U.S. Healthcare Midterm

Discuss HCIN that’s not your own and connect to course material

People are increasingly using AI to search their symptoms and avoid going to the doctor they are relying on AI, this relates to learning about preventative vs more curative care and the patterns we see of this with rising healthcare costs, as healthcare and health insurance becomes more expensive we see more people avoid getting annual checkups or getting check when they’d on’t feel well they are turning to AI due to the financial burden of healthcare and then we see more sever illnesses that could’ve been prevented if checked before

Chapter 1: Major Characteristics of US Healthcare Delivery, vocab and key concepts

The US health care system includes hospitals, doctors, insurance companies, and government programs. Its main challenges are high cost and unequal access to care.

Chapter 2: Foundations of US Healthcare Delivery, vocab and key concepts

Health is affected by genetics, lifestyle, environment, and medical care. Public health focuses on preventing illnesses and improving community health.

Chapter 3: Historical Overview of US Healthcare Delivery, vocab and key concepts

Healthcare has improved through better medical training, hospitals, technology, and insurance. Medicare and Medicaid were created in 1965 to help people get coverage.

Chapter 6: Financing and Reimbursement Methods, vocab and key concepts

Health care is paid through private insurance, government programs, and patients. Premiums, deductibles, co-pays, and co-insurance affect how much patients pay.

Chapter 12: Cost, Access, and Quality, vocab & key concepts

The main issues are the high cost of care, access to medical services, and the quality of treatment. The goal is to make healthcare affordable, available, and effective.

Critical Care Documentary - Be familiar with 1 or 2 advantages and 1 or 2 disadvantages of other countries health systems

Health Care in America vs. The world

• Millions of Americans have no health insurance and live in fear that one illness could bankrupt them. Even though the U.S. spends far more on health care than other wealthy nations, Americans die of preventable diseases at greater rates

• Switzerland: advantages: universal coverage, high-quality care, short wait times, choice of care disadvantages: costs more, financial pressure w/ mandatory out-of-pocket costs, exclusion of basic dental care

• Australia: advantages: universal access, high quality of care disadvantages: coverage gaps, long wait times, workforce shortages, healthy young adults leaving priv insurance while elderly stay in it and it drives up the cost more

Social Determinants

non-medical factors that influence health outcomes, most commonly seen to be determined by socioeconomic factors and then health behaviors

Health Disparities vs. HealthCARE disparities

health disparities are unfair and preventable burden of disease of selected populations (differences in health outcomes0

healthCARE disparities are unfair differences in ACCESS among elected populations (differences in access to care)

Triple Aim

• Quality, Access, Cost

• Tinkering with one impacts the others

Goals of health care reform

to expand access, improve quality, and control costs

Universal Declaration of Human Rights

recognizes medical care as a fundamental right

Health insurance vs. health care (financing vs. clinical care), understand connection between having health insurance and health outcomes, understand why overstating the link between health insurance and health otcomes is problematic

Paradox of health care

best care and innovation in the world that many can’t access

Comparative Healthcare Systems

• U.S. spends the most money on healthcare but has worth health outcomes comparatively to economically similar countries, shorter life expectancies, and worse infant mortality rate, chronic illness, obesity, drug deaths

• only industrialized nation in the world without universal health care, no public option (a fall-back option that government provides if cannot obtain)

• medical bankruptcy is extremely rare in most countries with universal care

• global models: beverage, Bismarck, single payer (national/universal), out of pocket *The US has all of them*

Cost-sharing

You pay some of your health care costs and your health insurance company/gov. pays sone. (cost of coverage is shared by patient and others like employer, government)

Co-pay

set amount for each visit regardless of care provided, varies widely between plans and types of visits

Premiums

annual cost of ‘membership’ in a health plan, usually paid monthly, varies widely between plans (for both private and public)

Deductible

a fixed amount that a patient must pay each year before their health insurance benefits begin to cover the costs, varies widely between plans, plans with lower deductibles will have higher monthly premium costs and vice versa (for both private and public)

Co-insurance

for each time you receive medical care, you split the bill with your insurance. If you have 80/20 medical plan then AFTER you meet your annual deductible your insurance company pays 80% of health care costs while you pay 20% (some plans pay 100%)

Where do Americans get coverage?

About half employer, 35-40% government, 9-10% uninsured meaning out of pocket

What are some barriers of accessing health insurance?

cost, lost/changed jobs, job doesn’t offer, ineligible, undocumented, forms and applications too complicated, literacy level

What does it mean to be under-insured?

Insured but inadequate coverage or too expensive to use

How do providers get reimbursed by insursers/gov.? Not how patients pay providers (Volume driven vs. Value driven, uncompensated)

• Volume driven: fee for service = payments (reimbursements) to providers based on each individual service (retrospective payments mean after the care has been provided)

• Value driven: care is reimbursed to incentivize providers based on patient health outcomes (bundled payments) The U.S. is primarily volume driven (reimbursement for care based on each visit)

• The ACA changed how providers get reimbursed to incentivize good health outcomes, bundled payments (prospective) based on DRG’s: Diagnostic Related Group (the coding providers use to get reimbursed by Medicare, Medicaid, private insurance)

• Uncompensated Care: unpaid bills (when patients can’t/don’t pay) this increases prices for those who do pay bills, private insurance costs more, gov. pays for some hospital uncompensated care, our taxes support the gov., loss of tax revenue by workers who are too injured/sick to work, increase in social safety net expenses by gov.

4 Historical Periods

• Pre-industrial era: other countries more advanced, domestic not professional, medical training not based on science, no health insurance, few hospitals, unsanitary, only in cities, institutions served poor, mentally ill, criminals “pest houses”, free market (competition to practice)

• Post-industrial era: organized medicine, professional organizations formed like AMA, private health insurance and employer-based (for profit), creation of medicaid/medicaire, accredited medical schools, licensing that excluded blacks, flexer report closed black medical schools, scientific discoveries, mental health institutions/care

• Corporate era: corporation of health care delivery, information revolution (telemedicine), globalization (cross border economic activities and trade), foreign direct investment, exporting of health professionals (excludes minorities and low-income communities based on ability to pay)

• Reform efforts: passage of ACA and lawsuits against it

Why did reform efforts fail?

• minorities and low income did not have political/power voice

• decentralized American system gave little control over state social policy

• German social insurance denounced during WWI - we were at war with Germany and ‘socialized’ was seen as the enemy

• powerful AMA opposed national health insurance

• middle class values = mistrust of big government, capitalism, self-determination

• middle class averse to higher taxes

• corporization

US Health Care Services (be familiar with types of providers)

• private for-profit

• private non-profit

• public options (government)

• out of pocket

• combo of above

Financing: 4 parts of system (how care is paid for, cost applies to all levels)

• Financing: government, employer, self-funded

• Insurance: companies, self

• Delivery: medical providers, hospitals, nursing homes, diagnostic centers, medical equipment vendors, community health centers, etc

• Payment: insurance companies pay health care providers, employers pay insurance companies, insurance bills patients, or insurer IS the provider

What are the 4 types of National Health Insurance Models? What is the US?

• Beveridge: single-payer national health service

• Bismarck: social health insurance model

• National Health insurance model: single-payer notional health insurance

• Out-of-Pocket: market-driven

Market Justice vs. Social Justice

• market justice: based on “ability to pay”. market forces of a free economy drives innovation (capitalism)

• social justice: based on “fair distribution”. Well-being of an entire community prioritized over individual

• US system has both, private insurances are market justice, medicare and medicaid are social justice

Reasons for high health care costs

• third-party payments (some argue health care shouldn’t work like this)

• growth of technology

• increase in elderly population (and baby boom generation retiring)

• medical model of health care delivery

• multipayer system and administrations costs (The US has no centralized system)

• defensive medicine

• waste and abuse (not by individuals, by institutions, ex: nursing homes)

• practice variations

Medicare 1965

• same program nationwide

• administered only by the federal gov (single payer)

• insurance over 65+ (70 million beneficiaries)

• Not income-based, only age

• Disabled under 65 must qualify for social security

• 4 parts: A: inpatient, B: outpatient, C: medicare advantage (private plans), and D: drugs (A is supplemental, BCD are additional costs)

• does not cover long term care, vision, dental (except medicaid advantage part C0

• over 80% of recipients like it, gets HIGH ratings, low admin overhead

• BBB changes will impact

Medicaid 1965

• varies state by state,

• administered by the federal gov and the sates, share costs but states decide eligibility

• income-based and categorical

• insurance the low-income, disabled children, pregnant women, usually impaired

• CHIP: Children’s Health Insurance Program

• covers some long term care

• covers some very low income on medicare (dual-eligibles)

• BBB passed and 10-16 million expected to lose health insurance over next 10 years

Affordable Credit Act (ACA)/ Obamacare 2010

• 3 legged stool: subsidies, guaranteed issue, individual mandate

• Subsidies: discounts to purchase private insurance plans in newly created marketplace exchanges (other laws expanded the subsidies then allowed to expire, millions expected to lose coverage)

• Guaranteed Issue: can’t be denied coverage based on pre-existing conditions

• Individual Mandate: must have insurance or pay tax penalty (later zero’d out by congress) AND employer must provide it (over 50 employees)

• Not health insurance from the government

• Supreme Court ruled in 2012: yes ACA constitutional and no states do not have to expand

• ACA included prevention, workforce development, and funded construction

• reformed financing to incentivize reimbursement of providers based on good health outcomes, value-based, bundled payments rather than fee-for-service (drs don’t choose how they are reimbursed)

• BB passed in 2025, 10-16 million expected to lose health insurance over next 10 years

• Medicaid: Goals of ACA achieved in states that expanded, goals of ACA NOT achieved in states that did NOT expand

3 legged stool

• Subsidies: discounts to purchase private insurance plans in newly created marketplace exchanges (other laws expanded the subsidies then allowed to expire, millions expected to lose coverage)

• Guaranteed Issue: can’t be denied coverage based on pre-existing conditions

• Individual Mandate: must have insurance or pay tax penalty (later zero’d out by congress) AND employer must provide it (over 50 employees)

Medicare and Medicaid Dual Eligibility

• Low income people who are disabled and cannot work

• low income people 65+

Federal Poverty Level

• Formula that determines eligibility for many federal and state benefits

• the ACA law required states must off minimum eligibility at 138% of FPL

• many states expanded to more than 138% of FPL (meaning higher incomes eligible)

• this meant many poor and middle income people could finally qualify

Graph of number of uninsured and uninsured rate amount the non elderly population: know this story

Number of uninsured and uninsured rate among the nonelderly population 2008-2019, over 44 million did not have insurance (17% of pop uninsured) kept going up all the way to 46.5 mill, after ACA it dropped, made huge drop in 2014 because major provisions took effect, signed into law 2010 but everyone had to comply 2014 which is when you saw real effect, election in 2016, tax for individual mandate zerod out 2017 which increased uninsured a little, started slowly going up a little, record low of 9.6% in 2022 bc another law passed

Power to Heal Documentary

• Flexner Report (1910): Flexner evaluated 155 medical schools. Forced the closure of 5 of 7 Black-serving medical schools. Effects still felt today: underepresentation of providers and med school students that reflect the population to be saved

• Hill Burton Act (1946): Funded hospital construction, federal segregation written into law for first time in 20th century. “Separate but equal” wings constructed. In practice, not equal at all

• Brown v. Board of Education (1954): Supreme Court ruled “separate but equal is unconstitutional. This overturned 1896 Supreme Court ruling Plessy v. Ferguson that racially segregated public facilities were legal, so long as the facilities for Black people and whites were equal.

• Civil Rights Act (1964): a landmark law that banned discrimination in many aspects of American Life (legally but not practically)

• Medicare/Medicaid passed (1965): forced integration of hospitals by threatening to cut off federal payments to hospitals that didn’t integrate. Black patients would also lose hospital access if the hospital lost federal money.

What type of justice is based on people’s willingness and ability to pay?

market justice

What is the “One Health” approach?

an approach to health that recognizes the interconnectedness of human, animals, and environment

Name one feature of the American Health Care system during the pre-industrial era

• domestic not professional

• not based on science

• no health insurance

• few hospitals that were for the homeless, mentally ill, or criminals

Name one feature of the American Health Care system during the post-industrial era

• organized medicine like professional orgs such as AMA

• private health insurance and employer-based

• accredited medical schools

• scientific discoveries

The American Health Care system is financed in many different ways: briefly name one method of health care financing

taxes, out of pocket, employer, government

The US spends the most money in the world on healthcare (and does not have the best health outcomes). Briefly identify one of the reasons listed in Chapter 12 that the US has such high health care costs

high elderly population, they are majority of costs seen in healthcare, more intervention rather than prevention

Summarize an article we’ve read this year: NYT We’ve never seen healthcare cuts this big

Medicaid cuts, millions expected to lose coverage, adding eligibility requirement paperwork