Public Health

Dr. Lamm Presentation: Massachusetts Medicaid Program (MassHealth)

• Social Determinants of Health (SDH): Non-medical factors influencing health outcomes.

• Examples of SDH covered by MassHealth:

  • Food and Nutrition Assistance: Access to medically tailored meals, food pantries, and nutrition education programs.

  • Transportation Services: Non-emergency medical transportation to and from healthcare appointments.

HCIN:

• Choose one other article

• Take-home as it relates to course content:

  • A federal funding freeze has left officials of the Special Supplemental Nutrition Program for Women, Infants, and Children (W.I.C.) uncertain about its impact.

  • W.I.C., a $7 billion federally funded program, provides vouchers for healthy food and infant formula to low-income pregnant and postpartum women, infants, and children.

  • While the Trump administration stated that programs offering direct assistance should be exempt, W.I.C. funds are distributed to states, creating ambiguity.

  • Officials are seeking assurances that W.I.C. will not be affected, though quarterly funding should keep operations running for now.

  • Immigrant families have historically avoided public benefits due to fears about their legal status, a trend that persists despite policy changes. Families are encouraged to continue using W.I.C. services until more information is available.

Documentaries:

• Critical Care: Examines the U.S. healthcare system by comparing it to those in other developed countries.

  • Hosted by PBS NewsHour correspondent Amna Nawaz, it explores why the U.S. has the most expensive healthcare system yet struggles with affordability, accessibility, and health outcomes.

  • Contrasts the U.S. system with those in Canada, the U.K., and Germany, where healthcare is more accessible and costs are lower.

  • Discusses medical debt, insurance coverage gaps, and government involvement in healthcare.

• Power to Heal: Explores how Medicare’s implementation in 1966 helped desegregate hospitals in the U.S.

  • Highlights how Black civil rights activists and government officials used Medicare funding to enforce hospital integration under the Civil Rights Act.

  • Reveals how hospitals previously denying care to Black patients were required to integrate to receive federal funding.

  • Emphasizes the ongoing struggle for health equity in America.

Laws:

• 1910 Flexner Report: Standardized and improved medical education but led to the closure of many medical schools, including African American institutions.

• 1946 Hill-Burton Act: Funded hospital construction, legally enforcing segregation under a "separate but equal" framework, which was not truly equal.

• 1954 Brown v. Board of Education: Declared separate but equal as inherently unequal, overturning Plessy v. Ferguson.

• 1964 Civil Rights Act: Legally banned discrimination, though practical enforcement was inconsistent.

• 1965 Medicare/Medicaid: Forced hospital integration by threatening to cut off federal funding for non-compliant hospitals.

Determinants of Health:

• 30% Health Behaviors: Income, housing, education, environment, sex, race, culture, etc.

• 70% Out of Our Control:

  • 10% Clinical Care

  • 40% Social Determinants of Health (SDH):

    • Economic stability

    • Social & community context (biggest factor)

    • Neighborhood & environment

    • Health care

    • Education

    • Genetics

Goals of Healthcare Reform:

• Universal Declaration of Human Rights (UDHR)

• Difference Between Health Insurance and Healthcare:

  • Health Insurance: Financial coverage for medical expenses.

  • Healthcare: Clinical care provided to patients.

• Health Disparities: Differential burden of disease among different populations.

• Paradox of U.S. Healthcare: High-quality care and innovation, yet many lack access.

• U.S. Spends the Most on Healthcare but Has Worse Outcomes compared to other economically similar nations.

Historical Periods of U.S. Healthcare:

1. Preindustrial Era: Few hospitals, no health insurance, medical training through apprenticeships.

2. Post-industrial Era: Similar to preindustrial, lacking structured training and regulation.

3. Corporate Era: Introduction of telemedicine, globalization, and exporting of health professionals.

4. Reform Efforts: E.g., passage of the Affordable Care Act (ACA).

History of U.S. Healthcare Reform Attempts:

• National Health Insurance (NHI) Efforts Have Failed Due to:

  • Middle-class aversion to higher taxes

  • Mistrust of government involvement

  • Preference for capitalism and self-determination

U.S. Healthcare System:

• Types of Healthcare Services: Private for-profit, private non-profit, public options, out-of-pocket payments, or a mix.

• Four Parts of Healthcare Financing:

  • Financing: Government, employer, self-funded (insurance)

  • Insurance: Private companies or self-funded plans

  • Delivery: Medical providers, hospitals, nursing homes, diagnostic centers, community health centers

  • Payment: Insurance companies, employers, or direct patient payments

Healthcare Payment Models:

• Volume-Based Care: Reimbursement based on each visit.

• Value-Based Care: Financial incentives for keeping patients healthy.

• Uncompensated Care: Unpaid bills covered by providers, hospitals, or government.

Healthcare Ethics: Market Justice vs. Social Justice

• Market Justice: Care distributed based on willingness and ability to pay.

• Social Justice: Ethical responsibility for equitable healthcare distribution.

Reasons for High U.S. Healthcare Costs:

• Third-Party Payment System: Government subsidies reduce cost-awareness.

• The Triple Aim of Reform:

  • Cost: Price of treatments and provider fees.

  • Quality: Patient/provider experience.

  • Access: Who receives care and at what level.

Four National Health Insurance Models:

1. Beveridge Model: Government-run, tax-funded healthcare system.

2. Bismarck Model: Privately run, employer-funded insurance.

3. National Health Insurance Model: Government insurance with private providers.

4. Out-of-Pocket Model: Market-driven healthcare where patients pay directly.

Health Insurance Cost-Sharing Terms:

• Co-payment: Fixed amount paid per visit after deductible.

• Premiums: Monthly payments for insurance coverage.

• Deductible: Amount paid before coverage begins.

• Coinsurance: Percentage split between insurer and enrollee (e.g., 80/20).

Healthcare Coverage in the U.S.:

• Employer-Based Insurance: ~50% of Americans.

• Government Programs (Medicare/Medicaid): 35-40%.

• Uninsured: ~9-10%, relying on out-of-pocket expenses.

The ACA (Affordable Care Act) and Its Impact:

• Three-Legged Stool Model:

  • Guaranteed Issue/Access: No denial for pre-existing conditions.

  • Individual Mandate: Required health insurance or pay tax (repealed in 2017).

  • Government Subsidies: Discounts for low-income individuals.

• Marketplace Exchanges: Platforms for comparing and purchasing insurance.

• ACA Results:

  • Uninsured rates dropped post-2010 but began rising again after 2016.

  • Declined again in 2021 due to COVID-19-related measures.

Medicare, Medicaid, and ACA Differences:

• Medicare: Federal program for those 65+, includes four parts (A, B, C, D).

• Medicaid: State-managed, income-based program covering low-income individuals.

• ACA: Expanded Medicaid, established insurance marketplaces, but was not universal coverage.

• Dual Eligible: Individuals qualifying for both Medicare and Medicaid.