Insurance costs are on the rise as Congress continues to debate the future of Obamacare. But members of the House and Senate are not under the same pressure as many Americans thanks to a special healthcare plan that has some firewall protection.
Members of the House and Senate and their staff receive health insurance through an exchange known as the DC Shop. They, like many other employed consumers of large corporations, get a portion (about 73%) of their premiums covered by their employer, the U.S. Government.
Sabrina Corlette, research professor and lawyer with the Center on Health Insurance Reforms at Georgetown University Health Policy Institute, told Talk Business & Politics that Congress purchases insurance through the exchange as mandated by law three years ago. Corlette said the level of government contribution toward insurance premiums is on par with what large employers offer.
The difference for Congress is the exchange from which they are required to participate – known as the DC SHOP (Small Business Health Options Program) – is one of the most stable marketplaces in the country. Corlette said there are around 12,000 members from the Congressional bodies and staffers and that makes up a stable, guaranteed pool of participants.
Craig Wilson, health policy director for the Arkansas Center for Health Improvement, told Talk Business & Politics the DC SHOP is more stable than most exchanges because of the number of young people in the pool. He said that isn’t the case in other areas around the country.
Prior to the Affordable Care Act in 2014 Congress and congressional staffers were covered under the Federal Employee Health Benefits Program (FEHBP). That is not an option today for members of Congress, according to the Congressional Research Service report which states: “The ACA regulations do not require Members and staff to enroll in a health plan offered through the DC SHOP; rather, DC SHOP plans are the only plans that will be made available to them with respect to their federal service.”
The growing problem in some states is a lack of exchange options. Corlette said two counties nationally don’t have a single carrier in their individual market exchanges. She said for better or worse, the Affordable Care Act was set up to deliver health coverage through private insurance. But with the rhetoric and uncertainty out of Washington, insurance providers have pulled out of markets leaving some consumers with few or no options.
Another area of uncertainty is with cost-sharing subsidies paid to insurers to reduce the out-of-pocket costs of premiums for lower income individuals. This week the Congressional Budget Office said the government paid about $7 billion to insurers this year to extend health care to roughly 5.9 million low-income Americans. If those cost-sharing incentives were cut insurance premiums would increase as much as 20% next year. The Kaiser Family Foundation estimates a lack of cost-sharing incentives to insurance companies would push premiums up 15% in Arkansas.
“The actuaries don’t really have a model for predicting how the Trump administration will act, so, to some extent, the insurance companies are really guessing,” said Cynthia Cox, author of the recent Kaiser Foundation study.
Corlette said insurance companies don’t like uncertainty. She said talk about losing this incentive could exacerbate the problem of insurers pulling out of exchanges.
Wilson said Arkansas has had at least three providers offering coverage in its individual market exchanges since 2014 and that has not changed. What has been missing in Arkansas and other markets is the lack of younger, healthy people signing up for insurance which has created an imbalance in the risk pools.
Corlette agreed, saying without a mandate there were too many people opting out of the plan. She said unless healthy people are required to purchase insurance then premiums will continue to rise. She said failing to enforce the mandate is driving premiums up as much as 20% and when that is added to the 20% hike if cost-sharing incentives are pulled, some Americans will see a huge increase in premiums, which is not sustainable.
“These policy decisions around healthcare coverage are hard discussions that need to be had at the federal and state level, and at some point Congress has to get into more difficult questions to contain costs within the system so health insurance premiums don’t continue to rise,” Wilson said.
Members of Congress have a backstop to receive medical care should the entire Affordable Care Act implode. Congressional members are eligible to receive limited services from the Office of the Attending Physician in the U.S. Capitol for an annual fee. The services include routine exams, consultations, and certain diagnostic tests. This office does not provide vision or dental services. Prescriptions may be written but not dispensed, according the to the Congressional Research Office.
Members of Congress are also authorized to receive medical and emergency dental care at military treatment facilities. There is no charge for the outpatient care if it’s provided in the National Capital Region. For inpatient care, members are billed at full reimbursement based on rates set by the Department of Defense. Outside the region, all services are billed at full reimbursement rates for congressional members. These services are not available to their families or staff.