Exam 1 Flashcards
What is Medicare?
Federal health insurance for anyone age 65 and older and some people under 65 with certain disabilities and conditions
What is Medicaid?
A joint federal and state program that gives health coverage to some people with limited income and resources
Helps pay for all or some of participants’ medical bills
How did the US relate to other countries in terms of Covid 19 mortality?
It had the most deaths (among the highest even when adjusting for population size)
How does the US relate to other well developed countries in terms of life expectancy?
It is the lowest and has been for years
How many years did US life expectancy lower between 2019 to 2020?
1.87 years, 3.88 and 3.25 for Hispanic and Non-Hispanic Black populations (largest lower since WWII)
Compared to the average of .22 years in 16 other OECD countries
What are health disparities?
preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations
(differences between groups)
What is health equity?
when every person has the opportunity to “attain his or her full health potential” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances.”
According to Healthy People 2030, what are the social determinants of health?
economic stability
education access and quality
healthcare access and quality
neighborhood and built environment
social and community context
How did “The Commonwealth Fund” rank OECD peer countries in terms of health?
Norway, the Netherlands, and Australia ranked top
The UK, Germany, and New Zealand ranked middle
France, Switzerland, and Canada ranked lower
The United States ranked a much lower last
In the US, is healthcare seen as a market good or a social good?
A market good (like any other good or service people buy)
but likely should be
a social good (society has a responsibility to provide health care services)
Name some major US healthcare system historical benchmarks.
1850: Franklin Health Assurance Company begins providing accident insurance
1929: The Baylor Plan
1930s: several significant life insurance companies begin offering health insurance
1940-50s: employee benefit plans and expansion of health insurance plans
1965: Introduction of Medicaid and Medicare
What was the Baylor Plan?
The “Baylor Plan” was established in 1929 by Baylor administrators during the Great Depression to help area citizens afford hospital care. It is the first prepaid hospital insurance plan in the United States and predecessor of Blue Cross.
What are some historical benchmarks of Medicare?
1935: FDR signs Social Security Act
1965: Lyndon B Johnson signs Social Security Amendments enacting Medicare and Medicaid
1972: eligibility extended to persons under age 65 with long term disabilities and end stage renal disease.
1977: Health Care Financing Administration (HCFA) established
1982: hospice care added
1983: diagnosis groups (rather than cost related payments) begin to get use
1987: nursing home quality standards established
1988: Medicare Catastrophic Coverage Act (adds prescription benefits and cap on out-of-pocket expenses)
1989: Resource Based Value Scale for physicians established (replacing charge based payments)
2001: HCFA renamed Centers for Medicare and Medicaid Services (CMS)
2003: Part B added (premiums for recipients with higher incomes)
2006: Part D added (prescription drug benefits)
2010: ACA reforms Medicare
2015: Sustainable Growth Rate replaced by new payment system
What are some historical benchmarks of Medicaid?
1935: FDR signs Social Security Act
1965: Lyndon B Johnson signs Social Security Amendments enacting Medicare and Medicaid
1967: periodic screening for children in program required
1972: those receiving (the new) SSI are covered by medicaid
1977: Health Care Financing Administration (HCFA) established
1981: Home and Community Based Services (HCBS) waivers for long term care established
1984: mandatory expansion to children and pregnant women in poor families not receiving welfare
1988: expanded cost sharing for individuals below 100% FPL
1989: mandatory expansion to kids (up to age 6) and pregnant women at or below 133% FPL
1990: mandatory expansion to kids (ages 6-18) in families at or below 100% FPL
1996: end of link between Medicaid and Welfare
1997: CHIP established
1999: Olmstead decision, broader HCBS coverage for individuals with disabilities
2001: HCFA renamed Centers for Medicare and Medicaid Services (CMS)
2010: ACA expands Medicaid to nearly all adults with families at or below 138% FPL (with mostly federal funds)
2012: ACA medicaid expansion becomes state option
2015: 29 states (including DC) enact ACA expansion
Which states adopted the ACA Medicaid Expansion after the initial 2015 enactment?
Virginia (2019)
Maine (2019)
Kentucky (2019)
Utah (2020)
Idaho (2020)
Nebraska (2020)
Oklahoma (2021)
Arkansas (2021)
Missouri (2021)
Montana (2022)
South Dakota (2023)
North Carolina (2023)
Which states have still not adopted Medicaid Expansion (as of 2/10/24)?
Wyoming
Kansas
Texas
Wisconsin
Tennessee
Mississippi
Alabama
Georgia
Florida
South Carolina
What was Truman’s Healthcare Plan (1948)?
Truman’s plan was that all Americans would pay a certain amount in fees and taxes each month to cover the new healthcare program’s costs.
It was defeated in Congress and was opposed by the AMA and Unions.
Who was one of the first to offer employee healthcare?
Kaiser Family (Richard Kaiser ship building and yards)
Couldn’t compete with wages so they offered healthcare and childcare
How did the UK get universal healthcare?
In 1939 (during WWII) most doctors were put into “the field” to treat armed forces. Regional hospitals with free healthcare were put up to care for those left at home. After the war, the UK wanted to keep this and “voted Winston Churchill out” to do so.
What is a moral hazard?
Insurance coverage that protects consumers from financial risk and induces them to consume more healthcare services
When did Oklahoma begin to offer free, universal pre-K?
In 1998
What is the Child Tax Credit from the American Rescue Act of 2021?
Expands the child tax credit into 2021
Those who qualify can receive up to $250 per month for each child age 6 to 17 (limit $3000) ad $300 per month for each child under 6 (limit $3600)
(cut child poverty in half, expanded to age 17)
What countries are a part of the OECD?
- Australia
- Austria
- Belgium
- Canada
- Chile
- Colombia
- Costa Rica
- Czechia
- Denmark
- Estonia
- Finland
- France
- Germany
- Greece
- Hungary
- Iceland
- Ireland
- Israel
- Italy
- Japan
- Korea
- Latvia
- Lithuania
- Luxemborg
- Mexico
- Netherlands
- New Zealand
- Norway
- Poland
- Portugal
- Slovak Republic
- Slovenia
- Spain
- Sweden
- Switzerland
- Turkiye
- United Kingdom
- United States
What is the American Rescue Plan?
The American Rescue Plan Act (ARP; P.L. 117-2) was signed into law on March 11, 2021. It is the sixth COVID-19 relief bill enacted and provides fiscal relief funding for state and local governments, education, housing, food assistance, and additional grant programs.
What is the Affordable Care Act (2010)?
The comprehensive health care reform law with 3 primary goals:
- Make affordable health insurance available to more people. (Provides subsidies (premium tax credits) to lower income households)
- Expand Medicaid to cover all adults with income below 138% FPL (not all states have adopted this)
- Support innovative medical care delivery methods designed to lower the costs of health care generally.
What did the US spend on healthcare in 2021?
$4.3 trillion or 12,900 per capita
1.2 trillion through private health insurance
901 billion through Medicare
734 billion through Medicaid
The remaining is through other insurers or out of pocket
What percentage of government funds were spent on healthcare in 2021?
34% ($1.5 trillion) as opposed to 26.5% ($21.8 billion) in 1971
What were major finds of the RAND study?
participants who paid for a share of their care used less services than those who got free care
cost sharing equally reduced the use of both high and lower effective services
free care provided benefits (such as improvement in hypertension, vision, dental) especially in the sickest and poorest patients
How does US healthcare spending compare to other countries?
2x spending per capita
17.8% of GDP (compared to 9.6% in Australia and 12.4% in Switzwerland)
What makes the costs of US healthcare so high?
Prescription drug prices
Overuse of technology (such as imaging)
Specialist prevalence and salaries
High margin, high volume procedures
Administrative burden (need more streamlining)
Costs of procedures
Lack of primary care emphasis and practitioners
Aging population
Fraud (such as upcoding)
How does US healthcare insurance coverage compare to other OECD countries?
Lower insured (90% compared to 99-100%)
Highest proportion of private insurance (55.3%)
What are health outcome issues separating the US from peer countries?
- Lower life expectancy
- More adverse birth outcomes
- Higher rates of injury and homicide
- Higher prevalence of adolescent pregnancy and STI
- Higher prevalence of HIV and AIDs
- Higher drug related mortality
- Higher rates of obesity and diabetes
- Higher rates of heart disease
- Higher rates of chronic lung disease
- Higher rates of overall disability
How does the US compare with other countries in terms of the ratio of health spending : social service spending?
Though the US spends more GPD than any other country on healthcare, it has the lowest ratio of social service spending : health care spending. Countries with these lower ratios tend to have worse health outcomes.
What is the “Medicaid Gap?”
The coverage gap exists in states that have not adopted the ACA Medicaid expansion for adults who are not eligible for Medicaid coverage or subsidies in the Marketplace.
Medicaid expansion covers up to 138% FPL
Medicaid (not expanded) covers up to 38% FPL and tax credits begin at 100% FPL (up to 400%)
Unexpanded states have double the uninsured as expanded states.
Full expansion would cover about 3.5 million adults
What is the Federal Medical Assistance Percentage?
The federal medical assistance percentage is determined by a statutory formula based on state per capita income, which varies across states and adjusts over time. On average, the federal government pays 57% of Medicaid program costs, but matching rates across states range from 50% to 74% in 2015, with poorer states receiving more federal assistance.
What is Medigap Insurance?
Medicare Supplemental Insurance
29% of Medicare recipients had this in 2016
Private insurance that covers all or part of Part A and B Medicare costs
What are Medicare Advantage Plans?
Medicare Part C
A plan offered by a private company that contracts with Medicare
1/3 of Medicare eligible select this plan instead
Advantage plans are required to limit beneficiaries’ out-of-pocket spending for in-network services covered under Medicare Parts A and B to no more than $6,700, and may also cover supplemental benefits not covered by Medicare, such as eyeglasses, dental services, and hearing aids.
How much of federal spending goes to Medicaid / Medicare?
Nearly 25%
How many Americans received health insurance from Medicaid / Medicare?
Over 30%
What are the different parts of Medicare?
Part A (1965): acute care hospitalization, skilled nursing home care, some home health, hospice (mandatory)
Part B (1965): outpatient, physician, home health, and preventative services (voluntary and supplemental)
Part C (1997): Medicare Advantage (usually includes A,B, and D)
Part D (2006): outpatient prescription drug coverage (voluntary, subsidized)
What are other significant benchmarks in public health system history?
1946: The Hill Burton Act (a Truman initiative that provided construction grants and loans to build hospitals where they were needed and would be sustainable.)
1985: Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal COBRA is a federal law that lets you keep your group health plan when your job ends or your hours are cut. Federal COBRA requires continuation coverage be offered to covered employees, their spouses, former spouses, and dependent children.
1986: Emergency Medical Treatment and Labor Act (EMTALA) requires hospitals with emergency departments to provide a medical screening examination to any individual who comes to the emergency department and requests such an examination
1996: Health Insurance Portability and Accountability Act (uninterrupted health coverage between jobs, health information privacy)
How do the elderly and disabled figure into Medicaid enrollment and costs?
They comprise 23% of enrollees but >69% of costs
What is MACRA (2015)?
The Medicare Access and CHIP Reauthorization Act (MACRA) is a law that significantly changed how the federal government pays physicians. Passage of the law permanently repealed the flawed sustainable growth rate (SGR) and set up the two-track Quality Payment Program (QPP) that emphasizes value-based payment.
What are the major subsystems of US healthcare delivery?
managed care system
military and veteran systems
vulnerable population system
Indian health system
integrated delivery systems
long term care system
behavioral health system
public health system
What is Managed Care?
Managed care refers to a healthcare insurance approach that integrates the financing of health care and the delivery of care and related services to keep the costs to the purchaser at a minimum while delivering what is appropriate for a given patient or population of patients.
(Includes HMOs, PPOs, and POS)
What are Health Maintenance Organizations?
A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO.
An organization responsible for the financing and delivery of comprehensive health services to an enrolled population for a prepaid, fixed fee.
What are Preferred Provider Organizations?
A PPO has a network (or group) of preferred providers. You pay less if you go to these providers. Preferred providers are also called in-network providers. With a PPO, you can go to a doctor or hospital that is not on the preferred provider list.
The most popular type of employer sponsored health insurance.
What are Point of Service Plans?
POS stands for “point of service,” which refers to the provider of the healthcare services. They’re called point-of-service insurance plans because at each point you need healthcare services, you can decide whether or not to stay in the network. With this type of insurance, your costs all depend on that “point” of service, referring to the healthcare provider or medical facility.
What is the difference between a PPO and a POS?
PPO health insurance allows you more freedom to get care anywhere, while a POS plan may allow out-of-network care but demand a primary care referral. A PPO health insurance plan doesn’t typically require that you name a primary care provider to oversee your care.
What are Accountable Care Organizations?
Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve.
ACOs accept financial accountability for their services (shared risks and benefits) which helps promote quality care
(some private insurers also use this model)
What is the Patient Centered Medical Home Model?
The patient-centered medical home (PCMH) model is an approach to delivering high-quality, cost-effective primary care. Using a patient-centered, culturally appropriate, and team-based approach, the PCMH model coordinates patient care across the health system.
These receive fee for service as well as incentive pay for quality measures
What is the Veteran’s Health Administration?
The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,321 health care facilities, including 172 medical centers and 1,138 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.
What is TRICARE?
TRICARE is the uniformed services health care program for active duty service members (ADSMs), active duty family members (ADFMs), National Guard and Reserve members and their family members, retirees and retiree family members, survivors, and certain former spouses worldwide.
What is CHAMPVA?
CHAMPVA is a Department of Veterans Affairs health care program. It covers the spouse, widow, or widower and dependent children of disabled or deceased disabled veterans.
How many Americans were unemployed in 2019?
28.9 million (10.9% of the population) - steadily increasing since 2016
What is eligibility criteria for Medicaid in Georgia?
Low income and:
pregnant
child or teen
age 65+
legally blind
disabled
nursing home care
What is Georgia Pathways to Coverage?
a new program to help low-income Georgians Qualify for Medicaid who otherwise would not qualify for traditional Medicaid.
Must prove you engage in 80 hours per month of certain activities (including employment, on the job training, job readiness training, community service, vocational education, or higher education)
Must also be 19 to 65, a Georgia resident, have income of 100% FPL or less, not be incarcerated, and not be eligible for any other medicaid
What is the current FPL in Georgia (as of 2/2024)?
14,580 for individuals
19,720 for family of 2
24,860 for family of 3
30,000 for family of 4
35,140 for family of 5
40,280 for family of 6
45,420 for family of 7
50,560 for family of 8
Beyond this, add 5,140 per person
