Insurance History and U.S. Healthcare

What is the difference between for-profit and not-for-profit hospitals?

2/3 of all community hospitals are NFP. FP hospitals are run by owners, the goal is to make a profit, the profit is distributed to the owners, the institution is taxed, and the institution owns a publicly traded stock. NFP hospitals are charitable/religious, the goal is to meet the needs of a community, the profit is put back into the organization, the institution is not taxed, and the institution does not own a publicly traded stock.

How does failure to receive adequate healthcare drive up the overall healthcare costs?

By not receiving care in a timely manner, this costs the system more due to having to have more serious treatments, like emergency surgery or cancer diagnoses in later stages.

After the ACA's major coverage provisions, which racial/ethnic groups had the largest declines in uninsured rates?

Hispanics and Blacks had the largest declines in uninsured rates. All people of color generally had larger coverage gains than Whites.

What are the three largest categories of healthcare goods/services?

Hospital services, ambulatory services, and prescription drugs. There has been a turn toward faster (but still moderate) growth in aggregated spending on these three categories.

When are people considered underinsured?

If they have had health insurance for a full year, but have high deductibles or out-of-pocket expenses relative to their income.

Which individuals are at the highest risk of being uninsured?

Individuals below poverty are at the highest risk of being uninsured. Over 80% of uninsured are in low- or moderate-income families, meaning they have incomes below 400% of poverty.

Over the past 10 years, how have high deductibles contributed to underinsured rates?

More people than ever have plans with deductibles, and those deductibles are taking up larger shares of people's incomes. In 2003, 40% of people with private health insurance had no deductible, while in 2014 just 25% did not have one! In 2014, 14 million people had deductibles that were 5% or more of their income, while only 4 million had deductibles that high in 2003. People in small firms with insurance through their jobs were more likely to have high deductibles than those in larger firms.

What proportion of the uninsured are non-citizens?

Most of the uninsured are U.S. citizens (79%) and 21% are non-citizens. Legal immigrants residing in the U.S. for less than five years are ineligible for federally funded health coverage.

Do all workers have access to healthcare coverage through their job?

No! Almost 3/4 of uninsured workers are self-employed or work for firms that do not offer health benefits. Of those who do work for firms that offer coverage, the most common reason for remaining uninsured was that the coverage was unaffordable.

Although Americans are insured, do most of them receive adequate coverage?

No, a large amount of Americans are underinsured. 31 million people with health coverage in the U.S. were underinsured in 2014.

What is the diverse array of individuals and legal entities who fund healthcare?

Services are provided by commercial, charitable, and government entities - a mix of public and private funding.

What was the average premium for single coverage in 2015? What about family coverage?

Single coverage: $521/month Family coverage: $1,462/month

How have premiums changed from 2005 to 2015?

The total premiums have increased by 61% and the worker's share has increased by 83%, outpacing wage growth.

What are some important aspects of today's U.S healthcare system?

There has been a dramatic expansion in coverage since late 2013/2014. Spending growth has slowed, but it still outpaces economic inflation. The average premium for employer-based family coverage has grown. Average deductibles in employer coverage have risen.

What are the pros of today's healthcare system?

There is the least amount of wait time for non-emergency care. We are superb in developing medical technology, techniques, and new drugs. We have a well-educated and well-trained workforce. We have sufficient physical facilities. And we have innovative programs and higher provider incomes.

Why do some poor uninsured adults end up in the "coverage gap"?

They earn too much to qualify for Medicaid but not enough to qualify for Marketplace premium tax credits.

What is the issue with uninsured adults being unable to pay their medical bills?

This can lead to increased costs to others

Which regions of the United States are more likely to be uninsured?

Those living in the South or West are more likely to be uninsured. The 10 states with the highest uninsured rates in 2014 were all in the South and West.

Are underinsured rates higher in smaller or larger firms?

Underinsured rates were higher among those working in small firms with health benefits throughout heir jobs: 27% underinsured compared to 14% in firms with 100+ workers.

How is out-of-pocket spending better protected now than it was before the ACA became law?

Virtually all workers enrolled in employer coverage now have a limit on their annual out-of-pocket spending. This is a protection that more than 1/6 enrolled workers lacked when the ACA became law.

What are the cons of today's healthcare system?

We have the highest spending, but have less access to hospital care, lower life expectancies, and higher infant mortality rates. There are issues regarding access to care: cost of healthcare, lack of knowledge regarding providers, and insurance problems. There is a gap between the rich and the poor. A large amount of Americans are uninsured.

How is eligibility a barrier to insurance coverage?

Work-related reasons: being unemployed or not having an offer through work. Some individuals are ineligible/cannot receive coverage due to their immigration status.

Are people who receive health insurance through their jobs typically underinsured? Why or why not?

Yes, people with health insurance through their jobs are increasingly underinsured as employers, particular firms with 100 or fewer employees, are sharing more of their healthcare costs with employees, especially in the form of higher deductibles. The share of people with employer insurance who are underinsured has doubled since 2003.

Where does all the money for healthcare spending go?

1. Hospital care 2. Physical and clinical services 3. Prescription drugs 4. Nursing care facilities and continuing care retirement communities

For those who were underinsured, how was the ability to pay off medical bills? How did this impact these individuals?

51% of those who were underinsured had problems paying medical bills or were paying off medical debt over time. Of these individuals, many were contacted by a collection agency over unpaid medical bills and many had to change their way of life in order to pay their medical bills. Many/some of these individuals received a lower credit rating, used all of their savings, took on credit debt, took out a mortgage against their home or a loan, and/or declared bankruptcy.

What was a key goal of the Affordable Care Act?

A key goal of the ACA was to decrease the number of uninsured individuals. The ACA provides Medicaid coverage to many low-income individuals in states that expand and Marketplace subsidies for individuals below 400% poverty. Under the ACA, as of 2014, Medicaid coverage was expanded to nearly all adults with incomes at or below 138% of poverty in states that expand, and tax credits are available for people who purchase coverage through a health insurance Marketplace.

Who is more likely to be uninsured: adults or children?

Adults are more likely to be uninsured than children. Low-income children qualify for Medicaid or SCHIP.

Who was underinsured at the highest rate of any group?

Adults under age 65 who were disabled and covered by Medicare were underinsured at the highest rate of any group.

How did clinics flourish in the 80s?

Clinics flourished due to fee-for-service payment. Dependent on the quantity of care rather than the quality of care.

Describe healthcare/coverage post Medicare/Medicaid

Dramatic increase in utilization of healthcare services. Healthcare costs have been increasing a lot.

How are U.S. healthcare businesses classified?

Facilities owned by the government (governmental, public, or tax-supported), privately owned facilities, for-profit (FP) facilities, and not-for-profit (NFP) facilities.

What efforts have been imposed to help control healthcare expenditures?

Federal Health Maintenance Act (1973) and Knox-Keene Act (1975) tried to control health insurance costs and allowed formation of Health Maintenance Organizations (HMOs). This was the birth of managed care (1975, there were 217 HMOs). Balanced Budget Act of 1997 imposed caps on outpatient PT. Various moratoriums on caps for PT services since then. Patient Protection and Affordable Care Act (PPACA) of 2011 was an expansion of coverage that is by far the largest since the decade following the creation of Medicare/Medicaid which helped drive down costs.

What is the philosophy behind tax-supported healthcare?

It's the social philosophy that the government has a responsibility to provide healthcare to those in need. Approximately 2/3 of tax supported healthcare is for Medicare.

In recent years, there has been slow growth in health care costs. How do we keep these positive trends going (i.e. slowing/reducing the growth)?

Keeping these positive trends going will require that we continue to make good use of the tools provided but he ACA, including: moving our healthcare system toward payment models that reward efficient, high-quality care; continuing to foster a transparent and competitive Health Insurance Marketplace; and implementing the law's tax provision that encourages high-cost employer plans to become more efficient.

What are some barriers to the uninsured accessing healthcare?

Lack of a regular place to receive care, postponement of seeking care due to cost, lack of preventative care, failure to fill prescriptions because of cost.

Why do some individuals who are eligible for assistance fail to sign up for coverage?

Lack of knowledge about eligibility or enrollment barriers. Among uninsured adults in fall 2014, over half reported that they did not attempt to gain ACA coverage in 2014, but almost half of these adults were likely eligible for Medicaid or Marketplace tax credits.

Are lawfully-present immigrants eligible for Marketplace tax credits?

Lawfully-present immigrants under 400% of the poverty line are eligible for Marketplace tax credits. However, only those who have passed a five-year waiting period after receiving qualified immigration status can qualify for Medicaid.

What significant gains did the ACA's major coverage provisions lead to?

Lots of people were enrolled in state or federal Marketplace pans. Medicaid enrollment grew. The uninsured rate dropped significantly (however, low-income workers were more likely be uninsured than higher earners). There was a small decline in uninsured children. The uninsured rate among non elderly adults dropped significantly (decreased by 9 million). Uninsured rates dropped more across states that chose to expand Medicaid.

What did many uninsured people cite as the main reason they lacked coverage?

Many uninsured people cite the high cost of insurance as the main reason they lack coverage. Many people do not have access to coverage through a job. Some people, particularly poor adults in states that did not expand Medicaid, remain ineligible for public coverage. Undocumented immigrants are ineligible for Medicaid or Marketplace coverage. Few uninsured adults said they were uninsured because they do not need coverage, oppose the ACA, or would rather pay the penalty.

What is the current trend in healthcare/coverage?

More movement toward policy holders having larger percentage that they are responsible for paying for (i.e. higher deductibles, larger co-pays, etc.) and more accountability for providers (i.e. data tracking).

How likely is it for people of color to be uninsured?

People of color are at higher risk of being uninsured than non-Hispanic Whites. 45% of the uninsured are non-Hispanic Whites, people of color are at higher risk of being uninsured than non-Hispanic whites. People of color make up 40% of the overall U.S. population, but account for over 50% of the total uninsured population.

Among those insured by small firms, large firms, or by personal coverage, who is most likely to be underinsured?

People who buy coverage on their own are still more likely to be underinsured than those with employer coverage. Personal coverage < small firm < large firm.

For people who were underinsured, how did this affect their propensity to seek healthcare?

People who were underinsured skipped needed health care. 44% of the uninsured either did not go to the doctor when they were sick, did not fill a prescription, skipped a physician-recommended medical test/follow-up visit, or did not see a specialist when their doctor told them to do so.

How does health status affect likelihood of being underinsured?

People with health problems were more likely to be underinsured. 30% of people in poor health or who had a chronic health problem/disability were underinsured, compared with 16% of those who were healthier.

What are the different levels of care? Which level of care do most physical therapists work in?

Prevention, acute care (initial medical care; less than 30 days), and post-acute care (longterm care; greater than 30 days). Most physical therapists work in post-acute care, including ambulatory care (50%) and restorative care (20%) settings. Less than 17% of physical therapists work in the acute care setting.

Provide a brief history of U.S. healthcare

Prior to WWII, most expenses were paid out-of-pocket by the consumer (including cash payments and bartering of goods/services). During WWII, the government imposed caps on wages paid to civilian workers due to civilian and military manpower shortages. The War Labor Board permitted civilian employers to offer benefits of up to 5% of annual salaries -health insurance was provided to workers/families as a recruitment tool. A significant percentage of the U.S. population had healthcare paid for by civilian and government employers. Post WWII, there were many union-sponsored health plans. 2/3 of the entire US population had some form of insurance-based healthcare coverage by 1958.

When was the Medicare/Medicaid program signed into law? What was the result of this?

The Medicare/Medicaid program was signed into law in 1965. As a result, a majority of the U.S population had access to health care with most of the expense covered by government or employer insurance.

When was the Patient Protection and Affordable Care Act signed into law? What was the result?

The PPACA was signed into law in 2011. More individuals had insurance after this.

How does U.S spending on healthcare compare to other industrialized nations?

The U.S. still spends more on healthcare than any other industrialized nations, and those countries provide health insurance to all of their citizens. Healthcare is the top expenditure item of household income.

For which minority is the disparity of insurance coverage especially high?

The disparity in insurance coverage is especially high for Hispanics, who account for 19% of the total population but 34% of the uninsured population. Hispanics and non-Hispanic Blacks have significantly higher uninsured rates than Whites.

What were the largest shares of total health spending sponsored by? What is the money spent on?

The federal government and households. The government spent money on Medicare/Medicaid/VA while households spend money on private health insurance or out-of-pocket costs.

In which field is 9% of all employment in the U.S.?

The healthcare field