients, however, are at a disadvantage because there is no cap for out-of-pocket expenses. They "are paying copayments or coinsurance forever," Dr. Newcomer explained.

"What we are already seeing is that patients who are on Medicare are coming to hospital settings; they are not being treated at their doctor's office or their infusion center because the doctors can't afford to do it," said Dr. Swain. The doctors would actually lose money on this, so the patients are coming to a higher-priced facility — a hospital — to get their infusion, she explained. "I think it is really going to have an effect, not on the patients but on the economy in general," she added.

The decline in Medicaid budgets has added challenges to medication access for recipients of this program.

Health insurance costs ate 7.7 percent of total payroll expenses for private-sector employers in 2012, according to the NIHM study.

n 2013, individuals paid, on average, $5,900 in total annual premiums for employer-sponsored coverage. On average, family plans cost more than $16,300. “With employees’ costs for medical coverage growing much more quickly than general inflation, hourly earnings and family income, some workers are inevitably (being) priced out of coverage,” the study said.

2018, 40 million American employees will be enrolled in private exchanges