Interview Prep: A Primer on the Affordable Care Act

Session 235

Jen Briney is the host of the Congressional Dish podcast. She joins me today to talk about our current healthcare system and where it may be headed.

Today’s guest is very interesting, as it’s someone who wouldn’t normally be here on a podcast for premed students. But with the changing landscape of our U.S. healthcare system, I thought of bringing on an expert in this field.

Jen Briney’s Congressional Dish podcast is devoted to talking about bills that go through Congress. She has read the Affordable Care Act (ACA), the current TBAC, and the new AHCA, so she can discuss what’s in there and what’s not. She’s here today to talk about these things so you can be prepared for your medical school interviews. This episode was recorded in early 2017, but it should remain a good primer on our healthcare system for a long time to come.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[03:15] The Affordable Care Act

Being a Congress-watcher, Jen watches Congressional hearings and reads bills and laws being created so that taxpayers, like her, know what’s going on with their money. What led her to become so familiar with healthcare was the government shutdown in 2013 when the Republicans were trying to repeal the Affordable Care Act (ACA). (And remember that “Obamacare” is just another term for the Affordable Care Act.)

Jen did not like the ACA as a whole because it’s an insurance system, not a healthcare system. But it’s better than what we had before because rules have been put on the insurance industry. Currently (in 2017), the Republicans have control of the whole government. They’re trying to repeal the Affordable Care Act, but instead of repealing it, they’re putting together bills very quickly with no hearings and no overall plan.

'I don't like Obamacare as a whole because it's an insurance system, not a healthcare system.'Click To Tweet

[05:22] An Insurance Policy, Not a Healthcare Policy

There are different ways you can give people healthcare. A lot of other countries do “single payer” where you pay taxes and the government pays for healthcare. It’s one of those essential government functions.

Conversely, we in the United States buy health insurance, which is supposed to cover the big catastrophes. Before the ACA, what these for-profit health insurance companies would do is only cover healthy people because it would cost them the least.

With health insurance, you give them something like $100 a month and as long as you’re healthy, they just put that in their pockets. That’s profit. But as soon as you get sick, that’s when they have to start to pay for stuff, and they really don’t like that part.

As soon as you get sick, that's when the insurance companies have to start paying for stuff, and they really don't like that part.Click To Tweet

In order to have this system that still had private insurance at the center of it, the Affordable Care Act put rules in place. Before the ACA, there would be lifetime limits on how much the insurance companies would pay for your healthcare. You’d sign up for a plan. You’d get cancer, and then when you look in the fine print of your insurance, it says, “Once we hit $1 million, we’re not paying for anything for you ever again.” And so you would go bankrupt paying the rest yourself.

Another common problem that would happen is that once someone would get sick, the insurance company would just drop you. They would no longer cover you because they don’t have to. Basically, they were doing all kinds of shady things to make money.

ACA Restrictions on What Insurance Companies Can Do

So the ACA places some more rules on what the insurance companies can do. For instance, there are now 10 essential health benefits that if you buy health insurance, they must cover, and this includes preventive care.

One time when Jen went to get a physical exam, after all the little bills came in, it cost her over $400. Nowadays, that’s illegal, thanks to the Affordable Care Act. Insurance companies now also have to cover things like ambulances, hospital stays, maternity, prescription drugs, and more. These rules from the ACA help you know what you’re getting when you buy insurance. According to Jen, it’s better than it was before—but it’s still based on private insurance.

Health insurance companies liked the old days better because they could profit by making up all the rules. Click To Tweet

These insurance companies liked the old days better because they could profit by making up all the rules. Now the people in Congress working on behalf of the insurance industry are trying to make these rules go away. These are the people writing legislation designed to help the insurance industry to be more profitable. They’re eliminating these rules, so these essential health benefits can be flexible or leave it to up to state governments to decide. Jen says this is not something that’s good for the people, but it’s good for businesses.

[08:50] Congress Working for Businesses, Not the People

Jen mentions the website OpenSecrets.org, which allows you to see where politicians are getting their campaign funding from. In almost every case, you can see the health insurance industry funding the politicians who are working to loosen these restrictions put in place by the ACA.

Then you can see these companies get invited to help write these bills to repeal the Affordable Care Act. In fact, these insurance companies were in the room to write the Affordable Care Act, too, as well as the pharmaceutical companies. These health insurance companies want to keep existing and profiting, so they use their lobbying power to ensure a continued existence for themselves.

'The health insurance companies were in the room to write the Affordable Care Act, as well as the pharmaceutical companies.'Click To Tweet

Jen explains why she says these politicians are working for businesses and not for us. It’s because when you look at what they’re doing, it’s the businesses who benefit. Always looks at who benefits financially. With the American Health Care Act of 2017 (AHCA), it’s the businesses that benefit.

[10:21] More on the Affordable Care Act (Obamacare)

In Episode 48 of the Congressional Dish podcast, Jen talked all about Obamacare. Here she is just sharing some of the big takeaways. One of those big takeaways is this: Although Obamacare puts rules on the private insurance industry, it allows the private insurance industry to remain the main way that people cover their healthcare in the United States.

Although Obamacare puts rules on the private insurance industry, it allows the private insurance industry to remain the main way that people cover their healthcare in the United States.Click To Tweet

Medicaid, Medicare, and Private Insurance Under Obamacare

Medicaid is a program for low-income people that gives them their health insurance. The federal government picks up all of the Medicaid funding for the states that accepted it. It basically expanded the program beyond what it used to be. So it allows poor people to get government-funded health insurance.

Medicare, on the other hand, is for people over the age of 65 and for the most part, they also get government-sponsored healthcare.

Everybody else is in the middle. If you make more than 133% of the poverty line and you’re under the age of 65, you have to buy health insurance or get it from your job in order to have healthcare, for the most part. This is the basis of the Affordable Care Act. It’s a very complicated system that tries to put rules on the private insurance companies so that they won’t go bankrupt but still have to cover people with pre-existing conditions.

This is expensive because as your healthcare provider, these insurance companies have to pay for those benefits for your entire life, and they don’t want to do that. Hence, the ACA forces them to cover you, and it forces healthy people to get health insurance, too, to outweigh those costs. Jen thinks it’s a very delicate system with a lot of moving parts that have to work together in order to make this private insurance system work.

However, as of the time of this recording in 2017, Obamacare is being actively dismantled by the Republicans. We really don’t know how much of it is going to survive.

[13:15] Different Ways to Get Health Insurance

One way to get health insurance today is the individual marketplace, which didn’t exist before Obamacare. For instance, Jen as a podcaster doesn’t have a big company paying for her health insurance. Prior to Obamacare, if she were single and needed health insurance, she would have had to go to each individual insurance company and try to figure out what they cover, which can be very confusing. Referring to the story she told earlier, Jen ended up with a $400 physical because she had no idea what she was buying.

One of the basics of the ACA is that it has created this individual insurance market where people could go on a website and pick a plan from a selection of companies offering it and compare them based on the premium, coverage, and percentage—all of which are being explained. This didn’t exist before.

The ACA Separated Healthcare from Your Employer

The ACA also separated your healthcare from your employer, so you could quit your job and still have health insurance. Apparently, there are so many people in this country that are clinging onto jobs they don’t like because of their health insurance.

There are so many people in this country that are clinging onto jobs they don't like because of their health insurance.Click To Tweet

Other ways of getting health insurance include the small group market and large employers, where most people in the country are still getting their insurance. The ACA also requires that employers buy plans that cover those ten essential benefits mentioned earlier.

Jen ultimately stresses that the Affordable Care Act keeps the private insurance company at the center of our healthcare system and aims to keep those businesses profitable, while also getting more people coverage with fewer medical bankruptcies. This did not eliminate medical bankruptcies in the U.S., nor did it cover everybody, but it is better than it was before. Basically, Obamacare is a stepping stone.

[15:25] The Consequences of Medical Bankruptcy

Before the ACA, Jen’s friend got cancer at 15 years old. She went into remission. They had one awesome summer, and then her cancer came back. She was told she was going to need a bone-marrow transplant. That’s what was submitted to her health insurance company, but someone behind the desk decided it was too expensive and said no. Because her parents were not millionaires, she died.

What About Hospitals Covering Your Healthcare?

Even if you don’t have insurance, you’re going to get care anyway, right? You show up to a hospital and you’re going to get the care you need. Is this how it works?

Jen firmly says it’s inaccurate to say that hospitals have to cover you. They do cover the minimums like emergency care, but the maintenance and preventive stuff, that’s what keeps you alive long term. And those things are not covered, especially not on a systemic level when there 325 million people in the U.S.

Hospitals do cover minimums like emergency care, but the maintenance and preventive stuff, that's what keeps you alive long term.Click To Tweet

If you got hit by a car and you get brought to a hospital, you’re going to get the basics so you can get out of there. But what about the follow-up care? What about cancer treatments? You can’t get that in emergency rooms.

[17:14] Democrats Versus Republicans

Jen has observed that there is so much corporate influence in our Congress right now on both sides. You have the Republican party that wants the insurance industry to write the rules. They believe so strongly in free-market economics that Jen is convinced they’re not really looking at it from the people’s perspective. They want people to have access to healthcare, but access is different from actually getting healthcare.

'There is so much corporate influence in our Congress right now on both sides.'Click To Tweet

The Democrats are also corporate in a certain way, so they’re the ones who created the Affordable Care Act. Instead of nationalizing the healthcare industry like it is in so many other countries, they decided to do the middle-of-the-road thing. They decided to keep the health insurance companies central as long as there are rules.

[19:00] Healthcare as a Business

Unfortunately, there is no side that is saying that access to doctors and healthcare is just an essential that everybody needs. Jen thinks there is an ideological battle happening, and it seems to her that the government should be covering the things that we all need at different times.

The problem with treating healthcare like any other business is that you can’t opt out of it. It’s not a restaurant. You can’t choose to not go there and cook at home. You need the doctors when you need them. And the Republican party, specifically, sees healthcare as a business.

The problem with treating healthcare like any other business is that you can't opt out of it. It's not a restaurant. You can't choose to not go there and cook at home.Click To Tweet

Jen says the question really is whether healthcare is a business that should be for profit, or should it be part of the government? This is the real battle going on right now, and business is winning big time.

The Difference Between Healthcare and Other Businesses

Let’s say, you got bitten by a dog and you’re bleeding. Are you supposed to go to Yelp for doctors and figure out which one is the cheapest? And then go to the cheapest one questioning where this doctor actually got their degree. Jen doesn’t think this makes sense on so many levels. When you’re sick, the only thing you want is to get better. You’re afraid for your actual life.

This is why health insurance companies are an amazingly profitable business: it’s something we all need and will pay anything for. We don’t want to have to question our doctors.

Health insurance is an amazingly profitable business because it's something we all need and will pay anything for.Click To Tweet

Again, it’s not a business; at least, it’s not supposed to be a business, according to Jen. It’s not like buying a shirt and choosing from different stores. It matters so much because it’s your health. You only have one body, and if you screw it up, game over.

[23:45] Healthcare Is Going to Get More Expensive!

Jen bluntly admits that she is horrified with what the current administration under Trump is trying to do by making it all for-profit again. It’s not a normal business, and so a lot of people are going to get hurt by this. With the new “American Health Care Act,” if it becomes a law, people with pre-existing conditions still have to be covered technically, but there are so many loopholes that they’ve now written into the system.

The 'American Health Care Act,' if it becomes law, will allow more loopholes out of covering pre-existing conditions.Click To Tweet

The MacArthur Amendment got passed in the house. It’s basically a waiver that lets states waive the essential health benefits. States can choose the essential health benefits, state by state. This implies that not only will states be able to define the categories of benefits, but they also get to decide what’s in those categories. For example, a state may decide to only cover three prescription drugs instead of a lot of them which were covered by Obamacare, or a state may decide they won’t cover ambulances anymore.

Moreover, when you get sick, the ACA puts a limit on what you have to pay out-of-pocket. This is tied to the essential health benefits. With the MacArthur Amendment, each state is allowed to determine what “essential health benefits” means, and the states now also determine your lifetime and annual limits and what your out-of-pocket expenses will be. Jen thinks this is just going to be much more expensive for people on so many different levels.

Expensive Health Insurance Means More People Going Without Care

Jen thinks people are going to skip care because they can’t afford it. Republicans say their proposals are designed to reduce premiums. By eliminating the rules on the insurance companies, it’s true that premiums might go down because the plans do not cover as much. Jen had one of those originally. She got her plan for $80 a month, but when she went to get a physical, it was $400. Imagine if she actually got sick! That’s what they’re going back to.

By eliminating rules on insurance companies, it's true that premiums might go down because the plans do not cover as much.Click To Tweet

Republicans promise this is only the first step. The main goal is to allow the private insurance companies to do what they will. This is Jen’s biggest concern (and ours too!). Fundamentally, health insurance companies exist not to provide the best healthcare but to make as much money as they can and divvy it up to their shareholders.

This is what for-profit corporations do. It’s not necessarily evil, but Jen argues that it becomes evil when you do it with healthcare. Again, you’re talking about desperate people that will pay anything for their own health. So she doesn’t see anything good about it.

Fundamentally, health insurance companies exist not to provide the best healthcare but to make as much money as they can.Click To Tweet

[27:35] The Car Insurance Analogy

Let’s look at an analogy to car insurance. When you’re looking for car insurance, you’re typically looking for the cheapest thing possible. You’re not checking for aspects like towing service, accident coverage, or parts replacement. All you want is the cheapest premium because you’re a poor college student.

'Health insurance companies want to allow patients to choose the cheapest health insurance premium without understanding the back-end of what they're actually buying.'Click To Tweet

So the loosening of restrictions on healthcare that Republicans are pushing is like this, according to Jen. Health insurance companies want to allow patients to choose the cheapest health insurance premium without understanding the back-end of what they’re actually buying. They’re betting that the American population won’t read the fine print of what their plans actually cover. They don’t want you to be aware of how incomplete your coverage is because they want to get out of covering you when you do get sick.

Jen switched to a cheaper plan for her car insurance a while ago. Then her battery died, and she called her insurance asking for roadside assistance. But she found out she’s not covered for it anymore. She ended up asking for help from someone else. Good thing it wasn’t a big deal, but what if it was?

The problem with comparing health insurance and car insurance is that you actually don’t need a car to live. So if you don’t want to pay premiums, you may choose not to have a car. But you don’t have the option to not have a body. You basically don’t have any choice, Jen explains.

The problem with comparing health insurance and car insurance is that you actually don't need a car to live.Click To Tweet

[30:40] Where to Read and Understand the Bills

For those who want to know more about these healthcare policies, Jen recommends you go straight to the bill. It can be super painful to read legislation, but you’ll get a lot of conflicting information from sources written by other people. The best way to truly understand it is to go to Congressional sources and read what they’re reading. Jen says it’s not that hard. She’s outlining the stuff on Congressional Dish to help you, and she links to all the individual provisions.

It can be super painful to read legislation, but you'll get a lot of conflicting information from sources written by other people.Click To Tweet

Jen uses GovTrack.us to look at the status of bills, as well as those that have already been enacted. Reading the Affordable Care Act was the most miserable experience for her, and she found it the most difficult. It has ten sections. She actually read the first nine and then found out that the tenth section edits the first nine.

But if you truly want to understand our healthcare system, you have to go to the bills and U.S. codes and read them. The codes can be confusing to read because of all the numbers or codes written in, but the laws are written in plain English. So you can go to the sections of the law itself and just read it to understand. It’s not as hard as reading bills because you don’t have to jump back and forth.

[33:20] What Happens to the AHCA Now?

As of this recording in May 2017, the AHCA has passed the House and now is in the Senate. Jen explains that what happens from here is that it may be changed because the Senators are not happy with it as it is. Jen doesn’t have hope that it’s going to be changed in a way that protects people more.

There are certain Republican senators who are uncomfortable with people losing their insurance and having it be more expensive. But there’s also a group who don’t believe the government should put any kind of restraints on private business, and they see healthcare as a business. Two of these people, Ted Cruz and Rand Paul, are going to be involved in the shaping of the Senate’s version.

Jen says the best we can hope for in this Congress is that the whole thing just stops. She hopes we can make enough noise that the Senate doesn’t vote on it or it fails in the Senate timing-wise.

[35:40] Jen’s Message to Doctors and Future Doctors

Private insurance requires a lot of paperwork. There are a lot of receptionists hired to fight with the private insurance industry, and a lot of times, the doctors care more about the patient. What happens to many doctors is they end up having to be insurance experts to help their patients get better and not go bankrupt.

So doctors are involved in this, and if you want to minimize your costs, minimizing the role of insurance companies would be good. Insurance companies don’t want to pay out, and you want to get paid. So it’s important for doctors and future doctors to pay attention to what’s going on right now. Having read the AHCA bill, Jen encourages doctors to fight it, as she thinks there is no good going on here.

It's important for doctors and future doctors to pay attention to what's going on with the proposed changes to healthcare right now.Click To Tweet

Jen’s friend has Crohn’s disease, and she’s working on moving to New Zealand so that if this becomes a law, she’s out. So these are serious issues for your patients. It sounds extreme, but it is extreme! This is what keeps Jen awake at night, and she thinks this should keep us awake at night, too.

[39:05] Not a Carefully Crafted Bill

Lastly, Jen emphasizes how fast the AHCA is being crafted. It’s not something the Republicans have been working on for the last eight years since the Affordable Care Act. The bill they passed in the House was not available to read the night before the vote. It was not on the Internet at all. The Congressional Budget Office does the really in-depth analysis of the financials, but they were not done with this until the week of May 22, which is in the future of when this bill was actually passed.

They simply just wanted to get something passed, and so they passed it. Jen thinks this is reckless. It’s not a carefully crafted bill but something that has been thrown together last minute. Jen says this is like a doctor not evaluating a patient but just giving them some antibiotics and if it doesn’t work, another doctor will fix them.

[40:30] Hear More from Jen on Healthcare

Jen outlined the Affordable Care Act on the Congressional Dish podcast Episode 48 and linked out to specific provisions. Episode 151 is Jen’s next episode about the American Health Care Act.

Since this episode was recorded, Jen made a few more episodes relevant to healthcare issues and premed students: