Q: What type of health insurance do members of Congress receive? Is it a single-payer, government-run system?

A: Until 2014, members of Congress were covered by private insurance under the same system that covers all federal workers.

FULL ANSWER

(Note: This item is no longer current. It was accurate at the time it was written in 2009, when the Affordable Care Act was being debated. But starting Jan. 1, 2014, House and Senate members, and their staffs, can only obtain employer-subsidized, private coverage through the exchanges established under the ACA. The exchanges, or marketplaces, were designed for those who purchase their own insurance and small employers. For a full discussion of current health insurance options for members of Congress, see the 2015 Congressional Research Service paper “Health Benefits for Members of Congress and Designated Congressional Staff.” Over the years, we’ve seen false claims that Congress was somehow “exempt” from the health care law. But, in fact, the law places this additional requirement on Congress that doesn’t pertain to other Americans with employer-provided health care.)

Members of Congress have good health insurance by any standard, but it’s not free and not reserved only for them – and it’s not government insurance. House and Senate members are allowed to purchase private health insurance offered through the Federal Employees Health Benefits Program, which covers more than 8 million other federal employees, retirees and their families.

It’s not a “single-payer” system where the government acts as the one and only health insurance company. As President Bush’s chief of personnel Kay Coles James said in 2003, while lecturing at the conservative Heritage Foundation, “the FEHB program is not centralized, government-run health care.” It has drawn praise both from conservatives and liberals, including President Obama, who held it up as a model for his own health care proposals.

According to the Congressional Research Service, the FEHBP offers about 300 different private health care plans, including five government-wide, fee-for-service plans and many regional health maintenance organization (HMO) plans, plus high-deductible, tax-advantaged plans. All plans cover hospital, surgical and physician services, and mental health services, prescription drugs and “catastrophic” coverage against very large medical expenses. There are no waiting periods for coverage when new employees are hired, and there are no exclusions for preexisting conditions. The FEHBP negotiates contracts annually with all insurance companies who wish to participate. There is plenty of competition for the business; FEHBP is the largest employer-sponsored health plan in the U.S.

Those who don’t like their coverage may switch to another plan during a yearly “open season” period. To help with the choices, FEHBP conducts an annual “satisfaction survey” of each plan with more than 500 members and publishes the results.

Like other large employers, the government pays a large share of the cost of coverage. On average, the government pays 72 percent of the premiums for its workers, up to a maximum of 75 percent depending on the policy chosen. For example, the popular Blue Cross and Blue Shield standard fee-for-service family plan carries a total premium of $1,327.80 per month, of which the beneficiary pays $430.04. Washington, D.C.-based employees who prefer an HMO option might choose the Kaiser standard family plan. It carries a total premium of $825.15 per month, of which the employee pays only $206.29.

In addition, members of Congress also qualify for some medical benefits that ordinary federal workers do not. They (but not their families) are eligible to receive limited medical services from the Office of the Attending Physician of the U.S. Capitol, after payment of an annual fee ($491 in 2007). But services don’t include surgery, dental care or eyeglasses, and any prescriptions must be filled at the member’s expense.

House and Senate members (but not their families) also are eligible to receive care at military hospitals. For outpatient care, there is no charge at the Washington, D.C., area hospitals (Walter Reed Army Medical Center and National Naval Medical Center). Inpatient care is billed at rates set by the Department of Defense.

Update, Aug. 6, 2012: This item was updated to reflect the employee share of the monthly insurance premiums for 2012.

Sources

English, Barbara. “Health Benefits for Members of Congress.” Congressional Research Service. 25 Sep 2007.

“Non-Postal Premium Rates for the Federal Employees Health Benefits Program; Fee-for-Service Plans (FFS).” Office of Personnel Management. rates for 2009. undated, accessed 24 Aug 2009.

“Non-Postal Premium Rates for the Federal Employees Health Benefits Program; Health Management Organizations (HMO).” Office of Personnel Management. rates for 2009. undated, accessed 24 Aug 2009.