Public Policy and Health Care

public policy doctrine

• Body of principles that underpin the operation of the legal system

• Reflects the values of the organization, civilization and culture in which it is formulated

• Reflects the social, moral and economic values

triggers

These may be based on cases in the legal system

i.e. a body of judicial actions

policy and practice of US health care

• Founded in the principle of the free market

• Arguments about whether access to health care is a right or a privilege

social justice

in contemporary politics, social science, and political philosophy, the fair treatment and equitable status of all individuals and social groups within a state or society

• Advocacy

• Professional Responsibility

leading health indicators

a small subset of high-priority Healthy People 2030 objectives selected to drive action toward improving health and well-being. Most LHIs address important factors that impact major causes of death and disease in the United States, and they help organizations, communities, and states across the nation focus their resources and efforts to improve the health and well-being of all peopl

Healthy People 2030 objectives

• Attain healthy, thriving lives and well-being free of preventable disease, disability, injury, and premature death.

• Eliminate health disparites, achieve health equity, and atain health literacy to improve the health and well-being of all.

• Create social, physical, and economic environments that promote ataining the full potental for health and well-being for all.

• Promote healthy development, healthy behaviors, and well-being across all life stages.

• Engage leadership, key consttuents, and the public across multple sectors to take action and design policies that improve the health and well-being of all.

private health insurance

• Employer based

• Employer pays a portion of the premium and individual pays a portion

• Tied to employment so it is cancelled when you separate from employment

• No choice in coverage: It is what your employer has contracted with

• Prior authorization required for all scheduled procedures (not primary care visits)

united health care

• Eighth largenst company in the world

• Claim denial rate is twice industry average at 32-33%

• Covers more than 50 million people including 7.8 million Medicare Advantage

• Third quarter net income was 6.06 billion; overall revenues 102 billion

• In fall, 2025, United Health care notified members of dropping about 180,000 people from their Medicare Advantage Plans

medicaid

• Joint federal/state program

• Health insurance program for individuals & families whose income meets definition of federal poverty level

• States determine services covered, provider payments and certain eligibility qualifications within federal guidelines

• No premium is paid

• Medicaid also provides a comprehensive set of acute and long-term care benefits for people with disabilities, including retaining health coverage through programs like SSI

CHIP

• If you make too much money to qualify for Medicaid, coverage may be obtained from CHIP

• Provides low cost health insurance for children

patient protection and affordable care act (ACA) of 2010

• Prohibits discrimination by insurance carriers in plans offered

• in 2017, the penalty was reduced to 0, making the individual mandate eliminated

• Establishment of Health Insurance Exchanges or “marketplaces”

• Expanded MedicAid coverage for individuals up to 138% of poverty level

• Established minimum standards for health insurance policies

• Mandates businesses that employ 50 or more people offer health insurance to employees

• Eliminated additional payments for many health insurance screenings

• Now is the insurance for 45 million people, either through the Marketplace or MedicAid expansion

basic health benefits program

• Provided for by ACA

• Health benefits program for people with incomes between 138-200% of federal poverty level

• Must include 10 essential health benefits specified in the ACA

essential health benefits

• Ambulatory Patient services

• Emergency services

• Hospitalization

• Maternity & newborn care

• Mental Health services

• Prescription drugs

• Laboratory services

• Pediatric services (including oral and vision)

• Preventive & wellness services (including chronic disease management)

• Rehabilitative and habilitative services

medicare part A

• Covers Acute Hospital Costs

• Also, skilled nursing (for a certain length of time), some home health

• Hospice

• $1,736 deductible before starts to pay then 0 dollars for 60 days

• After 60 days there is a copayment of $434/day

medicare part B

• Doctor’s visits

• Outpatient therapy services

• Elective

• You have to pay a premium for this, depending on income from $185 to $689

medicare part C

• Medicare Advantage Programs: Managed Health care plans approved by Medicare and run by private companies

• Different co-pays and deductibles and may require use of certain providers only in plan

• Some offer prescription drug, vision, dental and hearing coverage

• May get through former employer, but if the elder drops the plan at any time, may not be able to pick it back up

• Must continue to pay Part B premium, but some plans pay partof it

medicare part D

• Prescription Drug Coverage – available since 2006

• Run by private companies with separate enrollment than Medicare Part A and B

• Most Premiums $30.00 – 40.00 per month, limited to “formularies”

• Deductible and Co-payments (up to 25%) until reach “Donut Hole” (limit of $2510.00)

• Beneficiary must pay full cost while in hole until out of pocket expenses reach $4050.00

• Then go into “Catastrophic” coverage: $2.25 for generics, $5.60 for non-generics or flat 5% co-insur

entitlement programs

• Supplemental Security Income (SSI)

• Social Security Disability Insurance

critical access hospital

• Located in rural area, 24/7 emergency care

• Provides care for short durations

• Limited size: no more than 25 inpatient beds

• Must maintain an annual avg LOS of no more than 96 hours for acute inpatient care

• Reimbursement on cost basis, not standard fixed reimbursement rates

• Focus on providing care for common conditions and outpatient care, while referring other conditions to larger hospitals

long term acute care (LTAC)

• Free standing or within a hospital

• Higher acuity

• LOS 25 days or greater

• Prospective Payment System (PPS) similar to DRG but includes other insurances other than Medicare

• No more than 25% of referrals can come from host hospital or any single provider

skiled nursing facility/unit or skilled beds

• Once DRGs were established, shorter lengths of acute hospital stay followed

• This meant earlier discharges of the elderly more sick/ill ?

• Many not ready to return home, so new care area created to receive skilled services = nursing, therapy or both

• Reimbursement in this setting by Prospective Payment System (PPS)

SNU or SNF rules

• Must have a minimum 3 day acute care hospitalization first, i.e, known as a “qualifying hospital stay”

• May not be not “strong enough” to qualify for “rehabilitation setting”

• Must meet the need for skilled care: “reasonable and medically necessary”services that are not available at home

• Medicare Part A for 100 days ONLY (no coverage after that)

• First 20 days are covered in full and then pt is charged a co-pay starting at day 21– 100 (approx $209.50)

• After that, all costs go to the individual
  

the rehab hospital

• Many elderly do not meet stamina criteria for a rehabilitation hospital: Must be able to tolerate 2 – 3 hours of therapy a day, up to 15 hours in a 7 day week

• 10 day evaluation period allowed to see if this can be accomplished

• PPS determined by Patient Assessment Instrument which includes the FIM, and comorbidities

• Medicare Part A for 150 days (days added to acute care days), co-payments start at day 61

CMS 13-75% rule

• Acute stroke, spinal cord injury, TBI

• Congenital deformity

• Amputation, burns

• Major multiple trauma, hip fracture “major” neurologic condition: Parkinsons, MS

• Active arthropathies (RA), vasculitis

• Severe OA involving 2 or more “WB joint”

• Joint replacement if bilateral, obese or > 85 years old

home health

• Medicare Part A, prospective payment system

• PPS tool to determine acuity is “OASIS”

• HH Agency is then paid that set amount for a 60-day episode of care

• Must be “homebound” but can leave for church & MD appointments

• Must be re-certified by MD every 60 days

• No limit but must show progress

hospice

• May be in home or in facility

• Palliative end of life care

• Must be “terminal” to qualify

• Medicare Part A, insurance, pro-bono

IDEA part B

Free Appropriate Public Education

• 3-5 year olds (Pre-School)

• 6-21 year olds (School Age)

• Individual Education Plan educated in most appropriate environment

IDEA part C

• Early Intervention

• Birth to 3rd birthday

• Occurs in natural environment (home based)

ADA Title I

Prohibits employment discrimination

ADA Title II

State and Local Government Services and Transportation

ADA Title III

Public Accommodations

ADA Title IV

Telecommunications

ADA Title V

Miscellaneous Provisions