Your Health Care System:
Part A
A Map
I
f you’re trying to pin down a moment from 1994 when the fate of the Clinton health care plan was sealed, you could do worse than January 25. On that night, then-Senator Bob Dole responded to the president’s State of the Union address. Clinton had hoped to use the speech to help sell his proposal; Dole used his response to help kill it. And he did it primarily not through what he said, but what he showed on camera. Dole brought with him a chart, depicting how American health care would work if the Clinton plan came into effect. And it was not a pretty picture. Lines were all over the place. The boxes were full of confusing acronyms and scary-sounding institutional titles like “National Health Board” and “Regional Health Alliance.” The chart had actually come from a colleague, thenRepublican Senator Arlen Specter, who’d asked a staffer to draw it so he could better understand what Clinton had in mind. But Specter— and, soon enough, his Republican colleagues—quickly saw the chart as an effective propaganda weapon. The impression of the chart was accurate enough: The Clinton plan was tremendously complicated. And given how many of the old Republican arguments against health reform are resurfacing this year, it’s likely we’ll be seeing a similar chart sometime this summer. But these charts leave out one key fact: The U.S. health care system is already a mind-numbing web of institutions, agencies, and businesses. And, while that may be self-evident to anybody who’s ever had to handle a billing dispute between insurer and hospital, it’s easy to lose sight of that in the scrum of congressional debate. So, just to keep this very relevant piece of information in mind, we’ve drawn up our own chart—of American health care, as it is now. And, just to make sure we weren’t getting it wrong, we got some help from our friends at the Henry J. Kaiser Family Foundation. Jonathan Cohn
24 July 1 , 2 0 0 9 Th e Ne w R e publ ic
The part of Medicare that pays hospital bills
You
Part B
The part of Medicare that pays physician bills
The new Medicare drug benefit
VA clinics and hospitals
Medicare Advantage
Medicare Operated by the Centers for Medicare & Medicaid Services, benefits set by Congress
Private sector alternatives to Medicare
Medicaid Program for the poor and disabled, administered by states, jointly funded with federal government, frequently administered through private plans
Agents and Brokers
People who sell individual and some group insurance policies
MedPAC
Independent agency that advises on Medicare payment policies
S-CHIP Program for low-income children and some families, jointly funded with federal government, frequently administered through private plans
Groups that offer insurance for members
Benefit Consultants
Employers That Don’t Self-insure Businesses that buy employee coverage from private insurers
They advise employers and other purchasers on buying insurance and finding ways to save money
FEHBP
The Federal Employees Health Benefits Plan– menu of private plans for government workers
Wellness Coordinators
They offer advice, primarily to self-insuring employers, on how to encourage healthy living and hopefully reduce medical costs PBMs
Employers That Self-insure Businesses that pay insurers to administer benefits, but bear risk for expenses on their own
Pharmaceutical Benefit Managers–intermediaries that buy drugs at a discount
Purchasers: Employers, associations, etc. Private Insurers Government Insurers
INSPECTORS & LICENSING BOARDS
Responsible for making sure providers of care adhere to regulations regarding safety, etc.
DrugMakers The pharmaceutical industry
AHRQ
Agency for Healthcare Research and Quality– researches treatment efficacy; no real power
Device Makers The companies that make implantable medical devices, etc.
Suppliers Consultants & Intermediaries
Equipment Manufacturers The companies that make scanners, etc.
Taxes Money Transfer
Physicians in Private Practice Doctors who operate on their own as individual proprietors or in small groups Independent Practice Associations Large networks of physicians that contract with insurers, sometimes through capitation Group Practices Integrated, multi-specialty groups of physicians that coordinate and manage care
Scanning Centers
Stand-alone establishments that offer scanning Specialty Clinics
Private Insurers Bearing Risk Insurers that both administer benefits and pay for them with reserves, built up from premiums and other income sources
Stand-alone medical clinics, including surgical centers, that offer a particular medical specialty or closely related group of specialties
Revenue Consultants
Consultants who help providers get paid from insurers and individuals
Private Insurers: Administration Only Insurers that administer benefits for companies that self-insure
Long-Term Care Insurance
Private insurance for long-term care not covered by regular insurance
Institute of Medicine
Independent advisory board about practice of medicine; no real power
Government Agencies Providers: Doctors, Hospitals, Clinics
Private supplementary insurance that fills in the gaps of Medicare
Part D
Veterans health Administration
Professional Associations
MEDIGAP & SUPPLEMENTAL BENEfiTS
DEPARTMENT OF LABOR
Under law known as ERISA, federal agency that regulates plans not under state jurisdiction
Public Hospitals Hospitals owned and operated by the government Private Safety Net Hospitals Hospitals that provide large amounts of care to the poor and uninsured Private Non-Safety Net Hospitals Hospitals that provide care mostly to the insured and relatively affluent Nursing Homes Long-term care at homes and institutions Community Clinics Clinics, often funded by the federal government, that provide basic medical care to the poor and uninsured
FDA
Food and Drug Administration– regulates safety and usage of drugs, devices, etc.
State Governments Finance state insurance programs and low-income providers, regulate insurance plans
Consulting or Regulatory Relationship
Th e N ew R epubl i c
July 1 , 2 0 0 9
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