United States Healthcare Midterm 1

PHTH 1260

What are the social determinants of health?

Non-medical factors that influence health outcomes

What is the biggest predictor of health outcomes?

Socioeconomic status

Social determinants of health contribute to (rates/causes/access) [of disease]

Causes of disease

What are health disparities?

Unfair and preventable burden of disease of selected populations (ex: Black women have lower breast cancer rates than white women but higher mortality rates.)

Health disparities contribute to (rates/causes/access) [of disease]

Rates of disease

What are health care disparities?

Unfair differences in access among selected populations

Health care disparities contribute to (rates/causes/access) [of disease]

Access

What are the 4 historical periods?

Pre-industrial era, post-industrial era, corporate era, reform efforts

What are the characteristics of the pre-industrial era? (How do we stand vs other countries? Who can practice and how? How is the system structured?) State of hospitals and trainings?

Other countries are more advanced, medicine is domestic and not professional, training is not based on science, health insurance doesn’t exist. Very few hospitals, all unsanitary, institutions primarily served the destitute, mentally ill, and criminals and were called ‘Pest houses”. It was a free market; anyone could practice

What are the characteristics of the post-industrial era? (How was the system organized, how did it operate, and how did people get access to care?)

Medicine is becoming more organized; Professional organizations are formed (AMA opposes universal coverage), medical school accreditation is created (but this shuts down the majority of Black medical schools and with it, limited Black communities’s access to care). For-profit health insurance from employers is created, Medicare/Medicaid created. Anesthesia, microbiology, imaging, antibiotics all created, and there were overall reforms to care and mental health institutions, largely because de-institutionalization and privatized medicine were put at a disadvantage

What are the characteristics of the corporate era?

(Corporatization of health care delivery, information revolution (telemedicine), globalization (cross-border economic activities and trade), foreign direct investment, exporting of health professionals; minoritized and low-income communities are often excluded based on ability to pay

What are the characteristics of the reform efforts/era?

Current era; mainly passage of ACA and lawsuits against it

Why did reform efforts fail in the U.S.?

Labor/political instability wasn’t an issue like other countries (minoritized and low income didn’t have political power/voice here), decentralized US system had very little control over state social policy, German social insurance and socialism as a whole was made public enemy during WWII, American Medical Association (AMA) opposed national health insurance; Middle class had big distrust of gov, valued capitalism and self determination, doesn’t want higher taxes, and health care had been corporatized.

What are the different types of health insurers? (5)

Private for-profit, private non-profit, public options (government), out-of-pocket (cash), or some other combination of the above

What are the types of providers of health care?

Insurance, HMOs (health maintenance organizations), PPO’s (preferred provider orgs), hospitals, nursing homes, inpatient mental health facilities, home health care agencies/hospice, community health centers, HIV clinics, early intervention clinics, etc., dental/pharmacy/nursing schools

What are the four parts of the healthcare funding system?

Financing (gov, employer, self-funded, i.c. insurance → how different entities fund things), insurance (companies, self), delivery (med. Providers, hospitals, diagnostic centers, medical equipment vendors, etc. all need to be paid), payment (insurance companies pay health care providers, employers pay insurance companies, insurance pays patients, or insurer IS the provider)

What is managed care?

It’s the system that manages all four parts of the health care financing system (financing, insurance, delivery, payment). They negotiate contracts with providers or hospitals and offer a care network to its insurees

The United States is the ONLY economically comparable country in the world…

without some type of universal health care system. No public option

What does a public option mean?

“Public option” refers to a plan set up by the government that people can fall back on. Anyone can fall back on this option; in other countries, this is called a national or universal coverage/plan

What is the paradox of United States healthcare (in terms of both spending and access)?

The United States spends the most money per capita on health care, least on social services, but has worse health outcomes and shorter life expectancy than comparable countries. The United States has some of the best care in the world but so many people can’t actually access it because they can’t afford it.

Medical bankruptcy is _____ in most countries with universal care.

Extremely rare

What are the global models of healthcare (4)? Which one is the U.S.?

Beveridge model, Bismarck model, the National Health Insurance Model (national/universal), the Out-of-Pocket Model; the US is all four.

What is the Beveridge Model?

Single-payer national health service; Staff providers are government employees, health is a human right, single-payer, patient pays through taxes (no bills), providers (gov.) don’t profit, gov. controls prices/costs

What is the Bismark model?

Social health insurance model; Staff/providers are private, decentralized, not run by gov., people pay into “sickness funds” to employer, payroll deductions required, insurance plans private but insurers do not make a profit, there are one or multiple insurers that can be private or non-competing; gov. Controls prices/costs

What is the National Health Insurance Model?

Single-payer national health insurance; combo of Beveridge and Bismark → Gov is single payer (Beveridge), providers are private (Bismark), everyone is covered, insurance doesn’t make a profit or deny claims, some models allow private entities

What is the Out-Of-Pocket Model?

Market-driven; less wealthier countries and the US use it, mainly volume-based: patient billed for care, fee-for-service model, out-of-pocket → cash paid directly for bills by patient

What is a premium?

The annual cost of ‘membership’ in a health plan. Usually paid monthly, varies widely between plans for both public and private plans

What is a deductible?

A fixed amount that a patient must pay each year before their health insurance benefits begin to cover the costs. Varies widely for both public and private plans. Plans with lower deductibles will have higher monthly premium costs and vice versa.

What are co-pays?

A set amount for each visit regardless of the care provided. Varies widely between plans and types of visits (physician vs emergency department vs specialist)

What is co-insurance?

When for each time you receive medical care, you split the bill with your insurance or with your employer. Activates after you meet your annual deductible

What is volume-based care?

When providers are re-imbursed on a fee-for-service basis; payments are made to providers based on each individual service.

What is value-based care?

When care is reimbursed to incentivize providers based on patient health outcomes

How did the ACA change provider reimbursement?

It changed how providers are reimbursed to incentivize good health outcomes (ex: bundled payments→ retrospective or prospective, based on DRGs (Diagnostic Related Group) → this is the coding that providers use to get reimbursed by Medicare, Medicaid, private insurance, etc.

What are the consequences of uncompensated care?

It increases prices for those who do pay bills; ppl with private insurance pay higher prices bc gov pays hospitals for some of their uncompensated care, our taxes support the government. There’s a loss of revenue by workers who are too injured/sick to work and an increase in social safety net expenses by the government (first responders, homelessness, jails/prisons, etc.)

What are the two ways the economy functions? (hint: justice) Which system does the US have?

Market justice and social justice. The US relies on both (Private insurance → market justice, medicare, medicaid → social justice)

Where do Americans get coverage? (With percentages)

About 50% get through employer, about 35-40% get it through government (Medicare, Medicaid, VA, Tricare) and about 9-10% uninsured (emergency room care or out of pocket payments)

What does it mean for someone to be under-insured?

Insured but coverage is inadequate or coverage is too expensive to use

What is market justice?

People gain access based on ability to pay. Believes market forces of a free economy drives innovation (capitalism). Individual well-being is prioritized

What is social justice?

Based on fair distribution. Well-being of an entire community prioritized over individuals.

What is the Triple Aim and what does each category entail?

1. Cost → The price of health treatment/services, cost paid to hospitals, cost sharing by consumers, etc) 2. Quality and patient/provider experience → Are we getting our money’s worth, morbidity/mortality, what we say it means to be “healthy,” patient (faces discrimination or no), provider experience (facing burn out or no), value/branding; 3. Access → Who gets access and to what? People get iced out by cost, and health care worker volume, expertise, etc. varies

What are the reasons for high health care costs? (8 options)

Third-party payment, growth of technology, increase in elderly population, medical model of health care delivery, multipayer system and administrative costs, defensive medicine, waste/abuse, and practice variations.

What is “third-party payment?” (health care costs)

When the government or private insurance pays the larger portion for most of the services used. Individual patients pay a price that is far lower than the actual cost of the services; the patient (demand) and provider (supply) have little incentive to be cost-conscious.

What is the “growth of technology” (health care costs)

Research and development are costly and included in health care expenditures. New technology’s existence creates demand, contributes to moral hazard and provider-induced demand.

What is the “increase in elderly population?” (health care costs)

Life expectancy is increasing in the US, meaning there’s been an increase in the elderly population in the US. Costs for elderly health care are nearly 3x higher than for the general population (and there’s more strain on social security)

What is the “medical model of health care delivery?” (health care costs)

It’s the United States’ health care model that emphasizes medical intervention rather than prevention or lifestyle/behavior changes, leading to reliance on more costly procedures once a situation has become dire enough to merit a visit

What is the “multiplayer system and administrative costs?” (health care costs)

Administrative costs in a multipayer system are often duplicated and account for as much as 25% of the total health care expenditures in the US

What is “defensive medicine?” (health care costs)

Involves tests and services that are not medically justified but are used to protect against lawsuits

What is “waste and abuse?” (health care costs)

General waste, Medicare/Medicaid fraud, providing more services than medically necessary, third-party billing for services not actually provided; done typically by institutions (nursing homes), not individuals

What are “practice variations?” (health care costs)

Referred to as small-area variations, geographic variations in treatment patterns across the country increase costs without improving outcomes

How many people are expected to lose coverage based on the Medicare/Medicaid/ACA eligibility and tax changes?

11-15 million people are predicted to lose insurance

How does Medicare/Medicaid work? (program structure, how it’s administered, who is eligible)

Medicare is same program nationwide, administered only by federal government, and is not based on income → those over 65 or disabled under 65 that receive social security or have ALS/end-stage renal disease are eligible. Medicaid varies by state (51+ programs), it’s administered by both the federal government and by the states, states determine eligibility criteria, ppl qualify if they meet the income requirements and are also disabled/children under 19/ aged 65+/pregnant woman/blind/need nursing home care, etc. (income based and categorical)

What year was Medicare created? What year was Medicaid created?

Both were started in 1965

What program includes CHIP? What is CHIP?

Medicaid; The Children’s Health Insurance Program

What program is the largest insurer of long term-care under 65?

Medicaid

What are Medicare and Medicaid satisfaction rates like?

Medicare: over 80% of recipients like it; Medicaid: High satisfaction rates

Which insurance system in the US is like a single payer system?

Medicare

How does the ACA provide coverage?

The ACA is a law, not a bill. It gives people access to a marketplace on which they can buy health insurance. Created a place for people to go ‘shopping’ on the ‘Marketplace Exchanges’ to get cheaper rates → law was expanded then reversed Jan 2026 → millions expected to lose coverage

What are the three legs of the ACA? Are they all still standing?

1. Subsidies→ Tax credits = discounts to purchase in the marketplace; available to ppl 138% - 400% of FPL. 2. Guaranteed issue→ insurers can no longer deny coverage based on pre-existing conditions. 3. Individual mandate → All people must have insurance or be charged a tax penalty. If more than 50 people are employed, the employer must offer health insurance. The individual mandate is no longer standing → The tax penalty was zeroed out in Trump’s first term, but the employer mandate is still in place.

Why did 20 million people gain coverage under the ACA?

It expanded Medicaid (made more people income eligible), allowed the Marketplace exchange, and created the employer mandate

Why are millions expected to lose access to Medicaid?

Because of the work requirements instated under the Big Beautiful Bill and the changes in eligibility requirements + losses from marketplace due to the expanded subsidies being allowed to expire in Jan 2020

How many people are enrolled in Medicare? How many dually eligible? (2010 vs 2025) How many on Medicaid?

Medicare : 70 million, dually eligible: 12.5 million, Medicaid: 77 million (as of 2025) BUT 2010 → Medicare: 50 mil, Medicaid: 66 mil

What is the criteria to be dually eligible for Medicare and Medicaid?

Low income people who are disabled and cannot work, low income people 65+

What is FMAP?

Federal Medical Assistance Percentage → for Medicare; it’s the amount the federal government pays the states based on the state’s average personal income.

What are the details of Medicaid expansion?

ACA required states to expand, the Supreme Court ruled it was unconstitutional → all but 10 states have expanded. Expanding means changing the income eligibility so that higher incomes are eligible → must be 138% at or above the Federal Poverty Level (FPL). Some states have even higher percentages.

Does the US have a “public option?”

No (public meaning universal/national, available to anyone)

What was the ACA’s full name and what was its timeline of activation?

Patient Protection and Affordable Care Act passed 2009, signed into law 2010, took effect 2014. Before 2014, uninsurance rates around 17%, dropped 2014. Started to go back up in 2017 when Donald Trump zeroed out the non-insurance penalty. Was never intended to cover everyone, was first bill to include prevention (public health). During the pandemic, insurance rates increased.

What is the aim of Medicaid expansion? (who gains coverage?)

It makes more poor single adults elibible to be insured and also makes more poor parents eligible for coverage (extends to adults at 138% of FPL)

What is the International Declaration of Human Rights?

It’s a document put out by the UN and it lists fundamental rights. Health care is one of them. Some countries do not have this aspect written into law, some have it written into law but not policy/practice or implemented inadequately.

What is the 1910 Flexner report?

When Flexner evaluated medical schools and made a report setting criteria to standardize and improve them. Many schools were forced to close, some of which being 5 of only 7 Black-serving medical schools. Even today, its effects are still felt: There’s an underrepresentation of providers and med school students that reflect the population to be served

What is the 1946 Hill-Burton Act?

Funded hospital construcion and was the first time “separate but equal” was written into federal law in the 20th century. “Separate but equal” hospital wings made. Legalized segregation.

What is 1954 Brown v. Board of Education?

Supreme Court case ruling “separate but equal” unconstitutional.

What is the 1964 Civil Rights Act?

A landmark law banning discrimination in many aspects of American life (legally but not in practice)

What is the 1965 Medicare/Medicaid passage for Civil Rights?

It forced the integration of hospitals by threatening to cut off federal payments to hospitals that didn’t integrate. However, Black patients would also lose hospital access if the hospital lost federal money. Civic servants from across the gov. Volunteered and vetted hospitals to ensure compliance. However, even after desegreation, discriminatory/unequal practices persists

What are the four parts of Medicare?

Part A: Hospitalization (inpatient). Covers you during short term inpatient hospital stays and hospice. Limited skilled nursing facility care and certain in-home healthcare services. Part B: Outpatient → covers everyday care needs (ex: doctors’ appointments, urgent care visits, counseling, medical equipment; Part C: Medicare Advantage → private plans approved by the federal gov and sold separately, combine Parts A and B’s coverage, parts of Part D into a single plan plus other perks like dental, vision, gym memberships, etc; Part D: Prescription drug coverage → stand alone plans that only cover your medications, provided through private insurance companies. Parts B, C, and D all cost extra, have additional premiums, deductibles, co-pays