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25 terms you should know to understand the health care debate

  • 25 terms you should know to understand the health care debate

    The United States has one of the highest costs of health care in the world, in 2017 spending about $3.5 trillion or an average of about $11,000 per person. Costs have grown to 18% of GDP from 5% of GDP in 1960. That means millions of Americans go without medical insurance or face medical expenses they cannot pay, making health care one of the most critical issues of our time. Nearly 30 million Americans have no health insurance, and rates vary dramatically by state. A full one-quarter of Texas residents had no health insurance in 2018, compared with one person in 10 in Michigan and one person in 20 in Massachusetts. Uninsured Americans tend to be adult males who are low-income and have less than a high school education.

    Then there are the underinsured—people with high deductibles and out-of-pocket expenses who struggle to pay medical bills or delay or skip care because of costs. Among insured adults, 29% percent were underinsured in 2018, many with employer-based health plans.

    Aimed at making health care more accessible and equitable, the Affordable Care Act is one of the most recognizable legacies of President Barack Obama and a high-profile target of Republicans and President Donald Trump. But it's far from universal coverage. Members of the U.S. House were scheduled to vote on June 29 on an update to the Affordable Care Act. There is a slew of updates including expanded Medicaid funding and a call to lower drug prices. The bill aims to make health care coverage more affordable by lowering premiums and out-of-pocket costs. Canada and Scandinavian countries have universal health care, for example, but it is an idea that meets with stiff resistance in the United States. Norway’s universal health care system began in 1912. Of Americans with health-care coverage, employer-based insurance is most common at 56%, followed by Medicaid at about 19%, and Medicare at about 17%.

    Looking ahead, health-care costs are estimated to hit $6 trillion, or about $17,000 per person, and 19% of GDP by 2027. And with a presidential election on the horizon,  debates have been revived over what is best for the American people: a public option, a mixed solution of private and public-funded plans, or a more private system left more to market forces and less to the government? Keep reading to learn 25 key terms to help you better understand the complexities of the health care debate.

  • Single-payer health care

    Under a single-payer system, a government-run agency would finance health care for all, typically through taxes. Supporters say it would help cover uninsured and underinsured Americans, control costs, and make health care a right, not a privilege. Opponents argue that single-payer health care would stifle innovation by leaving pharmaceutical companies, device makers, and others with less money for research, give the government too much control, and limit treatments to the most cost-effective.

  • Public Option

    With a public option, the government would provide health insurance for people to purchase that would perform like a private plan. Supporters say such a plan would be cheaper because it would not be run for profit, its size would give it bargaining power with providers, and it would allow buyers to move or change jobs without losing or changing their health insurance. Opponents argue that health care providers would be reimbursed at low rates and may even reject patients using a public option plan. Private insurance companies say a public option might put them out of business, in effect leading to a single-payer system.

  • Pre-existing condition

    A pre-existing condition is a medical illness or injury that existed or was treated before a person joins a new health care plan. It might be chronic or long-term, such as diabetes, epilepsy, COPD, cancer, or sleep apnea. Before the Affordable Care Act took effect in 2010, insurance companies could deny coverage or offer coverage at inflated rates for those who had pre-existing conditions.

  • Universal coverage

    Everyone has access to health care under universal coverage. Some 32 countries have universal coverage, including Canada and Norway. A single-payer system would be one form of universal coverage.


  • Age-band rating

    An age band rating sets a range in which insurers can charge more to older consumers than to younger people. Before the Affordable Care Act (ACA), most states allowed a 5 to 1 ratio, meaning insurers could charge seniors as much as five times what they charged younger patients in premiums. Under the ACA, the ratio was capped at 3 to 1.

  • Affordable Care Act

    The Affordable Care Act is a health care reform law that took effect in 2010. Its key feature is private individual market health insurance plans sold in health insurance exchanges. These plans are run not by the government but offered by major health insurance companies that comply with the law’s various requirements. Designed to make health care more affordable and accessible, the act provided tax credits and subsidies, expanded Medicaid coverage, required all insurance plans to cover a number of treatments, eliminated lifetime and annual coverage limits, and allowed children to stay on their parents plans longer. An expanded version of the Patient Protection and Affordable Care Act Enhancement Act was up for a vote on June 29, 2020. With the updates come more money allocated towards grants and insurance affordability programs as well as expanded Medicaid funding. 

  • Risk corridor

    The risk-corridor program was established under the ACA as a safety net in the first three years of the health insurance exchanges. Plans with higher-than-expected medical claims could recoup some losses, while those with lower-than-expected costs would pay into the program. Congress in 2014 required that the program be budget neutral, and a giant shortfall followed. Health insurers have sued to recover their expected payments that amount to more than $12 billion, but the federal government has said it is limited by Congress on what it can pay. The U.S. Supreme Court plans to take up three consolidated risk corridor cases in its next term starting in October.

  • Cooperatives

    A health-care cooperative is a nonprofit, member-owned medical insurance plan designed to provide affordable health insurance and increase competition and choice. Nearly two dozen co-ops were created under the Affordable Care Act. However, all but a handful have closed. Some were unable to handle the size of the risk pools or unable to compete with private insurers, while others encountered more or less enrollment than expected.

    [Pictured: U.S. House Speaker Nancy Pelosi (D-CA) holds a news conference about health care legislation and the Affordable Care Act.]

  • Self-insured plan

    Self-insured health plans are likely to be found in large companies at which the employer collects premiums from employees and pays their medical claims. The plans might be self-administered or contracted out to a third party.

  • Medicare

    Medicare is a federal health insurance program for people 65 and older and for certain younger people with disabilities. Medicare Part A is hospital insurance, usually premium-free, covering inpatient stays, nursing care, and some home care. Medicare Part B, which charges a monthly premium, is medical insurance that covers certain doctors’ services, outpatient care, medical supplies, and preventive services. Medicare does not cover long-term care, such as assisted living or nursing homes, most dental care, dentures, hearing aids, and eye exams for prescribing glasses.

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