A

Accountable Care Organization (ACO) - health care organization whose payment is tied to achieving health care quality goals and outcomes that result in cost savings. Results have not been that encouraging, including efforts to reduce specialists’ charges.

Actuarial value - percentage of total average costs for covered benefits, for a population, that a plan will cover.

Affordable Care Act (Obamacare) - federal health care plan designed to 1) Provide consumers with subsidies (“premium tax credits”) that lower costs for households with incomes between 100% and 400% of the federal poverty level. 2) Expand the Medicaid program to cover all adults with income below 138% of the federal poverty level. (Not all states have expanded their Medicaid programs.) 3) Support innovative medical care delivery methods designed to lower the costs of health care generally. Four options are available to applicants: Bronze, paying 60% of costs while patient pays 40%, Silver paying 70% while patient pays 30%, Gold, paying 80% while patient pays 20%, and Platinum, paying 80% while patient pays 10%. Deductibles vary as well.

All-payer health care - health care system in which all payers use the same fee schedule

Amenable mortality - rates of death considered preventable by timely and effective care. A lower rate of amenable mortality means an improvement in quality of care

Annual limit - cap on the benefits an insurance company will pay in a year while insured is enrolled in a particular health insurance plan. These caps are sometimes placed on particular services such as prescriptions or hospitalizations. Annual limits may be placed on the dollar amount of covered services or on the number of visits that will be covered for a particular service. After an annual limit is reached, insured must pay all associated health care costs for the rest of the year.

Association plan - group health plan that employer groups and associations offer to provide health coverage for all their employees

B

Balance billing - the difference between the amount a provider charges and the amount insurance pays. The amount that insurers pay providers is almost always less than the providers’ “retail price.” Some providers will bill the patient for the difference, or balance: balance billing.

Benefits - the health care items or services covered under a health insurance plan

Beveridge model - health care system in which health care is provided by the government and financed through tax payments. Britain’s National Health Service is an example.

Billing and insurance - process of billing and collecting from payers. In a multi-payer system this requires an extensive and costly administrative department, sophisticated computer systems, advisors, in-service training, etc. In a single-payer system, this process is streamlined.

Bismark model - health care system in which everyone is covered by insurance (non-profit “sickness funds”) financed jointly by employers and employees through payroll deduction. The system in Germany, where it originated, is one example.

Brand name drug - drug sold by a drug company under a specific name or trademark and that is protected by a patent (usually lasting twenty years before generics can be produced)

C

Capitation - payment system in which providers are paid a monthly fee for caring for a patient rather than a fee for each service provided (fee-for-service). Capitation can encourage limitation of care while fee-for-service can encourage excessive care.

Care coordination - organization of treatment across several health care providers, as in the case of medical homes and Accountable Care Organizations.

Catastrophic health plan - plan that meets all of the requirements of Qualified Health Plans (QHPs) but that doesn't cover any benefits other than 3 primary care visits per year before the plan's deductible is met. The premium amount is lower than for other QHPs, but the out-of-pocket costs for deductibles, copayments, and coinsurance are generally higher. To qualify for a Catastrophic plan, applicant must be under 30 years old OR get a "hardship exemption" because the Marketplace determined applicant was unable to afford health coverage.

CHIP (Children’s Health Insurance Program) - insurance program that provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid but not enough to buy private insurance. In some states, CHIP covers pregnant women.

CMS - Centers for Medicare & Medicaid Services, part of the Department of Health and Human Services (HHS) that oversees the Medicare and Medicaid programs

COBRA (Consolidated Omnibus Budget Reconciliation Act) - federal law that may allow workers to temporarily keep health coverage after their employment ends, they lose coverage as a dependent of the covered employee, or another qualifying event. Enrollee pays 100% of the premiums (~$20,000 a year), including the share the employer used to pay, plus a small administrative fee.

Co-insurance - the percentage of costs of a covered health care service enrollee pays after they’ve paid their deductible

Community rating - rule that prevents health insurers from varying premiums within a geographic area based on age, gender, health status or other factors. Contrast risk or experience rating, in which medical underwriting is used to base premiums on risk of disease rather than ability to pay.

Coordination of benefits - determination of who pays first when two or more health insurance plans are responsible for paying the same medical claim

Co-pay (co-payment) - fee that a health insurer requires the patient to pay upon incurring a medical expense (as for a routine office visit, surgical procedure, or prescription drug) covered by the health insurer.

Cost - the expense incurred for creating a product or service being sold by a company. This is often used synonymously with, and confused with, “price,” which is the amount a customer is willing to pay for a product or service. The difference between the price paid and the cost incurred is the profit.

Cost sharing - the share of costs covered by insurance that a patient pays out of pocket (at point of service). This generally includes deductibles, coinsurance, and copayments, or similar charges, but doesn't include premiums, balance billing for non-network providers, or the cost of non-covered services. Cost sharing in Medicaid and CHIP does include premiums.

Cost sharing reductions/subsidies (CSR) - government subsidies paid to insurance companies to reduce co-payments and deductibles for enrollees. Available in Silver plans only.

Coverage Gap - term applied to situation when a plan provision allows non-payment for care. The Donut Hole is an example in the case of drugs, while the ACA Coverage Gap applies to people in non-Medicaid Expansion states who do not have access to Medicaid and also do not qualify for ACA subsidies because they make less than 100% Federal Poverty Level.

D

Deductible - the amount an insured must pay for covered health care services before the insurance plan starts to pay. Then the insured may be required to pay a copay and/or coinsurance.

Denial of care - insurer’s or Medicare’s refusal to pay for a service because it is not covered in the patient’s plan, or they otherwise determine it is inappropriate. Medicare Advantage has been accused of excessive denials.

Donut hole - coverage gap when enrollee is responsible for full drug cost in Medicare D, occurring between Deductible and Initial Coverage periods, and Catastrophic Coverage period

E

Electronic health record (EHR) - digital record of all aspects of a patient’s case, largely available to all involved parties. An Electronic Medical Record (EMR) is a digital record of an office chart, most useful for an individual practitioner. Billing and coding features included in some software have been blamed for over-billing at times.

Employer-based health insurance - insurance, including plan options, chosen by the employer for their workers, with premiums being paid for by both employer and worker (tax free). Some 40% of employers self-insure, meaning they assume the risk and are not required to offer essential benefits.

EPO (Exclusive Provider Organization) - similar to HMO but with exclusive list of providers (no coverage for out-of-network providers) and no referral to specialists required

ERISA (The Employee Retirement Income Security Act) - a 1974 federal law that sets minimum standards for most voluntarily established retirement and health plans in private industry. ERISA limits states’ ability to experiment with different health care models.

Essential health benefits - 10 services health insurance plans must offer under the ACA.

Exchange (Health Insurance Marketplace) - a shopping and enrollment service for medical insurance created in 2010 by the Affordable Care Act (see above).

F

Fee-for-service - payment system in which providers are paid for individual services (see Capitation)

For-profit company/corporation - one whose main goal is to make money. It is owned by its shareholders and is contrasted with non-profits or not-for-profits, which have other non-business goals such as helping the community.

Formulary - list of prescription drugs covered by a prescription drug plan or another insurance plan that includes prescription drug benefits. Also called a drug list.

Fully insured plan - commercial health insurance in which employer pays the premium and insurer assumes the risk. Contrast “self-insurance.”

G

Generic drug - pharmaceutical that contains the same chemical substance as a drug that was originally protected by chemical patents

Global budget - payment arrangement negotiated between a payer (for instance, the government) and a provider (for instance, a hospital), setting a fixed amount of funding for a fixed period of time (typically one year), as opposed to payments for individual services or cases as they occur.

H

Health care - see “Healthcare”

Healthcare - goods and services that medical professionals, hospitals, drug and device companies, etc., provide. The term can also refer to the system in which these are provided, including their economic and organizational aspects, a distinction that is not always clear. Generally synonymous with “health care.”

Health insurance - a health care funding arrangement in which an insurance company collects money from a selected insured population and pays for the care the company approves. It differs from public funding of health care as pointed out in Health Affairs in 2012: “The basic difference between Medicare and commercial insurance is that Medicare is designed to absorb risk, serving individuals who have or may have costly and complex medical needs as well as the relatively healthy, whereas commercial insurance is required to protect its business interests by avoiding those most likely to use medical care.”

Health Savings Account (HSA) - savings account that individuals with High Deductible Health Plans can set aside on a pre-tax basis to pay for qualified medical expenses (deductibles, copayments, coinsurance, but not premiums). Studies show, however, that few individuals with high deductible plans fund their accounts sufficiently to cover needed care.

High Deductible Health Plan - as of 2019, any plan with a deductible of at least $1,350 for an individual or $2,700 for a family.

HMO (Health Maintenance Organization) - medical insurance group that provides health services from a network of providers (professionals and hospitals). Charges are usually higher for “out-of-network” providers and primary care referrals for specialists are usually required.

I

Improved Medicare for All - Medicare for All improved with broader coverage (dental, eye, ear care, medications, long term care), elimination of cost sharing, elimination of commercial insurance as in Medicare C or Medicare Advantage), drug and device price negotiation. Examples include Senator Sanders’ Medicare for All Act of 2019, Rep. Jayapal’s Medicare for All Act of 2019 and the Physicians’ Proposal of Physicians for a National Health Program

Indemnity Plan - health plan without provider network that reimburses patients for a portion of their bill

Individual insurance - health insurance policy for an individual who does not have health care coverage through work. It can be obtained directly from an insurer or through the Marketplace.

Individual Mandate (Shared Responsibility Payment) - fee assessed through the ACA on those without health care insurance. It was repealed in the 2019 Tax Cuts and Jobs Act.

J

Job lock - restriction of life choices a worker may feel when their access to health care is tied to their employment. This could include fear of changing jobs, starting a new business, or participating in a strike because they might lose their provider.

Junk insurance - see Short term plan

L

Lifetime limit - cap on the total lifetime benefits received from an insurance company. This may be a total lifetime dollar limit on benefits or limits on specific benefits, or a combination of the two. After a lifetime limit is reached, the insurance plan will no longer pay for covered services.

M

Major medical - health insurance as it is generally understood, not including limited benefit plans, fixed indemnity plans, dental/vision plans, accident supplements, critical illness plans, etc., none of which are regulated by the Affordable Care Act.

Marketplace - see Exchange

Medicaid - Title XIX of the Social Security Act of 1965, a health care program that provides free or low-cost health coverage to some low-income people, families and children, pregnant women, the elderly, and people with disabilities; and covers long term care. It is funded by state and federal taxes and many states have expanded their Medicaid programs to cover all people below certain income levels.

Medicaid expansion - extension of Medicaid to previously ineligible adults up to age 64 with incomes up to 138 percent of Federal Poverty Level. In June 2012, the Supreme Court ruled that states could not be forced to expand their Medicaid programs: it was left to each state to determine whether to do so. To date, 38 states (including DC) have adopted the Medicaid expansion and 13 states have not.

Medical-industrial complex - network of corporations which supply health care services and products for a profit. The concept of a "medical–industrial complex" was first advanced by Barbara and John Ehrenreich in the November 1969 issue of the Bulletin of the Health Policy Advisory Center in an article entitled "The Medical Industrial Complex" and in a subsequent book, The American Health Empire: Power, Profits, and Politics (Random House, 1970). The concept was widely discussed throughout the 1970s, including reviews in the New England Journal of Medicine (November 4, 1971, 285:1095). It was further popularized in 1980 by Arnold S. Relman, MD, while he served as editor of The New England Journal of Medicine in a paper titled "The New Medical-Industrial Complex." (Wikipedia)

Medical home - “a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family…. the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients… [and] is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.” (Joint Principles of the Patient-Centered Medical Home March 2007)

Medical loss ratio - the amount of money paid out in health care claims divided by the amount of money taken in as premiums. The ACA set this ratio at at least 80% for individual and small group plans, and 85% for large group plans, leaving the remainder for administration, marketing, and profit. Insurers can thus allow provider charges (claims) to rise and then set premiums 25% higher than that (20% is 25% of 80%), so that the difference (what they keep) is larger. This is one theoretical explanation for rising health care costs in a commercial insurance system.

Medical Savings Account - Similar to HSA, but contributions can be made by either the employee or employer but not both during any year.

Medical underwriting - A process used by insurance companies to assess applicants’ health status so they can determine whether to offer coverage, at what price, and with what exclusions or limits. This one of the causes of the high cost of commercial health insurance, and does not occur in public or universal health care systems.

Medicare - Title XVIII of the Social Security Act of 1965: publicly funded, privately provided health care for those over age 65, younger people with disabilities. Medicare (but not Medicare Advantage) also covers all adults with one specific disease, End Stage Renal Disease, an example of the power of special interests over Medicare, but also an indication that people’s needs, not their age, should determine public responsibility for health care.

Medicare Part A (Original) - public health care coverage for individuals over 65 and certain other groups for inpatient care, skilled nursing home care, some hospice care. People with qualifying work histories pay no premium.

Medicare B (Original) - public health care coverage for individuals over 65 and certain other groups for outpatient services such as doctor visits, outpatient tests, home health care, durable medical equipment, and certain preventive services. Premiums are set annually

Medicare C (Medicare Advantage) - Medicare program administered by private insurance companies approved by Medicare. Original Medicare benefits (but not the expensive and chronic management of End State Renal Disease) must be included, and others often are, such as Part D drug coverage and routine vision, dental, and hearing services. There may be provider networks. MA options include HMOs, PPOs, SNPs (Special Needs Plans), and PFFS plans (Private Fee-for-Service plans). MA has been criticized because of how it is subsidized by taxpayers and for cases of Medicare fraud.

Medicare D - optional prescription medication plan Medicare beneficiaries may add to Original Medicare, and that involves four phases of payment: Deductible phase (pay total cost), Initial Coverage Period (share cost with plan), Coverage Gap (“donut hole” - pay total cost up to $6350 in 2020), Catastrophic Coverage (plan pays most until cycle restarts next calendar year)

Medicare Advantage - see Medicare C

Medicare for All - national, “single-payer” health care system in which the federal government collects monies, largely through taxes, and pays private providers. It can be thought of in general as Original Medicare extended to all Americans from birth. See Improved Medicare for All.

Medigap - extra private health insurance purchased to cover costs not covered by Original Medicare such as co-payments, deductibles, and health care delivered outside the U.S. Long-term care, dental care, vision care, hearing aids, eyeglasses, private-duty nursing, and prescription drugs are not usually covered. Ten different plans are available, identical for all insurers.

Metal groups - Bronze, Silver, etc. See Affordable Care Act.

Multi-payer system - a health care system in which funding comes from two or more sources. In the United States those sources include federal and state governments, hundreds of different commercial insurance companies, and out-of-pocket payments. Contrast single-payer system, as in Canada or Taiwan, in which one, usually governmental entity pays for most health care.

N

Navigator - An individual or organization trained to help consumers, small businesses, and their employees as they look for health coverage options through the Marketplace

Network - a panel of health care providers. Providers want to be included to have access to more patients, and insurers want to include providers whom patients want to see, and who agree to their fee schedule. These competitive forces can drive provider prices up or down. A “narrow network” consists of a limited number of selected providers.

Non-duplication of benefits - ruling that prevents insureds from profiting by being covered by two separate policies that insure the same risk. For example, some public plans prohibit insurers from covering benefits included in those plans.

O

Obamacare - Affordable Care Act (see above)

Original Medicare - Medicare Parts A and B. There may be copayments and coinsurance and no annual cap on out-of-pocket expenses

Out-of-network provider - one who is not included on an insurer’s list of providers with whom they have contracted, and therefore one whose bill they will not pay. See “surprise bill.”

Out-of-pocket costs/expense - expenses for medical care that aren't reimbursed by insurance, including deductibles, coinsurance, and copayments for covered services plus all costs for services that aren't covered

Out of pocket maximum (limit) - the most a health insurance policyholder will pay each year for covered health care expenses, not including premiums or balance billing. After OPM is met, insurance pays 100% of allowed health care expenses. For the 2020 plan year, the out-of-pocket limit for a Marketplace plan was $8,150 for an individual and $16,300 for a family.

P

Pay or play (employer share responsibility, employer mandate) - requirement that employers with over 50 FTE employees provide health insurance to their employees ("play") or pay a tax or premium toward a publicly provided system that covers people without private insurance (“pay”).

Pharmacy benefit manager - third-party administrator of prescription-drug programs for private insurers and Medicare Part D plans. PBM administrative functions, manufacturer rebates, “price spreading,” and “clawbacks” (copays) have been blamed for some drug price increases.

Poll tax - fixed tax on every liable individual, as opposed to one based on income or other variable. In the case of employer-based health insurance, the fee all workers pay for health care is similar to a poll tax because it is usually the same no matter their income.

PPO (Preferred Provider Organization) - Similar to HMO, but less restrictive and more expensive

Pre-approval/prior authorization - health plan cost-control process by which health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage

Preemption - primacy of federal over state law in the case of employer benefits, thus restricting some states’ efforts to reform their health care systems.

Pre-existing condition - health problem present before insurance coverage starts

Pre-existing condition exclusion period - the time period during which a health plan won't pay for care relating to a pre-existing condition. Under a job-based plan, this cannot exceed 12 months for a regular enrollee or 18 months for a late-enrollee.

Premium - the pre-paid cost of health insurance, usually paid monthly. A premium tax credit can lower this cost in some Marketplace plans.

Premium tax credit - refundable credit that helps eligible individuals and families cover the premiums for their health insurance purchased through the Health Insurance Marketplace

Price - see Cost

Primary care - health services that cover a range of prevention, wellness, and treatment for common illnesses

Primary care provider - doctors, nurses, nurse practitioners, and physician assistants who provide primary care. They often maintain long-term relationships with patients, serve as the first point of contact when illness arises, advise and treat on a range of health-related issues including prevention, coordinate care with specialists and other services, and maintain long range, comprehensive records. Pediatricians, Internal Medicine doctors, Family Practitioners, Obstetrics-Gynecology doctors, and various “holistic” professionals are considered primary care providers.

Provider - professional or institution that provides medical care

Public option - single, publicly funded health care plan that would exist alongside private plans and is to be contrasted with a single-payer plan, which refers to an entire public health care system.

Public plan - health care plan funded by, and overseen by, state or federal government. In the United States this generally refers to a plan in which the provision of care remains private.

R

Rationing - the control of the supply of a scarce service or product, such as health care. When health care is funded by commercial insurance it is rationed by the insurer’s ability to make a profit, when publicly funded it is rationed by the government’s assessment of medical value and the funds the voters and their representatives approve.

Resource-based Relative Value Scale (RBRVS) - system for determining medical provider reimbursement. It replaced the previous Usual, Customary, and Reasonable scheme as part of the 1989 Omnibus Budget Reconciliation Act and is used by Medicare and most HMOs. Procedures are given Current Procedural Terminology (CPT) codes (maintained by the AMA) and are assigned a Relative Value (54% for physician work, 41% for practice expense, and 5% for malpractice expense). These are multiplied by a conversion factor and published in the Physician Fee Schedule. Much of the data used for these calculations comes from the specialist-dominated American Medical Association/Specialty Society Relative Value Scale Update Committee, or RUC, and as of 2010 the CMS had accepted more than 94 percent of RUC’s recommendations. In 2020, the Conversion Factor for Original Medicare was reduced 11%, giving an edge to Medicare Advantage.

S

Self-insurance - employer-based health insurance plan in which the employer uses their own money to cover employees' claims. Most self-insured employers contract with an insurance company or independent third party administrator for plan administration, but the actual claims costs are covered by the employer's funds. Such plans do not require coverage of the essential health benefits designated in the Affordable Care Act or a cap on older enrollees’ premiums; but do require considerable medical economic sophistication on the part of the employer, and the acceptance of risk. Contrast “fully insured plan”

Short-term plan (“Junk” insurance) - type of health insurance coverage designed to fill gaps in coverage that may occur when an individual is transitioning from one plan or coverage to another plan or coverage, such as in between jobs. Though premiums are low, these plans are not required to cover the full list of ACA health benefits. A 2019 federal rule extended the duration of short-term plans to 365 days, lifting a 3-month term limit established at the end of 2016. Starting in 2019, consumers were able to purchase short-term plans which are renewable for up to 3 years in some states.

Single-payer health care system - a national or state health care system in which a single public agency funds health care for its citizens. In the socialist model (England) and communist model (Cuba) the government employs the providers and owns the facilities; in the models seen in other countries (Canada and Taiwan), the provision of care is private. See also, Bismark and Beveridge models. The term is often used, erroneously, as a synonym for “universal health care.”

Socialism - “Any of various theories or systems of social organization in which the means of producing and distributing goods is owned collectively or by a centralized government that often plans and controls the economy.” (American Heritage Dictionary). Many opponents of public health care plans call such plans socialistic, which, by this definition, they are not. Funding in such plans is “socialized,” but not the heath care funded.

Specialty care - health care limited to one organ or system, as opposed to primary care which is concerned with most aspects of a person’s physical and mental health

State-Based Universal Care Act of 2019 (H.R.5010) - a bill proposed in the House that would “amend title I of the Patient Protection and Affordable Care Act to authorize the establishment of, and provide support for, State-based universal health care systems that provide comprehensive health benefits to State residents, and for other purposes.” If passed, this bill would greatly simplify the complex waiver applications now required to avoid ERISA and other challenges to state universal health care proposals.

Subrogation - process that allows insurers and self-funded health plans to shift the liability associated with medical expenses to another appropriate party, allowing them to maintain their premium levels.

Supplemental plans - see MediGap

Surprise bill - provider’s bill that is not covered by insurance because the provider is not in the insurer’s network

U

UCR (Usual, customary, and reasonable) - the amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. It was introduced into Medicare (Title XVIII of the Social Security Act of 1965) to placate the American Medical Association. See Resource-based Relative Value Scale.

Under-insurance - health care coverage status of adults who were insured all year but experienced at least one of the following: out-of-pocket costs, excluding premiums, equaled 10% or more of income; out-of-pocket costs, excluding premiums, equaled 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income. (Commonwealth Fund)

Universal health care - health care for everyone in a certain population. Medicare is UHC for all citizens over 65, VA care is UHC for veterans.

Upcoding - criminal and punishable practice in which providers bill for services using higher procedure codes than those that should apply, resulting in a higher payment by Medicare or third-party payors

Urgent care center - category of walk-in clinic focused on treatment of minor illnesses and injuries. Their numbers have increased dramatically in recent years because of their convenience (immediate service) and relatively low cost for patients, and their ability to bring customers into associated pharmacies and otherwise siphon off health care dollars for corporations. Problems with this trend include reduction in the role of primary care providers, cases of inappropriate care such as antibiotic overuse, and the restriction of cases to straightforward ones.

V

Value Based Payment - form of reimbursement that ties payments for care delivery to the quality of care provided and rewards providers for both efficiency and effectiveness. It has emerged as an alternative and potential replacement for fee-for-service reimbursement which pays providers retrospectively for services delivered based on bill charges or annual fee schedules. Models include the Medicare Shared Savings Program and Pioneer Accountable Care Organization (ACO). Private payers have in turn adopted similar models of accountable, value-based care. Critics point to the additional paperwork required for providers, and the lack of evidence that these models reduce cost or increase quality significantly.

W

Waiver - exemption from a law or rule, such as ERISA and other federal restrictions on a state’s ability to modify its health care system. Section 1332 of the ACA, for example, “allows states to implement innovative ways to provide access to quality health care that is at least as comprehensive and affordable as would be provided absent the waiver, provides coverage to a comparable number of residents of the state as would be provided coverage absent a waiver, and does not increase the federal deficit.” See “State-Based Universal Health Care Act of 2019.”

 

1798 Early example of federal responsibility for health care: “An Act for the relief of sick and disabled Seamen,” requiring shipmasters to pay into a health care fund for sailors, and stating that the “… President of the United States is hereby authorized, out of the same, to provide for the temporary relief and maintenance of sick or disabled seamen, in the hospitals or other proper institutions now established in the several ports of the United States.”
1883 Bismark’s government-mandated health insurance
1912 “National health service” part of the Progressive Party platform
1915 American Association of Labor Legislation bill (cost shared by workers, employers, state). AMA first supported, then opposed, AFL opposed.
Post WWI Compulsory insurance a “Prussian menace,” “Bolshevist”
1929 Blue Cross established, non-profit company providing community rated insurance for hospital care of workers
1930s Committee on the Cost of Medical Care promoted voluntary insurance schemes
1935 FDR’s Committee on Economic Security excludes health care from Social Security for fear it wouldn’t pass
1939 Blue Shield founded for provider reimbursement
Wagner National Health Act (grants in aid to states for voluntary expansion of healthcare coverage) opposed by Republicans, AMA
1940s Employer-based insurance used increasingly as way to recruit and retain workers in face of wartime wage restrictions
1942 Beveridge Report proposes NHS in England
1943 Wagner-Murray-Dingell Bill (compulsory national health insurance, payroll tax) first introduced. Despite being reintroduced for many years, it never passed.
1945 Truman health care plan (single system) opposed by the AMA and others as socialistic, communistic.
1946 Anthem founded
1948 National Health Service established in England.
1950s Not-for-profit HMOs (e.g., Kaiser) using the capitation system began.
1960 Kerr-Mills Act - created the Medical Assistance for the Aged program that preceded the 1965 creation of Medicare and Medicaid.
1962 Single-payer plan begun in Saskatchewan
1965 Medicare (limited to elderly [life expectancy age 70 at the time] because of opposition, especially by segregationists), Medicaid established. Blues involved as intermediaries.
1966 Canada’s Medical Care Insurance Act (Medicare)
1971 Ted Kennedy proposes Health Security Act (single-payer system financed through payroll taxes) .
1974 Nixon’s Comprehensive Health Insurance Program, developed in reaction to Kennedy’s plan, would preserve private insurance, with government assistance for the poor.
Employee Retirement Income Security Act  (ERISA) limits states’ ability to modify employer-based health insurance.
1982 Blue Cross Blue Shield Association formed (merger)
1985 Consolidated Omnibus Budget Reconciliation Act (COBRA, and amendment to ERISA) allows workers to continue insurance after leaving workplace.
1987 Physicians for a National Health Program founded.
Full tax-exempt status of BCBS plans removed
1990 Congress’ Pepper Commission report (universal coverage for people under 65, and long term care support)
1991 Universal Health Care Act would have amended the Social Security Act to add a new title XXI (National Health Insurance) to establish a national, single-payer health insurance program under which every U.S. citizen would be eligible for enrollment.
1993 American Health Security Act (nationally financed, state-run universal health care)
Clinton’s "Health Security Act" (employer mandates, subsidies for the unemployed, and "managed competition"). Harry and Louise ad by Health Insurance Association of America (America’s Health Insurance Plans predecessor)
Maine: LD 1285 An Act to Provide Family Security through Quality, Affordable Health Care
1994 BCBS Association allows member companies to be for-profit
1995 Maine: Recommendations for Health System Reform report of the Maine Health Care Commission (“…an individual state cannot implement universal coverage by itself… universal coverage must be initiated and supported at the federal level.”)
1999 Maine: Fund for a Healthy Maine established.
2000 Maine: Anthem acquired BCBS of Maine
2001 Anthem converts from mutual insurance company to stock corporation.
Maine: LD 1490 - Resolve, to Establish the Commission to Develop and Finance Health Care Coverage for All Maine People.
Maine: Health Security Board first meeting, leading to HEHAF grant for Mathematica fiscal study of a single-payer plan for Maine
2002 Maine: Mathematica report: Feasibility of a Single-Payer Health Plan Model for the State of Maine (“a single payer system appears to be economically feasible for Maine.”)
Maine: Health Insurance Coverage Among Maine Residents survey by Muskie School/Mathematica. “Survey respondents voiced a broad-based openness to expanded public solutions to the health coverage problems.”
2003 HR 676 - Rep. Conyers’ Expanded and Improved Medicare for All Act first introduced
Medicare Modernization Act - Medicare Part D
Maine: Report of the Health Care System and Health Security Board - “The Health Security Board supports universal coverage for all Maine citizens”
Maine: LD 1611 An Act To Provide Affordable Health Insurance to Small Businesses and Individuals and To Control Health Care Costs (Dirigo Health)
America’s Health Insurance Plans (AHIP) formed by the merger of Health Insurance Association of America and American Association of Health Plans
2003-2013 Maine: Dirigo Health - commercial insurance (Anthem) provided for small businesses and individuals. As a result of the implementation of the Affordable Care Act, it was discontinued in 2013. The Maine Quality Forum, which is "responsible for monitoring and improving the quality of health care in the State of Maine," continues to operate.
2004 Wellpoint, Inc. formed by merger of Anthem and WellPoint Health Networks, Inc, and continued using Anthem name.
2005 Kennedy Medicare for All Act (Medicare plan or federally approved commercial plan)
Maine: LD 377 - Resolution, Proposing an Amendment to the Constitution of Maine to Establish Health Care as a Right
2006 Massachusetts passes An Act Providing Access to Affordable, Quality, Accountable Health Care. It includes a mandate to obtain health insurance, and employers who do not offer health insurance to employees are subject to an assessment. Also assures access to coverage through premium support programs and providing so-called "safety net" care.
2007 Maine: Commission to Study Primary Care Medical Practice
2008 Maine: Maine Medical Association physician survey shows 52% of respondents favor a single-payer plan. (See 2014 update.)
2009 LD 1365 An Act To Establish a Single-payer Health Care System (Maine Health Care Plan established, no commercial insurance that duplicates)
2010 Affordable Care Act passed
Maine: Joint Select Committee on Health Care Reform Opportunities and Implementation (re: Maine in the ACA era)
2011 Green Mountain Care enacted (withdrawn 2014 over concerns about tax burden)
Maine: LD 1397 An Act To Establish a Single-payor Health Care System To Be Effective in 2017 (See LD 1365)
Maine: LD 57 Resolve, To Update the Study Regarding the Feasibility of Establishing a Single-payor Health Care System. Unsuccessful attempt to update 2002 Mathematica study
2013 Maine: LD 1345 An Act to Establish a Single-Payer Health Care System to Be Effective in 2017.
2014 Green Mountain Care withdrawn.
Maine: 50 people testify in support of LD 1345. Passed by the Legislature in 2014, vetoed by the governor, amended into a resolve, also vetoed by the governor, then the override attempt fell short 91-54 (with 6 being absent) on 5-1-2014. (Information from Joe Lendvai)

(Title change from “Resolve, To Study the Design and Implementation of Options for a Universal Health Care Plan in the State That Is in Compliance with the Federal Patient Protection and Affordable Care Act”)

Maine: Medical Association physician survey shows support for single-payer model up to 65%.
2015 Maine: LD 815 An Act To Establish a Unified-payor, Universal Health Care System (See LD 1365)
Maine: LD 384 - Resolve, To Study the Design and Implementation of Options for a Universal Health Care Plan in the State That Is in Compliance with the Federal Patient Protection and Affordable Care Act. Vetoed by Governor LePage
2016 Physicians’ Proposal of Physicians for a National Health Care Plan, outlining how a national single payer plan could work.
Colorado Amendment 69 (ColoradoCare) defeated 80% to 20%.
2017 Sen. Sanders introduces Medicare for All Act of 2017
Maine: LD 386 An Act To Establish Universal Health Care for Maine (concept draft referring to Vermont and Colorado plans)
Maine: LD 1274 An Act To Promote Universal Health Care, Including Dental, Vision and Hearing Care (Healthy Maine established, secondary payor) - 58 people testified in support, 90 posted comments to Insurance and Financial Services Committee, leading to establishment of Task Force on Health Care Coverage for All of Maine.
2018 Partnership for America’s Health Care Future founded by Federation of American Hospitals, America’s Health Insurance Plans, and Pharmaceutical Research and Manufacturers of America, to oppose Medicare for All and related universal health care efforts. AMA eventually drops out.
Rep. Jayapal introduces State-Based Universal Health Care Act of 2018 (HR 6097). It would repeal and replace existing Section 1332 waiver provisions under the ACA with waiver provisions that allow states to establish comprehensive universal health care plans, in accordance with specified requirements.
Several alternative national universal health care efforts are proposed: Public plan option, based on Medicare, that would be offered to individuals and some or all employers through the ACA marketplace (The Choice Act by Rep. Schakowsky, H.R. 635, and Sen. Whitehouse, S. 194); The Medicare-X Choice Act by Sen. Bennett, S. 1970, and Rep. Higgins, H.R.4094; and the Choose Medicare Act by Sen. Merkley, S. 2708 and Rep. Richmond, H.R. 6117)

Medicare buy-in option for older individuals not yet eligible for the current Medicare program (Sen. Stabenow, S. 1742; Rep. Higgins, H.R. 3748)

Medicaid buy-in option that states can elect to offer to individuals through the ACA marketplace. (Sen Schatz, S. 2001 and Rep. Luján, H.R. 4129).

Maine: Task Force submits its final report.
2019 Rep. Jayapal introduces Medicare for All Act of 2019
Maine: Maine Center for Economic Policy study shows savings with a universal health care plan for Maine.
Maine: LD 407 An Act To Promote Universal Health Care, Including Dental, Vision and Hearing Care (similar to LD 1274)
Maine: LD 1611 An Act To Support Universal Health Care (based on Minnesota plan)
2020 COVID-19 causes job losses, and with that commercial health insurance losses. Federal government assumes some responsibility for supporting the health care system in this instance.
Maine: Maine Health Access Foundation study shows, among other things, that 80% of those polled strongly or slightly supported “a national improved and expanded Medicare for All healthcare system.”
Maine: Bangor, Blue Hill, Penobscot, and Brunswick town councils passed resolves directing the Maine Legislature to develop a universal health care system for Maine.
Maine: Amendment to LD 1611 passed: Resolve, To Establish the Commission To Plan for Universal Health Care in Maine. 1.To examine and develop a universal health care system to provide quality and affordable health care to all people living in Maine, including the uninsured and underinsured and people who are not eligible for coverage through federal programs or the federal Affordable Care Act; and 2. To examine and develop a single payer system instituted at either the state or federal level and to develop a plan to institute such a system in Maine.

 

 

 

 

 

Compiled and edited by Daniel Bryant, MD