Health Reform-ese: we help you decipher the provisions

We've put together a brief guide to some of the most frequently used terms and phrases associated with provisions of the nation's recently passed health reform legislation.

Advance care planning consultations – A controversial provision of H.R. 3200 would have paid physicians to provide counseling to elderly or terminally ill patients who request the counseling. The provision – ultimately omitted from the passed health reform legislation – would have paid for one counseling session at least every five years, during which patients could discuss advance care planning, advance directives, living wills, palliative care and hospice and possible life-sustaining treatments for the terminally ill. Critics said the proposal would create "death panels" and described its intent as "guiding you in how to die."
Related terms: "death care"

Affordable Care Act (ACA) – is the landmark health reform legislation passed by the 111th Congress and signed into law by President Barack Obama in March 2010. The legislation includes a long list of health-related provisions that began taking effect in 2010 and will "continue to be rolled out over the next four years.". Key provisions are intended to extend coverage to millions of uninsured Americans, to implement measures that will lower health care costs and improve system efficiency, and to eliminate industry practices that include rescission and denial of coverage due to pre-existing conditions.
Related terms: "Patient Protection and Affordable Care Act (PPACA)"

Cooperatives or insurance cooperatives were proposed in the Senate as an alternative to a proposed government plan or public option. The cooperatives, which would have been structured as non-profits and owned by their members, would offer a network of health care providers or contract out for medical services. The concept championed by some Democrats would provide "seed money" for the cooperatives, which would then be sustained by customer premiums. Read news coverage about insurance cooperatives. Read this Commonwealth Fund history of health cooperatives
Related terms: insurance cooperatives

"Death care" – A provision of H.R. 3200 would have paid physicians to provide advance care planning consultations to elderly or terminally ill patients who requested the counseling. The provision would pay for one counseling session at least every five years, during which patients could discuss advance care planning, advance directives, living wills, palliative care and hospice and possible life-sustaining treatments for the terminally ill. Critics dubbed the proposal "death care" and described its intent as "guiding you in how to die."
Related terms: advance care planning consultations

Employer mandate – The new health reform legislation requires employers with 50 or more employees to provide health coverage to those employees and sets a minimum baseline of coverage and employer contributions. Employers who do not comply will face annual penalties based on the number of employees in the firm.
Related terms: individual mandate

Employer-sponsored plans currently provide some level of health coverage for approximately 160 million Americans. Employer-sponsored health plans are more likely to be provided by larger companies; in fact, an estimated 99 percent of companies with 200 or more workers offer health benefits, according to recent testimony in Congress. However, the plans face rapidly escalating premiums – up 119 percent since 1998 – and even at larger firms, up to 21 percent of workers may not be eligible for coverge, even it it's offered. Health reform legislation proposals in Congress may include an employer mandate, designed to increase participation by employers and by more of their employees.
Related terms: employer mandate

Employer tax credits – or Small Business Health Care Tax Credits – provide a tax credit of up to 35 percent of small business premium costs in 2010 &ndash with that rate increasing to 50 percent in 2014. Who's eligible? Employers with fewer than 25 full-time workers and average annual wages less than $50,000. Read more about the credit..
Related terms: Individual affordability credits, individual subsidies, subsidies

Exchanges – An exchange mechanism is a key provision of health reform legislation, established to provide a selection of competing providers, each offering different qualified plans. All qualified plans msut meet standards established and enforced by the Health Choices Administration. For instance, participating plans will not be allowed to discriminate against applicants based on health history (pre-existing conditions) or future risk. Competition between the plan providers would, in theory, encourage the providers to improve the quality and pricing of offered plans.
Related terms: Health insurance exchanges

Health Choices Administration – Health reform legislation called for the creation of a federal agency that would oversee its provisions, including the establishment of health plan benefit standards, establishment and operation of the Health insurance exchanges, and administration of individual affordability credits or subsidies. The commission's additional responsibilities would include prevention of abuses within the Health Insurance Exchange system.
Related terms: Health Choices Commissioner, Health insurance exchanges

Health Choices Commissioner – Health reform legislation called for the creation of a federal agency called the Health Choices Administration. Overseeing that agency would be the Health Choices Commissioner, an individual appointed by the President to oversee provisions of health reform, including the establishment of health plan benefit standards, establishment and operation of the Health insurance exchanges, and administration of individual affordability credits or subsidies. The commissioner's additional responsibilities would include prevention of abuses within the Health Insurance Exchange system.
Related terms: Health Choices Administration, Health insurance exchanges

Health insurance exchanges – An exchange mechanism is a key provision of health reform legislation, established to provide a selection of competing providers, each offering different qualified plans. All qualified plans msut meet standards established and enforced by the Health Choices Administration. For instance, participating plans will not be allowed to discriminate against applicants based on health history (pre-existing conditions) or future risk. Competition between the plan providers would, in theory, encourage the providers to improve the quality and pricing of offered plans.
Related terms: exchanges

Individual affordability credits – are included in the health reform legislation to help ensure the goals of the legislation's individual mandate. Legislation provides premium subsidies on a sliding scale to eligible individuals and families with incomes up to four times the federal poverty level to help them purchase coverage through the health insurance exchanges.
Related terms: employer tax credits, individual subsidies, Subsidies

Individual mandate would require citizens to have insurance coverage that meets minimum standards set as part of health insurance exchanges, including guaranteed access to affordable coverage, essential benefits and other consumer protections. The legislation imposes a tax penalty on individuals – with some exceptions – who do not purchase coverage.
Related terms: employer mandate

Individual subsidies – or individual affordability credits – are included in the health reform legislation to help ensure the goals of the legislation's individual mandate. Legislation provides premium subsidies on a sliding scale to eligible individuals and families with incomes up to four times the federal poverty level to help them purchase coverage through the health insurance exchanges.
Related terms: employer subsidies, Individual affordability credits, Subsidies

Insurance exchanges – An exchange mechanism is a key provision of health reform legislation, established to provide a selection of competing providers, each offering different qualified plans. All qualified plans msut meet standards established and enforced by the Health Choices Administration. For instance, participating plans will not be allowed to discriminate against applicants based on health history (pre-existing conditions) or future risk. Competition between the plan providers would, in theory, encourage the providers to improve the quality and pricing of offered plans.
Related terms: exchanges, health insurance exchanges

Non-profit cooperatives or insurance cooperatives have been proposed in the Senate as an alternative to a proposed government plan. The cooperatives, which would be structured as non-profits and owned by their members, could offer a network of health care providers or contract out for medical services. The concept championed by some Democrats would provide "seed money" for the cooperatives, which would then be sustained by customer premiums. Read more about insurance cooperatives.
Related terms: insurance cooperatives, cooperatives

Patient Protection and Affordable Care Act (PPACA) – also known as the Affordable Care Act (ACA) – is the landmark health reform legislation passed by the 111th Congress and signed into law by President Barack Obama in March 2010. The legislation includes a long list of health-related provisions that began taking effect in 2010 and will "continue to be rolled out over the next four years.". Key provisions are intended to extend coverage to millions of uninsured Americans, to implement measures that will lower health care costs and improve system efficiency, and to eliminate industry practices that include rescission and denial of coverage due to pre-existing conditions.
Related terms: "Affordable Care Act (ACA)"

Pre-existing conditions are medical conditions that may result in an insurance company's denial of your application for health insurance coverage. Proposed health reform legislation would prohibit companies from offering plans in Health insurance exchanges if the company denied policies based on pre-existing conditions.
Related terms: rescission

Public option – also referred to as a public plan – is a provision within health reform legislation (H.R. 3200) moving through Congress that would create a qualified health benefit plan to compete with other plans that qualify for Health insurance exchanges. The public plan would be subject to the same requirements – regarding benefit levels, provider networks, consumer protections and cost sharing – that would apply to other plans within the Exchanges. The legislation stipulates that a public plan would be financed through premium revenues and that initially, provider rades would be set at Medicare rates. After three years, a new process would be imposed to set rates.
Related terms: public plan

Public plan – also referred to as a public option – is a provision within health reform legislation (H.R. 3200) moving through Congress that would create a qualified health benefit plan to compete with other plans that qualify for national Health insurance exchanges. The public plan would be subject to the same requirements – regarding benefit levels, provider networks, consumer protections and cost sharing – that would apply to other plans within the Exchanges. The legislation stipulates that a public plan would be financed through premium revenues and that initially, provider rades would be set at Medicare rates. After three years, a new process would be imposed to set rates.
Related terms: public option

Rationing – actually the threat of rationing – is one of the most powerful arguments leveled against proposals for an expanded government control of the U.S. health care system. Critics of such expanded control – which might take the form of a public plan or public option – argue that in order to control costs in a revamped system, the government would have to restrict (or ration) care, by refusing to pay for certain procedures or medication or by putting limits on care for the elderly or terminally ill. Some proponents of increased government control argue that health care is already, in effect, rationed in the United States, as consumers are limited in their ability to get adequate health insurance – and health care – by rapidly climbing health care costs.
Related terms: public plan, public option

Rescission is an insurance industry practice in which an insurer takes action retroactively to cancel a policy holder's coverage by citing omissions or errors in the customer's application, even if the policy holder has been diligently keeping their policy current. Starting in September 2010, recissions will no longer be allowed except where fraud is proven.
Related terms: pre-existing conditions

Single-payer system is a health care system in which one entity – a single payer – collects all health care fees and pays for all health care costs. Proponents of a single-payer system argue that because there are fewer entities involved in the health care system, the system can avoid an enormous amount of administrative waste. Instead, all health care health care providers in a single-payer system would bill one entity for their services. Within a single-payer system, all citizens would receive high-quality, comprehensive medical care PLUS the freedom to choose providers. Paperwork would be dramatically reduced with the elimination of bills, co-pays and deductibles. A single-payer system – like the system in Canada – is NOT socialized medicine. Read here for a comparison of single-payer and socialized medicine. Read more about the difference between a single-payer system and socialized medicine. Current health proposals moving through Congress are NEITHER single-payer nor socialized medicine solutions.
Related terms: socialized medicine, universal health care

Socialized medicine is, by definition, a health care system in which the government owns and operates health care facilities and employs the health care professionals, thus also paying for all health care services. Examples abroad include the British National Health Service, and national health systems in countries such as Finland and Spain, but NOT including Canada's Medicare system (which is publicly funded but which does not own all of the health facilities). Closer to home, the Veterans Health Administration is, as one author points out, "actually socialized medicine, where the government owns the hospitals and employs the doctors." Read more about the difference between a single-payer system and socialized medicine. Current health proposals moving through Congress are NEITHER single-payer nor socialized medicine.
Related terms: single-payer system, universal health care

Subsidies – are included in the health reform legislation to help ensure the goals of the legislation's individual mandate. Legislation provides premium subsidies on a sliding scale to eligible individuals and families with incomes up to four times the federal poverty level to help them purchase coverage through the Health insurance exchanges.
Related terms: employer tax credits, individual affordability credits, individual subsidies

Waiting periods were among the fears vocalized by opponents of single-payer health care systems. Critics of single-payer systems in countries such as Canada cite lengthy waits for some elective surgeries. Proponents of single-payer systems note that a high percentage of Americans already are being unable to obtain medical care – including medication, testing and treatment – because of costs, while a much smaller percentage of residents in single-payer systems report that costs had limited their access to care.
Related terms: rationing, single-payer system