Health Care Reform Flashcards
What comprises US health insurance?
Job-based private insurance (employed)
Individual private insurance (typically small-employer, unemployed)
Medicare (over 65 years old or disabled)
Medicaid (poor)
VA insurance (military veterans)
Roughly how many Americans do not have health insurance
30 million
Describe what private insurance is
Protection against big medical expenses
Utilizes risk pooling: healthy subsidize sick
Cost of policy typically shared by employer and employee
Insurance company helps cover health expenses incurred by enrollees
Define premium
Cost of the policy
Define deductible
Out-of-pocket amount that patient must pay before insurance kicks in
Define co-pay
Upfront fixed amount to access certain health services (ex: $40 co-pay for office visit, $20 co-pay for prescription meds)
Define co-insurance
Percent patient pays after deductible is met (ex: 80/20 policy: insurance pays 80%, patient pays 20%)
What are some private insurance models?
Fee-for-service
HMO’s
HSA + high-deductible plan
Define fee-for-service (private insurance)
Is the traditional model
Providers bill insurance for each individual service (insurance company reviews each item, decides whether to authorize payment)
Is expensive, administratively burdensome (providers/hospitals have incentive to deliver more procedures, tests, services; difficult for insurance company to limit costs)
Define HMO
HMO = Health Maintenance Organization
“Managed care”: a cost containment model
Requires use of in-network providers, hospitals, labs
In-network providers (employees or contract with HMO at a discount)
Primary providers as gatekeepers (control specialist referrals, labs, imaging AKA control excessive cost spending)
Define High-deductible plan + HSA
Is the current trend
High-deductible plan: less expensive, shifts cost to the individual, aims to reduce utilization, barrier to care
Health savings accounts (HSA): individual makes pre-tax contribution to a personal health account (AKA still comes from paycheck), can be used toward out-of-pocket expenses not covered by insurance (deductibles, co-pays)
Problems with job-based insurance for employers
Huge cost burden
Increasing costs limit growth, hiring and wages
Problems with job-based insurance for employees
“Job lock”: can’t leave dead-end job because you need the insurance
If you lose your job, you lose your insurance
Name some types of public US health insurance
Medicare, Medicaid, Veteran Administration
Define Medicare
Health insurance financed by federal government (no state funding only federal)
Enacted in 1965
Eligibility: 65 years old and older, permanently disabled, chronic renal disease
Parts A, B, C, D
Define Medicare Part A
All Americans enrolled at 65
Covered services: hospitalization, skilled nursing facility up to 100 days, home health care, hospice care
Financing: payroll tax (employers and employees 1.45% each (3% total)), patient deductibles, copays
Define Medicare Part B
Optional extra coverage for additional premium ($165/month in 2023)
Covered services: provider services, outpatient tests, medical equipment, PT/OT
Define Medicare Part C
“Medicare Advantage”
Individual pays additional premium to enroll in private HMO (a secondary insurance to Medicare)
Government pays HMO a lump sum per beneficiary per month; HMO then administers the insurance
More costly to government than traditional Medicare
Define Medicare Part D
Prescription drug benefit
Enacted 2003
Pay additional premium
Administered by private insurance
Government not allowed to negotiate prices with drug companies (disadvantage to expensive drugs that patients may need)
Define Medicaid
Health insurance for the poor, enacted 1965: low income families with children, poor pregnant women, disabled, blind
Expanded coverage under ACA (in states that have opted in)
Federal program, administered by states (financing shared between federal and state governments)
Minnesota’s program: “Medical Assistance”
Medicaid problems?
Low reimbursement rates (<70% of Medicare rates)
Many providers won’t take Medicaid patients –> restricted access to care –> patients often go to ED’s, county hospitals, community clinics
Cost of US healthcare/health insurance?
17.7% of GDP (2x as much as other democracies)
Unaffordable for many (average family premium: $22,400)
___% of bankruptcies are related to medical bankruptcies
67%
___ people in America are saddled with health care debt
100 million
