There is a full spread across the political table when it comes to health care matters and how the election may impact the future of employee benefits. Political parties in the U.S. propose very distinct approaches on how to keep Americans healthy and health care costs down. As feds continue passing the plate on these discussions, this election will definitely have something to say about the impact on employer-sponsored health insurance and, specifically, the Affordable Care Act (ACA) for U.S. citizens enrolled in the individual market plan.
With so much to process on how the outcome of November's election will affect Americans, let's first distinguish the five health care models of coverage that fuel many Capitol Hill debates.
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The 5 types of health care models
Universal coverage models (where everyone is automatically covered at birth):
- Single payer, single provider: Health care is provided and financed by the government through taxes (e.g., Veteran Affairs).
- Single payer, multiple providers: Health care is provided by private doctors in private facilities (e.g., Medicare/Medicaid).
- Multiple payers, multiple providers: Employers and employees fund national health insurance through payroll taxes. Health insurance companies are private, but nonprofit and government regulated (e.g., Affordable Care Act).
Non-universal coverage models (where everyone has to acquire insurance):
- Multiple payers (private insurance), multiple providers: A variety of payers, including state and federal level, plus commercial health insurance providers, reimburse health care providers on a fee-for-service basis (e.g., most commercial U.S. health plans).
- Out-of-pocket: Patients pay out-of-pocket for health care services (e.g.,self-insured or non-insured).
What is being debated
Here are highlights on different perspectives and suggestions to adopt or improve upon the country's health care system.
Proposal: Expand the Affordable Care Act to reduce the uninsured population and increase health care affordability
ACA, the current multi-payer, multi-provider health care model features:
- Public health care exchanges
- Expanded Medicaid
- Subsidies to reduce monthly premiums and out-of-pocket costs for lower income consumer exchange purchases
- Pre-existing conditions receive coverage
- Mandated essential health benefits
- Zero-cost preventive services
- Dependent coverage to age 26
- Allows individuals and businesses to keep their private health insurance, if preferred, while offering automatic coverage to vulnerable segments of the population, such as elderly or newborns.
Proposed improvement: Increase federal subsidies for more Americans to afford coverage.
Proposal: Medicare for All
Medicare for All calls for the repeal of the ACA and replacement with:
- Rapid, nationalized health care for all Americans.
- Proposed funding by increased taxes on employers and certain segments of the public to pay for all health care through a single-payer (the federal government) system.
- The government would control what in-network providers can do and charge.
- No patient out-of-pocket fees or cost sharing.
- Guarantees same access to care. Nobody receives a bill.
- Dental and vision would be included as well.
- Private insurers would be limited only to niche plans covering elective and other non-essential medical procedures.
Debate point: It places taxpayers at risk for overuses through free access leading to rising costs or higher taxes.
Proposal: Medicare for All who want it
Proposes increased access to Medicare for All, including:
- Maintaining a role for private insurers through supplemental Medicare plans for additional coverage
- Babies may be born into Medicare, depending on the proposal, while leaving the opportunity for parents to opt-out of that coverage for their children.
- Proposed funding through premiums and partly through taxes.
- Maintains a role for private insurers, while establishing a foundation of government negotiated rates, designed plans, while reducing the uninsured rate.
Proposal: Continuation of current state
This reform aims to repeal and replace the current ACA:
- Proposes rules to expand access to short-term, limited duration insurance, association health plans, and health reimbursement arrangements.
- Association health plans (AHPs) would allow business and individuals to band together to create group health plans that are less expensive. Final rules of the proposed AHPs violate standing ACA rules and are subject to lawsuits.
Understanding plan changes for 2021
So, what is actually at stake for short-term changes? If you currently receive health coverage from your employer, your individual employer will continue to provide details for coverage changes for your upcoming benefits plan year. If you receive government-run health insurance (Medicare or Medicaid), you will receive information from your state or federal organizations or from insurers who manage your coverage.
For those who have health care through ACA, it's important to understand:
- ACA has not been repealed or replaced.
- ACA lawsuits do not impact upcoming plan enrollment.
- The individual mandate penalty for non-compliance does not apply in most states.
Although political parties greatly differ on their preferred approaches to these models or how to improve them, one piece of legislation that is getting bipartisan support is the proposed "STOP Surprise Medical Bills Act," a surprise medical bill legislation that prohibits balance billing in certain scenarios. For example, a patient who receives emergency care at an out-of-network hospital and treated by out-of-network physicians would be prohibited from receiving a surprisingly high balance bill.
The topic of reforming and optimizing how Americans access health care will remain at the forefront of debate, regardless of November's election outcome. We will all continue to wait and see.
Melody Cooper is senior copywriter at FBMC Benefits Management, Inc.
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