Public Health: Chapter 11 - Health Insurance & Healthcare Systems

medicare

federal insurance for adults 65+ and disabled individuals, funded through payroll taxes and general federal revenues

medicaid

joint federal-state insurance for low-income individuals and children, pregnant women, etc.; funded with federal matching funds

VA (Veterans Health Administration)

government-run healthcare system for military veterans; funded by federal government

TriCare

health insurance for active duty military members and their families; federally funded

IHS (Indian Health Service)

healthcare for Native American and Alaska native populations; funded by federal appropriations

payroll tax (medicare financing)

a tax taken from employee and employer wages to fund medicare Part A

medicare Part A

covers hospital care, nursing facilities, hospice, and some home health after hospitalization

medicare Part B

optional coverage for outpatient services, diagnostics, equipment, and therapeutic care

medicare Part C

private plans offering medicare benefits with provider networks and added vision/dental/hearing

medicare Part D

prescription drug coverage for those enrolled in A and B

employment-based health insurance

insurance provided through an employer; the largest source of coverage in the U.S.

community rating

premiums based on the average health risk of a large population, not individual health status

experience rating

premiums set based on the specific health risk of an individual or group

fee-for-service (FFS)

insurance pays providers for each service performed; encourages higher use of services

capitation

providers receive a fixed payment per patient per month, regardless of services provided; encourages cost control

health maintenance organization (HMO)

capitated managed-care plan requiring use of network providers; emphasizes prevention

pay for performance

providers’ payment increases when they meet quality or performance targets

provider salary

providers are paid a set annual amount regardless of services delivered

preferred provider organization (PPO)

insurance type allowing more provider choice but lower costs for using in-network providers

point of service plan (POS)

hybrid plan: HMO with option to go out-of-network for higher cost

health insurance marketplace

online platform offering insurance plans, often with federal subsides

subsides (ACA)

financial assistance to lower premiums and deductibles for low and middle income individuals

uninsured

people lacking health insurance, commonly young adults, low-income workers, or small-business employees

consequences of being uninsured

less preventive care, later diagnosis, more emergency department use, higher mortality risk

canada’s healthcare system

single payer system where the government funds most care, but services are delivered by private providers

united kingdom’s NHS

government-funded and government-delivered healthcare system where most providers are public employees

U.S. vs Canada/UK

U.S. relies more on private insurance, has higher costs, and offers greater choice but less universal coverage

administrative costs

high costs from billing, insurance paperwork, and hospital operations

overuse of technology

excessive or unnecessary use of expensive tests and devices

unnecessary services

services that do not improve outcomes or are not medically needed

high prices

higher drug, procedure, and hospital prices compared to other countries

fraud and abuse

billing for services not needed or not performed

defensive medicine

extra tests/procedures done to avoid lawsuits rather than for patient benefit

cost sharing

using deductibles, copayments, and coinsurance to reduce overuse

regulation

government limits on prices, services, or malpractice claims

reimbursement reform (capitation/DRGs)

paying providers based on fixed amounts rather than service volume

malpractice reform

reducing unnecessary tests driven by fear of lawsuits (defensive medicine)

increasing competition

encouraging price shopping, multiple provider options, and negotiated costs