So I actually hate healthcare jargon. The phrases and buzzwords that the industry comes up with make me want to gag. But, alas, you’re going to hear these words — a lot:
Affordable Care Act / The ACA / Obamacare
These are all the same thing. The ACA was the most recent broad healthcare reform, enacted by Barack Obama in 2010. It gave individuals greater access to health insurance by expanding government funding for Medicaid. Obamacare allows people to buy health insurance plans from the government, and low-income individuals can qualify for reduced, subsidized rates.
- Read more about specific ACA policies and more in-depth analysis here.
Medicare for All
A Democratic health policy that would remove the current private medical health insurance model and put everyone on a government-run health insurance plan. It’s funded by higher taxes but would replace your employer’s health insurance plans, including all deductibles, co-pays, and out of pocket costs.
The entirety of healthcare is covered under one payer, whether that payer is Medicare or managed by a private company. Note that Medicare for All is a TYPE of a single-payer system.
Think of it as an employer health insurance plan run by the government that anyone can buy into.
Medicare vs. Medicare Advantage
Medicare is an entitlement program — a federally run health insurance plan — that everyone pays taxes for. Once individuals reach the age of 65, they qualify for Medicare.
- Medicare Advantage is a type of Medicare plan run by private insurers. Individuals can opt into these plans to get expanded benefits not included in just ‘original’ Medicare. Medicare Advantage plans are growing like crazy with the Baby Boomer influx.
- Medicaid is a social welfare program that was expanded by Obamacare in 2010. It’s a federal and state program that provides health coverage for certain people with limited income and assets.
If you have diabetes or had a stroke or whatever the condition may be, then you have a “pre-existing condition.” Prior to Obamacare in 2010, people with pre-existing conditions had to pay more for health insurance coverage. When Obamacare was instituted, health plans could no longer charge higher premiums to those with pre-existing conditions.
- Nowadays, it’s extreme political taboo and very unpopular to discuss taking away the protections given to those with pre-existing conditions.
Repeal and Replace
- Back in 2017, Trump and Republican Congressional representatives attempted to repeal Obamacare in an effort to replace it with a conservative healthcare plan. It didn’t gain enough traction. However, the ideas within the proposal are still popular with Trump and Republicans to form a new healthcare reform plan.
Medicaid Work Requirements
- Another proposal where proof of work must be given in order to be covered under Medicaid.
Surprise Medical Billing, or just Surprise Billing
Surprise Billing occurs when a patient receives a much larger-than-expected medical bill from services and treatments received while at the ER.
- The most important thing to remember when it comes to surprise billing is that a hospital can be in-network on a patient’s insurance plan, but the physician might not necessarily be covered.
If the physician practice is out of network with the patient’s insurance, they can bill much higher out-of-network rates that the patient is completely responsible for.
This unfortunate fact happens because hospitals generally contract with physician groups, who then contract SEPARATELY with insurance plans. That’s why patients generally receive two bills whenever they go to the ER. Physicians can opt-out of any insurance plan if they don’t like the negotiated rate that the insurance plan is offering.
- Patients grow confused — “Wait,” they thought. “I thought my insurance covered an emergency room visit?” Well, yes, Karen — your insurance might cover the facility (hospital) portion of the bill, but the emergency physician treating you (who is separately contracted and probably works in an emergency physician practice) might not be covered at all. Which would put YOU on the hook for 100% of that out of network bill. Yikes.
So, in summary, patients receive 2 bills for an ER visit — one from the hospital, called the “facility” bill. Then, one from the physician, called the “professional” bill. The physician bill can be out-of-network, even though your insurance covers the hospital bill.
- Surprise billing is so contentious because patients in a medical emergency can’t exactly choose which hospital they can go to. Obviously, they’re going to go to the closest one. And if the ER physicians at that hospital are out of network with your insurance? Well, you’re SOL.
Surprise Billing: Benchmarking vs. Arbitration
Who wants what in surprise billing? what are the proposed solutions? Each of the candidates has varying solutions. All of the solutions boil down to one of two proposals centered around benchmarking and arbitration, while some are a hybrid of the two approaches.
- Arbitration would settle payment disputes for out of network emergency bills by asking a third party to decide what payment a provider should receive. Arbitration would allow providers to negotiate for favorable rates and argue their side.
- Unsurprisingly, in direct contrast to providers, health insurers want Congress to cap surprise billing payments at some agreed-upon rate — this is called “Benchmarking.”
Social Determinants of Health
Could we have picked a stuffier term for this? Essentially, what this means is that there are other ‘social’ aspects to your livelihood that ‘determine’ how healthy you are — diet/access to nutrition, neighborhood, income, etc.
- Learn more about them here.
Prescription Drug Importation
Since other developed countries like Canada pay less for drugs, the thought here is that the U.S. would allow patients or drug distributors to purchase prescription drugs from other pre-approved countries (that meet the right safety requirements) and import them into the U.S. for much cheaper than what they would pay for them in the U.S itself.
Direct Drug Price Negotiation
Democrats, in particular, want the government to be able to directly negotiate with drug companies on how much they can charge for their drugs.
The government, through the Department of Health and Human Services (HHS), would negotiate on behalf of both public (Medicare, Medicaid) and private (your employer-based health insurance plans) to determine prices that drug companies can charge for your prescriptions AND how much drug companies can raise prices in the future.
Generally speaking, Democrats want to tie drug pricing inflation to the standard U.S. inflation rate — which is pretty low right now.
Interoperability — It’s a horrible way to say that you want all electronic health records systems to be able to play nice with each other.
- For instance, if your primary care physician is on one electronic health records system, but your gastroenterologist is on another, the two systems can’t communicate with each other to transfer your data.
- Many current policy proposals — on both the right and left — want ALL electronic health records systems to be able to send data to each other. It’s a major-minor issue in healthcare right now.