PUBH 6012 Exam 2 Actual questions and answers with 100% accuracy(VERIFIED BY PROFESSOR)

What are the two main types of policy analysis, and what distinguishes them?

Prospective: predicts or recommends future actions and outcomes; main approaches: policy options analysis and policy simulation/forecasting models

Descriptive: examines policies that have already been adopted; main approaches: retrospective, evaluative, and economic analysis

What are the three main types of descriptive (ex-post) policy analysis?

- Retrospective: descriptive interpretation of past policies and implementation

- Evaluative: evaluates impact on desired outcomes - did the policy work?

Economic: CBA (Cost-Benefit Analysis), CEA (Cost-Effectiveness Analysis), CUA (Cost-Utility Analysis) - what value was achieved for resources spent?

What is the purpose of economic policy analyses (CBA, CUA, CEA)?

To find the most efficient means of achieving desired objectives - either minimize resources used to achieve an objective, or maximize the amount of objective achieved given a fixed expenditure of resources

What is Cost-Benefit Analysis (CBA) and how is it measured?

Purpose: determine which intervention produces the greatest net monetary benefit

Measurement: both costs AND benefits measured in monetary units. Net benefit = total benefit - total cost

What is Cost-Effectiveness Analysis (CEA)?

Purpose: determines which intervention produces the most of a desired outcome for a given expenditure (or costs the least to achieve a given outcome)

Measurement: costs in monetary units, effectiveness in a nonmonetary unit (e.g., years of life saved, HIV infections averted, smoking cessation rates)

Note: cost-effective does not equal cost savings

What is Cost-Utility Analysis (CUA) and what makes "utility" different?

Purpose: determines which intervention produces the most utility per dollar

Utility: the pleasure/satisfaction a person derives from a good or service - subjective, varies between people. Measured on a scale (e.g., death = 0, perfect health = 1)

Common measures: Life Years Saved (LYS), Quality-Adjusted Life Years (QALYs)

CBA vs. CEA vs. CUA - what is the OUTCOME measured in each?

- CBA: benefits = monetary units (dollars)

- CEA: effectiveness = nonmonetary units (e.g., infections averted, years of life saved)

- CUA: utility = nonmonetary units, on a 0-1 scale (e.g., QALYs)

Costs are always in monetary units

What is the definition of a policy options analysis? (Wilensky & Teitelbaum)

An analysis that provides informed advice to a client related to a public policy decision and includes a recommended course of action (or inaction) and is framed by the client's powers and values

Weakness: myopia from client orientation and time pressure

What are the 6 steps of the basic policy analysis process?

1. Verify, define, and detail the problem

2. Establish evaluation criteria

3. Identify alternative policies

4. Evaluate alternative policies

5. Distinguish among alternatives

6. Monitor implemented policy

What are the 5 elements of a policy options analysis?

1. Problem identification

2. Background

3. Landscape

4. Options (with criteria)

5. Recommendation

What makes a GOOD problem identification?

- Frames the issues, key to the analysis

- May be defined by the client

- Neutral or value-laden

- Analytically manageable

- Not a yes/no answer (allows multiple options to be considered)

What is the purpose of the background section?

Provides key information/statistics needed to understand the problem and the options being considered

Must be comprehensive and objective - do not include information that supports your recommendation solely

What is the purpose of the landscape section?

Provides political and factual context by identifying key stakeholders and their views on salient issues

Considers political, social, legal, practical, and economic aspects

What are the rules for OPTIONs in a policy options analysis?

- Options must address the problem identified

- All options must be assessed by the same criteria

- All options must be within the client's powers and values

- All options must have pros and cons

- Common criteria: cost, political feasibility, administrative ease, fairness, effectiveness

What are the rules for the RECOMMENDATION section?

- Choose only ONE of the options analyzed

- Do NOT combine options

- Explain why the preferred option is best

- Base recommendations on the client's powers and values

- Cannot base recommendations on criteria you didn't analyze for all options

What are the PRIMARY sources of law? (i.e., "the law" itself)

- Constitutions (federal and state)

- Statutes (created by legislation, codified

- Regulations (rules) issued by administrative agencies

- Common law (court decisions)

What are SECONDARY sources of law?

Sources to understand the law, but not the law itself. Can be cited, but are not authoritative

- Treatises

- Law review articles

- Government reports

- Legal encyclopedias

Is there a general right to health care in the US?

No

Exceptions:

- Prisoners

- Native Americans

- People in entitlement programs (e.g., Medicare, Medicaid)

Generally, providers have professional autonomy and can choose their patients

What does EMTALA do, and why is it significant?

Emergency Medical Treatment and Labor Act - essentially the only right to health care in the US

Requires hospitals to screen and stabilize/transfer emergency patients

What does Title VI of the Civil Rights Act of 1964 cover? What are its limits?

Prohibits discrimination based on race and national origin (NOT gender or age) in programs receiving federal funds

Important limit: no private right of action for disparate impact cases - only the government can sue, individuals cannot

What does the Americans with Disabilities Act (ADA) of 1990 protect against?

Prohibits discrimination on the basis of disability in health care and other public accommodations

What are the 4 elements required to prove medical negligence/malpractice?

1. Duty - defined by state law, standard of care, or scope of practice

2. Breach of that duty

3. Damages (injury)

4. Causation - the beach caused the injury

What did Dobbs v. Jackson Women's Health Organization (2022) do?

The Supreme Court overturned Roe v. Wade and Planned Parenthood v. Casey, eliminating the federal constitutional right to abortion before viability

Returned the issue to states - some actions may now be crimes in one state but required under a standard of care in another

What rights does a patient have AFTER accessing the health care system?

- Make informed decisions about treatment (informed consent)

- Be free from wrongful discrimination (Title VI, ADA)

- Be free from malpractice/negligence

- Individual autonomy - right to leave AMA, deny necessary care

Note: typically no right to compel a provider to provide any specific service

What is health economics, and what are its 3 key features?

Health economics: application of microeconomic tools to health issues - the societal allocation of scarce resources for health care

Key features:

1. Scarcity of resources

2. Rational decision making

3. Marginal analysis

What is DEMAND, and what are the demand changers?

Demand: quantity of goods/services a consumer is willing and able to purchase over a specific time

Demand changers:

- Price

- Income

- Quality (perceived and actual)

- Substitutes

- Complements

Price elasticity of demand: how responsive demand is to a 1% change in price

What is SUPPLY, and what are the supply changers?

Supply: the amount of goods/services producers are willing and able to sell at a given price over a given time

Supply changers:

- Price of the good

- Input costs

- Number of sellers

- Change in technology

What are the characteristics of a perfectly competitive market?

- Goods offered by sellers are largely the same

- Many buyers and sellers

- All resources are mobile

- Firms can freely enter and leave the market

- No government involvement

- Perfect knowledge and information

The health care market is NOT a perfectly competitive market

What does it mean for a market to be PARETO OPTIMAL? How does this relate to equity?

Pareto optimal: perfectly competitive markets efficiently allocate resources - no one can be made better off without making someone else worse off

Efficiency vs. equity: equity asks what is fair? - who should receive care, how much, at what cost? Efficiency and equity often conflict

Positive vs. normative analysis: positive = how things are; normative = how things should be

What is market failure, and what are the 4 main reasons it occurs?

Market failure: when resources are not allocated efficiently

Reasons:

1. Imperfect information

2. Concentration of market power

3. Consumption of public goods

4. Presence of externalities

What are public goods, and what 2 properties define them?

Public goods have two properties:

1. Non-rival: more than one person can enjoy them simultaneously

2. Non-exclusive: impossible or too costly to exclude individuals from enjoying it

Examples: national defense, lighthouse, air, herd immunity

Consumption leads to free riders and underprotection of the desired good

What are externalities, and how do they cause market failures?

Externality: when one person's actions create a benefit or impose a cost on others

- Positive: herd immunity from vaccination, mosquito abatement

- Negative: pollution, hazardous waste, secondhand smoke

Leads to underproduction (positive externalities) or overproduction (negative externalities) from society's perspective

What are the main types of government intervention to correct market failure?

- Government directly provides goods (e.g., VA hospitals)

- Government finances provision (e.g., Medicare, Medicaid)

- Taxes/subsidies

- Mandates

- Prohibitions

- Control on market entry: licensure, certificate of need, drug approvals

What is the difference between EXPERIENCE and COMMUNITY rating for setting premiums?

Experience rating: premiums on the individual/group's expected health costs

Community rating: premiums set based on the broader community's risk - does not penalize individuals for being high-risk

Deductible vs. coinsurance vs. co-payment

Deductible: the amount you pay before insurance starts paying

Coinsurance: percentage you pay after the deductible (e.g., 20%)

Co-payment: flat dollar amount per service (e.g., $20 per visit)

Plans may also have an annual out-of-pocket limit

What is adverse selection?

A phenomenon where insurers face the probability of loss due to risk not factored in at sale

People who expect high costs (high consumption) choose more comprehensive/expensive plans, while low-cost people choose restricted/cheap plans

Can lead to a death spiral

What is moral hazard?

The concept that if health care is less expensive to me, I'll use more of it and be less likely to take action to avoid using it

(Insurance reduces the cost of care to the patient, which increases utilization)

What is cherry picking?

When an insurer chooses to sell only to individuals it expects to be low-cost (low consumption) and excludes those it expects to be high-cost

What is a death spiral?

A vicious cycle where premiums rise because healthy people leave the insurance pool, leaving only sicker people. This drives premiums even higher, causing more healthy people to leave, and so on.

What does HIPAA (1996) do, and what does it NOT do?

Does: first national standards for portability (preserving access to insurance when changing jobs) and accountability (avoiding fraud/abuse). Limits pre-existing condition exclusions with continuous coverage (no gap > 60 days). Privacy and security regulations

Does NOT: protect uninsured or individual market enrollees; cap premiums; require employers to offer insurance; require any specific benefits

What's the difference between a fully insured and self-insured group health plan?

Fully insured: employer pays premiums to an insurance company; insurer pays claims

Self-insured (self-funded): employer assumes the financial risk of paying claims directly. May buy reinsurance and contract with a TPA (third-party admin)

Why it matters: ERISA (1974) exempts self-insured employers from state insurance laws, with few remedies for wronged beneficiaries. Employees often don't know they're in one

What is the key difference between fee-for-service and managed care?

Fee-for-service (FFS): providers are paid for each service - no incentive to do less or use cheaper services

Managed care: integrates payment and delivery of services. Features: defined benefit packages for a preset fee, provider network with contractual relationships, financial incentives to control delivery, use, quality, and cost

Distinguish cost containment tools vs. utilization tools in managed care

Cost containment tools:

- Performance-based salary bonuses/withholdings

- Capitated payments

- Discounted fee schedules

Utilization control tools:

- Gatekeeper

- Utilization review

- Case management

What are the key features of an HMO?

- Provider network (staff, group, network, or IPA model)

- Patients must use a primary care gatekeeper

- Referrals required for specialty care

- Must use the provider network

- Lower payments for members vs. PPO/POS

- Stringent quality and utilization standards

What are the key features of a PPO? Why is it the most popular MCO?

- Network providers have a contractual relationship with PPO

- Discounted fee schedules

- Patients may use in-network or out-of-network providers

- No gatekeeper, no referral required for specialty care

- Often fewer utilization strategies

Popular because of flexibility and choice

What are the key features of a POS (Point of Service) plan?

A hybrid model:

- Can go out-of-network at a higher cost

- BUT needs referral from an in-network primary care physician

- Pays less if you stay in-network

Combines HMO gatekeeping with PPO out-of-network flexibility

What is a High-Deductible Health Plan (HDHP)?

- Higher deductibles than traditional plans in exchange for tax benefits

- 2022 IRS definition: deductible of at least $1,400/individual or $2,800/family

- Can be paired with an HSA (Health Savings Account) or HRA (Health Reimbursement Arrangement) to pay for qualified out-of-pocket expenses pre-tax

- Out-of-pocket limits apply (2022: $7,050 individual / $14,100 family)

What is a catastrophic plan, and who can buy one?

A type of HDHP through marketplaces for people under 30 (or those with a hardship/affordability exemption)

- Very high deductible, low premiums

- Some limited benefits before deductible: preventive services + 3 primary care visits/year

- Cannot use subsidies with these plans

What is the full name of the ACA, and when did it pass?

Patient Protection and Affordable Care Act (2010)

Also called Obamacare

What are the major new rules for insurers under the ACA?

- Can't deny coverage for pre-existing conditions

- Premiums can ONLY vary based on: age, geographic area, tobacco use, family size

- No lifetime limits

- Can't rescind coverage

- Young adults can stay on parents' plan until age 26

- Waiting period limited to 90 days

What is the Medical Loss Ratio (MLR) and what are the required percentages?

MLR requires insurers to spend a minimum % of premium income on medical care and quality improvement (the rest goes to admin, marketing, profit)

- Individual and small group markets: 80%

- Large group market: 85%

Does NOT apply to self-insured plans (those must still provide minimum value = 60% actuarial value)

Plans must provide annual rebates if they fall short

What are the 10 essential health benefits that individual and small group plans must cover?

1. Ambulatory patient services (outpatient)

2. Emergency services

3. Hospitalization

4. Maternity and newborn care

5. Mental health and substance use disorder services (incl. behavioral)

6. Prescription drugs

7. Rehabilitative and habilitative services and devices

8. Laboratory services

9. Preventive and wellness services + chronic disease management

10. Pediatric services

What are the ACA's minimum value and affordability standards for large employer plans?

Minimum value: plan must pay at least 60% of the total cost of medical services for a standard population AND include substantial coverage of physician and inpatient hospital services

Affordability: employee-only coverage costs no more than 9.12% (2023) of household income. If affordable AND meets minimum value, the employee isn't eligible for a premium tax credit on the marketplace

What preventive services are covered with NO cost sharing under the ACA?

Includes screenings for cancer, mental health, STDs, vaccinations, and the full range of FDA-approved contraceptives for women (not abortions or vasectomies)

Religious employers exempt from birth control requirement, some are suing to avoid covering PrEP

What are the 4 metal tiers in the ACA marketplace plans, and what are their actuarial values?

Based on how much the plan pays vs. the individual:

- Bronze (60/40)

- Silver (70/30)

- Gold (80/20)

- Platinum (90/10)

Who is eligible for premium tax credits (subsidies) on the marketplace?

- Income between 100-400% FPL

- 100-133% FPL: those NOT eligible for Medicaid

- 133-400% FPL: available on sliding scale

- Over 400% FPL or below 100% FPL: no subsidy

- Tax credit amount depends on plan cost and how much the premium exceeds a set % of income

- Can be applied to any metal level plan

Who qualified for cost-sharing reduction (CSR) subsidies, and what's the catch?

Available to those with an income below 250% FPL, to reduce out-of-pocket costs (deductibles, co-pays, coinsurance)

Catch: must select a SILVER plan for CSR to be applied. CSRs are in addition to premium tax credits

What is the benchmark plan used to determine subsidy amounts?

The second-lowest cost silver premium for a 40-year-old

This is separate from the essential health benefits benchmark

What is the coverage gap, and why does it exist?

The Coverage Gap exists in states that did NOT expand Medicaid

Congress drafted the ACA to cover everyone up to 133% FPL via Medicaid, then subsidies for 100%-400% FPL. But after NFIB v. Sebelius, Medicaid expansion became OPTIONAL

In non-expansion states, people too poor to qualify for subsidies (below 100% FPL) but who don't fit pre-ACA Medicaid categories fall into the gap - no Medicaid, no marketplace subsidies

What did NFIB v. Sebelius (2012) decide about the individual mandate?

The Supreme Court upheld the individual mandate as a legitimate cause of Congress' taxing power

However, the Court rejected the argument that the Commerce Clause justified it - Congress cannot compel people to participate in commerical activiry under that clause (ony regulate existing activity)

What did NFIB v. Sebelius decide about Medicaid expansion?

The Court held that the federal government cannot require states to expand Medicaid to 133% FPL as a condition of continued Medicaid participation. The incentive (losing all Medicaid funding) was so great that it was unconstitutionally coercive - a violation of states' rights

This created two Medicaid structures in the US: expansion (income-based) and non-expansion (categorical, pre-ACA rules)

What were the primary federal powers at issue in the ACA constitutional challenges?

Three primary federal powers:

1. Tax

2. Spend

3. Regulate interstate commerce

Main questions: Is the ACA (especially the individual mandate) a legitimate exercise of federal power? Does it infringe on the Tenth Amendment (states' rights)?

What happened with Texas v. Azar and the 2017 Tax Cut and Jobs Act?

2017: Congress passed the Tax Cut and Jobs Act, which zeroed out the individual mandate penalty (effective 2019)

2018: 20 republican state AGs sued (Texas v. Azar), arguing that since the penalty is $0, the mandate is no longer a valid excuse of taxing power - and since the mandate is essential, the entire ACA must fall

2021: Supreme Court dismissed the lawsuit, no injury without penalty, ACA remains valid

What did the American Rescue Plan (2021) and the Inflation Reduction Act (2022) do to ACA subsidies?

American Rescue Plan (2021):

- People up to 150% FPL can get silver plans for $0 premium with reduced deductibles

- Additional subsidies up to (and above) 400% FPL

- Originally for 2021-2022 only

Inflation Reduction Act (2022): extended those enhanced subsidies through 2025

Uninsured rate hit an all time low in 2022

What is the bottom line on the ACA's legal status today?

- The ACA remains valid and unlikely to be overturned as a whole

- Individual provisions continue to be challenged (e.g., preventive services mandate ruled unconstitutional by a federal court in 2022/2023)

- Coverage gap persists in non-expansion states

- Reproductive and preventive care coverage is in jeopardy

- Enhanced subsidies in effect until 2025