Weeks 10 and 11
rise of employment based benefits
1930's: The Great Depression led to the New Deal & Social Security and Federal government role in social welfare (minimum wage, etc.) Employers used benefits such as pensions and health insurance to satisfy workers National health also opposed as Socialism After WWII, employers acted to reign in government involvement Became a tug of war between unions and corporations
rising costs and reactions
1970s: Congress tried to cut back on excess costs with a program called Diagnostic Related Groups (DRGs) which standardized and limited care -- but providers circumvented efforts 1980s: Employers and regulators turned to managed care corporations to rationalize care and profit from saving money Cost containment had small impact but led to greater role of corporations in managing health care and more for-profit entities.
cost sharing subsidies eliminated
A cost sharing reduction program (CSR) to subsidize premiums for low-income enrollees was authorized by the law, but Congress never appropriated money to pay for it. CSR was paid from a fund established for tax credits and refunds. 2016: D.C. federal court ruled that Congress is the only source for such an appropriation--no public money can be spent without one. October 2017: Trump ordered the CSR payments to be stopped. implications: Insurers still have the obligation to reduce cost sharing by enrollees: Insurers increased premiums to compensate for the loss of CSRs (exchange premiums up 16% in 2018 and off-exchange up 6%) Some insurers terminated their marketplace participation, reducing choice in several states. A federal court approved insurers to sue the federal government for the payments. In September, Montana Health Co-op won suit for $5.3 million in unpaid subsidies.
Mikulski Women's Preventative Health Amendment to the Affordable Care Act
All insurers must cover at no cost to the woman: Screening for gestational diabetes HPV co-testing as part of cervical cancer screening for women over age 30 Counseling on sexually transmitted infections Counseling and screening for HIV FDA-approved contraceptive methods and supplies Breast-feeding counseling and equipment Screening and counseling to detect and prevent intimate partner violence and Yearly well-woman preventive care visits to obtain recommended preventive services
medicare and medicaid development
As part of Johnson's "War on Poverty" enacted through amendments to the Social Security Act in 1965 At this time 50% of the 65+ population over age sixty-five had no medical insurance AMA threatened a national boycott of Medicare, but Johnson maneuvered them into publicly supporting. Provided needed health services for the old and those in poverty where these services were not previously available
insurance market reforms and regulations
Ban on preexisting conditions (which for women included C-sections and domestic violence) Eliminating premium markups based on health status, age, or gender Pre-ACA women on the individual market could pay up to 1.5 times more than men for health insurance Capping administrative overhead and profits Standardizing coverage Minimum (essential) health Benefits
1930s blue cross/blue shield
Blue Cross (hospitalization) and Blue Shield (medical care) Jointly developed by AMA and AHA who feared a national health system would reduce autonomy and income Had a unique charter as a non-profit insurer Public lost interest in National Health with new coverage Plans allowed doctors to make all judgements about what care was needed
features of the environment that affect health
Built environment: Pollution (exposure to toxic elements) Basic Shelter (housing quality and crowding) Physical order/disorder (broken sidewalks, graffiti) Density (population and business) Connectivity (directness of travel routes) Service Environment: Access to (and cost of) food and basic products (supermarkets, drugstores, banks, restaurants, Distance to health care (physicians, hospitals) Transportation infrastructure The social environment: connections to neighbors; availability of support; safety, violence and crime, social disorder. The economic environment: socio-economic composition of the area robustness of its businesses and economy
neighborhoods as community/social networks
Community social relationships among residents of a neighborhood, including mutual trust and connectedness Social Network Structure or pattern of relationships among individuals. Comprises both members of a group and ties or connections between them Social Networks can show associations for multiple reasons: Homophily: similar individuals associate with each other Confounding: when an association is the result of shared environmental factors Social contagion: the process whereby individuals influence one another's behavior
pre ACA plans
Costs continued to rise & firms shift more cost burden to employees (premiums & deductibles) priorities: Assure affordable, quality health coverage for all Americans Improve patient safety and quality care Reduce long-term growth of health care costs for business and government Protect families from health care debt Guarantee choice of doctors and health plans Maintain coverage if you change or lose your job End barriers to coverage for people with pre-existing medical conditions goals -> plans Coverage Delivery and Payment Reforms Insurance Market Reforms and Regulations Prevention & Wellness
ACA debate
Early summer 2009: The debate at this point was heavily focused on external actors Insurance Companies Worried about Pre-existing conditions▪ And pharmaceutical coverage AMA Worried about losing Autonomy And Reimbursements Medical Device Companies and Big Pharma Worried about Comparative Effectiveness Research Hospital Groups Worried about Electronic Health Records• Cost, Interoperability, Management, Security white house public forum and summit: Concerns from external groups were valid In order to hear from everyone The White House held a summit open to: Previously mentioned groups Members of Congress And the public We also heard from Over 200 experts Summer 2009- kennedy dies; threatens super-majority thanksgiving 2009 I brought the first amendment to the floor Mikulski Amendment on Women's Health Amendment focused on preventing gender from being used as a pre-existing condition Rape C-Section Sen. Lisa Murkowski brought a competing Amendment passing: Senate voted to pass its bill on Christmas Eve 2009 Bill passed by both Houses in Spring 2010 Once passed, the Affordable Care Act is immediately under attacks to repeal In fact, I voted against its repeal 57 times before I left Congress in January 2017 We always knew we would have to Review and Reform a bill of this size. But the law is being taken apart piecemeal by the Right without any attempt to review or reform
medicare
Federally administered program Provides hospital and medical insurance for people aged 65 years or older, regardless of financial resources (plus some permanently disabled persons) Original was Part A for hospital costs and Part B for medical costs. Now includes Part D (Rx drugs) Covers 16% of the population 21% are "dual-eligible" (Medicare/Medicaid)
myth of universal access as a cure-all
For a long time, many believed and claimed that access alone to a Qualified teacher Or doctor was enough But these social contexts and disparities reveal why simply providing access alone is not enough To diagnose and effectively treat you need to use more than just access, you need: Prevention, Intervention, Containment Methods, and Elimination
medicaid work requirements
Four states have approval to condition Medicaid eligibility on meeting work & reporting requirements New rules are reducing numbers of enrollees (8.5k lost enrollment) Of 25 million adults age 19-64 enrolled in Medicaid in 2016, 60% were working, and 80% lived in a family with a full time worker Many who are working (even FT) have salaries low enough to qualify for Medicaid In states with Medicaid expansion a higher % are working because income eligibility is higher. Industries with the largest number of Medicaid enrollees are Food Service and Construction
Coverage (expanding access)
Individual and employer mandates: Require individuals to have a minimum level of health insurance. Require employers of a certain size to offer insurance or help pay for coverage of their employees. Provide subsidies for low income individuals - linked to a % of poverty metric to help them access the private insurance market Create a health insurance exchange to facilitate purchase by individuals and small businesses Medicaid expansion AND an buy-in option to Medicare for those under 65.
Tax reform eliminated the individual mandate starting in 2019
Individual mandate diversifies the risk pool and keeps premiums down Without the mandate: Premiums are expected to increase by about 10 percent per year over the first decade The number of people uninsured will increase by 4 million in 2019 and 13 million by 2027 Some states are investigating State level individual mandates
delivery and payment reforms
Invest heavily in Health IT - electronic medical records, system interoperability, physician order entry Didn't involve physicians, creating additional burdens Reduce Medicare and Medicaid payments to providers Reward quality with incentive payments (Pay for Performance) Conduct comparative effectiveness research for new techniques, procedures and medicines
altruism and neighborhood trust
Lost Letter experiments (Milgram 1977) distributed (dropped) preaddressed, stamped letters throughout an area and tabulated the rate at which they were picked up and mailed Originally designed to measures attitudes (envelopes were addressed to different groups) More recently has shown neighborhood differences: More affluent neighborhoods have higher mail rates Diversity doesn't matter E-mail has much lower rates of forwarding...
US health insurance system pre-reform
Not a true "system" but a blending of publicly and privately financed health insurance programs Insurance coverage typically tied to employment (small employers less likely to offer insurance) In 2011, 47.9 million Americans were uninsured. 1912: Theodore Roosevelt proposed national health in campaign 1930s: FDR considered insurance alongside Social Security 1940s: Truman's attempts blocked by the AMA as 'creeping socialism' 1965: Johnson passes Medicare & Medicaid 1979: Carter's efforts derailed by inflation 1990s: Clinton's attempt to provide universal health care coverage failed 1997: CHIP: Children's Health Insurance passed 2010: Passage of the ACA
neighborhood conditions
Physical Disorder discourages healthy behaviors like social activity and exercise Disorderly neighborhoods reflect a breakdown in social control, as there is noise, litter, abandoned or poorly maintained houses and buildings, vandalism, graffiti, fear, and crime Physical Disorder is more common in Low SES neighborhoods Children spend more time at home and school in neighborhoods, so may be more vulnerable to unhealthy conditions, with consequences for health both in childhood and later in life Older Adults spend more time in their homes, experience mobility impairments, and may no longer drive, and are more affected by housing conditions
neighborhoods are the means by which SES affects health
Poor neighborhoods have disproportionate exposure to harmful conditions (toxic waste dumps, freeways; poor-quality housing; pests; lead paint) Escaping health-damaging environments is challenging, These neighborhoods typically lack employment opportunities and services (good schools; transportation) that can lead to upward social and economic mobility. Racial segregation exacerbates class differences. Minorities are more likely to live in low SES neighborhoods and to have worse housing, and lower access to economic opportunities. Many studies have found relationships between neighborhood disadvantage and health even after considering individual risk factors.
prevention and wellness
Promote self-care through personalized prevention plans, media campaigns, and incentives to states and businesses to implement health and wellness programs. Mikulski Women's Preventative Health Amendment
The links between neighborhood social environments and health
Residents of "close-knit" neighborhoods are more likely to work together to achieve common goals (cleaner and safer public spaces, healthy behaviors and good schools), exchange information (e.g., regarding childcare, jobs and other resources that affect health), and maintain informal social controls (e.g., discouraging crime, littering and graffiti)
1997 SCHIP
The Children's Health Insurance Program (CHIP) was signed into law in 1997 Provides federal matching funds to states to cover uninsured children & pregnant women whose families are low-income but above the cut-off for Medicaid eligibility Covers 9 million people Expired September 30, 2017 and states are expected to run out of resources by March 2018 unless it is reauthorized.
1948 Treaty of Detroit
Treaty of Detroit, the 1950 contract signed between General Motors (GM) and the United Auto Workers (UAW) GM would pay only half of the health insurance premiums and would not let the union participate in administration or financial arrangements. The State receded and business took over. Benefits varied within and across businesses.
non-ACA health "plans"
Trump administration is promoting types of plans that can be exempt from ACA requirements including: Short-term, limited duration (STLD) health insurance policies that are intended to be temporary and have high deductibles, limited benefits and are non-renewable. Association Health Plans (AHPs) designed for small businesses to pool resources. Trying to exempt them from ACA standards and broaden definition Just released rule that allows States to use CSRs for these plans that don't cover essential health benefits.
medicaid
Welfare program operated by individual states States and the federal government share the cost of health care for the poor Each state is required to cover all needy persons receiving cash assistance Pre-ACA Medicaid covered limited categories of poor or medically needy. In most states, childless adults <65 were ineligible 43% of enrollees are children (2016 KFF) Primary payer for 60% of nursing home residents
ACA stats
approved in october was 50% approve, 42% disapprove Overall percentage decreased from 20.4% in 2013 to 11.9% in 2016 Up to 12.8% in 2017 34 states took expansion, 3 considering, 14 not Coverage Gap: In Non-Medicaid expansion states, many adults are above Medicaid eligibility limits but below Marketplace subsidies ACA intended low-income people to receive coverage through Medicaid, so it does not provide financial assistance to people below poverty for other coverage options.
obesity and social networks
clusters of obese people in social networks Critics published studies showing that including environmental confounders (school level trends) reduces the "social network effect" of BMI Also studies show implausible social contagion effects on height, acne, and headaches Sensitivity analyses suggest that contagion effects for obesity and smoking cessation are robust to environmental confounding
ACA goals
goals: Assure affordable, quality health coverage for all Americans Improve patient safety and quality care Reduce long-term growth of health care costs for business and government Protect families from health care debt Guarantee choice of doctors and health plans Maintain coverage if you change or lose your job End barriers to coverage for people with pre-existing medical conditions
neighborhoods and health flow chart
residential segregation by race/ethnicity and socioeconomic position/inequalities in resource distribution -> neighborhood physical environments (exposure, food and rec resources, built environment, natural spaces, services, quality of housing) and its' impacts/vice versa on neighborhood social environments (safety/violence, social connections/cohesion, local institutions, norms) -> behavioral mediators and stress -> health other impacts of personal characteristics (maternal resources, psychosocial resources, and biological attributes)
Neighborhoods and health- roux and mair
residents in poorer areas have 50% higher death rate etc. after controlling for physical health, disabilities, and more manski group effects: 1- endogenous effects (aggregate impacts on individual) 2- contextual effects of group condition 3- environmental effects 17/20 find significant relationship between environment and BMI
Social Networks and health- Smith and Christakis
social networks affect health through: social support (perceived and actual) social influence (norms, social control, etc.) social engagement person-to-person contact (pathogen exposure, 2nd hand smoke) access to resources (money, jobs, info) social network studies focus explicitly on network links; probe impact of network and examine types of ties (social support studies count members in network, say how supported someone feels, etc.) study both egocentric/local networks and sociocentric/global networks (global also includes indirect ties) dyads studied extensively since they're easiest (spouses, etc.), study nonspousal as well because they're more numerous, even weak ties produce social benefits, and raises important health questions campaigns (i.e. quitting smoking) do better when they include peers supradyadic effects (e.g. obesity study; no neighborhood effects so it's not due to shared environment, but due to interpersonal interactions) biological/physiological pathways that let neighborhoods impact health: physiological stress responses psychological states (self-esteem/efficacy) health behaviors (+ and -)
book history of health care
stakeholder mobilization- organized political opposition by groups with vested interest in the outcome (labor unions mobilized against national healthcare) 1930s had rise of HMOs commercial insurance- for profit, use actuarial risk rating as opposed to community rating (focus on people who would give least bills) managed care 1980s, negotiate prices with doctors + offer bonuses to doctors with low costs (utilization review) + make lists (formularies) of cost-effective drugs. backlash against managed care (focus on autonomy, over-treatment as bad, etc.) HCSA- failed, essentially would have spread access to healthcare without entrepreneurial issues (but failed due to complexity and insurance fighting it) health care costs still rising (1k in 1980, now 8k, should be 12k in 2022) americans are in hospital, outpatient, etc.; low rate of malpractice lawsuits (so little defensive medicine); america is aging but not more than other countries; technology only accounts for small % of health care costs cost comes from: fragmented system -> administrative costs, providers hold more power over consumers, and how health care is for-profit reduce medicare/caid costs with DRGs (diagnosis-related groups- US reimburses hospitals based on average amount spent on treatment for certain diagnosis -> if they keep costs down they profit big pharma- laws allowed people to patent drugs, doubled lives of those patents, and won right to market drugs directly to consumers underinsured- insured but don't have enough money to pay medical bills; more than 20% of adults under 65
klinenberg- social network in neighborhoods
studied excess heat related deaths in neighborhoods of Chicago Similar neighborhoods had vastly different mortality He used a technique called "social autopsy" to examine the social and political organs that break down in a crisis. "Edgewood" community had more abandoned houses, more violent crime and the elderly were afraid to go outside. They also had less power and connection to the city government to get emergency cooling services. Nearby community had a lively street life that allowed the elderly to walk about to cool themselves off and for other residents to check up on their more vulnerable neighbors. Disasters can reveal the basic power structure of society, including gender, race, and class. Prior scientific explanations relied on stereotypes and failed to grasp the social and geographic interactions that led to specific failures to save lives: "Areas with high mortality had distinctive compositional and ecological features...the quality of public spaces, the vigor of street-level commercial activities, and the centralization of support networks and institutions...as well as proportions of seniors living alone" Usually assumed that natural disasters are a "great equalizer" but most victims are poor and disconnected.