U.S. health care system field guide: Terms and Key Players

Key Players

Sen. Max Baucus, D-Mont.


As chair of the Senate Finance Committee, Baucus is in charge of the committee that will be responsible for drafting one of two versions of a Senate health care reform bill. Baucus, a 30-year veteran of the Senate, is known as a moderate Democrat who is trying to establish a broad coalition of support for a health care reform bill. He has said he favors including a public plan option.

Max Baucus’s Senate Web Site

Rep. Roy Blunt, R-Mo.


The House minority whip is leading the GOP’s Health Care Solutions Group that holds weekly meetings to talk about health care reform.

Roy Blunt’s House Web Site

Dan Danner


NFIB is expected to be one of the key voices representing the interests of businesses in health reform. Of particular concern to the group is the potential cost burden placed on small businesses in building a universal health care system.

National Federation of Independent Businesses

Nancy-Ann DeParle


DeParle has a long history in the health care field. She managed Medicare and Medicaid during the Clinton administration, before that she was commissioner of the Department of Human Services in Tennessee — a position she took on at age 29. In her new job, she shuttles regularly between the White House and Congress, meeting with Congressional leaders on health care reform.

Nancy-Ann DeParle’s Official Bio

Doug Elmendorf


During President Clinton’s effort to reform health care in 1994, a key development that helped defeat the plan was a negative assessment by the non-partisan Congressional Budget Office. Then-CBO Director Robert Reischauer told Congress that the plan would be much more expensive than the White House had advertised, which helped sink the reform effort. This time around, Elmendorf’s office will again play a major role in the perceived cost of reform plans offered up by the Obama administration or Congress.

Doug Elmendorf’s Official Bio

Rahm Emanuel


Emanuel, a former Illinois congressman and staff member for President Bill Clinton, will be a central figure in pressing the president’s health care reform agenda on Capitol Hill. As President Obama’s chief of staff, his background in both the executive and legislative branches makes him an effective emissary to Congress. Emanuel’s brother, Ezekiel, is a doctor who has emerged as a special adviser on health care reform and a possible behind-the-scenes player in the reform debate.

Emanuel: Cost, Competition Central to Health Reform

Sen. Chuck Grassley, R-Iowa


As the highest-ranking Republican on the Senate Finance Committee, Grassley will play a key role in how the GOP influences the health care reform process and in deciding whether a bill will receive bipartisan support. Grassley has suggested that the inclusion of a public insurance plan could be a legislative deal breaker.

Chuck Grassley’s Senate Web Site

Karen Ignagni


As president and CEO of America’s Health Insurance Plans (AHIP), Ignagni is a powerful lobbyist who represents the health insurance industry — a group that has much at stake as President Obama and congressional Democrats push to lower the cost and expand the coverage of health care in America. AHIP’s predecessor, the Health Insurance Association of America, helped kill health care reform legislation in 1993. This time the association has pledged to work with other groups to support health care reform efforts. However, they oppose a public plan option that would compete with private insurers.

America’s Health Insurance Plans

Sen. Edward Kennedy, D-Mass.


Sen. Edward Kennedy died August 25, 2009 of brain cancer. Kennedy, who was chairman of the Senate Health Committee, was a longtime advocate for universal health care. He organized twice-weekly meetings between organizations and individuals with major stakes in the health care reform process in order to facilitate a reform bill. However, he was not able to take a public role in this year’s reform effort as he battled brain cancer. President Obama invoked his memory in a speech to a Congress in September, aiming to convince lawmakers to support reform.

Edward M. Kenndy, 1932 – 2009

Peter Orszag


At age 40, Orszag is the youngest member of President Obama’s Cabinet, and he acts as one of the White House’s top representatives in reform negotiations. He worked on the issue as former director of the Congressional Budget Office.

Peter Orszag’s Official Bio

Rep. Nancy Pelosi, D-Calif.


Pelosi, the speaker of the House, has promised to deliver health care reform before Congress’ summer recess and is in a powerful position to guide legislation through Congress. Pelosi favors including a public plan in the legislation — a government-run insurance option for people who do not have other coverage.

Nancy Pelosi’s House Web Site

Rep. Charles Rangel, D-N.Y.


As chair of the House Ways and Means Committee, New York congressman Charles Range will help shape the House version of a reform bill. On the liberal end of the Democratic spectrum, he’s in favor of a public plan option and opposed to taxing employer-provided health benefits, an idea that has been floated to pay for health care reform.

Charles Rangel’s House Web Site

J. James Rohack


This Texas cardiologist leads the nation’s largest group of doctors. AMA has said that it does not support a public health insurance option that would require doctors to participate.

American Medical Association

Kathleen Sebelius


Although she was President Obama’s second choice to lead the Department of Health and Human Services after former Sen. Tom Daschle withdrew from consideration over tax troubles, Sebelius will be another of the Obama administration’s point persons on pushing a reform plan through Congress this year. Sebelius previously served as governor of Kansas and that state’s health insurance commissioner.

Kathleen Sebelius’s Official Bio

Andy Stern


Stern oversees the concerns of one of the fastest-growing unions in the country. The Service Employees International Union has more than 2 million members, and 50 percent of them work in the health care industry. Stern has been lobbying for health care reform with President Obama and members of the pharmaceutical and hospital industries.

Service Employees International Union

Rich Umbdenstock


Umbdenstock represents the interests of America’s hospitals. The group has signed on to participate in health care reform, but it opposes cutting reimbursement rates to hospitals in order to pay for reform.

American Hospital Association

Rep. Henry Waxman, D-Calif.


As both a supporter of comprehensive health care reform and chair of the House Energy and Commerce Committee, Waxman will help mold the House version of a health care reform bill. Waxman has a reputation as a tough legislator — in his previous job as chairman of the House Oversight and Government Reform Committee, he took on both tobacco companies and major league baseball.

Henry Waxman’s House Web Site


“Bending the Cost Curve”

National spending on health care has been rising by more than 6 percent a year, according to the government’s yearly National Health Expenditure estimate. When policymakers talk about “bending the cost curve,” they mean making changes to the health care system to try to decrease the rate at which spending goes up.


Allowed Charge

The maximum amount a health insurance provider will pay for a medical service. Any difference in cost is often paid by the insured individual. See Cost Sharing.



A payment structure in which health care providers are paid for “episodes of care” rather than individual medical procedures. The aim is to improve care and reduce costs by providing doctors and hospitals with an incentive to reduce complications and unnecessary procedures.



A fixed, per-person payment given to a health care provider to provide medical care for a group of people.


Catastrophic Health Insurance

A type of health insurance plan that has a very high deductible and covers only catastrophic injury or illness, not ongoing or preventive care.


Centers for Medicare & Medicaid Services

Federal agency within the Department of Health and Human Services that administers Medicare, Medicaid and the State Children’s Health Insurance Program.


Children’s Health Insurance Program

Free or low-cost health insurance jointly funded by the state and federal governments for uninsured children. CHIP is intended to reach uninsured children whose families earn too much to qualify for Medicaid but not enough to get private coverage. Each state determines the design of its program, eligibility groups, benefit packages, payment levels for coverage and administrative and operating procedures. The program began in 1997 and was most recently renewed in 2009.



Mechanism in which an insured person is required to pay a percentage of covered medical costs. For example, the insurance company might pay 70 percent and the beneficiary 30 percent. See Cost Sharing.



A flat fee paid by an insured individual for a covered health service. For example, the insured individual might pay $20 for a doctor visit and the insurance company would pay the rest of the bill. See Cost Sharing.


Comparative Effectiveness

Comparative effectiveness research compares different medical treatments, interventions and strategies to decide which strategies are most effective in different populations and situations. The aim is to improve care and reduce costs.


Cost Sharing

Any system in which payment for a health service is shared by the insured and the insurer. See Allowed Charge, Co-insurance, Co-payment, Deductible and Out-of-pocket Expense.



The amount an insured person must pay each year for medical expenses before the insurance policy begins to pay. Deductibles are common in fee-for-service plans and PPOs. See Cost Sharing.


Employer-sponsored Coverage

A system in which an employer pays an annual premium to a health insurance provider for a health plan that is offered to employees. Employees pay a percentage of this premium to receive the health plan.


Federal Poverty Level

Income figure used to determine eligibility for government programs, including Medicare, Medicaid and State Children’s Health Insurance Program; officially called Federal Poverty Guidelines and issued annually by the Department of Health and Human Services, based on U.S. Census Bureau data, to determine the minimum amount an individual or family needs for food, clothing, transportation and shelter.


Fee-for-service Plan

“Traditional” type of health insurance in which an insurer pays a health care provider a specific payment for each service rendered for a covered individual. Fee-for-service plans generally require monthly premiums, deductibles and other forms of cost-sharing. They may not cover preventive and routine care.


Generic drug

A prescription drug that has the same active ingredients as a brand name drug and is often less expensive.


Group Insurance

A type of insurance in which a group of individuals, such as employees or university students, are covered under one insurance policy, and the premiums are the same for every person or family in the plan. See Employer-sponsored Coverage.


Health Insurance Coop

A member-owned cooperative, similar to a credit union or a rural electric cooperative, that would provide its members with health insurance options. Cooperatives could be formed at a national, state or local level, and could include doctors, hospitals and businesses as member-owners. As nonprofit entities, health insurance cooperatives would compete with private for-profit insurers. Some Republicans and more conservative Democrats support the idea of health insurance cooperatives instead of a government-run public plan as the best option to provide insurance to people who are not covered by employer-sponsored plans. Some Democrats worry that coops would be too weak to provide real competition with the private market.


Health Maintenance Organization

Type of health plan in which members pay a monthly premium for comprehensive care, including preventive and routine doctors’ visits. Typically, HMOs contract or employ their own health care providers, and members must visit those doctors, except in emergencies or when medically necessary. See Managed Care.


Health Savings Account

Personal savings account made available to those enrolled in a qualified high-deductible health plan. Funds are tax-free, tax deductible and may only be used for qualified health services.

An expansion of the Medical Savings Account, but unlike MSA, HSA allows everyone covered by a high deductible health plan to participate (including all size employers, the self-employed, individuals and families who are not self-employed); funding by the employer, employee or both within the same taxable year; portability; larger contributions; and broader deductible ranges. See Medical Savings Account.


Individual Insurance

Health insurance purchased individually by a person or family; premiums vary by age, health status and other factors. See Private Coverage.


Individual Mandate

Requirement from a state or federal government that all individuals in that jurisdiction purchase private health care. And individual mandate often includes a fee or tax penalty to enforce the requirement. In 2007, Massachusetts was the first state to implement an individual mandate.

Battle Lines Drawn on Individual Mandate

Managed Care

Type of health care plan that integrates the payment and delivery of services to enrolled beneficiaries. Managed Care plan providers contract or employ their own health care providers. See Health Maintenance Organization.


Mandated Employer Insurance

Requirement from a state or federal government that all employers in that jurisdiction provide health benefit coverage to employees.



Insurance program funded jointly by the federal and state governments for individuals and families with limited incomes or resources. Each state determines its eligibility requirements.


Medicaid Buy-in Programs

Programs that allow individuals and families to purchase Medicaid coverage if they otherwise earn too much income to qualify for regular Medicaid. Programs include State Children’s Health Insurance Program, Children and Youth with Special Health Care Needs, and Working People with Disabilities.


Medical Savings Account

An account in which individuals, usually those self-employed, can deposit tax-deferred dollars for medical expenses. See Health Savings Account.



Federal health insurance program for individuals over age 65 and the disabled. There are no financial or income eligibility requirements. See Medicare Part A, Medicare Part B, Medicare Part D.


Medicare Part A

Hospital insurance component of Medicare, which covers inpatient hospital stays, care in a nursing facility, hospice care and some home health care.


Medicare Part B

Component of Medicare that is not covered by Medicare Part A; helps pay for doctors’ services, outpatient hospital care and medical equipment.


Medicare Part D

Component of Medicare that subsidizes the cost of prescription drugs.


National Health Expenditure

A country’s total spending on health services, including doctor’s visits, hospital care, prescriptions and over-the-counter drugs and products, nursing home care, insurance costs, public health spending, health research and construction.


National Health Insurance

Health care system in which the government is the single payer for all health services, using revenue from taxes. See Single-payer System, Socialized Medicine, Subsidized Health Insurance, Universal Health Care.


Out-of-pocket Expense

Payment for health services not covered by an individual’s health plan. See Cost Sharing.


Payment Rate

The total payment for a health service. See Allowed Charge.



The ability for an individual to have continuous health coverage while moving between insurance plans.


Pre-existing Condition

A medical condition or illness that an individual has before beginning coverage under a new health insurance plan. Pre-existing conditions can make it more difficult for a person to find health insurance. Depending on the type of health insurance plan, some insurance companies may not cover treatment for a pre-existing condition for a certain period of time.


Preferred Provider Organization

Health plan in which enrollees use doctors, hospitals and providers that belong to the insurer’s network and that agree to provide specific services for a set fee. Enrollees can use doctors, hospitals and providers outside of the network for an additional cost.



The amount paid, usually monthly, for health insurance.


Prescription Drug Benefit

Insurance that covers both brand-name and generic prescription drugs at participating pharmacies.


Preventive Care

Routine health care to prevent (rather than treat) illnesses, disease, or other health problems; includes tests, pelvic exams, flu shots and screening mammograms.


Primary Care Provider

Health care professional who provides basic care, including general family checkups and internal medicine.


Private Coverage

Employer-sponsored coverage or health insurance purchased by an individual or family on the private market.


Public Plan Option

A government-sponsored health insurance plan that would compete with private insurance plans, and provide an insurance option for people not covered by employer-sponsored plans. President Obama and many Democrats have called for a public plan to be included in any health care reform legislation. However, Republicans and some more conservative Democrats are firmly opposed, and have suggested creating nonprofit health insurance cooperatives as an alternative. Some members of Congress advocate creating a “trigger” that would establish a public plan if there is not enough competition creating lower prices by a designated time.

Public Plan Option Proves Contentious

Purchasing Pool

A group, usually of states or public or private employers, that pools resources to purchase health care plans or prescription drugs from pharmaceutical companies for its citizens or employees.


Single-payer System

A health care system in which one entity — usually a government — is the single payer for all health care services, using revenue from taxation. See National Health Insurance, Socialized Medicine, Subsidized Health Insurance, Universal Health Care.

Single-payer Advocates Make Case for Reform

Socialized Medicine

A publicly financed and administered form of health care. There is no one definition, but often means that the government is the single payer for all health services and owns and operates health care facilities. See National Health Insurance, Single-payer System, Subsidized Health Insurance, Universal Health Care.


Subsidized Health Insurance

Health care in which the government pays for a portion of health services. See National Health Insurance, Single-payer System, Socialized Health Insurance, Universal Health Care.


Third-party Payer

Any organization, such as a private health insurer, Medicare or Medicaid, that pays for some of the health care expenses of its enrollees.


Uncompensated Care

Health care or services provided by hospitals or others without payment from the patient, or government-sponsored or private insurance program.


Universal Health Care

A system in which all residents of a state, country or other geographic area have access to health care. See National Health Insurance, Single-payer System, Socialized Health Insurance, Subsidized Health Insurance.

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