Block 1 Flashcards
What three things are considered in an acceptable health care system?
Access
Cost
Quality
Define healthcare Access
All citizens are enabled to obtain needed services
Define Cost in the Healthcare System
Healthcare services are Cost Effective
Define Healthcare Quality
Services must meet established standards
Banyan Tree Analogy for US Healthcare “System”
Loosely capitalistic / market oriented in terms of morals and ethics and governmental oversight
Fragmented system with multiple payers, sets of rules, lots of money made by different stakeholders
Broadly described: financing insurance, delivery, payment mechanisms are somewhat coordinated by public and private actors
Unique attributes of US Healthcare System
Highly fragmented: in regulation, financing, and delivery
High rates of uninsured and underinsured
Major inequality in quality of care
No comprehensive payment systems for services
For-profit
Expensive
T or F: The US has the highest expenditure per capita in the world for healthcare
True
T or F: The US spends the highest % of GDP in the world on healthcare
True
Cultural Beliefs and Values Influencing American Healthcare System
Self-reliance, Independence, Individualism
“Welfare” only for most needy
Decentralized government (state> fed) and resistance to increased taxes
Social Changes Influencing American Healthcare System
Demographic Shifts, Immigration, Urbanization
Decreasing % of White only demographics & Increasing % of Non-White and 2+ race demographics
Increasing Urbanization
Technological Advancements Influencing American Healthcare System
New treatments are expensive
Progressively increased training of health professionals creates more expensive system
Tech, Facilities, & Equipments advancing = increased cost
Economic Constraints Influencing American Healthcare System
Health care costs
Health Insurance Cost
Family Incomes disproportionately increasing alongside service costs
Political Opportunism Influencing American Healthcare System
President’s agenda
Domestic and Foreign priorities
Party politics
Power of interest groups (APTA)
Laws, regulations, policies
Three Eras of US Healthcare System
Pre-Industrial
Post-Industrial
Corporate
Pre-Industrial Era
Minimally educated physicians, some nurses
Inexpensive: cash payment or trading
Medical Institutions: Poorhouses (Almshouses) run by government, Hospitals were few w/ poor conditions, Asylums for housing people w/ chronic untreatable illnesses (esp. mental illness)
Post- Industrial Era
Development of medical and nursing professions: increased education, urbanization begins office-based practice rather than house calls, science and technology begins to drive medicine
Development and growth of hospitals: centralized and institutional approach from medical science advancement for facilities and equipment & nursing especially becomes a profession
Post - Industrial Era Insurance
Health insurance emerges: care advancement = cost increase, so people invested in insurance for unpredicted care needs, largely provided by hospitals early on due to Great Depression
Provider inspired insurance followed including: American Hospital Association’s Blue Cross & State Medical/Physician Societies Blue Shields
Creations of public health insurance like Medicaid (poor) and Medicare (elderly)
Post Great Depression: economy booms and employers utilize health insurance as a benefit to attract employees instead of raising wages
What post-industrial insurance policy emerged in 1954?
Congress made employer based health insurance non-taxable
equivalent of getting more salary with out having to pay taxes
4 Main Features of the Corporate Era
Corporatization
Growth of Non-Physician Workforce
Information Revolution
Globalization
Corporatization : Corporate Era
Medical care is dominated by large corporations with little attention from federal government (no anti-trusts enforced) resulting in:
Managed care insurance companies
Large pharmaceutical and device manufacturers
Large hospital systems
Large physician practices ( can be owned by hospital systems)
How has the Information Revolution impacted the Corporate Era?
COST!!!
Telehealth, Electronic Health Records, massive amounts of information and resources at everyone’s disposal creates larger health service costs
Globalization in Corporate Era
Cross-border exchange of goods and services
Migration of health professionals: majority of PCPs in America have immigrated from other countries to fulfill residencies
Historical Reasons for Failure of US Health Care Reform
Anti-German feelings and criticism of social insurance during WW I
Lots of rhetoric has been historically created that equates national health insurance to socialized medicine
Opposition from the AMA (literally fuck the AMA so bad)
🦅🦅Traditional American Beliefs and Values 🦅🦅: capitalism, self-determination, distrust of big government, tax aversion
Affordable Care Act
2010
Access > Quality > Cost
Political Battlefied
Why do people have insurance?
To reduce their risk of financial strain in the event of the need of medical services
Guaranteed Issue
the government passes a law stating that if an individual applies for insurance that the insurance company has to sell a policy that applies
Individual Mandate
Insurance mandate
the government has determined that everyone living in the country is required to obtain insurance
Employer Mandate
Insurance Mandate
all employers are required to provide insurance to their employees
Underwriter in Health Insurance
A person employed by an insurance company who decides whether or not the company should sell a policy to an individual who has applied
low risk, high risk, etc
Risk Pool
A certain group of people who have bought an insurance policy from a company
Characteristics: Large vs Small and Healthy vs Sick
ex: Large, healthy pool or small, sick pool changes how premiums work
Favorable Selection
Higher number of healthy people in the risk pool
Adverse Selection
Higher number of sick people in the risk pool
Bad for insurance companies b/c increased claims and decrease $
What Risk Pool will pose the highest risk for insurance companies and how does this affect?
a Large, Sick pool because adverse selection
The insurance company will likely increase premiums to stabilize the risk pool or refuse to operate in a region
Individual Rating
Rating individuals by select factors
Preferred by insurance companies
They would be able to charge people more/not sell at all if they are old, of child bearing age, have pre-existing conditions, risk factors, etc
Community Rating
The policy being sold by the insurance company has to be the same for all individuals who apply
Modified Community Rating
ACA
An Insurance company cannot use individual rating; however to allow more Healthy people into the Risk Pool, they can give lower premium rates if :
younger, in a region where it is inexpensive for insurance company to do business (urban), and does not use tobacco
T or F: The Affordable Care Act allows price variation based only on age, geography, and tobacco use
True!
This is a part of the Modified Community Rating concept
T or F: The ACA only allows a limited amount of price variation
True
Rescission
Existed before ACA
An insurance industry practice in which an insurer takes action retroactively to cancel a policy holder’s coverage by citing omissions or errors in the customer’s application even if the policy holder has diligently kept their policy current
Usualy occured when someone would suddenly get a bad diagnosis
Common Insurance Practices Prior to ACA
Denying
Excluding
Charging based on gender, pre-existing, or certain occupations
Limiting benefits associated with mental health, substanc use, maternity, prescription drugs, pre-existing
Imposing lifetime or annual benefit caps
Changes to Insurance Following ACA
Elimination of: Recission, Underwriting, Individual vs Community
