Update on Healthcare Financing and Coverage Flashcards
Describe the history of healthcare financing, insurance, government healthcare funding in the US.
Before insurance - patients expected to pay all health care costs out of their own pockets.
costs were low in the past compared to today bc US health expenditure as a % of GNP was way less (5%)
1920s
some hospitals offered services on a pre-paid plan
1929
the first employer-sponsored plan was created by teachers in Dallas, TX
1935
Social Security Act – no health coverage
WWII
employer-sponsored plans as a benefit dramatically
expanded as a direct result of wage controls
1946
Hill Burton Act – hospital construction
1948
President Truman proposes national health insurance
1954
tax deduction for employers in the Revenue Act
Entire health insurance system was built on the
employer sponsored model
– A system for the retired (Medicare) 1965
– A system for the poor (Medicaid) 1965
– A system for the self-employed who had to buy insurance on their own through exchanges (ACA) 2010
Describe the role of the ACA and the American Rescue Plan in expanding healthcare coverage to the uninsured in the US.
goals of the affordable care act:
* Improve Accessibility to Coverage
* Decrease number of uninsured
* Improved efficiency of providing care
* Improve Quality of Care
* Decrease Cost of Care
taxpayers did not like the ACA
30 day readmission penalties
- Historically 20% of Medicare patients are readmitted within 30 days
- Review of the data indicates 75% of readmission are preventable
- Savings to Medicare could be $12 billion/year
- ACA penalizes hospitals for excessive readmission
rates (3% in 2016) - Current diagnosis tracked: AMI, CHF, Pneumonia,
Knee/Hip Replacement, and COPD
History of medicare
- Lyndon B. Johnson, president from 1963-1968, made passage of Medicare his top legislative priority
- House vote: 307-116; Senate vote: 70-24
– Medicare was also a priority of JFK but lost by 4 votes in 1962. - President Harry Truman and his wife Bess were presented with the first two Medicare cards.
- Medicare and Medicaid were enacted as Title 18 and Title 19 of the Social Security Act.
– Signed into law on July 30, 1965
History of medicaid
– Begins January 1, 1966
– Health insurance for the poor and medically indigent of all ages.
* Inpatient; Outpatient;
* Not required - last state to implement – AZ in 1982
– Federal-State partnership program.
* Matching funds based on state per capita income - 50-83% (now up to 90%)
* Federal standards for services
* Managed by state govt
* Wide variation in the quality and range of services in various states.
developed into important aspect of nation’s social welfare program
Medicaid milestones
– 2014:
*ACA goes into affect expanding Medicaid eligibility for states that choose to opt in.
*Allows people with income up to 138% of FPL to qualify. ($17,775; $36,570 –family of 4)
*In 2022, > 50% of the nation’s uninsured live in states that have opted out of the expanded program.
*ACA and beyond: Healthcare and especially Medicaid has become somewhat of a political football.
Medicaid is comparable to ______ for access to care
private insurance
Medicaid per enrollee spending is significantly greater for
the elderly and individuals with disabilities compared to children and adults
Describe who is eligibility for Medicare enrollment.
Medicare: begins july 1, 1966
Health insurance for the elderly (≥65yo)
* Disabled
* People of all ages with End-Stage Renal Disease or Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s Disease); 19 million initially enrolled, no dental or eye benefits, no drug benefit for outpatients
Describe who is eligibility for Medicaid enrollment.
- Low-income families who meet certain state requirements. < 138% of FPL in IN
- Infants born to Medicaid-eligible pregnant women.
- Children <6 yo and pregnant women with incomes < 138% of FPL (varies by State - <158% in IN)
- Pregnant mothers are covered 12 months
after the pregnancy ends. - Certain Medicare beneficiaries.
Hoosier healthwise
children and pregnant women
Hoosier care connect
> 65 not eligible for medicare; blind; disabled
Traditional medicaid
> 65 eligible for medicare; LTC; home or community based waiver services
Healthy indiana plan
low income adults 19-64 with income < 138% FPL
National enrollment for Medicaid
- Mandatory Services: LTC, Hospital, Physician, Home Health, Prenatal care, Family
planning services - Optional Services: Pharmacy, Dental, ICF for mentally retarded; Mental health rehab
- Enrollment: ~85 million covered by Medicaid + CHIP; Assist 60% of all nursing home residents; Assist 40% of all childbirths (38% in Indiana)
National eligibility Medicaid
- 1/3 of all children are insured through
Medicaid. - 60% of low-income children insured through Medicaid
- While children are eligible for dental coverage, few dentists participate.
- ACA: Provides eligibility for most low-income adults
<65 with incomes <138% of FPL; Fed Gov pays 100% of expansion cost 2014-16, then declines to 90% in 2020?
Medicaid reimbursement is
100%
Who will contribute to higher medicare enrollment
an aging population
Describe the coverage of the different parts of Medicare.
Part A, B, C, D
spending on physician services and other part B services accounts for the largest share of medicare benefit spending
Part A
hospital coverage
– covers hospital costs
– No premium costs
– SNF care – max 100 days
– Some home health care; hospice care
Part B (medigap)
medical coverage
– Premium costs deducted from SS.
– covers physician costs – not required
– Medical supplies
– drugs admin in MD offices
Part C (medicare advantage)
– Parts A + B + D (May cover broader list of services)
– Managed care (private insurance companies)
Part D
prescription coverage
- drug benefit
- premium costs deducted from SS
Enrolling in part A
- Enrollment can begin about 3 months before 65th birthday; enrollees do not need to be retired.
- You do NOT have to enroll as long as you have a comparable insurance plan.
- Starts when you start receiving Social Security benefits.
- Most people receive Part A for free.
- Penalty for late enrollment – impact on part B.
What is not covered by part B?
- Long-term care
- Dental care
- Cosmetic surgery
- Eye examinations for prescribing glasses
- Routine foot care
- Hearing aids and exams
- Acupuncture
General rules for meds - parts A, B, or D?
– Where it will be used: Used in the hospital (A), doctor’s office (B) or used at home (D)
– What it is for?: For example: oral methotrexate used for arthritis (D) or as immunosuppressive / cancer treatment (B)?
– How it will be used?: For example: Insulin for pump (B) or Insulin for syringe (D)
Medigap - medicare supplement
- Not administered through CMS, but standardized by Federal law
- Picks up deductibles for Part A
- Picks up deductibles and copays for Part B
- Standard options in each state
- Purchased through private companies. – Premiums vary - $24 to $3,200
Explain the concept of Medicare advantage plans (Part C) and its advantages and disadvantages.
– Features similar to managed care plans on private market (premiums,
deductibles, networks, optional services)
– PAs very common
– Recently aggressively advertised with greatly expanded list of services.
total medicare advantage enrollment is increasing
Features of advantage plans
- Administered by private companies, but the beneficiary is
still considered enrolled in Medicare. - Premiums or the costs of services (co-pays and deductibles) can be lower than they are in Original Medicare or Original Medicare with a Medigap policy.
- They may offer extra benefits including vision and dental.
- Some plans include prescription benefits and may be at a cost lower than in the stand-alone Medicare Prescription Drug Plans (Part D).
- Coordinate your care, fewer choices, using networks and referrals potentially reducing cost of overall care.
- Ease of billing.
Medicare star rating system
- Used by CMS to measure how well Medicare
Advantage and Part D plans perform. - Plans are reviewed annually.
- 1to 5
- Rated on how well plans perform in the following categories:
– Staying healthy; screenings, tests, and vaccines.
– Managing chronic conditions.
– Plan responsiveness and care.
– Member complaints, problems getting services, and choosing to leave plan.
– Health plan customer services.
Medicare - Part D
- The largest change in insurance processing in retail pharmacy history.
- Millions who had no prescription drug coverage now had an option.
- Not a single entity. Beneficiaries need to voluntarily enroll and select a plan. – Average monthly cost = $41
- Run by private insurance companies, but CMS sets minimum standards.
- Formularies for each plan are DIFFERENT
– Not all Medicare approved drugs will be on formulary - Pharmacists can assist pts with their selection of plan.
this program was never funded!
Medicaid drug spending and rebates
more coming back in rebates than what was actually spent
Work status of women on medicaid
most women covered by medicaid work outside the home
If the 14 remaining states expanded to implement medicaid
70% of uninsured adults would become newly eligible for medicaid if they lived in 4 states - TX, FL, GA, NC
A broken HC model?
we do not have a single payer system where everyone has the same level of coverage; how we pay for it is a way that makes it broken
What makes up the largest percent of healthcare coverage
employer only insurance
Who is uninsured
young, latinx/hispanic, poor, sicker, and living in the south
people with chronic health problems
Majority of the federal budget goes to
social security
Majority of state budget goes to
education
Why do people need health insurance?
help pay for medical services that may be outside of my needs
because HC is expensive and uncertain
American rescue plan
- People up to 150% FPL can now get silver plan at zero premium and lower deductibles.
- Premium subsides for people up to 400% of FPL.
- Extended enrollment periods.
- Premium subsidies for people with COBRA plans.
- States can extend Medicaid coverage for post- partum women up to 1 year.
- Incentives for more states to expand Medicaid coverage.
- Subsidies for rural providers adversely impacted by COVID.
American rescue plan - Rx provisions
- Require the federal government to negotiate prices for some drugs covered under Medicare Part B and Part D with the highest total spending, beginning in 2026
- Require drug companies to pay rebates to Medicare if prices rise faster than inflation for drugs used by Medicare beneficiaries, beginning in 2023
- Cap out-of-pocket spending for Medicare Part D enrollees and make other Part D benefit design changes, beginning in 2024
- Limit monthly cost sharing for insulin to $35 for people with Medicare, beginning in 2023
- Eliminate cost sharing for adult vaccines covered under Medicare Part D and improve access to adult vaccines in Medicaid and CHIP, beginning in 2023
- Expand eligibility for full benefits under the Medicare Part D Low-Income Subsidy Program, beginning in 2024
