ACA and economics Flashcards
Pt protection and affordable care act
2010
- laws enacted 2010-2015
- health insurance exchanges, mandatory medicaid expansion, ind mandates, emphasize preventative care, insurer regulations, potential overturn or revision with new admin
National federation of independent business v Sebelius
2012
- upheld the ind mandate for health insurance
- ruled that mandatory Medicaid eligibility expansion was unconstitutional
Tax cuts and jobs act
2017
- called for removal of individual mandate in 2019
- before that penalty or taxes if did not carry health insurance
- fam can deduct any medical expenses that exceed 7.5% of their income (before act, was 10%)
Outcomes of removal of ind mandate
- 13mil fewer ppl insured
- gov saved lots money by not having to pay subsidies
- hc costs rise bc ppl don’t get preventative care
- health insurance lost $ and health ppl dropped coverage, more proportion of sick enrollees
ways to get insurance with ACA
- your employer
- health insurance marketplace
- from government
Changes to employee health insurance with the ACA
- encourage employer to offer insurance
- benefits and coverage disclosure laws
- incentive for workplace wellness programs
What do workplace wellness programs focus on?
Preventative care
How does ACA encourage employer to offer insurance
- SHOP marketplaces to help small businesses offer insurance
- employer-shared responsibility payment for premiums (>50 emps)
- 90d max wait period before hc kicks in
State health insurance marketplace
- subsidize health insurance for low-middle income who wouldn’t qualify for medicare but could not afford employment plan (100-400%)
- competition in health plans (options)
- sign up through state or federal exchanges
- marketplaces have responsibility to monitor private insurance companies
Outcomes of KYs marketplace
KYnect
- 500k obtained insurance
- expanded coverage for SUD and MI
- uninsured fell to 9%
- ended in 2017 and reinstated 2022
What program created state marketplaces?
ACA
Medicaid changes with ACA
- ACA tried to raise minimum eligibility requirement to 138% of FPL to cover 100-148% gap
- supreme court ruled unconstitutional but states can voluntarily participate
Medicaid gap
exists in states where states have not expanded, gap in 50-100% FPL where ppl don’t qualify for medicaid and can’t afford subsidized health insurance
Difference in policy outcomes with expansion vs not expansion
- in states with expanded medicaid, uninsured rates for people in poverty fell lots
- rates of uninsured stayed the same
How is the ACA funded?
- fees from pharmaceutical and medical device companies
- taxes from ind who earn >200k/y, Cadillac plans, and indoor tanning
- penalties: ind mandate (prior to 2019) and companies with >50 FTE who don’t buy insurance
- cost control measures with provider incentives, waste, fraud and abuse, prevention and wellness promotions, dec in Medicare spending
ACA outcomes
- dec # of uninsured among nonelderly pop
- 60% of ppl w/ new coverage went to dr, hospital , or bought rx
Insurer regulations under the ACA
- bans against yearly and lifetime limits
- can’t deny coverage for kids/adults with preexisting condx
- can’t drop clients when they get sick
- all plans must include contraception and preventative care
- must cover dep kids til 26
- can’t charge M and W differently
- lower cost for preventative services
- small business tax credit to provide employees coverage
- max out of pocket based on family income relative to poverty line
- mammogram, pap smear, maternity services must be covered
Current future of hc in US
- unknown bc current sys unsustainable
- US spend more money for worse outcomes
- millions uninsured
- partisan politics interfere with rational hc sys decision making
private health insurance
focus on ind health like curative, rehab, custodial
- now preventative and early dx and tx too
- fee for service basis
- ind care provided for by HCPs and based on managed care or capitated payments like HMOs
philanthropic hc insurance
- addresses health of ind w/ specific dx via funding mechs
- funded thru private donations and fundraising
- global focus often and provide welfare of others
- disease specific like cancer, kidney
- finance research, direct care, supp care
- no legislative pwoer
- power of public
public hc sys
- efforts organized by society to protect, promote, restore ppl’s health
- mandated by US constitution to promote general welfare
- federal, state, and local levels
- services coordinated under the US dept of health and human services (USDHHS)
US DHHS goals and abilities
- goal is population health
- works with Surgeon general
- targets disease prevention, health promo, and rehab of gen pop, special pops, and intl health
- develops programs mostly
- laws, regulation, rule to protect the public
US DHHS current plan
- transform hc
- advance sci knowledge and innovation
- adv health, safety, and wellbeing of US citizens
- inc efficiency, transparency, and accountability of DHHS
- strengthen nation’s health and human services infrastructure and workforce (the profs who ensure a healthy pop)
State health dept
- health of states’ citizens and central authorities in public hc sys
- guided by federal level but establishes own state laws
- local health dept subsystem
Local health dept subsystem
- local, county
- do direct care delivery of health services like flu shots
- comm and enviro health services, MH services
- limited personal health services bc of dec funding
Phase 1 of US hc sys
1800-1900
- hc concerns r/t social and public health problems
- sanitation, overcrowding, no running water
- ppl avoided hospital bc got care in home
Phase 2 of US hc sys
1900-1945
- control acute infectious disease (control spread, improve mortality)
- growth of hospital and health dept
- water purity, sanitary sewage disposal, housing improvements
- new meds incl insulin (1922) and sulfa (1932)
Phase 3 of US hc sys
1945-1984
- shift away from acute infx to chronic health prob
- major tech advances
- birth of NPs and certified midwives
- inc insurance companies
- start comm-based clinics for primary care
Phase 4 of US hc
1984-present
- limited resources
- emphasis on containing costs, restrict growth in hc industry, reorg care delivery
- computer and internet: more knowledgeable patrons; can find own tests/procedures that can elevate costs
- hospital and sicker patients, shorter, stay, more intensive care and smaller ratios
phase 5 of US hc
incoming
How do we finance hc
- private pay (out of pocket w/o insurance (IV fluids, aesthetics)
- health insurance
- federal and state medicare/aid
When did health insurance switch from private pay to health insurance plans
1930
When did employers start to offer health insurance
Post ww2; fringe benefit
Third party reimbursement
- pt gets tx and insurance pays the provider
- encouraged growth of hc industry to what it is today
health insurance in the 60s
inc focus on social justice–inc usage in Universal hc coverage
- 1965 Medicare/aid
indemnity
Fee for service plans
- choose provider, more flexibility, more services
- high deductibles at a cost
- overall dec hc costs
Where health insurance comes from
- indemnity
- self-insured employee plans
- managed care plans
3 types of managed care plans
- HMOs
- PPOs
- POS
Health maintenance orgs (HMO)
- prepaid plan
- members have fixed monthly payment for services (premium)
- copays when services are used
- plans comprehensive and include preventative care
- require gatekeeper to oversee care (designated PCP to contain hc costs)
- fixed fee when see provider in network
- provider contract with HMO
Downside of HMOs
Less flexible and costs increase when seeing services outside the plan
Preferred provider org (PPO)
- like HMOs but has higher premium and deductible and consumer has more options
- no gatekeeper and wider network
- based on contract btwn Dr, hospital, insurance company
- providers deliver services to enrollees for a discounted rate negotiated with insurance company (in-network)
- can see providers out of network for an inc rate
Benefit of PPOs for providers
guaranteed inc in # of consumers
Plan of service (POS)
- combo of HMOs and PPOs
- require copay and gatekeeper in-network
- can see out of network providers but costs are reimbursed on a higher fee for service basis
Medicare
- 65+ age of permanent disability
- 100% federally funded except for supplemental dental and vision for purchase
- hospitals reimbursed based on dx
- there are caps on inpatient and deductibles
Medicare part A
- covers hospitals and facilities
- some have home hc, hospice, skilled nursing care
- has deductible, funded by federal payroll taxes
Medicare part B
- covers outpt care, home health, equipment and supplies, lab, ambulance, preventions services
- elective supplemental purchase
- supported by general tax revenue and small income based premium from enrollees
Medicare part C
- Advantage plan
- expand options for medicare recipients
- adv plan like HMOs and PPOs when eligible
Medicare part D
- Rx drug coverage (2000)
- premiums, deductibles, copays
- variety
- higher earners pay more for part D under ACA
Accountable care org
- part of ACA to dec costs and improve quality of care thru cooperation and coordination among providers
- physicians and other providers work together to manage and coor care for Medicare fee for service beneficiaries
Shared savings programs
ACOs get portion of shared savings if they sufficiently dec $ and improve quality
CHIP
Children’s health insurance program
- part of Medicaid (state and fed funding)
- hc coverage for low-income kids, generally those in households w/ income under 200% FPL w/o Medicaid and would otherwise be uninsured
Eligibility for Medicaid
Very poor, family with kids, blind, disabled, poor and preg, older adults, SSI (blameless in pov)
What does Medicaid cover
hospital, dr, dentist, home health, preg, glasses, hearing aids
dual eligibility
When someone qualifies for Medicare and Medicaid
- Medicaid with Medicare as a supplement
What does Medicaid vary by?
State and pop groups in state
Tricare
- uniformed services and dependents and retirees
- cover hospital, medical, dental, rx
VA health insurance
- for vets, services at any VA medical center
- inc enrollment in 2004
Indian health services
- must live on/near a reservation in most cases (not always, incl some urban areas)
- outcomes have improved but still disparities
hc financing reform
- need more emphasis on pop level hc
- lack of insurance is a major fx assoc with a lack of medical access
- trends of cost sharing, health alliance, self-insurance, flexible spending accounts, health promo and disease prevention
nurse’s role in hc insurance
- researcher
- educator
- providers
- advocate
Future of life expectancy in US
at current rate, kids now will have shorter lives than parents
Is Medicare funded by federal and state?
NO - just federal
Is Medicaid funded by federal and state?
YES
