2 American Healthcare Flashcards
what type of healthcare system does the US have?
does not provide universal coverage and can be defined as a mixed system (public spending accounted for 45% of total health spending)
Medicare and Medicaid does not offer coverage for everyone!
what type of health coverage/financing is there in the US?
publicly financed government Medicare and Medicaid health coverage coexists with privately financed market coverage (private health insurance plans)
BUT out-of-pocket payments and market provision of coverage predominates as a means of financing and providing healthcare
90% is estimated to have health coverage (public/private)
what act introduced Medicare and Medicaid?
the Social Security Act
1975
who’s eligible for Medicare
ensured a universal right to healthcare for those age 65+, individuals under age 65 with long-term disability or end-stage renal diseases
what are the parts of Medicare?
Part A: hospital insurance
Part B: medical insurance (limited outpatient prescriptions and vision services)
Part C: Medicare Advantage (method of receiving coverage)
Part D: voluntary outpatient prescription drug coverage option provided thru private carriers
who’s eligible for Medicaid?
low-income families, the blind, individuals with disabilities, low-income pregnant women, children up to age 18
eligibility criteria vary by state
what is the Children’s Health Insurance program?
a public, state-administered program for children in low-income families that earn to much to qualify for Medicaid but are unlikely to be able to afford private insurance
in some states, it operates as an extension of Medicaid. in other states, it is a separate program
differentiate between Medicare and Medicaid
Medicare is federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions.
Medicaid is a joint federal and state program that gives health coverage to some people with limited income and resources.
—- needs to be recertified annually
what is the Affordable Care Act?
represented the largest expansion to date of the government’s role in financing and regulating health care
requiring most Americans to obtain health insurance or pay a penalty (the penalty was later removed)
extending coverage for young people by allowing them to remain on their parents’ private plans until age 26
opening health insurance marketplaces, or exchanges, which offer premium subsidies to lower- and middle-income individuals
expanding Medicaid eligibility with the help of federal subsidies (in states that chose this option).
introduced a federal marketplace, HealthCare.gov, for purchasing individual primary health insurance or dental coverage through private plans. States can also set up their own marketplaces
what is the role of the federal government?
setting legislation and national strategies
administering and paying for the Medicare program
cofunding (w/ state gov) and setting basic requirements and regulations for the Medicaid program
cofunding (w/ state gov) CHIP
funding health insurance for federal employees as well as active and past members of the military and their families
regulating pharmaceutical products and medical devices
running federal marketplaces for private health insurance
providing premium subsidies for private marketplace coverage.
what portions of total health spending was from public insurance and private insurance?
public = 45%
private = 34%
however, private insurance is the primary health coverage for 2/3 of Americans
how are primary care physicians paid?
negotiated fees (private insurance)
capitation (private insurance and some public insurance)
administratively set fees (public insurance)
the majority (66%) of primary care practice revenues come from fee-for-service payments
what can outpatient specialists do in regards to insurance?
outpatient specialists are free to choose which form of insurance they will accept.
for example, not all specialists accept publicly insured patients, because of the relatively lower reimbursement rates set by Medicaid and Medicare.
access to specialists for beneficiaries of these programs—not to mention for people without any insurance—can therefore be particularly limited.
describe long-term care coverage in the US
there is no universal coverage for long-term care services. Public spending represents approximately 70 percent of total spending on long-term care services, with Medicaid accounting for the majority
medicare and most employer-sponsored plans cover only post–acute care services following hospitalization, including hospice, short-term nursing services, and short-term nursing home stays (up to 100 days following acute hospitalization).
private long-term care insurance is available but rarely purchased; private insurance represented only a small portion of total long-term care spending in 2016.
what is TRICARE?
the health care program for uniformed service members, retirees, and their families around the world.
TRICARE provides comprehensive coverage to all beneficiaries, including: Health plans, Special programs, Prescriptions, Dental plans.
most TRICARE health plans meet the requirements for minimum essential coverage under the Affordable Care Act.
TRICARE is managed by the Defense Health Agency under leadership of the Assistant Secretary of Defense (Health Affairs).
