hpm 211

Question 1

Federally Qualified Health Centers

Answer 1

Relies on hrsa
Receives cost-based, enhanced reimbursement from Medicaid

Question 2

HRSA Criteria:

Answer 2

Serves in a medically-underserved area or serves a medically-underserved population (low-income urban, rural, HIV+, migrant workers, LGBT, etc.)
Governing board at least 51% patients
Non-profit or public
Takes all patients, regardless of ability to pay / immigrant status

Question 3

DSH payments:

Answer 3

• Federal funds provided via Medicaid & Medicare to help hospitals caring for a disproportionate share of low-income and publicly-insured patients
• States decide how to disperse to qualifying hospitals: mostly non profit hospitals

Question 4

Safety net definition:

Answer 4

Providers who either by legal mandate or explicitly adopted mission they maintain an ‘open door,’ offering access to services for patients regardless of their ability to pay;

Question 5

Vulnerable populations/ why they matter

Answer 5

defined by race/ethnicity, socio-economic status, geography, gender, age, disability status, risk status related to sex and gender, and other populations identified as at-risk for health disparities.
They matters because of how policy impacts the population/definition

Question 6

Voltage Drop Barriers to care from Eisenberg and Power

Answer 6

• The different voltage drops subset/transition into the next
  -Ensuring high-quality health care requires that each of these “voltage drops” be recognized and addressed.

Question 7

Who lacks health insurance:

Answer 7

40 million uninsured pre aca
This number drops to 25 million after ACA

Question 8

Insurance coverage by age:

Answer 8

-65+ is more covered because of medicare
- children because of chip
- Non-elderly childless-adult lacks coverage

Question 9

Independent risk factors for being uninsured:

Answer 9

income, citizenship, age, education level, race/ethnicity

Question 10

Causes of uninsured status:

Answer 10

affordability, cultural barriers, lack of knowledge, eligibility for public programs

Question 11

Churning

Answer 11

• transition between different types of coverage and/or becoming uninsured.
• More gaps in non expansion states due to churning

Question 12

What does insurance do:

Answer 12

• Strong evidence that it improves financial burden, care access, and utilization.
• Fairly good evidence that it impacts health and mortality. Bens paper shows that theres a 3% decline statewide
• Expanding health insurance does impact health disparities that are related to insurance status

Question 13

Insurance does not:

Answer 13

-Expanding health insurance will not save us money
-Does not impact large health disparities

Question 14

Oregon health insurance experiment:

Answer 14

-study showed that Medicaid coverage generated no significant improvements in measured physical health outcomes (no statistically significant change in diabetes control, cholesterol, or blood pressure)in the first 2 years,
-but it did increase use of health care services, raise rates of diabetes detection and management, lower rates of depression, and reduce financial strain.

Question 15

Kosnick paper on insurance impacts:

Answer 15

Study showed no mortality impact of health insurance

Question 16

Sommers paper on insurance impacts:

Answer 16

3% decline in mortality statewide (esp in low-income counties and for health-care amenable causes)
- improvements in self-reported health, usual source of care, and physician’s visit in past year

Question 17

Pre aca medicaid requirements:

Answer 17

Low Income and some other eligibility category - disabled, pregnant,

Question 18

Post ACA mediciad:

Answer 18

-ACA took away the categorical requirements.
-Expanded to all citizens up to 138 FPL.

Question 19

Medicaid expansion in 2023:

Answer 19

40 states expanded, 1 pending, 10 states have not expanded and it is an equity issue across states

Question 20

medicaid expansion status in 2014

Answer 20

23 states did not expand, 26 did, 2 maybes

Question 21

Coverage gap for non expansion states:

Answer 21

The options are Medicaid or marketplace; but there is a gap inbetween
-In states that didn’t expand, there is a coverage gap for childless adults. 44% -100% fpl do not have a place to get coverage

Question 22

Medicaid benefits:

Answer 22

Medicaid is the Only payer for long term care. Medicare does not.
Federal requirements: outpatient, inpatient, ER, maternity, and long-term care
Federal limits on cost-sharing (5% income)
Optional benefits: drugs (though all states offer), vision, dental, medical equipment

Question 23

Section 1115 wavers

Answer 23

trial periods for new things to add on to medicaid coverage
- experimental, pilot, or demonstration projects
- Approved by CMS for 5-year periods

Question 24

Medicaid managed care:

Answer 24

private payer gets capitated funds from state to provide coverage
Per member per month payment to private payer
Now covers 70% of beneficiaries
Studies on medicaid mcos are mixed:

Question 25

MCO state pros/cons

Answer 25

State Pros: budget predictability, improve incentives for cost containment, delegate to private sector
State Cons: resources spent on selection and overhead

Question 26

MCO Beneficiaries pros/cons

Answer 26

Beneficiaries pros: focus on preventive care, oversight and care coordination
Beneficiaries cons: limited provider networks, inexperience of private plans in caring for the Medicaid population

Question 27

Medicaid take-up with ACA

Answer 27

Take up of medicaid is not 100% even with aca
86% of children, 62% of eligible adults

Question 28

Medicaid Churn

Answer 28

• Persists regardless of what coverage besides medicare
• 28% of children leave medicaid after a year, 50% of adults leave after 2 years

Question 29

Medicaid churn causes and solutions

Answer 29

Causes: Variable incomes (Medicaid calculates monthly), multiple programs (CHIP/Medicaid), intentional cost saving policies
Solutions: Guaranteed 12 month coverage, less onerous renewals, automated processes, integrate systems (CHIP/Medicaid)

Question 30

Medicaidchallenegs - causes and solutions to access to care -
Patient side:

Answer 30

Causes: transportation, language barriers, competing life priorities, no physician will take insurance
Solutions: wrap around services, physician workforce diversity

Question 31

Access to care - Provider side:

Answer 31

• Pay all providers more
• Pay certain providers more
• ACA increased Medicaid primary care to Medicare rates for 2013-2014 – most states didn’t continue this

Question 32

Where can states cut medicaid when budgets are tight?

Answer 32

Provider reimbursement, Payment to MC plans, Optional eligibility groups, Optional benefits (vision, dental, transport, etc.)

Question 33

Changes under ACA

Answer 33

New insurance regulations - adults 26 stay on/ adds healthier individuals to risk pool
Eliminates pre-existing condition exclusions
Eliminates lifetime or annual limits on benefits
Premiums based only on age/smoking status (not gender)
No cost-sharing for certain preventive visits
Standardized benefits – “Essential Health Benefits” including maternity, drug RXs, home-based service, child

Question 34

ACA effects mortality:

Answer 34

Strong evidence on health insurance and mortality: IRS goldman study
Insurance gained via nongroup private coverage (i.e. Marketplaces)
Led to increased rates of office visits and prescriptions filled
Increased diagnoses of high BP & cholesterol

Question 35

how many people on medicare?

Answer 35

63 million

Question 36

medicare part A

Answer 36

hospital care/INSURANCE and tied to payroll tax (traditional)
0$ premium
no out of pocket cap

Question 37

Medicare part b

Answer 37

outpatient care and doctor services - if you do not have to have part b and usually it is because the person is still working.
no out of pocket cap
20% coinsurance after deducitble

Question 38

medicare part c

Answer 38

• medicare advantage - bundles A, B and through a private provider that follows medicare rules
  many plans to choose from
• has an out-of-pocket cap
  there are Medicare advantage part d plans

Question 39

medicare part D

Answer 39

optional prescriptions drug plan
“Donut Hole” was a portion of drug spending without any
coverage, that was eliminated by the ACA

Question 40

Medicare problems:

Answer 40

Medicare Cost sharing is high: and medicare individuals have limited assets
- Can purchase medigap for cost sharing - but very expensive and tight window to enroll

• You lock into traditional or medicare advantage - both have problems
• Lots of choice in MA- which is a hurdle
• Most physicians take traditional medicare; Medicare advantage can have issues with that
• No long term care
• No dental hearing vision

Question 41

medigap

Answer 41

• Can purchase medigap for cost sharing - but very expensive and tight window to enroll
• 33% on traditional medicare have medigap

Question 42

Inflation reduction act

Answer 42

• Emerged from the failed efforts to pass the Build Back Better Act in 2022
• Included several key drug provisions
• including drug price negotiations