I’ve had more than a few friends ask me how I have time to get all the things done–study, stay up on the news, run the blog, work on personal passion projects , do academic research, connect with friends and family. My daily to-do list could go on and on. So I thought I’d take you along for a “Day in the Life” of a first year medical student being pulled (willingly, I might add!) in a thousand directions.
4:58am I woke up 2 minutes before my alarm, so that’s 2 more glorious minutes to lay in bed.
I’ll be honest, I used to watch the VHS of Schoolhouse Rock: America about once a week as a kid. It might be more than a few decades old, but it’s still perfectly accurate thanks to Article I of the U.S. Constitution, which grants all legislative powers to Congress, including the authority for each chamber to make its own rules for processing legislation. Before we dive in to the nitty, gritty of drafting, considering, amending, reconciling, and voting on legislation, let’s (re)familiarize ourselves with some vital stats about Congress.
In 2016, a majority of Americans (49%) received health coverage through an employer, either as an employee or a dependent of an employee. [How did employer-sponsored health insurance become so widespread in the U.S.? Check out this article for a brief history starting with the creation of Blue Cross in 1929].
While the ACA mandates that individuals have health insurance (which has been made a tad more complicated by the recent tax bill passed by Congress), it does not require employers to provide health benefits to their workers. However, the Employer Shared Responsibility Provision of the ACA stipulates that certain businesses called Applicable Large Employers (or ALE’s) must offer affordable, minimum value coverage or face a financial penalty. That regulatory mumbo-jumbo essentially adds up to a mandate for businesses with more than 50 full-time employees to offer health coverage.
This flowchart should answer any lingering questions about employer responsibilities in terms of health coverage.
In 1979, the Department of Health, Education and Welfare (HEW) was separated into two cabinet-level agencies, the Department of Health and Human Services (HHS) and the Department of Education. It is comprised of 11 operating divisions which oversee “the health and well-being of all Americans” by supporting public health, medical, and social services. It is currently run by Secretary Alex Azar, who previously worked in the private sector at the pharmaceutical behemoth Eli Lilly and the public sector as General Counsel and then Deputy Secretary at HHS during the George W. Bush Administration. Let’s take a [very brief] tour of the divisions that most impact medical professionals and their patients on a frequent basis.
I recently saw an old episode of ER and did a double take at the publicly-facing patient board that listed full patient names, the reason for the ER visit, and curtain number. The episode revolved around Dr. Weaver’s attempt to protect patient confidentiality by implementing a comprehensive system of abbreviations and patient social security numbers on the board–a move not appreciated by the overworked staff. Yet, it got me thinking–when did patient privacy become an understood part of medical care and not an inconvenience?
Nearly every time we go to a medical visit, there are new forms to sign. How many of you are guilty of just signing without reading and turning the clipboard back in to the front desk? [I know I am]. If you’ve ever taken a good look at some of those forms, they often have to do with confidentiality and privacy of information. And, if you’re over 18 years old, you also use those forms to designate individuals to whom your private, medical information can be released–a spouse, parent, sibling, etc.
I’ve probably seen every episode of Law & Order: SVU at least twice. Those marathons on USA draw me in every time. Police procedurals on television have familiarized a generation to the reading of Miranda Rights, but did you know there’s another type of police power? Let’s pull out our handy dandy pocket U.S. Constitution and take a look at the 10th Amendment. [You think I’m kidding? I’m not, I actually have a well-worn copy that I purchased at the National Archives as an incredibly nerdy 16 year old.]
The 10th Amendment defines the division of authority between the federal government and state governments: “The powers not delegated to the United States by the Constitution, nor prohibited by it to the states, are reserved to the states respectively, or to the people.”
The individual mandate has been a magnet for contentious debate since the ACA became law in 2010. The ACA was not the first time a mandate to purchase insurance has been floated in the U.S.–the Clinton Administration supported the concept in the Health Security Act of 1993, which did not become law. Prior to the ACA, Massachusetts became the first stateto require all individuals over 18 to have health insurance and helped enacted measures to help facilitate the expansion in coverage. And, as art imitates (or predicts) life, the West Wing featured the health care debate even before Senator Obama became candidate-Obama. [You can watch it on Netflix. Season 7, Episode 7, “The Debate.” The health care portion starts at 16:43].
Before we get into the details of what the mandate requires (and an update on its current status), let’s take a quick look at the arguments on either side of the issue.Supporters of the mandate have two primary justifications: (1) it will help the U.S.’s private-public hybrid insurance system work most effectively by spreading the cost out among as large a risk pool as possible; and (2) a moral imperative that healthcare is a right, and not a privilege afforded to those with means. On the other side of the issue, opponents of the mandate argue that it is a government infringement on personal freedom.
Medicaid is jointly administered by the Centers for Medicare and Medicaid Services (CMS) and individual state Medicaid agencies. CMS is an agency within the Department Health and Human Services (HHS), which in turn is overseen by the President. CMS sets program parameters, provides policy guidance, and approves waivers excusing states from certain requirement. CMS issues guidance on eligibility, enrollment, medical assistance, coverage, provider participation, provider payments, cost-sharing, and a host of other policy issues related to the program.
In turn, each state creates a uniform, state-wide medical assistance program that is embodied in a federally-approved state plan. The state agencies are free to make choices within the parameters set by the federal government, often through waivers or creative programming.
Before the ACA, individuals without employer insurance bought an insurance plan directly from an insurer (i.e. United Healthcare, Aetna…). Plans were typically poorly regulated and had very few consumers to share the risk, so costs were high. The ACA sought to establish a single virtual marketplace, where consumers could shop for and purchase an insurance plan, allowing individuals across a county to be pooled together, minimizing risk and lowering cost. The health insurance exchanges established by the ACA offer transparent cost comparisons between plans and enforce the inclusion of essential health benefits to ensure quality across all plans.
Those in the individual market now have the opportunity to shop for a plan that best fits their needs with options ranging from the low premium/high deductible bronze plans to the high premium/low deductible platinum plans. Additionally, all marketplace plans are subject to a number of consumer protections, including: