Health care occupies a prime spot in today’s political theater — and an increasing share of national expenditures. But the Kaiser Family Foundation, a nonpartisan think tank that tracks the industry, found that three-quarters of Americans can’t define basic health insurance terms — and the situation is getting more complex.
Today, we conclude a two-part series that aims to bring you up to date so you can follow the issues that will influence your health care — and, potentially, your vote — for years to come.
What’s covered?
Once upon a time, it was up to employers, consumers and insurance companies to agree on what medical expenses each health plan covered.
People wanted their illnesses covered, but they didn’t want to pay for benefits they didn’t use. Insurance companies could offer a range of plans, from low benefits to high benefits, covering some medical costs but not others.
Employers or individuals would buy what they wanted and could afford.
The Affordable Care Act changed that by requiring a broad set of “essential health benefits” — outpatient care; emergency services; hospitalization; maternity and newborn care; mental health and substance abuse services; prescription drugs; rehabilitative services; laboratory services; preventive and wellness services; chronic disease management; and pediatric dental and vision services.
One impact: higher costs, because all health plans paid for more things. (Health plans under the ACA vary according to how much they pay and the amount of out-of-pocket costs required, but the benefit categories are uniform.)
Reducing costs has been a top goal of both sides on the ACA debate. Critics argue that the law has sped up the increase in insurance and medical costs, rather than slowing it down.
To reverse the spiraling cost trend, some Republicans have proposed ending the national essential benefits rules and letting each state decide what insurance plans should cover — and what they shouldn’t. That would be a return to pre-ACA days.
Already, states are allowed to seek waivers from the benefits rules if they don’t have competing insurance plans available.
There’s precedent for that.
Each state has an agency that oversees insurance within its borders. Although the states often coordinate their regulations, each state is, more or less, in charge of the insurance business within its borders. That includes setting standards for health insurance plans, although that power today is subject to the nationwide ACA rules.
Occasionally, state legislatures debate whether to require or limit health insurance coverage.
Should insurance companies be required to extend benefits to abortion procedures? Treatments for AIDS and HIV? Mental health? Substance abuse?
Before the ACA, the rules for coverage varied from state to state. If an insurance company wanted to offer health plans in a state, it must follow that state’s rules.
ACA backers view the essential benefits as supplying good insurance uniformly across the country. Opponents view the essential benefits as a cost-raising rule imposed on people by the federal law that should be reversed, with control returning to the states.