pubhlth 375 - 9/11

Employer-Sponsored Insurance (ESI – Group Market)

Financed by employers & employees (shared premiums); benefits vary by plan; covers services/products (e.g., prescriptions); cost-sharing includes coinsurance, copay, deductible.

Medicare

Universal social insurance program for older adults (65+); under 65 with disability after 2 years of Social Security (exceptions: ESRD, ALS); federally administered.

Medicaid

Jointly financed by federal & state governments; federal match 50–80% by state income; ACA aimed to expand (<138% FPL) but Supreme Court left to states; eligibility & benefits vary by state.

Individual Market

Plans purchased directly; pre-ACA: pre-existing conditions excluded or higher premiums; ACA created exchanges and subsidies (100–400% FPL).

Other Government Sources of Coverage

CHIP (federal-state program), Veterans Affairs (VA), Indian Health Service, Tri-Care (military & families).

Kingdon’s 3 Streams

Problem stream, Policy stream, Politics stream; must converge for policy agenda setting.

What is a Policy Problem?

Issue implying action is needed; generates costs (economic, social, political, health/well-being).

Identifying Policy Problems

Analytical task requiring descriptive data but also interpretation.

How Do We Know a Policy Problem Exists?

Indicators (data), Focusing events (crises, stories, symbols), Feedback, Budget concerns.

Problem Definition Leading to ACA

Indicators: health care’s financial impact; Feedback: decreasing access to affordable coverage; Budget: high costs but poor returns vs. other nations; Focusing event? debated.

Obama as a Candidate (2008)

Emphasized affordability; individual mandate, public option, Cadillac tax = contentious; strategy balanced dissatisfaction with fear of disrupting current care.

After the 2008 Election

Obama & Democrats won White House + Congress; economic crisis shifted debate over whether health care should be the early focus.