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- Members of Congress are required to have health insurance. If they don’t, they are subject to a fine, just as everyone else is
- They are offered insurance through DC Health Link, which follows guidelines established by the Affordable Care Act
- Members of Congress can decline the health insurance that they are offered. They can buy insurance independently, through a spouse, or through another organization
The Affordable Care Act requires all Americans to obtain health insurance. There are certain exceptions, but in general, you have to pay a penalty if you don’t have insurance. Members of Congress are not exempt from this rule. They are offered insurance through DC Health Link, a health insurance exchange based in the District of Columbia.
This insurance is optional for them, as they can find health insurance independently, through a spouse, or through any other program that they’re eligible for.
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Before the Affordable Care Act
Prior to 2014, members of congress along with some of their staff members could find insurance through the Federal Employee Health Benefits program. This program was open to all federal employees. Within the program, there were different types of insurance plans. Everyone in the federal system had similar choices when it came to health insurance.
The program still exists, but it’s no longer offered to members of Congress.
With the Passage of the Affordable Care Act
On January 1, 2014, the health insurance system changed. Rather than continue to use the Federal Employee Health Benefits program, members of Congress were directed to obtain health insurance through DC Health Link, according to Section 1312 of the Affordable Care Act. (DC Health Link is also known as DC SHOP.) Certain staff members are also offered insurance through DC SHOP.
In 2017, members of Congress were directed to choose a plan in the gold tier of options offered by DC SHOP. Gold plans are the third highest level out of the four plans available through the Health Insurance Marketplace. They generally have higher monthly premiums along with lower out-of-pocket costs for visits to a health care provider.
Members of Congress can also choose to open a Flexible Spending Account, obtain dental and vision insurance, and apply for a long-term care insurance plan.
There is an Office of the Attending Physician housed within the Capitol building. Congresspeople can receive limited services from this office for an annual fee. They are also able to receive care at military treatment facilities.
What is DC SHOP?
Health plans offered by DC SHOP comply with the regulations set forth by the Affordable Care Act. “SHOP” stands for “the small business health options program” exchange. The program was created in 2011 by the DC Health Benefit Exchange Authority.
DC Shop is run by a team of professionals, and it’s governed by an Executive Board which is appointed by the Mayor of DC. It’s similar to exchanges that are administered by states. Since the District of Columbia stands alone, it needed its own exchange system.
The program provides access to medical providers nationwide, and in some cases, internationally.
Who pays for health insurance for members of Congress?
The cost of health insurance is shared by the individual members of Congress and the employer, as it is for any federal employee. In this case, the employer is the federal government, which is funded by taxpayers.
The government contribution to health insurance premiums is about 75 percent of the total premium. This is also the same contribution that the government makes for any federal employee.
Technically, the government pays for the lesser of the following:
- 72 percent of the amount that is the program-wide weighted average of the yearly premiums for all plans
- 75 percent of the total premium for the specific plan that the individual has selected
The choice to get insurance through DC SHOP is ultimately up to the individual member of Congress. They are allowed to find insurance by other means.
Some purchase insurance through a spouse, some find it independently, and some may be eligible to receive insurance through other organizations. If they refuse insurance through DC SHOP, they will not get any assistance with their premiums.
The Current State of Affairs
In 2017, the US House of Representatives voted to approve the bill H.R. 1628. If this bill is approved by the Senate and the White House, it’s predicted to significantly affect the way that health insurance operates.
It would potentially affect premiums, eligibility for people with pre-existing conditions, and the number of people insured. However, it is not yet clear how the bill would affect the health insurance that Congress has.
While one version of the bill included language that exempted Congress from changes to the health insurance system, another piece of legislation was introduced to strike out that exemption.
In the end, experts believe that health insurance offered to Congress will not change significantly due to the fact that their insurance is received through DC SHOP and not a large state exchange.
Members of Congress receive health insurance through the health insurance exchange in the District of Columbia. It’s known as DC SHOP, and it’s also offered to employees of small businesses within the district.
In accordance with specific federal guidelines, members of Congress have to choose a gold plan. The government pays for about 75 percent of their premiums.
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