Finance and Policy Final

The Beveridge Model, Bismarck Model, and National Health Insurance Model describe the predominant ways in which nations structure health systems. Which of the following are the primary distinguishing features that differentiate these models? (select all that apply)

 

Whether insurers are public or private

Whether healthcare workers are public or private

Whether financing is public or private

Whether the country is in Europe, Asia, or North/South America

Whether insurers are public or private

Whether healthcare workers are public or private

Whether financing is public or private

What type of insurance is subsidized and administered by the federal government, and covers older adults (ages 65+)?

Medigap

Medicare Advantage

Medicaid

Traditional Medicare

Traditional Medicare

Which of the following are TRUE statements concerning Medicare and Medicaid? (select all that apply)

Medicaid is a major source of health care coverage for childbirth.

Most funding for Medicare and Medicaid comes from the federal government.

Once a Medicaid beneficiary turns 65 and enrolls in Medicare, they are no longer eligible for Medicaid. 

Patients with end stage renal disease may qualify for Medicare before they turn 65.

The large majority of Medicare beneficiaries are enrolled in Traditional Medicare.

Medicaid is a major source of health care coverage for childbirth.

Most funding for Medicare and Medicaid comes from the federal government.

Patients with end stage renal disease may qualify for Medicare before they turn 65.

Which of the following are TRUE statements regarding Medicare and Medicaid funding. (select all that apply)

Most Medicare funding comes from general revenue and payroll taxes.

Combined federal spending on Medicare and Medicaid exceeds Defense spending.

As with employer-sponsored health insurance, most Medicare funding comes from premiums.

Medicaid is jointly-funded by the federal and state governments.

There are no out-of-pocket costs for Medicare beneficiaries.

Most Medicare funding comes from general revenue and payroll taxes.

Combined federal spending on Medicare and Medicaid exceeds Defense spending.

Medicaid is jointly-funded by the federal and state governments.

Which of the following do "fee for service" payment mechanisms incentivize?

Providing high quality care

Providing fewer services

Providing more services

Providing preventive care

Providing more services

Which of the following are the three "streams" that must align to increase the probability of policy getting passed (according to Kingdon)? (select 3 answer choices)

Problem stream

Policy stream

Process stream

Politics stream

Priorities stream

Problem stream

Policy stream

Politics stream

All the following are examples of checks and balances in the U.S. government EXCEPT…

The Senate must confirm a President's appointments to the Supreme Court.

The courts may overturn an illegal and/or unconstitutional executive order.

The President can ignore a bill passed by Congress and thereby prevent the bill from becoming law and avoid returning a vetoed bill to Congress.

Congress may overturn a President's veto by 2/3rds majority vote in favor of a bill.

The President can ignore a bill passed by Congress and thereby prevent the bill from becoming law and avoid returning a vetoed bill to Congress.

What was the focal problem that made the Affordable Care Act more likely to pass in 2010?

The great recession of 2009.

The Clinton administration failed to pass health reform in 1992.

The 2008 presidential election.

The passage of comprehensive healthcare reforem in Massachusetts.

The great recession of 2009.

Select the program that best fills in the blanks in the following passage from The New York Times:

[BLANK], which covers more than 70 million people, is the largest health insurance program in the nation, and the largest single source of funding for states. More than 21 million adults who were not eligible for [BLANK] under pre-expansion guidelines received coverage last year. The program had previously restricted enrollment primarily to those who were pregnant, disabled or elderly. 

Medicare

Medicaid

Employer-Sponsored Insurance

The Indian Health Service

Veterans Administration Healthcare

Tricare

Medicaid

Select the TRUE statements regarding uninsured and under-insured. (select all that apply)

Those with insurance may still lack adequate financial protection.

The uninsured population has remained relatively stable over the last 65 years, unaffected by legislative changes or healthcare reforms.

Members of healthcare sharing ministries are classified as uninsured; however, they do have some financial protection through risk pooling.

Charity care is required of nonprofit hospitals as a condition of retaining their tax-exempt status.

The uninsured population has decreased over time, particularly following the passage of Medicare/Medicaid and later the Affordable Care Act.

Those with insurance may still lack adequate financial protection.

Members of healthcare sharing ministries are classified as uninsured; however, they do have some financial protection through risk pooling.

Charity care is required of nonprofit hospitals as a condition of retaining their tax-exempt status.

The uninsured population has decreased over time, particularly following the passage of Medicare/Medicaid and later the Affordable Care Act.

Financing, insurer administration, and facilities of Beveridge model

Public $, public admin, public facilities

Financing, insurer administration, and facilities of Bismarck model

Private $, private admin, private facilities

Financing, insurer administration, and facilities of national health insurance model

Public $ (taxes), public OR private admin, private facilities

Financing, insurer administration, and facilities of out of pocket model

Private funding ($), private OR NO admin, private facilities

What type of insurance is subsidized and administered by the federal government and covers older adults

Traditional Medicare

The large majority of Medicare beneficiaries are enrolled in...

Medicare Advantage

Most funding for Medicare and Medicaid comes from

The federal government

Patients with which disease may qualify for Medicare before they turn 65

End Stage Renal Disease

Which government health care coverage system covers the majority of childbirths

Medicaid

Requirements for Medicaid

US citizen, pregnant or has a dependent, <17 yo, disabled or lives w someone who is

T/F: there are no out of pocket costs for Medicare beneficiaries

False

T/F: combined federal spending on Medicare and Medicaid exceeds defense spending

True

T/F: Medicaid is jointly funded by the federal and state governments

True

T/F: most Medicare funding comes from general revenue and payroll taxes

True

T/F: as with employer-sponsored health insurance, most Medicare funding comes from premiums

False

T/F: those with insurance may still lack adequate financial protection

True

T/F: the uninsured population has remained relatively stable over the last 65 years, unaffected by legislative changes or healthcare reforms

False

Members of healthcare sharing ministries are classified as _____; however they do have some financial protection through risk pooling

uninsured

T/F: charity care is required of nonprofit hospitals as a condition of retaining their TAX EXEMPT status

True

T/F: the uninsured population has decreased over time, particularly following the passage of Medicare/Medicaid and later the ACA

True

Through the tax cuts and Jobs act that reduced the individual mandate penalty to $0, the Supreme Court ruled that the individual mandate was ______ under congress' power to tax

Constitutional

All of the following are examples of federalism in play in the passage and implementation of the ACA EXCEPT:

1. ACA was modeled after a law that achieved near-universal health insurance coverage in MA
2. Supreme Court ruling in NFIB vs Sebelius allowed states to decide whether to expand Medicaid under the ACA
3. States can set up and maintain their own health insurance exchange online or use the federal site
4. ACA payment reforms shifted Medicare reimbursement from fee4service to prospective

ACA payment reforms shifted from Medicare reimbursement from fee for service to prospective payments

T/F: if all immigration ceased today, the US population would stabilize (neither growing or decreasing)

False, it would decline

______ is a stronger growth factor for the US population and than birth rates

Immigration

Over the last 50 years, US population growth has _____

Declined

T/F: the share of population ages 65 and older has increased over time and is projected to continue growing

True

T/F: immigrants are an important source of entry level healthcare workers but are uncommon among healthcare providers

False - lots of foreign doctors!

T/F: a quarter of all docs in the US obtained their MD in another country

True

T/F: immigrants strain the healthcare system as their Medicaid use outweighs their tax contribution

False, it’s a net zero

T/F: immigrants, esp the undocumented ones, have relatively low healthcare utilization

True

The secret to quality (Avedis Donabedian) is...

Love your patient and profession!

Biggest insurer of Americans

Employers

______ is the largest payer of elderly inpatient hospital services

Medicare

Traditional Medicare is parts:

A or B

Part C Medicare is

Part A AND B

Medicare Advantage is

• Medicare + Choice

• + part D coverage

To retain tax exempt status, nonprofit hospitals must

FAP: financial assistance policy
Cap: cap charges to patients eligible for charity

Regulation

Requires or prevents action

Government management

Direct implementation or management or service/resources (education, defense, public parks, municipal services)

Education, information, and persuasion

Sharing information to influence behavior (exhortation: ie a post disaster speech)

Taxing and spending

Collecting and expending money

Market mechanisms

Use of the market to incentivize choices/correct problems (bonuses...not taxes or sanctions)

Legislation vs. Regulation

Legislation vs. Regulation

legislation is the development of laws by the process outlined in the constitution; the law and punishments for breaking the law

regulation is standards set by the executive branch to set requirements for the implementation of the laws; how the law is monitored and enforced

legislation is the destination, regulation is how we get there

charges for each individual service; incentive for overprescribing and substituting for more expensive options

Fee for service

Bundling together (diagnosis related groups), charged for group of services/procedures based on diagnosis

Case rates

Accountable care organizations; hospitals/providers grouping together to provide lower cost/more affordable rate to medicare patients

Population based

Population based provider payments promote what?

Proactive care, preventative measures, and improved population health outcomes

_____ = the patient health outcomes achieved per dollar spent

Measured by output, not input = patient outcome, not volume of services delivered

Not ordering unnecessary tests, low dosing to start, least invasive to begin with

value

Hospital based value purchasing

Encourages readmission reduction program

Incremental payments

Outline the history of employer-sponsored health insurance in the U.S

• 1940s wage supplements

• Voluntary for employer but tax incentive

• ACA generally requires employees w/ 50+ full time employees to cover them

Describe the patchwork that makes up health insurance coverage in the United States

Employer-sponsored, military, uninsured, medicare, Medicaid, nongroup

Describe trends in insurance costs (e.g., to employer and employee).

• Over time, employers are controlling an increasingly large portion of employee salaries.

• Trend is more expensive for everyone

• State-Federal partnership to insure the poor, disabled,
  pregnant women, and children

• Needs base coverage

• Federal govt sets core requirements, states administer within guidelines

Medicaid

Federal govt matches portion of state spending (at least 50%, but poorer states receive higher match)

Joint financing

• – hospital insurance

  • Inpatient hospital stays

  • Limited snf stays

  • Some home health visits

  • hospice

Medicare Part A

•  Physician Service

  • Physician visits

  • Outpatient services

  • Preventative services

  • Some home health visits

Medicare Part B

• Medicare + Choice

  • Government funded

  • Private plan (HMO (health maintenance organization/PPO preferred provider organization)

  • Part A + B benefits

Medicare Part C

• Prescription Drug Coverage

  • Voluntary (opt in) prescription drug coverage program

  • Private insurance

Medicare Part D

Underinsured populations in U.S.

black, latino, etc

Uninsured populations and what they do

Amish - financial risk pooling - Healthcare Sharing Ministries

Regulation – requires or prevents action

Ex: Laws, rules

Government management – direct implementation or management or services/resources

Defense, public works, municipal services, privatization efforts (jails)

Education, information, and persuasion – sharing information to influence behavior

Making appeals (post-disaster speech encouraging cooperation)

Public education campaign

Public reporting requirements

Taxing and spending - collecting and expending money

Taxing and spending - collecting and expending money

Taxing to discourage behavior

Not taxing to encourage behavior

Spending: money to citizens (Social Security), money to states (block grants)

Market mechanisms – use of the market to incentivize choices/correct problems

Intervene – cap-and-trade

Don’t intervene – allow supply and demand to work

Problem stream, policy stream, and politics stream all flow into policy window, leading to what?

• Increased probability of passing legislation

• Example: Problem (great recession), policy (Massachusetts healthcare reform), politics (2008 democratic party, highly partisan mood)

a system of government where power is divided between a national (federal) government and regional (state) governments

Federalism

•  Implements and enforces the law

  • President and vice president, cabinet, secretary of veteran affairs, secretary of human health

Executive branch

• Interprets the law

  • Supreme court

Judicial branch

• Draft, debate, and pass legislation

  • Congress = House of Representatives + Senate

  • Senate majority leader, senate minority leader, house minority leader, speaker of the house

Legislative branch

Congress = _____ + ____

House of Representatives + Senate

Describe how a bill becomes a law

• Bill introduced to congress, goes to committee

• Originating chamber debates and votes

• If bill passes 1 chamber of congress, goes to other part of congress

• If bill passes both parts of congress it goes to president

• President can: approve and pass (becomes law), veto (bill returns to congress, needs 2/3 majority to become law), no action (after 10 days if congress is in session bill becomes a low, if congress not in session bill doesn’t become law)

Impact of National Federation of Independent Business (NFIB) v. Sebelius

Medicaid expansion varies by state

Impact of King v. Burwell

Some states have their own exchanges (including Pennsylvania)

Impact of California v. Texas

court found the case had no legal standing; slight dip in market enrollments, the record high in 2024.

• Identify mechanisms through which nurses may influence public policy.

• Vote

• Become active member of professional organization

• Communication skills: written and oral

• Policy brief/analysis

• Research

• Contact representatives

• A goal: coverage for everyone; healthcare as a human right.

Universal coverage

• A government insurance plan available alongside private options

• (e.g., “Medicare for All” or a new government plan)

A public opinion

• One government-run, national health insurance company.

Single player health community

• Government-funded & govt.-run insurance + govt.-managed & govt.-employed health system.

Socialized medicine