HP 353 - Chapter 3: Health Insurance & Access to Care

Why is the healthcare market not a normal market?

Information asymmetry

Insurance as insulation

Conflicting interests (patients vs providers)

Tax subsidies (no price transparency)

Failure of competition

Financial barriers to healthcare include what?

Lack of insurance, underinsurance (coverage limits, EXPENSIVE deductibles & premiums, copayments/coinsurance, lack of coverage for LONG TERM CARE),

Who are the uninsured?

Employed uninsured and unemployed uninsured.

Employed uninsured

Low pay, part time, no health insurance. Think a person working 2 part time jobs to get by, but because they're working part time jobs, their jobs don't offer insurance (& they can't afford it alone).

Unemployed uninsured

Low income but ineligible for Medicaid. In MA, some old houses are worth 1 million $. You can't qualify for Medicaid even if you're low-income because your house is worth so much.

non financial barriers to health care

Primary care physician shortage

Finding a physician who will take your insurance

Scheduling an appointment

Physical distance between facilities and patients (rural)

Language/cultural incompatibility between provider and patient

Gender

Ethnic background

What's a premium?

• Monthly payment you make to your health insurance company to maintain coverage, whether or not you use any medical services.

• Separate from other costs like copays, deductibles, or coinsurance.

• Varies based on your plan type, age, location, and income.

What is indemnity health insurance?

A type of health coverage that allows patients to visit any doctor or hospital and pays a fixed portion of the costs for covered services.

What are the key features of indemnity health insurance?

Freedom to choose any provider, no network restrictions, fee-for-service model, reimbursement after care is received.

What are the benefits of indemnity health insurance?

Maximum provider flexibility

NO referrals needed for specialists

Useful for people who travel or live in multiple locations

You know the exact cash benefit you will receive for a covered medical event, making it easier to budget for medical expenses.

What are the drawbacks of indemnity health insurance?

Higher premiums and deductibles

More paperwork and claims filing

No built-in cost controls like managed care plans

What is an HMO health insurance plan?

A tightly integrated health plan that requires members to use a primary care physicians to coordinate care and make referrals.

What are the key features of an HMO plan?

• You must choose a primary care physician

• Your primary care physician (PCP) manages referrals and treatment approvals

• Copayments are required for services

What are the benefits of an HMO plan?

• Lower premiums and out-of-pocket costs

• No paper for claims

• Strong focus on PREVENTIVE care

are all benefits

What are the drawbacks of an HMO plan?

Limited choice of doctors and specialists

Must get referrals for specialist care

No coverage for non-emergency care outside the network

What is a PPO health insurance plan?

A managed care plan that offers a wide choice of providers, including both in-network and out-of-network options, with no referral required to see specialists.

What are the key features of a PPO plan?

• Most expensive premiums

• Provider network with partial coverage for out-of-network care

• Self-referral allowed (no need for a primary care physician)

• Providers are paid on a discounted fee-for-service basis

• Providers don't bear financial risk

What are the benefits of a PPO plan?

• Maximum flexibility in choosing doctors and hospitals

• No referrals needed for specialists

• Partial coverage for out-of-network services

Who might prefer a PPO plan?

People who want freedom to choose providers, those who dislike referral requirements, Individuals who want some coverage for out-of-network care.

What are the drawbacks of PPOs?

• Highest monthly premiums among managed care plans due to their flexibility

• Deductibles, copays, and coinsurance can be more expensive

• More paperwork

• Less coordinated care (due to lack of primary care physician)

• Confusing coverage rules

What is a POS (point of service) health insurance plan?

A hybrid plan combining features of HMO and fee-for-service models, where the primary care physician (PCP) is the central "point of service".

What are the key features of a POS plan?

• MUSE CHOOSE A PRIMARY CARE PHYSICIAN (PCP)

• PCP coordinates care and referrals

• more expensive than HMO, but LESS EXPENSIVE THAN PPO

• allows use of out-of-network providers

• requires paperwork for out-of-network reimbursement

What are the benefits of a point of service (POS) plan?

• Flexibility to use non-network providers

• Access to broader care options than HMO

• Preventive care coordination through PCP

• Costs less than PPO

What are the drawbacks of a POS plan?

• High copayments for out-of-network care

• Referrals for specialists may be hard to obtain

• Must submit paperwork for out-of-network reimbursement

Consumer driven high deductible health plan

• health insurance plan with lower premiums and higher deductibles

• often paired with a Health Savings Account (HSA) to help pay for out-of-pocket costs

What are the key features of a high deductible health plan?

• High annual deductible before insurance starts paying

• Lower monthly premiums

• Often includes access to a Health Savings Account (HSA) - tax advantage

• Encourages consumer responsibility in managing healthcare spending

• Flexibility in choosing providers

What are the drawbacks of a high deductible health plan?

• High upfront costs before coverage kicks in

• May discourage care due to OUT-OF-POCKET EXPENSES

• Not ideal for people with CHRONIC CONDITIONS/frequent medical needs

• Requires careful budgeting

Flexible spending account

Employee-controlled pretax earnings set aside to pay for certain eligible expenses, such as health care expenses, during the same year.

Not tied to a deductible value.

No high deductible needed.

You lose the unused $ @ the end of the year to a 3rd party :(

Health savings account

• Account tied to a HIGH DEDUCTIBLE health plan that shelters income from taxes and that can be used to pay health care expenses.

• $ you don't use DOES ROLL OVER YEARLY 🙂

• If you leave a job, you get the money back, but the job taxes the remaining balance

What is regressive healthcare financing?

A system where low-income individuals pay a higher percentage of their income toward healthcare costs than higher income individuals.

What are examples of regressive healthcare financing?

Flat premiums (same amount regardless of income), sales taxes on healthcare goods, out-of-pocket payments (copays and deductibles).

What are the drawbacks of regressive financing?

Places greater financial burden on low-income individuals, can limit access to care, may worsen health disparities.

What is progressive healthcare financing?

A system where higher-income individuals contribute a larger percentage of their income toward healthcare costs.

What are examples of progressive healthcare financing?

Income-based premiums

Payroll taxes for public programs like Medicare

Sliding scale subsidies under the Affordable Care Act (ACA)

What are the benefits of progressive financing?

Promotes equity, reduces financial barriers to healthcare, helps ensure universal access to healthcare!

What is the most widely used type of healthcare plan?

• Preferred provider organizations (PPOs) are the most widely used type of plan

• Flexible (you can see any doctor or specialist without a referral)

• Partial out-of-network coverage

• Despite expensive premiums and deductibles, PPOs are popular because of their convenience and freedom

What does COBRA stand for?

Consolidated Omnibus Budget Reconciliation Act of 1985

What are the main benefits of COBRA coverage?

It guarantees continued health insurance at group rates for up to 18 months after losing coverage due to qualifying life events.

What are the qualifying events for COBRA coverage?

job loss, divorce, death of a covered family member, child aging out of dependent status.

What is a major limitation of COBRA coverage?

Premiums may be unaffordable, since the individual pays the full cost of coverage plus a small administrative fee.

T/F: Medicare A provides inpatient hospital and skilled nursing care for people without premiums for ppl 65+ (or younger ppl w a disability).

True. Medicare part A provides inpatient hospital and skilled nursing care for people without premiums for ppl 65+ (or younger ppl w a disability).

T/F: enrollees must pay deductibles and coinsurance in both Medicare parts A & B.

True. Enrollees must pay deductibles and coinsurance in both Medicare parts A & B

T/F: Medicare includes long term care coverage

False. Medicare does NOT include long term care coverage.

T/F: With Medicare part C, you know exactly what you're paying for.

True. With the optional Medicare part C plan, you know exactly what you're paying for. No surprises.

Medicaid provides funding for medical and health-related services for those people within broad federal guidelines at or below _____ of the federal poverty line.

138%.

T/F: The Supreme Court ruled that states are required to follow the federal poverty line set by the Affordable Care Act.

False. The Supreme Court ruled that states are not required to expand Medicaid under the ACA. States retain the authority to set their own eligibility standards, including how they apply the federal poverty level, and determine the scope, amount, and duration of services as well as payment rates.

T/F: providers are legally bound to accept Medicaid and Medicare.

False. Providers must accept Medicare, but they do NOT have to accept MedicAID (#screwlowincomepplig).

T/F: ppl with Medicaid, compared to the uninsured, are more likely to have a regular source of care

True. They get more preventive services, and report fewer delays in getting care.

T/F: compared to insured, people on Medicaid are more likely to get medical care, prescription drugs, dental care, and eyeglasses.

False! People on Medicaid, compared to the insured, have MORE TROUBLE obtaining medical care, prescription drugs, dental care, and eyeglasses.

What are the dominant influences on healthcare status?

Public health interventions, medical care, socioeconomic status, and age.

You are a pediatrician seeing a child who is undernourished. You ask the mother who is on Medicaid, how much milk her child has had in the past 24 hours. She says she has run out of money and has been giving her child watered down milk. What else would you want to know about this situation? What would you do?

Are you on any medications? Do you have a source of transportation? Are you on food support? Are you nursing or using formula? What's your housing/water quality situation like?

What are the implications of the Whitehall study?

People in the lowest grades of jobs (doorkeepers, messengers) hand a higher mortality than that of men in higher grades of jobs (administrators). Low income level and health education level increase mortality. Also makes you think about people working low grade jobs who aren't able to take time off to receive care.

What issues do women experience accessing healthcare?

Dissatisfaction with physician care

lower quality of preventive care

inappropriate care

less likely than men to fill a PX (prescription)

more likely to be on Medicaid (more difficulty finding a physician)

Reduced access to certain services.

What issues do some MINORITY women experience in their pursuit of healthcare?

Poverty

No high school diploma

No health coverage

No doctor visits due to cost

No personal doctor (they even have a higher incidence of HIV/AIDS due to these factors).

Medical model

Assumes the existence of illness or disease.

Emphasizes CLINICAL diagnosis and medical interventions to treat disease and disease symptoms.

Definition of health assume absence of disease/illness.

Behavioral model of care

Assumes that health results from interaction between the individual and the environment (a state of complete, physical, mental, and social well-being, and not merely the absence of disease or infirmity).

Holistic model

Philosophy emphasizes the wellbeing of all aspects of a person's life and TAKES SPIRITUALITY INTO ACCOUNT (physical, mental, social, spiritual).

Improving partnerships between ______ & _______ is one strategy toward improving care.

Insurers and providers (physicians).

Why do employees in large (50+) firms typically have better access to health insurance.

Large firms often have more resources, negotiating power, and economies of scale, allowing them to offer comprehensive group health plans.

What are common benefits of health insurance in large firms?

Lower premiums due to group bargaining

Broader coverage options

Employer contributions to premiums

Access to wellness programs & additional benefits

What challenges do small firms face in offering health insurance?

Higher per-employee costs

Limited plan choices

Less bargaining power with insurers

Aren't required to offer coverage under the ACA if they have <50 employees.

Why do some doctors limit/refuse to accept Medicaid patients?

Medicaid typically reimburses providers at lower rates than private insurance or Medicare, which may discourage participation.

How does provider availability affect Medicaid access?

There are fewer providers who accept Medicaid, especially in specialty care and rural areas, leading to longer wait times and limited options.

What administrative challenges do Medicaid providers face?

Providers often deal with complex paperwork, pre-authorization requirements, and delayed payments, which can reduce their willingness to participate.

What are the consequences of limited access for Medicaid patients?

Delayed care, Fewer choices for providers, Difficulty finding specialists, Potential worsening of health outcomes.