hhs 350 final

what is a single payer model

one payer (usually the government)

what are the benefits of a single payer model

no market competition, low costs, standardized benefits, universal coverage

what are the drawbacks of a single payer model

risk of over utilization resulting in higher taxes

what is a multipayer model

multiple sources of payment

what are the benefits of a multi payer model

competition, choices

what are the drawbacks of a multipayer model

doesn't cover unemployed citizens

what part of the US system is most similar to Britain

both close to socialized medicine, veterans are treated similarly

What part of the US system is most similar to canada

65+ and medicare are treated similar

what part of the US system is most similar to germany

insurance is linked to employment, funding comes from employee salary, funding their own private health insurance

what is socialized medicine

government fully funds healthcare through taxes

what is universal coverage

system where everyone is covered and has access to healthcare

does the US have universal coverage

no

who is the purchaser and payer in employer-based insurance

purchaser: employee and employer

payer: insurance

what were the 3 problems of the ACA

lack of access, high costs, low quality

what is medical underwriting

denying coverage due to medical history or pre-existing conditions

what were the limitations in medicaid eligibility before the ACA

low income limits, most individual adults were not eligible

what are lifetime limits

total dollar amount a company will cover for an individual's entire life (example: NICU patients often reached before even leaving the hospital)

what is the fee for service model

providers are reimbursed for the service they provide regardless of quality or outcome of care

what are the 3 goals of the ACA

1. increase the number of people who had access to affordable insurance

2. expand the medicaid program

3. establish healthcare practices that cut overall medicare costs

what is individual mandate and what was its purpose

required all individuals to have qualifying health insurance coverage or face a tax penalty

was the individual mandate repealed, if so, when and why

yes, in 2019 because of the Tax Cuts and Jobs Act of 2017

what are the ACA marketplaces

helps people find and purchase healthcare, learn about their options, and compare plans

who can enroll in individual ACA marketplace coverage

any US citizen that does not have medicare coverage and is not incarcerated

what are subsidies

government financial aid given to individuals or businesses to reduce the costs of goods or services

what are marketplace premium subsidies and what are they designed to do

designed to help people afford health insurance purchased through the health insurance marketplace

what did title 1 of the ACA do

outlawed medical underwriting

allowed young people to stay on parents insurance until age 26

individual mandate

subsidies

who did medicaid expand to include

low-income adults and families, covering more individuals under the poverty line.

what did SCOTUS say about the medicaid expansion

the government could not force states to expand medicare by losing existing federal funding

what impact has the medicaid expansion had on health outcomes

increased health insurance coverage, improved access to care, increased overall health

what is title 9 of the ACA

increase in taxes for some individuals and for insurers, device manufacturers, and pharmaceuticals

what were the delivery system reforms

hospital readmission reduction program, fee for service —> value based payments

what is the hospital readmission reduction program

• penalizes hospitals with higher than expected 30 day readmission rates for certain conditions

• attempt to improve discharge planning and patient care

the ACA moved from fee for service to what

value based payements

which is the least successful ACA goal and why

establishing healthcare practices that cut overall medicare costs

• medicare costs have continued to rise

• healthcare system is still mostly fee for service

how did ACA expand coverage for women and families

created pregnancy assistance fund, added more funding to community health centers, created early childhood home visiting program

how did the ACA expand coverage for older adults/people with disabilities

added protections against discrimination, more funding to the aging and disability resource center, more affordable drugs

how did the ACA expand coverage for LGBTQIA individuals

reduced uninsured rate by nearly half, discrimination protections in health programs and insurance

how did the ACA expand coverage for minoritized racial and ethnic communities

established offices of minority health, provided more coverage, provided more protection against race/color, established the health profession opportunity grant

how has the uninsured rate changed since the passage of the ACA, by how much

cut by nearly half

what are 2 types of preventative services that are free of cost sharing since the ACA

cancer screenings, routine immunizations (like flu shots)

what are parts A, B, C, and D of medicare

A: hospitals

B: doctors visits and outpatient care

C: medicare advantage, dental or vision coverage

D: prescriptions

what parts of medicare are known as medicare advantage

C

what parts of medicare are traditional medicare

A and B

what are the pros and cons of medicare advantage vs traditional medicare

advantage: covers prescription drugs and dental/vision, lower premiums but also limits provider choices, and may increase out of pocket costs

traditional: more freedom when choosing providers but higher out-of-pocket costs and no coverage for prescription drugs.

who is covered under medicare

65+ and specific chronic conditions like esrd and als

does medicare have cost sharing

yes - includes deductibles, coinsurance, and copayments

how is medicare funded and administered

at the federal level

who is covered under medicaid

mainly low income individuals/families

how is medicaid funded

through both state and federal governements

how is the federal matching rate determined

considers state's per capita income relative to the national average, lower per capita = higher fmap (federal matching assistance percentage)

what are block grants

federal government gives states a fixed amount of funding to cover medicaid costs

what are the ways to access healthcare

employer based insurance, marketplace insurance, medicare/medicaid, out of pocket, private individual insurance

what is employer based health insurance, who are the contributors

employers provide health insurance to the employee as a benefit, both employer and employee are contributors

what is marketplace insurance, who is eligible, how do they sign up

healthcare plans offered through the health insurance marketplace for those who don't have employer based coverage, can apply online, by phone, etc.

what is cost sharing

the patient and insurance plan split the cost for healthcare services

define the terms: premium, deductible, copay, co-insurance, free services, out of pocket max

premium: what you pay every month to keep your insurance plan

deductible: what you pay before insurance kicks in

copay: fixed amount you pay for a healthcare service

co-insurance: you and insurance split cost after deductible

free services: vaccinations, screenings

out of pocket max: max amount you pay before insurance completely takes over

what is the point of cost sharing

was supposed to make insurance and healthcare more affordable

why can't patients make decisions about what is necessary care

they don't know what is and isn't necessary because they aren't educated on what is happening with them and have to trust their doctor

does cost sharing lead to less people complying with medically necessary treatment like drugs

yes

what is painful cost control

ways of reducing expenses that negatively impacts employees, providers, or quality of care

what is painless cost control

ways of reducing expenses that does not negatively impact employees, providers, or quality of care

who are financing controls between and what are the 2 methods

between purchaser and payer

methods are competition and regulation

who are payment controls between and what are the 2 methods

between payer and provider

methods are price and utilization controls

what are examples of price control

competitive and regulatory

what are the examples of utilization control

cost sharing, utilization management, supply limits, changing unit of payment

what are the pros/cons of individual mandate reform

pros: more healthy people in insurance pool, everyone is insured, people can keep the plans they have

cons: hard to enforce, unaffordable for those with high cost sharing and minimalist plans

what are the pros/cons of employer mandate reform

pros: provides insurance for employees who were not previously offered insurance

cons: significant burden for small businesses, loss of insurance/coverage gaps between jobs

what are the pro/cons of government funded reform

pros: no for profit, universal coverage, 1 entity to maintain cost controls, simplifies the system

cons: some people prefer private insurance, concern over gov running healthcare system

what are the pros/cons of pluralistic model reform

pros: both private and public options, decrease number of uninsured

cons: same problems that come with the other models, coverage gaps, complicated

what type of reform is the ACA

pluralistic model