The COVID-19 pandemic illuminated the critical role of access to health insurance for those not covered by governmental payers like Medicare, as well as the complex relationship among employment status, health insurance coverage, and access to care. A wide array of options for health care coverage have been debated in recent years. These have included eliminating the Affordable Care Act (ACA), strengthening the ACA, and adding new forms of Medicare that include a public option. Although many terms have become commonplace in public discourse, even politically savvy nurses can find the jargon and the multiplicity of options bewildering. What follows is an explication of the contemporary financing reform landscape, offered to support nurses' skillful analysis of policy options. Such informed nurses can offer nonpartisan education to others and advocate for patients.
First, we describe the impact of health insurance coverage on health outcomes and the ways Americans access such coverage. Next, we define key terms and explore relevant history that shapes our current circumstances. Then we describe the American Rescue Plan Act (ARPA), which was passed in early 2021. Finally, we offer suggestions to support nurses' further analysis, action, and informed advocacy.
HEALTH INSURANCE ACCESS AND HEALTH OUTCOMES
Lack of access to health insurance coverage is a key determinant of poor health as well as of economic duress. Even with the ACA, which significantly decreased uninsurance from 16.6% in 2013 to 10.9% in 2019,1 great disparities have been seen in uninsurance rates between states that elected to expand Medicaid (8.3%) under the ACA and those that did not (15.5%).2 Tolbert and colleagues, in a 2020 issue brief for the influential Kaiser Family Foundation, underscored that access to health insurance coverage matters, noting that most unemployed people have at least one worker in the family and are more likely to experience health care disparities and have low incomes; three in 10 uninsured adults in 2019 went without needed health care due to cost and were more likely to accumulate medical debt; and 85% of the uninsured are nonelderly adults, some of whom have suffered financial ruin as a result of loss of health insurance while facing catastrophic illness.1 Nearly one-third of Americans are concerned about their ability to pay for health care in the coming year.3 The pandemic further exacerbated these challenges and accelerated tensions about steps toward a more effective health care system.
How do people access health insurance coverage in the United States? The United States uses different payers to finance health care for different segments of society. Private, nongovernmental health insurance remains the most common, covering about two-thirds of the population in comparison to governmental payers such as Medicare and Medicaid that cover approximately one-third.4 Over 900 different insurance companies play roles in the private health insurance landscape, although most states have from five to 10 dominant players.5 Overall, the United States has been characterized by a “hodgepodge of systems” that are not designed to work cohesively.6
HOW MUCH SHOULD GOVERNMENT BE INVOLVED IN HEALTH CARE?
A major source of tension in policy debates is the degree to which government should be involved in providing health care coverage, with a growing but politically divided proportion of Americans supporting an expanded role for government.7 Americans' satisfaction with public insurance (Medicare, Medicaid, the Veterans Administration, military insurance) has been and remains high,8 ranging from 75% to 78%.9 (See Table 110-12 for a description of key governmental insurers.)
Table 1. -
Selected U.S. Governmental Payers by Eligibility for Coverage and Benefits10-12
||Who Is Eligible?
||What Services Are Covered?
|Medicare Part A
||Most people ages 65 and over; those with end-stage renal disease and amyotrophic lateral sclerosis, regardless of age; those under the age of 65 who have received SSDI for at least two years.
||Inpatient hospitalization, up to 100 days in a skilled nursing facility, hospice, home care if skilled nursing is needed. Does not cover long-term “custodial care.”
|Medicare Part B
||Same as above
||Professional services such as care from a physician or NP.
|Medicare Advantage (MA, originally called Medicare Part C)
||Same as above
||Both Part A and Part B services, except for hospice covered by Part A. Selected by beneficiaries who opt out of traditional Medicare (Parts A and B) and administered by a commercial insurance company, MAcovers 42% of Medicare beneficiaries. Since 2011, MA plans have been required to cap the amount beneficiaries would pay out of pocket and may provide additional benefits or reduce cost sharing. Provider networks are narrower than traditional Medicare, so beneficiaries may not be able to see the provider of their choice, but may have additional benefits like dental, hearing, and gym membership.
|Medicare Part D
||Same as above
||Prescription drugs, although some drugs are covered under Part B and by most MA plans.
||Eligibility varies by state, but federal law mandates coverage of low-income families, qualified pregnant women, and children and individuals receiving SSI. States may choose to cover additional groups, such as children in foster care or individuals receiving home- and community-based services.
||Hospital inpatient/outpatient, laboratory, X-ray, long-term care. If under age 21, dental and early and periodic screening diagnosis and treatment. Individual states may include additional services.
||While Medicare covers “skilled nursing,” Medicaid covers “custodial care” in long-term care settings. Currently, Medicaid covers five in eight nursing home residents, one in three individuals with disabilities, and one in five Medicare beneficiaries.
||Children in families that earn too much to be eligible for Medicaid, but have difficulty affording or accessing other insurance.
||Varies by state, but includes well and sick visits, immunizations, prescriptions, emergency services, laboratory, X-ray, inpatient/outpatient hospitalization, dental, and vision care.
CHIP = Children's Health Insurance Program; SSDI = social security disability insurance; SSI = supplemental security income.
Public rhetoric on the role of government is fraught with imprecise use and understanding of terms such as public option, single payer, universal health care, socialized medicine, and others. Universal health care is an umbrella term and is accomplished using a variety of strategies. The World Health Organization defines universal health coverage as all people having “access to the health services they need, when and where they need them, without financial hardship. It includes the full range of essential health services, from health promotion to prevention, treatment, rehabilitation, and palliative care.”13
The United States falls far short of this goal. Other wealthy nations achieve this aim to varying degrees and by using different financing strategies. The Netherlands and Switzerland, for example, achieve universal health coverage by requiring that all citizens have health insurance; this requirement is termed an individual mandate. Insurance rates are regulated and subsidies are provided to some low-income individuals or households who could not otherwise afford the premiums. Germany achieves its version of universal coverage through an employer-based insurance system.6 Still others employ national health insurance, a governmental guarantee that every person is covered for basic health care, with this care delivered in the private sector—that is, not by governmental employees working in government-owned facilities.
Unlike the United States, other wealthy nations use more stringent price controls, negotiations, capitated (fixed) salaries for providers, or global budgets to support affordability. Reported concerns about access to care because of cost exist but vary across countries and by personal income level, with cost concerns predominantly higher for Americans. For example, among lower-income individuals, 12% of UK respondents reported access problems related to cost—the lowest percentage of the 11 nations studied, whereas the United States ranked the highest (worst), with 50% of lower-income respondents reporting cost-related access problems.14 In this country, a substantial proportion (27%) of higher-income individuals also report health care access problems because of cost. Medical debt and bankruptcy secondary to health care costs, particularly common in states that did not expand Medicaid access under the ACA, are deemed uniquely American phenomena, as other wealthy countries embrace some sort of nationwide approach to mitigate cost burdens.
National health insurance that is financed by taxes is sometimes termed social insurance; for this reason, some people confuse it with socialized medicine. Unlike national health insurance, in a socialized system the government owns the buildings where care is provided, such as hospitals, primary care clinics, and long-term care facilities, and employs those who provide care, including physicians, nurses, nursing assistants, and others. We see this model in Great Britain with the National Health Service. By this definition—despite its complex mix of market-driven forms of insurance such as employer based and private insurance—the United States also has services that parallel a socialized approach, since they are financed by taxes and care is delivered by governmental employees in government-owned facilities. An example of this is the Veterans Administration.6
In contrast, although the Canadian system is largely financed through taxes, care within this system is delivered mostly in nonprofit hospitals rather than government-owned facilities and providers are not government employees. Thus, the Canadian system represents national health insurance with a single-payer approach, since all basic care is financed solely by the government through taxes, with options for supplemental insurance coverage paid for by citizens who elect to purchase it.
In the United States, Medicare offers a single-payer form of national health insurance for selected populations and conditions (most notably, those ages 65 and older). Access to health insurance is guaranteed to those eligible and is largely financed through designated payroll taxes and payments by those covered by Medicare, termed Medicare beneficiaries. Although this segment of the U.S. population is enrolled in a single-payer health care system, the overall U.S. system is a multipayer system.
HISTORY OF EFFORTS TO ACHIEVE UNIVERSAL HEALTH INSURANCE
The United States has a long history of efforts to move toward universal coverage using an array of strategies.
President Franklin Delano Roosevelt's initial plan for Social Security included universal coverage through national health insurance, in which people would pay into the program through taxes and have health insurance coverage in return. By the time Social Security was passed in 1935, many European countries had already implemented some form of universal health care in which virtually all citizens were covered. However, in the United States powerful lobbying groups, including the American Medical Association (AMA), accused Roosevelt of a “socialist conspiracy.”15 Opposition also came from the Republican party, and Roosevelt dropped national health insurance from the Social Security Act (SSA) over concerns that the entire act would not pass.16 Now, 85 years later, the SSA remains one of Roosevelt's most indelible legacies. President Harry Truman, Roosevelt's successor, unsuccessfully attempted to enact national health insurance in 1948,15 and throughout the post–World War II period health insurance access remained tightly dependent on employment status.
The growth and limitations of employer-based insurance. World War II wage and price controls prevented wage increases but allowed fringe benefits increases, including expansion of employer-subsidized health insurance. After the war, this country saw a dramatic increase in the number of Americans with employer-based health insurance, which was strongly supported by powerful labor unions.
Employment status as the portal to health insurance coverage, however, excluded those whose employers did not cover health insurance, along with those who were not working because of retirement, illness, or some other factor. By the early 1960s, the American cohort most likely to be living in poverty was the elderly, often because of growing health care–related costs.
The birth of Medicare and Medicaid. As part of President Lyndon Johnson's Great Society vision, amendments to the original SSA launched national health insurance for two groups in 1965:
- those over 65, who were eligible for Medicare (Title XVIII)17
- poor or disabled individuals without access to health insurance in other ways, who were eligible for Medicaid (Title XIX)18
Notably, the American Nurses Association supported Medicare in 1965 when the AMA did not.19 The American Dental Association also opposed the inclusion of dental benefits in original Medicare, a stance that continues today.20
The next major attempt at substantive health insurance reform came during President Richard Nixon's administration. Often described as more comprehensive and radical than the ACA, Nixon's plan for national health insurance was expected to pass but was thwarted by his embroilment in the Watergate scandal. In 1993, President Clinton unsuccessfully attempted to reform health care coverage through managed competition. During President Barack Obama's administration, Congress included national health insurance with a public option in the early drafts of what eventually became the ACA. However, it was removed from the final bill adopted by both chambers of Congress in March 2010.21 Many reasons have been given for the exclusion of the public option from the final version of the ACA: opposition from Republicans; lack of support from moderate Democrats; misinformation campaigns; and lobbying from insurance, pharmaceutical, and other health care industries and organizations.
UNIVERSAL COVERAGE THROUGH A PUBLIC OPTION OR MEDICARE
What might either a “Medicare expansion” or a public option look like? The answer could depend on which part of Medicare would be expanded: Part A, B, C, or D—or the creation of a new Part X. Regarding the proposed Medicare Part X, Oberlander notes that while Americans are more comfortable with the term Medicare than with terms like single payer, “Such plans are not Medicare for All, nor are they even Medicare for More since they generally seek to establish a new Medicare-like program rather than directly expand the current Medicare program.”22
Medicare Part X was originally proposed by Senators Tim Kaine (D-VA) and Michael Bennet (D-CO) in 2017 and was reintroduced in February 2021. This public option proposes a government-run insurance plan on the ACA exchanges to provide market competition with private insurance companies as a strategy to increase access and reduce cost. As proposed, Part X would have no cost sharing for primary care and certain preventative services.23 By comparison, traditional Medicare (Parts A and B) does not include first-dollar coverage (no deductible coverage): the Part A deductible is $1,484 for each benefit period, and Part B is $148.50 for most people. On average, people using health services under Parts A and B pay $20 for every $100 of services used, for copayments, deductibles, and coinsurance, unless they have purchased additional private coverage through what is commonly called Medigap coverage.
Other contemporary proposals to enhance access to health insurance include lowering the Medicare eligibility age to 60 and expanding benefits to include dental, hearing, and vision services. Finally, although this article describes federal efforts toward a public option, state-based versions have received legislative approval in a number of states, including Colorado, Nevada, Oregon, and Washington.24
COVID RELIEF SPENDING AND ACCESS TO HEALTH INSURANCE: THE AMERICAN RESCUE PLAN ACT
Some parts of the ARPA,25 passed in March 2021, expand on limitations of the ACA, with provisions addressing health care system challenges that were exacerbated during the pandemic.26 A massive COVID-relief plan, the ARPA has allocated $1.9 trillion to address economic disruption caused by the pandemic.27 Although all provisions end after 2022, and a few have already ended, they could be made permanent through further legislation introduced at a later time. However, political tensions about the magnitude of the investment are likely to be ongoing, so how much of this legislation will remain by 2023 is uncertain.
The ARPA included financing for the following28, 29:
- Expansion of the 1985 Consolidated Omnibus Budget Reconciliation Act (COBRA) until September 21, 2021, which provided a means during the worst period of the pandemic to retain employer-based insurance if a person quit, was furloughed, or was fired from a job. COBRA has long allowed individuals to stay on their employer-based insurance for 18 to 36 months after leaving, provided they pay the entire group rate premium out of pocket plus a 2% administrative fee, an opportunity that's too costly for some. While the expansion was in effect, the ARPA provided financial support for 100% of the cost of this option for those who had been laid off or had hours reduced and lost employer-based health insurance as a result.
- Expanded funding through numerous provisions for aspects of Medicaid and the Children's Health Insurance Program.
- The ACA provided an enticement for states to expand Medicaid by subsidizing 90% of the new enrollees, leaving states to pay only 10% of that expansion. The ARPA has expanded subsidies to existing Medicaid enrollees in states that had not previously expanded Medicaid.
- New options for states to extend postpartum Medicaid coverage to mothers for 12 months.
- Additional Medicaid support for home- and community-based services.
ADDITIONAL CONSIDERATIONS WHEN EXAMINING HEALTH POLICY QUESTIONS
While the future of health care financing reform always appears to be in flux, it is essential that nurses immerse themselves in the details, analyze potential intended and unintended consequences of policy actions and inaction, and become informed advocates for meaningful change.
Additional considerations include:
- What benefits package is proposed? Is it a basic or comprehensive package? Comprehensive packages are more expensive to fund but offer greater coverage.
- What is the level of cost sharing? Does cost sharing provide incentives to promote needed care and reasonable barriers to unnecessary or wasteful care? Or does it impose financial burdens that are prohibitive for many patients because of high deductibles and coinsurance costs, leading patients to avoid crucial preventive and emergent care?
- Will a consistent health care provider be available, and will the patient be able to choose their own provider?
- Will telehealth be covered and, if so, in what forms (video, phone, other) and for what services? Telehealth has been popular with patients during the pandemic and is likely to remain so. It has in many cases proven effective and cost-efficient for managing chronic illness, for mental health care such as psychotherapy, and even for some specialist appointments. But can we effectively address the evidence of massive telehealth fraud since the rapid increase of this care delivery method? Cautious expansion has been advised by policy experts.
- Is the proposed option the best option? Are there unintended consequences? For example, debates on the 2021 spending bill, Build Back Better, included the addition of hearing benefits to Medicare. Although expanding access to a valuable service to some Americans, it offers additional benefits to wealthy older Americans as well as poor, with the burden of financing its cost carried by younger generations.
IMPLICATIONS FOR NURSING ADVOCACY AND PRACTICE
The language of health care reform is confusing and poorly understood by many Americans. Nurses who are fluent in the terminology of health care financing can serve as a resource to coworkers and inform their patients and politicians of the choices, opportunities, and trade-offs. The language of finance is also powerful; nurses who are proficient in deploying this power can accelerate the path to a more just and equitable approach to health care.
The authors suggest the following next steps for readers:
- Expand on the foundation provided in this article to create a policy learning agenda that supports critical analysis of options.
- Expand your policy and payment vocabulary by noting new terms and researching their origins, dimensions, and controversies.
- Monitor nonpartisan, fact-based news.
- Encourage peers and coworkers to be interested and engaged in the language of reform.
- Explore political candidates' health care platforms. Give time, energy, and campaign contributions to those you support.
- Join like-minded organizations and efforts to augment and accelerate meaningful change.
The health of this nation and our patients may depend on it.
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