week 3 Flashcards
what is “health care reform”
pt protection and affordable care act
signed into law march 23, 2010
in general,
democrats and republicans support what
democrats support more governmental involvement in HC and more controls on markets
republicans believe in less governmental involvment and more market driven reforms
what were some big issues when ACA was passed
- out of control costs
- high # of uninsured
- higher number of underinsured
- risking premiums/deductibles
- underwriting (pre existing condition exclusions and rescission)
what are fundamental issues in the heathcare system
- access
- quality
- cost
what does access mean
what does quality mean
what does cost mean
what are the 5 fundamentals of ACA
- shared responsibility paymetn (ind mandate)
- medcaid expansion
- insurance exchange and subsidies
- 10 required essential benefits
- revenue to pay for it
individual mandate
explain the death spiral
explain the employer mandate
what is the min coverage for the emplyer mandate
what are some reasons why states did not chose to expand medicaid
prior to the ACA, medicaid excluded who
what are the choices for running health insurance/market?
- design/run your own with help of federal grants
- state and federal gvt work togetehr on designing and running exchange
- federal gvt runs it for you
requirements for exchange design
- Standard language/information to allow comparison
- Comparison of plans based on price, benefits, and other features
- Tiered: lowest to highest as bronze, silver, gold, platinum
- Some plans are divided geographically (e.g. must live/work in Denver to purchase plan through Denver Health Insurance Plan)
what does guaranteed issue eliminate and what does it limit
- pre existing condition
- rescission
allows for 3:1 rating variation based on
- age
- geographic area
- tobacco use
coverage limits:
- eliminates lifetime limts
- severly restricts annual limits
- in and out exchanges
what are the 10 min required essential benefits
- ambulatory (outpatient) care
- emergency services
- inpatient hospitlization
- maternity and newborn care
- mental health and substance use disorder service
- RX drugs
- rehab and habilitative services
- lab services
- preventative and wellness services; chronic disease tx
- pediatric services (dental care and vision for kids)
universally, what is thought to be the biggest issue
cost control
what are known reaons for high costs (esp premiums) under ACA
- essential health benefits in exchange
- who buys in the exchange
- pre-existing conditions coverage
- no life time and very limited annual maximums
- no cost sharing for basic prevention
whats the goal for medicare reforms
Goal: help to improve quality of care for seniors as hospitals would be more likely to find ways to help individuals stay well after a hospital discharge.
how has access changed from the reforms
- increasing the number of PCP
- community health centers
- extension of coverage for young adults
- PCP/general surgeon payments (medicare payment bonus of 10% to PCP and general surgeons practicing in areas with sig shortage of physcians)
- medicaid reforms (increase payments to primary care drs- family physicians, internal med, peds)
how has prevention changed with the refrom?
- free preventio benefits
- free prevention and wellness visits in medicine
chain resturants and vending machine co requires to disclose the nutritional content of each food
healthcare before the ACA included what
- deductibles
- premiums
- cost sharing
- underinsured population
- uninsured population
underinsurance
republicans have focused on
democrats have focused on
medicare for all =
bernie sanders
no premiums or deductibles
cost savings largely would depend o how much providers would be paid
currently private payers pay hospitals 100% more than medicare and physicans 43% more. (resistance from HC industry not to mention from insurance co)
providors would still overwhelmingly be private so “socialized medicine” is a misnomer
called “SINGLE PAYER” and most similar to canadas system
what is a “public option health plan”
refers to a health plan created by the government to offer consumers a high value, affordable alternative to fully provate plans.
traditionally, “public option” has referred to publicily funded plans that may or may not rely on provate entitites to provide some administrative functions
more recently, the phase has been applied to privatelty funded plands established pursuant to a state law and subject to certain heightened requirments meant to improve value and advance state goals, like cost containment.
washington nevada colorado fall in this latter category
Bidencare
would have premiums and cost sharing
was opposed by many in the HC industry and by insurers
he proposed expanding number of individuas covered by insurance by:
- lowering age of medicare to 60
- increasing premium subsidies on the ACA exchange
price:
cost:
profit:
price: cost + profit; hospitals charged
cost: hospitals spend
profit: difference between the two
what is behind making CO hospitals shoulder some of the burden of the public option
public private partnerships
states contract with private companies to create new insurance options to be overseen by but NOT run by the governement
has structural similarities to medicare part c
colorado public option law
colorado projects that the colorado option will ____
inflation reduction act
CMS inovation takeaways
- overreaching goal to having all traditional medicare beneficiaries and most medicaid beneficiiaries in an accountable care relationship by 2030
- health equity
- stratgegy centers on total cost of care models and embraces adv primary care and affords very little attention to speciality episodic models
progressive tax:
regressive tax:
flat (proportional) tax:
progressive tax: tax rate increases as income increases, increasing burden on higher wage earners (normal taxes)
regressive tax: tax rate burdens lower wage earners more than higher wage earners (ex: )
flat (proportional) tax: burden is the same across all individuals
political cost:
economic cost:
efficiency cost:
political cost: how hard would it be to get to make this happenin todays current poltical enviroment
economic cost: the net impact of the system design in overall cost for healthcare
efficiency cost: how complicated is the HC system in terms of paperwork, admin structure, regulatory review
preventative care = all 3 models
medical homes: chronic care conditions, careof minor acute episodes IF the person is already established within the medical home
ACO: care of major acute;
bundled payments: care of major acute;
