U.S. Healthcare System & the Law Review Flashcards

A comprehensive deck of 300 practice flashcards covering U.S. Healthcare Law, public health, insurance reform, and regulatory compliance based on UC Law SF lecture notes.

Public Health

Actions taken by a community, typically through government, to create conditions that enable individuals to be healthy.

Policy Interventions

Government-sanctioned actions in areas such as vaccination, workplace safety, and infectious disease control to promote public health.

Collective Action Problem

A situation where public health interventions require cooperation that individuals have incentives or reasons to avoid.

Community-Centric Actions

Interventions that must balance individual rights with the necessity of collective community well-being.

Affordable Care Act (ACA) Public Health Goal

Promotes public health outcomes by integrating strategies like wellness subsidies, preventive care, and health disparity data collection.

Social Determinants of Health (SDOH)

Conditions where people are born, live, learn, work, play, worship, and age that affect health and quality-of-life outcomes.

Economic Stability

A specific social determinant of health related to an individual's financial resource level and its impact on health access.

People First of Alabama v. Merrill (2020) Context

A legal case involving challenges to Alabama's restrictive absentee voting requirements during the pandemic.

Alabama Absentee Voting Requirements

Required a photo ID copy and the ballot to be witnessed by a notary public or two adults.

Merrill District Court Ruling

Ruled that Alabama's absentee voting requirements violated the plaintiffs' liberty interest in voting.

Police Power

The authority of a state to embrace reasonable regulations established by legislative enactment to protect public health and safety.

Jacobson v. MA (1905)

A landmark Supreme Court case that upheld the state's authority to mandate smallpox vaccinations.

Jacobson Reasonability Principle

The standard that a public health regulation must not be unreasonable, arbitrary, or oppressive.

Public Health Necessity

A limiting principle of the police power requiring that the measure be necessary for public health protection.

Reasonable Means

A limiting principle of the police power requiring that the methods used must be reasonably related to the stated goal.

Proportionality

The balancing of individual rights with common good promotion in public health law.

Harm Prevention

A core justification for the exercise of police power to stop the spread of disease or injury.

Klaassen v. Trustees of Indiana University (2021)

A case where students challenged a university vaccine mandate as a violation of bodily autonomy and medical privacy.

Klaassen Holding

The court denied the preliminary injunction, holding the vaccine mandate did not violate constitutional rights.

Zucht v. King (1922)

A case cited in Klaassen that previously upheld a city vaccination mandate under the Jacobson precedent.

Roman Catholic Diocese of Brooklyn v. Cuomo (2020)

A case involving strict scrutiny for orders targeting religious practices, which notably did not disturb the Jacobson ruling.

Rational Basis Review

The level of judicial review applied to public health mandates under Jacobson, barring other constitutional violations.

Cruzan v. Director, Missouri Department of Health

Recognized a right to refuse life-preserving resources, distinguished from public health mandates in Klaassen.

Washington v. Glucksberg

Recognized a right to refuse treatment, distinguished from public health mandates involving community risk.

Beshear v. Acree (2020)

A Kentucky Supreme Court case upholding emergency orders issued by the Governor during the COVID-19 pandemic.

KRS Chapter 39A

The Kentucky statute that necessitates the Governor's response in situations of emergency.

Separation of Powers Constraint

The administrative law requirement that public health measures must be properly delegated by statute.

Procedural Safeguards in KRS Chapter 39A

Criteria for emergency powers, limits on duration, and geographical scope that help prevent invalidation.

Analysis Framework: Policy Objective

The first step in evaluating a public health measure by identifying its specific goal.

Analysis Framework: Issuing Body

Determining if a measure was issued by a legislative or executive body to identify the applicable legal constraints.

Buck v. Bell (1927)

A Supreme Court case that infamously utilized the logic of Jacobson to justify the compulsory sterilization of the 'unfit'.

Eugenics in Public Health

The historical use of health law to prevent 'degenerate offspring' from continuing their kind.

Meta-Goals of Health Reform

The pursuit of equity through policy judgments and efficiency through health economics.

Equity in Health Care Reform

Interventions designed to address health disparities and justly distribute the burdens and benefits of the system.

Efficiency in Health Care Markets

Requires consumers to have information on quality and price and ensures robust competition between providers.

Adverse Selection

The tendency of sicker-than-average individuals to apply for or stay in insurance, driving up costs for the healthy.

Moral Hazard

A phenomenon where insured individuals consume more health services because their out-of-pocket costs are reduced.

Underwriting

The process by which insurers assess an applicant's risk level to determine enrollment and premiums.

Ratemaking

The process of predicting future expenses and losses to allocate costs across beneficiary groups via premiums.

Experience Rating

A ratemaking method where premiums are based on the historical claims of specific individuals or groups.

Community Rating

A ratemaking method where premiums are based on the total overall costs of all individuals in a pool regardless of histories.

Managed Care

A system that governs service delivery by collecting premiums, reimbursing claims, and controlling quality, price, and utilization.

Fee-for-Service Model Downside

The incentive for clinicians to provide unnecessary goods and services to increase their individual payment.

Medical Debt Burden

An issue where almost $50.00\%$ of U.S. adults (roughly $100$ million people) experience financial strain from healthcare bills.

Debt Collection Statistics

$58.00\%$ of all debt collections in the United States are related to healthcare bills.

Disproportionate Medicaid Impact

Racial injustice is highlighted when low reimbursement rates limit care for beneficiaries, who are often people of color.

Uninsurance

A status that deters health service utilization and can cause immense financial hardship for a patient.

Underinsurance

When individuals with insurance are still unable to assume the high out-of-pocket costs for goods and services.

2019 U.S. Health Care Spending

The United States spent $3.8$ trillion on health care, exceeding spending on defense or education.

Factors in High Healthcare Costs

Includes overutilization, high prices, aging demographics, administrative costs, new technology, and malpractice costs.

Quality Problems in U.S. Healthcare

Includes deficiencies in chronic disease management, care coordination issues, and delayed diagnoses.

Patient-Doctor Relationship Measures

An area where the U.S. performs well, involving counseling and shared decision-making.

Market-Based Health Reforms

Reform arguments that emphasize patient choice between various plans and providers.

Behavioral Economics in Plan Choice

Research showing people are often ill-equipped to choose among plans even with decision aids.

Supply-Side Reforms

Reforms targeting healthcare professionals to reduce incentives for unnecessary services or poor quality.

Demand-Side Reforms

Reforms targeting patients to reduce incentives to overconsume services, often called 'skin in the game'.

Managed Care Organizations (MCOs)

Entities that restrict members to provider networks and review utilization to control costs.

Capitation

A payment model where providers receive a lump sum for each patient, shifting incentives toward necessary care only.

Primary Care Physician (PCP) Gatekeeping

A managed care requirement where a PCP must approve a referral for insurance to cover a specialist visit.

Integrated Care Delivery

Coordination of services across providers tailored to patient needs, such as the Kaiser Permanente model.

Accountable Care Organizations (ACOs)

Provider-controlled entities that share savings when they meet specific cost and quality targets for a patient population.

Coady v. Walmart (Hypothetical Context)

Integration through mergers alone does not guarantee effective care coordination without aligning processes.

Cost-Sharing

Mechanisms like copays and coinsurance designed to reduce moral hazard in healthcare consumption.

Copay

A fixed dollar amount paid by patients at the time of receiving a specific health service.

Coinsurance

A percentage of the total fee for healthcare goods or services that the patient is responsible for paying.

Deductible

An amount patients must pay out-of-pocket before their insurance coverage begins to pay for services.

Shared Decision-Making (SDM)

A patient-centered care process where clinicians and patients use pamphlets or videos to make treatment decisions.

Managed Competition

A strategy to boost competition between health plans via standardized rules, used in the Affordable Care Act.

Public Health Insurance Option

A proposed reform allowing individuals to 'buy into' a government-run health insurance program.

Post-WWII Health Insurance Tax Exemption

Employer-based premiums have been tax-exempt since this period, explaining why most Americans get insurance from employers.

Guaranteed Issue

Requirement that insurers offer coverage regardless of pre-existing conditions.

Pre-existing Condition

A diagnosis or treatment received by an individual before their current health plan enrollment.

Price Transparency Laws

State mandates requiring notification before major price increases or disclosure of prices to state-run entities.

Price Caps

Regulations setting maximum prices for care, often proposed as a percentage (e.g., $175.00\%$) of Medicare rates.

Rate Setting

A comprehensive approach where all payers (insurers) pay the same rate for a given healthcare service.

Most-Favored Nation (MFN) Clause

A contract term preventing providers from offering lower rates to other insurance companies.

Medicare Administration

A fully federal program aimed at ensuring access for the elderly ($65$+) and disabled.

Medicaid Administration

A joint federal-state program primarily serving the indigent and low-income populations.

2024 Medicare Spending

Estimated at approximately $1,118.0$ billion.

2024 Medicaid Spending

Estimated at approximately $931.7$ billion.

Medicare Age Eligibility

Individuals qualify automatically for Social Security retirement benefits at age $65$.

Medicare Disability Wait Period

Most people with disabilities must wait $2$ years after becoming eligible for Social Security benefits before receiving Medicare.

End-Stage Renal Disease Eligibility

Individuals qualify for Medicare after a $3$-month wait period.

Lou Gehrig’s Disease (ALS) Eligibility

Qualify for Traditional Medicare immediately upon receiving disability benefits.

Traditional Medicare (TM) Parts

Consists of Part A (inpatient) and Part B (outpatient).

Medicare Part C

Also known as Medicare Advantage, which offers private managed care plans.

Medicare Part D

The part of Medicare that covers outpatient prescription drugs.

Traditional Medicare Gaps

Lacks out-of-pocket limits and contains high deductibles and copayments.

Medicare Modernization Act (MMA) of 2004

Legislation that created the Medicare Part D prescription drug benefit.

Medigap (MedSupp) Plans

Private supplement policies purchased to cover Traditional Medicare's out-of-pocket costs.

Dual Eligibles

Low-income individuals who qualify for both Medicare and Medicaid.

Part D 'Donut Hole'

A historical coverage gap where beneficiaries paid full drug costs after a certain limit until reaching catastrophic levels.

Inflation Reduction Act (IRA) of 2022

Enacted prescription drug pricing reforms, including a $2,000.00$ out-of-pocket cap starting in $2025$.

HHS Drug Price Negotiation

Authorized by the IRA for specific brand-name drugs under Medicare Parts B and D.

IRA Inflation Penalties

Penalizes drug manufacturers that raise prices faster than the rate of inflation.

Inpatient Prospective Payment System (IPPS)

Model used to standardize Medicare Part A payments to hospitals.

Diagnosis-Related Groups (DRGs)

A classification system that groups patients by diagnosis and expected resource use for IPPS payments.

Bellevue Hospital Center v. Leavitt (2006)

Case challenging CMS’s calculation of the hospital area wage index and implementation of occupational mix adjustments.

Occupational Mix Adjustment

A calculation used by CMS to adjust hospital wages, which must be implemented based on timely data.

Loper Bright Enterprises v. Raimondo (2024)

Supreme Court decision that overruled Chevron deference, requiring courts to use traditional statutory interpretation tools.