Day 5: US Health Care And Medicade/Medicare Flashcards
What has US healthcare traditionally been provided by? And what issues can be from this?
Its from the private sector
*What happens for people who don’t work or are children / retired
**also what if work does provide some kind of insurance to employees
What is the case for “private (free-market) run” healthcare system?
Some people say that when health care is run by the government it will slow everything and take away competition with will lead to worse care over all
**think about the VA or the DMV and how it always seem frustrating with long waits
**VA still needs private sectors incase there is to long of wait times pts can go to private care
What is the simple “KEY” summary of Medicaid?
STATE governments help people living in poverty to have access to medical care
What is a simple “KEY” summary of Medicare?
FEDERAL government helps the elderly to have access to medical care
What is a simple “KEY” summary of Medicare Part D?
FEDERAL government helps the elderly pay for out-patient prescription dugs
What is a simple “key” summary of the ACA?
Created to help people not covered by Medicaid or Medicare to have access to medical care
What are the government responsibilities when it comes to MEDICAID?
Its a joint FEDERAL and STATE program
The federal government sets eligibility standards that define the minimum Medicaid services that must be provided by state governments
Fed also pays the majority of the expenses
State government :
Administers the program
Complies with the fed requirement
**Determines if it wants to offer more than the minimum Medicaid services required by the fed government
Who is eligible to get Medicaid and how do they determine it, it hard for people to enroll into Medicaid?
Mostly used for low income people : Most of Medicaid is children
It’s Means tested: its tied to a persons income, the FED government defines the poverty level
Can be hard to enroll due to the amt of paperwork that is required and needing to prove you are in the level needed
Does Medicaid vary with the economy?
Yes, when the economy is weak, expect more individuals to enroll in Medicaid, but if the economy is strong, expect fewer to enroll in Medicaid
How is Medicaid financed?
FEDERAL AND STATE governments finance it (tax dollars)
The fed government provides money to the states
What’s a problem with the federal funding “match” program?
It discourages states from reducing spending
**if a state government reduces spending, it will then loses the matching federal spending that they would have gotten.
What is a problem with nursing home patients and Medicaid?
In order to get funding for nursing home a patient must prove that they don’t have any money. They will typically transfer their funds to someone else and then be able to take advantage of Medicaid nursing home
**nursing home is a very large expense for Medicaid
What are examples of Required and Optional Services?
Required: Physician services In-patient and out-patient services Labs and X-ray Vaccines for children
Optional Services:
RX DRUGS! (A lot of times they will be covered by some states can put in no coverage or a copay to control costs)
Dental
Physical therapy
How is the reimbursement rates to health care providers with Medicaid?
It’s an issue because state governments control costs by reducing reimbursement
They say Drs should not expect to get rich off of these services
This is an issue because some doctors will not accept Medicaid patients because they don’t get reimbursed enough to justify helping the patient
What are the Government Responsibilities for Medicare?
FEDERAL government program
The fed government administers the program
Determines eligibility thro Social Security
Also sets the policies for the program
STATE GOVERNMENTS ARE NOT INVOLVED!
Who is eligible for Medicare?
Persons > 65 of age
Worked > 10 years in Medicare covered employment
Some disabled individuals under the age of 65 can meet certain criteria
Patient with end-stage renal diseases (was added as a political part from LBJ to get it passed)
Is Medicare means tested?
NO!!! Only Medicaid is means tested
This means that anyone over the age of 65 is eligible (even billionaires)
This was done to increase the number of people who could be in the program like the middle class. This made it much easier to vote for and get everyone involved and the bill passed
How is Medicare Part A financed?
It’s funded by a Federal government trust fund (this is an issue because it relies on younger people to pay for the older group before they have access) When there isn’t enough young people in the work force it becomes hard for the federal government to pay for the older people
Payroll taxes
General Government tax revenues
Some premiums, deductibles and co-payments
How is Medicare part B financed?
Thro general federal tax revenues
Premiums, deductibles and co-pays
What is covered by Medicare part A and how do you enroll?
It has AUTOMATIC enrollment for any eligible - not a complex processes, once you hit 65 you get Part A
What does it cover?
Hospitalizations
Short-term convalescence
Rehab in skilled nursing facility
Home health care
Medicare Certified Hospice
What is covered by Medicare part B and how do you enroll?
It’s VOLUNTARY enrollment - most people enroll - only really rich people usually don’t enroll into it
What does Part B cover:
Physician visits
Emergency room
Some preventative services
Diagnostic tests, lab tests
Medical equipment
***Retain pharmacies may provide some services as an approved SUPPLIER (not PROVIDER) *like some shots
What is Medicare part C?
It’s Medicare advantage and has VOLUNTARY enrollment and it is a managed care option
If patients like the managed care they can use this
**managed care is basically when you get a specific PCP and they will then have a number of doctors and things that you can use
***PART C typically includes all of the other parts of Medicare A, B and D
What is Medicare part D?
It’s the FEDERAL government program to help MEDICARE beneficiaries pay for outpatient RX drugs
It’s an INSURANCE PLAN (like car insurance, important to get for people 65 and older just in case even if they don’t take drugs)
Who is eligible for Medicare part D and is it a voluntary program, what could happen if they don’t enroll?
Anyone who is also eligible for Medicare
VOLUNTARY program - must choose to enroll and they must pay a premium to enroll in the plain
If you don’t enroll you will have to pay a penalty if you try to enroll later
What are some important elements of the Medicare part D plan?
It has monthly premiums for patients
There is a deductible
Co-pays
Co-insurance (the pt pays a % of the drug costs)
What are important things for patients to consider when a patient is selecting a Part D plan
The cost os the monthly premium and deductible (these are inversely related, you can pay the higher premium and get a lower deductible and vis versa)
Drug coverage and restrictions
If you need a specific drug to be covered you have to make sure you pick a plan that is right for you that covers the more expensive drug in the plan
Convenient - is the pharmacy close or do they have mail order
What are the major themes of the ACA?
The ACA tried to make healthcare more accessible, affordable and improve healthcare quality
It standardized health insurance plan benefits (this is important because it required health insurance companies to offer plans with minimum benefits such as maternity care and mental health serves, preventative care, cancer screenings)
In 2010 they had an individual mandate (required people to pay for health insurance or have to pay a tax or penalty if they didn’t have insurance. **this was removed n 2017 and is no longer required
What did the the ACA include the individual mandate on people?
The more people who have health insurance, it would allow the cost to be spread around
**when healthy people buy insurance it will lower the cost of insurance for people with medical conditions (the idea was that if more people buy insurance it will decrease premiums overall for everyone)
**with the mandate gone in 2019 there will be less people buying health insurance meaning higher health insurance premiums
What are some of the benefits that were popular to providers?
Standardizes insurance company paperwork
Encourages policies that reward providers and organizations for providing healthcare
Also hospitals benefited from this because more people have insurance so when they come to the hospital they have a higher chance of being reimbursed
What were some of the benefits popular to individual from the ACA?
Children can remain on parents plan until they turn 26
Insurers cant deny coverage to individuals with pre0existing medical conditions
Insurance cant set a lifetime cost limit (if a person has cancer in there 30s and it costs a lot of money the insurance can restrict the amount money they get later on)
Sets up “high-risk” polls for patients with costly health conditions
Why did a certain number of individuals not like the ACA?
The health insurance cost was higher for some individuals
They made too much money but their employer doesn’t provide insurance and the government also would not help them pay for the insurance
For these few people it was cheaper to take the tax penalty than to buy health insurance
What does a businesses that employs more than 50 employees need to do after the ACA?
They need to provide insurance and if they don’t they will have to pay a financial penalty
Did the ACA make people buy benefits they didn’t want?
Yes
For example a 65 year old male would need to get a plan that covers maternity care. It would cost more than their old plan and it included things they did not need
Also a 30 year old male would need to buy a plan that has things like breast cancer screening
