The Healthy Muse (hospitalogy)

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 a more in-depth analysis here.

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 health insurance plans, including all deductibles, co-pays, and out of pocket costs.

Read more about it here.

Think of it as an employer health insurance plan run by the government that anyone can buy into.

Read more about it here.

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 single-payer system.

Premium: Your monthly ‘subscription’ fee you pay to have health insurance coverage.

Co-Pay: Portion of payment that the patient is responsible for in paying for medical services. 

Deductible: the amount of money you must pay each year to cover eligible medical expenses before your insurance policy starts paying.

More health insurance term definitions are here.

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. 

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 ideology is still popular with Trump and Republicans to formulate a new healthcare reform plan.

Another proposal where proof of work must be given in order to be covered under Medicaid. 

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 easily opt out of any insurance plan if they don’t like the negotiated rate that the insurance plan is offering.

Patients grew 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.

Who wants what in surprise billing? what are the proposed solutions?

Everyone wants to see patients protected from out of network bills. But we’re still struggling a bit to get there.

What providers (physicians, hospitals) want: Arbitration.

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.

The American Hospital Association went on to release a statement in favor of an arbitration clause, arguing that any “rate capping” measures (AKA “Benchmarking”) taken by Congress would give insurers more leverage – possibly even removing any incentive for insurers to contract with providers for reimbursement (since Congress would now be arbitrarily setting reimbursement rates).

What insurers want.

Unsurprisingly, in direct contrast to providers, insurers want Congress to cap surprise billing payments at some agreed upon rate – this is called “Benchmarking.”

Whether that payment rate is at a fixed percentage of Medicare (e.g., “we’ll give physicians / hospitals 200% what Medicare pays for the out-of-network portion of the bill) or the median in-network rate adjusted for geography, it would be a bigger win for insurers to get Benchmarking through Congress.

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.

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.

Read more: 10 FAQs on drug importation.  

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.

Read more:

• A brief history of Medicare drug price negotiation.
• The Congressional Budget Office stated that providing broad negotiating authority by itself would likely have a negligible effect on federal spending.
• (OPINION): Direct government negotiations on price would not save the government money.
• (OPINION): Remedy for high drug costs: let Medicare negotiate.

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.