Access to Health & Power to Heal Review

Vocabulary flashcards covering health insurance concepts, payment structures, historical evolution, managed care models, HMOs, and civil rights desegregation through Medicare.

Psychedelic Donut

A visual breakdown of the United States healthcare system types of coverage illustrating how fragmented healthcare coverage is across the population.

Insurance

A financial mechanism designed to spread costs and transfer risk across individuals.

Adverse Selection

A situation where individuals only purchase or pay for health insurance when they become sick.

Voluntary Health Insurance

Private health insurance purchased voluntarily by an individual, which includes Employer-Sponsored Insurance (ESI).

Compulsory Health Insurance

Universal health insurance provided directly by the government, such as TRICARE for active-duty military personnel.

Indemnity Plan

A payment method where the patient pays for care upfront out-of-pocket and receives reimbursement later (usually not fully), structured around fee-for-service payment.

Fee-For-Service

A payment model in which medical providers are paid a separate fee for each individual service rendered.

Service Plan

A payment system where an individual prepays the specific organization that provides their medical care, typically organized around capitation (e.g., Kaiser Permanente).

Capitation

A payment system in which a doctor or provider receives a fixed payment amount per person, regardless of the volume or frequency of care each patient receives.

Community Rating

A health rating method based on an even distribution of risk across all insured members, where every individual pays the exact same premium.

Experience Rating

A health rating method where insurance premiums are adjusted and calculated based on an individual's or group's past health history.

Cost Sharing

Direct patient out-of-pocket expenses designed to discourage seeking unnecessary medical care and to keep premium costs lower so individuals purchase insurance.

Premium

The recurring fee paid to obtain and maintain health insurance coverage (e.g., a monthly fee).

Deductible

The specified out-of-pocket amount an insured person must pay for healthcare services before insurance begins paying for care.

Copayment

A fixed flat fee paid directly by the insured patient for each specific medical service received.

Coinsurance

A set percentage of the total service cost that the insured patient is required to pay.

Maximal Out of Pocket (MOOP)

The maximum dollar amount an insured individual will pay for qualified medical expenses in a single year; it includes deductibles, copayments, and coinsurance, but does NOT include premiums.

Bismarck 1883 Health Insurance

The earliest historical model of social insurance, developed in Germany, providing compulsory sickness insurance for industrial workers.

American Association for Labor Legislation (1912)

An association that proposed a compulsory health insurance model bill for manual laborers (supported by the AMA at the time), which ultimately failed because the life insurance industry opposed its inclusion of funeral benefits.

Committee on Costs of Medical Care (CCMC)

A committee formed in 1927 whose report recommended voluntary health insurance; the report was strongly opposed by the AMA because it opposed government involvement in healthcare.

Blue Cross

A prepaid hospital care service plan for workers founded during the Great Depression that operated on community rating and capitation.

Blue Shield

A prepaid health insurance plan established to cover doctor and physician services, functioning in tandem with Blue Cross.

Moral Hazard

The concept that individuals who are protected against financial loss will alter their behavior, such as taking more risks or seeking unnecessary medical care.

Policy Trap

A condition where a healthcare system is fragmented and inefficient, yet enrollees remain satisfied enough to resist reform, while targeted programs assist politically sympathetic groups (such as the elderly and veterans).

Managed Care

A healthcare system designed to control which providers patients can see and regulate how much medical services cost.

Kaiser Permanente

An early managed care organization originating in 1937–1938 that utilized salaried physicians and a capitation model where patients pay a set amount regardless of how much treatment they receive.

Group Health Association (GHA)

A Washington, D.C. group health plan founded in 1937–1938 with the first unionized salaried physicians; the AMA's attempts to block its doctors led to a 1939 Justice Department ruling that the AMA was acting as an illegal monopoly.

Health Maintenance Organization (HMO)

A managed care service/capitation plan that only covers medical care provided by physicians within its network, aligning incentives toward preventative care while disincentivizing excessive treatments.

HMO Act of 1973

Federal legislation signed by President Richard Nixon that actively promoted and supported the adoption of Health Maintenance Organizations.

Gatekeeper

A cost-sharing and coordination mechanism within an HMO where a primary care physician must approve access to specialist care to prevent unnecessary treatments.

Utilization Review / Prior Authorization

An HMO administrative mechanism that double-checks physician treatment decisions to ensure standard-of-care adherence and stop unnecessary care, though it can delay care and limit physician autonomy.

Title VI of the Civil Rights Act of 1964

A federal law prohibiting racial discrimination by any recipient of federal funding; initially unenforced in hospitals, which allowed racial segregation in healthcare to persist.

Medicare (1965)

Federal healthcare legislation enacted in 1965 that civil rights activists leveraged to desegregate hospitals by conditioning federal Medicare funds on strict compliance with Title VI non-discrimination mandates.