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Health Services > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

Who does medicare cover?

A

coverage for elderly, disabled, and end-stage renal disease (ESRD)

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2
Q

What percentage of the total federal spending is spent on medicare?

A

15%

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3
Q

Who is medicare administered by?

A

federal government

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4
Q

When was medicare originally established?

A

1965

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5
Q

when did medicare expand to cover disabled and ESRD as well as the elderly?

A

1972

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6
Q

What does medicare part A cover?

A

inpatient hospital care (Room and board, nursing services)

skilled nursing facility, home health services, and hospice care

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7
Q

When is the initial enrollment period for part A?

A

3 months - 65 - 3 months

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8
Q

are there premiums in part A?

A

most beneficiaries do not pay monthly premiums

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9
Q

is there an out-of-pocket maximum for part A?

A

No

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10
Q

cost-sharing for part A…

A
  • part A deductible

- coinsurance

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11
Q

What does Medicare part B cover?

A
  • doctor’s services, x-rays, lab tests, home health services, preventive care services, durable medical equipment
  • some prescription drugs
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12
Q

initial enrollment for part B?

A

3 months - 65 - 3 months

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13
Q

are there premiums in part B?

A

monthly premium of $134 - $428 in 2018

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14
Q

is there an out-of-pocket maximum for part B?

A

No

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15
Q

cost-sharing for part B…

A
  • part b deductible
  • coinsurance (typically 20%)
  • waived for most covered preventive care services
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16
Q

examples of services not covered by medicare:

A
  • hearing aids
  • eye examinations related to prescribing glasses
  • eyeglasses/contact lenses
  • dental - cleanings, fillings, tooth extractions, dentures
  • long-term care
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17
Q

medicare supplement insurance is also known as…

A

Medigap policy

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18
Q

what does medicare supplement insurance help pay?

A

helps pay Medicare Part A and Part B cost-sharing

- does not cover hearing aids, eyeglasses, dental care, long-term care

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19
Q

what parts must you have to enroll in a medicare supplement insurance?

A

must have Part A and Part B

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20
Q

is there a premium for medicare supplement insurance?

A

beneficiaries pay monthly premiums

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21
Q

what does Medicare part D cover?

A
  • outpatient prescription drugs

- does not cover over-the-counter drugs

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22
Q

vaccines are covered by part B when…

A

if directly related to treatment of an injury or direct exposure to a disease or condition

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23
Q

vaccines are covered by part D when….

A

in absence of injury or direct exposure (ex. preventive vaccination) ex. shingles

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24
Q

when is hepatitis B vaccine covered by part B?

A

for beneficiaries at high or medium risk of contracting hepatitis B

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25
Q

when is hepatitis B vaccine covered by part D?

A

for beneficiaries at low risk of contracting hepatitis B

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26
Q

immunosuppressant drugs following kidney transplant covered by part B if….

A
  • enrolled in part A at time of transplant
  • transplant met Medicare coverage criteria
  • enrolled in part B when drugs dispensed
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27
Q

immunosuppressant drugs following kidney transplant covered by part D if….

A
  • not enrolled in part A at time of transplant
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28
Q

Do medicare beneficiaries choose their part D plan?

A

yes – plans differ by covered drugs, cost-sharing, and pharmacies
- choice of plan depends where you live (regions) – regions include 1 or more states

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29
Q

to enroll in part D you must…

A

be enrolled in part A OR part B

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30
Q

initial enrollment period for part D

A

3 months - 65 - 3 months

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31
Q

what/when is the open enrollment period for part D?

A
  • can join, switch plans, or leave a plan

- October 15 - December 7

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32
Q

what is unique to part D?

A
  • initial coverage limit
  • coverage gap/doughnut hole
  • catastrophic coverage threshold
  • catastrophic coverage
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33
Q

is there an out-of-pocket maximum for part D?

A

no

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34
Q

cost-sharing for part D…

A
  • deductible

- copayment and/or coinsurance

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35
Q

What is medicaid?

A

a public health insurance for low income individuals

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36
Q

who administers medicaid?

A

state administers the program but must follow federal guidelines

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37
Q

is state participation in medicaid voluntary?

A

yes - but all states have participated since 1982

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38
Q

what does medicaid being an entitlement program mean?

A

states must cover all individuals who meet the eligibility criteria and enroll
- poses a challenge when the economy is bad

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39
Q

what are the two different managed care organization Iowans can choose from currently?

A

Amerigroup and UnitedHealthCare

- starting in July 2019 = Iowa Total Care

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40
Q

how is medicaid funded?

A

jointly by the federal and state governments via an open-ended matching program

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41
Q

what is the percentage of costs paid by the federal government called?

A

FMAP - federal medical assistance percentage

  • varies by states but is currently 50-76%
  • some services and populations have higher FMAPs
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42
Q

who wasn’t eligible for medicaid pre-ACA?

A

childless adults and undocumented immigrants

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43
Q

when did the ACA begin?

A

January 1, 2014

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44
Q

what categorical eligibility was eliminated due to the ACA?

A

childless adults <65 years old would be eligible for the first time

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45
Q

who was still ineligible for medicaid under the ACA?

A

undocumented immigrants

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46
Q

the ACA increased the eligibility for children 6-18 and adults (parents/disabled) <65 to what?

A

133% of the FPL

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47
Q

when was the Affordable Care Act signed into law?

A

2010

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48
Q

what were the pre-ACA limited assets?

A
  • most states had eliminated asset limits for children and pregnant women
  • some states had eliminated asset limits for parents
  • asset limits in place for elderly and disabled
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49
Q

what are the limited assets that came from the ACA?

A
  • prohibited asset limits for children, parents, pregnant women, and childless adults
  • asset limits for elderly and some disabled still allowed
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50
Q

what did the supreme court rule was unconstitutional for the ACA medicaid program?

A

unconstitutional for the federal government to withhold funds for the state’s existing medicaid program if it did not proceed with the expansion

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51
Q

what became optional for state medicaid programs because of the supreme court ruling?

A
  • increased eligibility for adults <65 years old to 133% of FPL (OPTIONAL)
  • childless adults <65 years old would be eligible for the first time (<133% of FPL — OPTIONAL)
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52
Q

what was mandatory of the state medicaid programs from the supreme court ruling?

A
  • increased eligibility for children 6-18 years old to 133% of FPL (can be more, just NOT less)
  • pregnant women 133% FPL
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53
Q

Iowa medicaid expansion premiums are waived if…

A
  • complete health risk assessment

- get wellness exam or dental exam

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54
Q

Iowa medicaid monthly premiums (ACA):

A
  • <50% FPL = $0
  • 50-100% FPL = $5
  • 101-133% FPL = $10
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55
Q

in expansion states, what is available to low income adults age 19-64 not eligible for medicaid?

A
  • if earn <400% FPL, qualify for premium subsidies (Assistance) to purchase insurance through the ACA marketplace
  • employer based insurance, if offered and eligible
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56
Q

in non-expansion states, what is available to low income adults age 19-64 not eligible for medicaid?

A
  • employer based insurance, if offered and eligible
  • if earn 100-400% of FPL, qualify for premium subsidies to purchase insurance through the ACA marketplace
  • if earn less than 100% FPL, do NOT qualify for premium subsidies to purchase insurance through the ACA marketplace – coverage gap
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57
Q

what are the goals of state medicaid programs?

A
  • controlling total health care costs

- while maintaining access to health care services for their vulnerable populations

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58
Q

who can be enrolled in both medicaid and medicare - “dual eligible”?

A

low income:

  • elderly
  • disabled
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59
Q

what acts as the supplement coverage for dual eligibles?

A

medicaid acts as the supplement
- medicaid provides coverage for services that are not covered by Medicare (custodial nursing home care) and covers costs not covered by Medicare (medicare premiums and cost-sharing)

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60
Q

Part D and dual eligibles:

A
  • are required to enroll in medicare part D
  • are not responsible for part D premiums or deductibles (for certain plans)
  • are responsible for part D copayments
  • have part D out-of-pocket maximum (medicare beneficiaries usually do not have this)
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61
Q

what is CHIP?

A

Children’s Health Insurance Program

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62
Q

CHIP background…

A
  • established by the balanced budget act of 1997

- expand public health insurance for children

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63
Q

what is different about CHIP and medicaid?

A
  • federal funds are capped for each state for CHIP but not for medicaid
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64
Q

how does CHIP get financed?

A
  • states administer the program (participation is voluntary)
  • receive federal funds for the program but must follow federal guidelines to get those funds
  • states must contribute their own funds toward the program in addition to federal funds
  • federal matching rate is higher for CHIP than for medicaid
  • federal funds are capped for each state. each state receives a yearly allotment
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65
Q

what can states do with the CHIP funding?

A

states can use the CHIP funds to expand medicaid eligibility (CHIP-funded medicaid expansion), create a separate CHIP, or both

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66
Q

Separate CHIP

A
  • states have flexibility in choosing services to cover in a separate CHIP, but there are some services they must cover (child well care)
  • state may use premiums and cost-sharing in a separate CHIP
  • a separate CHIP is NOT an entitlement program like medicaid and therefore states may cap enrollment and have waiting lists
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67
Q

what is the separate CHIP in Iowa called?

A

Healthy and Well Kids in Iowa (Hawk-i)

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68
Q

how are hawk-i children covered?

A
  • premiums depends on family income

- coverage through one of the two medicaid managed care organizations

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69
Q

does CHIP need to be reauthorized periodically?

A

yes

70
Q

what does VHA stand for?

A

veterans health administration

71
Q

what is the VHA?

A
  • provides health care benefits for veterans
  • largest health care system in the US
  • composed of medical centers, community-based outpatient clinics, and other facilities
  • employs physicians, PAs, NPs, nurses, pharmacists, etc.
72
Q

VHA eligibility?

A
  • served in active military, naval, or air service
  • cannot be dishonorably discharged
  • meet minimum duty requirements
73
Q

service-connected disability

A

veteran applied for and was granted a disability rating for a condition that developed or was exacerbated while in the military

74
Q

higher spending on prescriptions translates to what?

A

higher premiums

75
Q

formulary defintion

A

a listing of drug products that are covered under an insurance plan

76
Q

drugs on a formulary are often categorized into what?

A

tiers

77
Q

health insurers are very UNLIKELY to pay for hospital stays by which method?

A

per service

78
Q

how does medicare usually pay for hospital stays?

A

per episode

79
Q

physicians are typically paid per what?

A

per service

80
Q

third party payers

A

a business - providing some kind of service/good (want to be profitable, but also want to satisfy their costumers because there is competition with the other many insurance companies)

81
Q

will the penalty for delay enrollment in part B end?

A

no - not as long as you are still enrolled in part B and AMOUNT depends on how long after the initial enrollment period the beneficiary enrolled

82
Q

will the penalty for delay enrollment in part A end?

A

yes - will not last forever and DURATION depends on how long after the initial enrollment period the beneficiary enrolled

83
Q

doughnut hole in part D:

A
  • beneficiary is responsible for 100% of the cost (pay until you reach the catastrophic coverage threshold)
  • to help reduce the expenses that Medicare spends, they had to implement the doughnut hole
84
Q

is there an out-of-pocket maximum for beneficiaries in Medicare Advantage for part A and part B?

A

yes there is

85
Q

what are the medicare advantage premiums?

A
  • pay the monthly part B premium

- pay an extra monthly premium charged by medicare advantage plan (Depends on plan chosen)

86
Q

what must you be enrolled in to enroll in medicare advantage?

A

part A AND part B

87
Q

when is the open enrollment period for medicare part D?

A

October 15 to December 7

88
Q

when is the open enrollment period for medicare advantage?

A

October 15 to December 7

89
Q

what is the majority of Medicaid expenditures for?

A

acute care

90
Q

what public insurance helps pay for long-term care (nursing home care)?

A

medicaid does

medicare does not

91
Q

what does open-ended matching for medicaid mean?

A

there is no cap on what the federal government will pay

92
Q

what group of people were not affected by the ACA?

A

the elderly

93
Q

medicare part D are more worried about what when it comes to assigning tiers?

A

cost of the drugs (don’t have to worry about the long-term value of the drug as much)

94
Q

assignment to tiers can be based on what?

A

cost of the drug (less expensive drugs are assigned to lower tiers)
value of the drug (more valuable drugs are assigned to lower tiers)

95
Q

specialty drugs

A
  • high cost
  • difficult to administer
  • requires special handling
  • requires ongoing clinical monitoring
  • usually is injectable drugs but growing for oral drugs as well
96
Q

specialty drugs insurance coverage/tier

A
  • may see a formulary tier composed solely of specialty drugs (with cost-sharing specific to that tier)
  • speciality drugs may be covered under the medical benefit or the drug benefit
  • if covered under drug benefit, may use same drug utilization management strategies used with traditional drugs
97
Q

what is a PBM?

A
  • pharmacy benefit manager – a organization that provides administrative and other services associated with processing prescription drug claims and managing a pharmacy benefit
  • NOT an insurance company
  • hired by health insurance companies and self-funded employers
98
Q

rebates

A

are payments made by pharmaceutical manufacturers in exchange for favorable placement of their products on formularies

99
Q

purpose for formularies

A
  • garner rebates
  • encourage selection of more cost-effective drug over less cost-effective drug
  • encourage selection of a drug with a better safety profile
100
Q

how does an insurer get a pharmacy to accept even lower reimbursements?

A

offer pharmacy inclusion in the preferred pharmacy network

101
Q

overview of PBM services

A
  • processing of prescription drug claims
  • drug utilization management
  • pharmacy network management
  • rebate negotiation
102
Q

PBM market is dominated by which 3 firms?

A
  • express scripts (Stand-alone PBM)
  • CVS/caremark (ownership by pharmacy chains – CVS purchased Caremark)
  • OptumRx (ownership by insurance companies – UnitedHealth)
103
Q

historically PBMs were owned by what?

A

pharmaceutical manufacturers (not anymore)

104
Q

current PBM revenue

A
  • administration fees
  • “spread” differences
  • rebates from pharmaceutical manufacturers
105
Q

PBM pricing “spread”

A
  • difference between what the PBM pays the pharmacy and what the PBM charges the client for the same prescription
106
Q

purpose of cost-sharing

A
  • encourage patients to purchase drugs they value and intend to use
  • reduce costs to insurer of purchasing drugs
107
Q

days supply limitations purpose

A

control the amount of medication that can be obtained at one fill

108
Q

quantity limits purpose

A

control how much of a medication will be reimbursed for a given number of days of therapy

109
Q

prior authorization purpose

A

criteria that have to be met before an insurer will pay for a drug
- cover the drug for certain individuals

110
Q

step therapy purpose

A

failure on one drug before insurer will pay for the desired drug
- cover the drug for certain individuals

111
Q

prospective drug utilization review purpose

A

make adjustments to medication prior to dispensing

112
Q

medication therapy management purpose

A

maximize safety and effectiveness of drug therapy

113
Q

exceptions to drug utilization management tools purpose

A

formulary exception

tier exception

114
Q

experience rating

A

a person’s premium is based on their own expected costs (Ex. people in poor health or with more health risk factors pay higher premiums than healthier people

115
Q

pure community rating

A

a person’s premium is based on the average expected claims in their geographic area. Premiums are not based on health status so sicker people pay the same premiums as healthier people

116
Q

modified community rating

A

allow premium variation on selected characteristics that are related to health (Ex. smoking status), but restrict premium variation based explicitly on health status

117
Q

who pays for employer-based insurance?

A
  • employer pays large share
  • employee pays some too
  • federal / state government (tax subsidies)
118
Q

pure community rating is mostly used in what insurance program?

A

Medicare and Medicare part D

119
Q

what is the biggest concern in pure community rating?

A

adverse selection –

healthy people leaving the pool

120
Q

Under ERISA (a federal regulation)…

A

self-insured plans avoid state insurance regulation

121
Q

self-funded plan

A

employer is the insurance company (they pay all the healthcare costs of their employees) ex. U of I (LARGE employers)

122
Q

premiums vary across employers and depend on things such as:

A

comprehensiveness of coverage, health care costs in the area, and health status of the employees

123
Q

employees costs for health insurance is increasing faster than what?

A

their earnings

Deductibles increasing the most

124
Q

is there a higher dollar subsidy for family coverage or single coverage?

A

much higher dollar subsidy for family coverage

125
Q

Why would the government subsidize the purchase of health care?

A
  • The prices are going up so much for everybody – want people to be insured
  • It would lessen the adverse selection problem (healthy people would be more likely to stay in the market)
  • Negative externalities – more ER visits from people who cannot afford care (which are very expensive)
    …People might not get treatment for contagious diseases so it would spread to everybody
126
Q

What is our current system for employer-based insurance like for subsidies?

A

everybody gets a subsidy (more income = more subsidy)

127
Q

What is the ACA market like for subsidies?

A

only low income get subsidies

128
Q

the government spends almost the same amount on subsidies for Medicaid/CHIP as it does for employer based insurance coverage T/F??

A

true

129
Q

what groups of workers will be most affected by the “Cadillac” tax?

A
  • Employers with a lot of older, sicker workers would have higher premiums
  • Occupations with a high risk of injuries
  • Employers that have a difficulty hiring people – need the incentive
  • Auto-workers (union workers) – have very comprehensive & generous coverage plans (more expensive)
130
Q

“cadillac” tax

A

beginning in 2022, 40% excise tax on employer health insurance premiums above a designated threshold
(Everybody above this threshold will have to pay this tax)

131
Q

what employers struggle to offer health insurance?

A

small employers and employers with many low wage workers (McDonalds, Walmart)

132
Q

what is the ACA “mandate” for larger employers?

A

“shared responsibility” requirement where employers with 50 or more employees must pay a penalty if they fail to offer full time employees affordable, comprehensive coverage
(largest effect is on the 50-100 employee firms and on firms with many low wage workers)

133
Q

why was the “mandate” included in the ACA?

A

Primarily didn’t want employers to be dumping the sicker employees on the self-insured market (exchange net)

134
Q

what are the “big 6” regulations for employer AND individual plans?

A
  1. guaranteed issue
  2. dependents can stay on parents’ insurance plan until age 26
  3. no pre-existing condition coverage exclusions
  4. free preventive care for all new plans ex. BC (not for grandfathered plans)
  5. out of pocket maximums
  6. no lifetime maximum and elimination of annual limits (not for grandfathered plans)
135
Q

ACA effect on small employers (less than 50 employees)

A
  • not subject to employer insurance mandate, but must follow the “big 6” new insurance regulations
  • change from experience rating (in most states) to modified community rating
  • creation of state level exchanges (marketplaces)
  • some small employers receive subsidies to help them purchase insurance
136
Q

what is individual health insurance?

A
  • insurance purchased directly from an insurer and not obtained through an employer or public program (can be single or family coverage)
  • the ACA increased the number of people with individual insurance
137
Q

ACA effects on the individual insurance market:

A
  • Created American health benefit exchanges (insurance marketplaces)
  • Insurance may be purchased through the exchange or off the exchange, but premium and cost-sharing subsidies ONLY available through the exchanges.
  • Insurance exchanges are a way to present information to consumers, organize the sale of insurance, and encourage competition.
138
Q

In the ACA, the states set rules for the exchanges under federal guidelines:

A
  • Federal government runs the exchanges if states opt not to create the exchanges.
  • Most states unwilling to or incapable of running their own exchanges.
  • Some rules for insurance sold on the exchanges were in the ACA, but others were determined by at a later date. There have been many rule changes in the last two years.
139
Q

ACA Rules for all New Individual Health Insurance Plans:

A
  • Modified community rating where premiums may only vary by age (1 : 3), geographic area, tobacco use (1 : 1.5), and number of family members.
  • All new plans must cover essential health benefits.
  • Specified coverage tiers.
  • Minimum loss ratio. Plans must spend at least 80% of premiums on health care costs and quality improvement.
  • Also must follow Big 6 insurance rules.
140
Q

New insurance policies sold on and off the exchanges must follow same rules. Why does this matter?

A

If the market isn’t regulated, the experience rating will always dominate (healthy, young people will buy this because it is based on your health status) and modified community rating would fail

141
Q

Essential health benefits defined in the ACA law.

A

10 categories of essential benefits. Of note, maternity care, mental health services, and prescription drugs are considered essential.

142
Q

Why have list of essential benefits?

A
  • Knew there was an adverse selection problem

- Makes it easier to comparison shop when all the plans have to cover these main buckets

143
Q

Who wanted a more specific list of essential benefits?

A

Physicians – they wanted their work to be covered/paid for too

144
Q

Catastrophic plans

A

high deductible health plans (only available for people under the age of 30)

145
Q

Does same actuarial value mean that the plans are the same?

A

NO

146
Q

if you are generally a sick person what type of insurance plan would you want?

A

low deductible plan (low out-of-pocket maximum plan)

147
Q

what is the premium tax credit based on?

A

based on the cost of the second lowest cost silver plan in the area, so the amount of tax credit varies geographically

148
Q

Pros of Medicare advantage:

A

Out of pocket maximums for A and B services
Likely covers more services than original Medicare (hearing, dental, vision)
Only dealing with one plan (simplicity)
Choice of plans

149
Q

Cons of Medicare Advantage:

A

More limited choice of providers
Chance there may not be network providers where you go to get treatment
Complexity of comparing (differ on many aspects)
Not steady, reliable like traditional Medicare  providers can move in and out of network in Medicare Advantage

150
Q

If manufacturer wants its drugs covered by state Medicaid programs it has to what?

A

it has to participate in the rebate program
In exchange, states must generally cover all drugs made by participating manufacturers
(Applies to brand and generic manufacturers)

151
Q

the formulary for medicaid is determined by what?

A

by manufacturer participation

152
Q

how many tiers are on the medicaid PDL?

A

2 tiers - preferred and non-preferred drugs

non-preferred drugs require PAs

153
Q

If a manufacturer wants its drugs to be preferred drugs, it has to offer what? (medicaid PDL)

A

it has to offer supplemental rebates (above and beyond federally mandated rebates)
Why Medicaid populations get brand name drugs over generic drugs (it costs the state less because of the rebates)

154
Q

cost-sharing for prescription drugs is allowed for who in medicaid?

A

adults

155
Q

medicare part D formularies

A
  • Each Medicare Part D plan maintains its own formulary
  • Tiered formularies with tiered cost-sharing are allowed
  • Medicare Part D plans are allowed to negotiate rebates from pharmaceutical manufacturers.
156
Q

what is public health?

A

what we as a society do collectively to assure the conditions in which people can be healthy (physical, mental, and social well-being)

157
Q

medical model vs. public health model

A

medical model: services provided to an individual (one person)
public health model: services provided to a population (many people)

158
Q

what are the 3 core functions of public health?

A

assessment, policy development, and assurance

159
Q

assessment of public health

A
  • assessment of health status and health needs

- Systematically collect, analyze, and make available information on healthy communities

160
Q

policy development of public health

A

Promote the use of a scientific knowledge base in policy and decision making

161
Q

assurance in public health

A
  • Ensure provision of services to those in need

- assurance that necessary services are provided

162
Q

macro-level public health

A
  • Planning level
  • Emphasize the assessment and prioritization of a community’s health-related needs as well as planning to address those needs.
  • Example: working with community representatives in identifying health-related community problems
163
Q

micro-level public health

A
  • Implementation level
  • All the activities required to implement public health initiatives. Many of these services are performed on a provider-to-patient or a program-to-population basis, usually with a specific health-related outcome in mind.
  • Example: disease screening
164
Q

primary prevention

A
  • Prevents an illness or injury from occurring at all, by preventing exposure to risk factors
  • Reducing the actual incidence and occurrence of diseases, injuries, and disability
165
Q

secondary prevention

A
  • Seeks to minimize the severity of the illness or the damage due to an injury-causing event once the event has occurred.
  • Decreasing the severity or progression of the disease, injury, and disability
166
Q

tertiary prevention

A
  • Seeks to minimize disability by providing medical care and rehabilitation services.
  • Treatment or rehabilitation to return the disease, injury, or disability to the initial or baseline state
167
Q

What is the impact of the decision not to pay the cost-sharing subsidies?

A
  • Under the ACA, the cost-sharing subsidies must be given to eligible individuals, so they still get them.
  • Insurers now must pay for the subsidies out of the money they collect for premiums.
  • Insurers increased premiums to compensate.
  • “Silver loading” was common.
  • People who were not eligible for cost-sharing subsidies were often better off switching to a non-silver plan.
  • Ironically, the federal government still pays the cost of the cost-sharing subsidies indirectly because they pay premium subsidies and the cost-sharing subsidies are now factored into the premiums.
168
Q

results of “silver loading”

A
  • Some gold plans had lower premiums than silver plans, even though they have a higher actuarial value.
  • Since premium subsidy amounts are based on the cost of the second lowest silver plan, the average premium subsidy amount increased.
  • Could’ve cost the government less to keep paying for the cost-sharing subsidies instead of the premium subsidies
169
Q

what are consequences of the repeal of the individual mandate?

A
  • it will affect the individual health insurance market the most (premiums will go up for individual private insurance)
  • Healthy people not eligible for subsidies would most likely drop out
170
Q

What are problems Mr. Lang is facing?

A
  • He chose to be uninsured because he was relatively healthy and made a good amount of money
  • He missed the open enrollment period
  • He is in the coverage gap so he is unavailable for subsidies
  • He is under 100% FPL (he is in a non-expansion state) so not eligible for Medicaid in his state
  • If he goes blind he would be eligible for Medicare and disability insurance
  • 2 year waiting process for disability insurance and a long process
171
Q

what is working in the ACA?

A
  • Number of uninsured is at an all-time low.
  • The process for purchasing individual health insurance is much simpler.
  • Possible for people in poor health to get health insurance.
  • Less uncompensated care for hospitals, particularly in states that expanded Medicaid.
  • Some improvement in the availability of affordable, comprehensive health insurance for low wage workers.
172
Q

what is not working under the ACA?

A
  • Still have very high health care costs.
  • Coverage gap in states that did not expand Medicaid.
  • Still have ~10% of the population that is uninsured.
  • Individual health insurance market still has significant problems.
  • Large premium increases.
  • Especially problematic for people who are not eligible for premium subsidies.
  • Narrow network plans.
  • Large deductibles create access problems for some patients.
  • Insurers leaving the exchange markets.
  • Changing rules create market instability.

Health Services (1 decks)

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