US Healthcare System
Why do some people remain uninsured?
-Some people who are eligible for financial assistance under the ACA may not know they can get help -Others may still find the cost of coverage prohibitive. -Undocumented immigrants are ineligible for Medicaid or ACA Marketplace coverage.
Indirect care on the state level
-State Division or Department of Public Health -Disease Surveillance -Vital Statistics -Behavioral Risk Factor Surveillance System -Policy development
Who is the Health and Human Services chief policy officer?
The Office of the Secretary
Focus of private health subsytem
The individual: for profit and nonprofit
What are the 3 core functions of public health?
assessment, policy development, assurance
APHA statement on health care access
"We believe in health equity and access to care for everyone in every community."
Describe the role of the State Public Health subsystem
-State health departments -Central authorities in the public health care system -Responsible for the health of state citizens -Dependent on federal level for guidance and resources -Formulates public health policy (state laws & regulations)
How does the Public US Health System function?
-Mandated through laws developed at national, state, local levels -Federal gov't has power to collect taxes and spend funds on general welfare -Once policies are determined, it is the job of federal agencies to oversee and implement through laws and regulations
Responsible for core function of assessment in Maryland
-Maryland Department of Health and Mental Hygiene (DHMH) -Annual Maryland Vital Statistics Report
Who remains uninsured (what demographic)?
-Most uninsured people are in low-income families and have at least one worker in the family. -People of color are at higher risk of being uninsured than non-Hispanic Whites.
What baseline services (set by federal gov't) are included in medicaid?
-Must include inpatient and outpatient hospital care, pregnancy-related care, vaccines for children, family planning services, rural health clinics, home health care, lab and x-ray services
Medicare Part C (Medicare Advantage)
-Optional "gap" coverage -Provided by private insurance companies approved by, and under contract with, Medicare -May include HMOs and PPOs -May include vision, hearing, dental care, and other services not covered by Medicare Parts A, B, or D
What impact did The Future of Nursing report have on public health nursing?
-Patient-centered care -Stronger primary care services -Deliver more care in the community -Seamless, coordinated care -Reconceptualized roles for health professionals -Interprofessional collaboration
Medicare Part D
-Prescription drug coverage -Must pay 100% of costs when costs reach "coverage gap" or "donut hole"
Information about Medicaid (Title XIX) - A public welfare assistance program
-Provides universal health care coverage for the indigent and children -A joint state and federal venture -Eligibility depends on the size and income of the family -Federal government sets baseline eligibility requirements, but states can lower eligibility -Priority participation is given to children, pregnant women, and the disabled
Medicare Part B
-Purchased by monthly fee; Not compulsory -Helps pay for out-of-pocket costs for physician services, hospital outpatient care, durable medical equipment, and other services, including some home health care -Enrollees must pay deductibles and coinsurance
Current healthcare proposals
-Repeal and Replace" ACA -"Medicare for All"
Potential US "National Health Plans"
-Single Payer (medicare for all) -Public Program with Opt Out -Public Plan Option -Medicare Buy-In for older adults -Medicaid Buy-In
What are models of private health care services?
-Solo practice -Single specialty group practice -Multispecialty group practice -Integrated health maintenance model
Institute of Medicine: 3 key reports to be aware of
1. To Err is Human (1999) 2. Who Will Keep the Public Healthy? (2003) 3. The Future of Nursing
What are the 8 agencies in the the U.S. Public Health Service?
1.Agency for Healthcare Research and Quality (AHRQ)* 2.Agency for Toxic Substances and Disease Registry (ATSDR)* 3. Centers for Disease Control and Prevention (CDC)* 4. Food and Drug Administration (FDA)* 5.Health Resources and Services Administration (HRSA)* 6. Indian Health Service (IHS)* 7. National Institutes of Health (NIH)* 8. Substance Abuse and Mental Health Services Administration (SAMHSA)*
What are the 4 Pillars of Change included in The Future of Nursing?
1.Nurses should practice to the full extent of their education and training. 2.Nurses should achieve higher levels of education and promote seamless academic progression. 3.Nurses should be full partners with physicians and other health professionals in redesigning health care in the United States. 4.Effective workforce planning and policy making require better data collection and an improved information infrastructure.
Examples of Assurance in Maryland
Teen Pregnancy Prevention Breast & Cervical Cancer Screening Maternal Child Health Bureau Maryland State Health Improvement Process (SHIP)
A federal healthcare milestone in the 1930s
The Great Depression and the New Deal -Social Security, Employer- and Hospital- provided health care -Truman's Universal Healthcare called "communist plot"
What is an example of a "Safety Net" provider in Montgomery County?
The Primary Care Coalition of Montgomery County Program goal is to improve the health status of the county's uninsured, through access to primary care
What are important questions to ask concerning the future of Public Health?
Who has access? Who pays? What services? How is it delivered? What is the role of gov't?
Medicare under the single-payer proposal (taken from a required reading)
Would replace the current Medicare program with a similar health care program that would cover all Americans. Medicare beneficiaries could get more benefits, including long-term care. There would be no cost sharing or premiums generally. But Medicare Advantage plans would go away.
Single-payer proposals, also called "Medicare for all" plans (taken from a required reading)
Would replace the entire health insurance complex with a single government-operated health care program, such as those in Canada, Great Britain and Norway. While you might have the ability to pay for private health care, those using the single-payer system would face little to no cost for all medically necessary services as well as dental, hearing and vision. However, taxes would need to go up substantially to cover the cost of government-run health care for all, and also would lead to a major restructuring of America's health insurance industry from how it operates today.
Public option proposals (taken from a required reading)
designed to improve on the ACA. The underlying concept: Give Americans who cannot afford or get access to high-quality insurance through the private marketplace an option for lower-cost, public-sponsored insurance.
Who runs Medicare
federal government
At what level do community/public health nurses provide direct care most often?
local level
Who manages the state health department?
State (or Territorial) Health Officer
ANA policy statement on health care access
"Ensure universal access to a standard package of essential health care services for all citizens and residents."
Alma Alta Declaration (1978)
"Health...is a fundamental human right"
What essential services are included in assessment?
Monitor health Diagnose and investigate
Do all communities have a Local Health Department?
NO
Examples of direct healthcare on the federal level (sees patients)
National Health Service Corps Indian Health Service Department of Defense - TRICARE Veterans Administration
Which hospitals receive tax exemptions?
Non-profit hospitals
Direct care in state health care services
Rarely does a state health department provide direct patient care. MAY have Mental Health Facilities (Spring Grove, Clifford T. Perkins) Facilitate Medicaid, CHIP, WIC
What is NACCHO?
- National Association of City and County Health Officials - Look to be a leader and voice for local health departments
Policy development on the federal level
-Affordable Care Act, 2010 -Social Security Act, 1935 -CDC's Public Health Law program
How many operating divisions are under Health and Human Services?
11
Who is eligible for CHIP?
Children under 18
What are indirect services?
Services that support the client.
Eligibility for medicaid?
• Must be documented US citizen. • Federal minimum income requirement at or below Federal Poverty Level (FPL) along with other qualifying conditions.
Who qualifies for Maryland's Children's Health Insurance?
•(Federal and State) •Federal provides matching funds; administered by the State •Eligibility: Qualifying FPL and documented US citizen. •Uninsured pregnant women à 6 weeks post partum; low income children up to 19 years.
Who qualifies for SNAP (aka food stamps) and how is it administered?
•Administered by the State & DSS •In Maryland, put on a debit card called the "Independence Card". •Eligibility: Food voucher program for families w/ children and qualifying FPL. •Certain income programs automatically qualify the family.
Eligibility for medicare?
•Eligibility: Individuals 65 years and older who paid, (or spouse paid) SS tax •Permanently disabled, regardless of age.
What is WIC and who qualifies?
•Funded by Federal grants, administered by state agencies •Nutrition supplement and education program for children and women. •Eligibility: at or below 185% FPL; pregnant to 6 weeks post partum; infants and children under 5 years old.
What is the US Federal Poverty Level and how is this measurement used?
-A measure of income issued every year by the Department of Health and Human Services (HHS). -Federal poverty levels are used to determine your eligibility for certain programs and benefits, including savings on Marketplace health insurance, and Medicaid and CHIP coverage.
What are the responsibilities of the Local Health Department?
-Community health services -Personal health services -Mental health services -Environmental health services
What are the sources of public health financing?
-Employee Federal income tax -Employee State income tax -Philanthropic donations -Corporate taxes -Health Insurance enrollee premiums -Consumers' out of pocket expenses
What does Medicare Part A cover?
-Includes inpatient care in hospitals/skilled nursing facilities, hospice care, some home health care -Must pay a deductible for health services -Does not pay for all health care costs of enrollees; co-payments required after 60 days
Assessment on the federal level
-Vital Statistics -Census Data -Centers for Disease Control & Prevention
Importance of "Who Will Keep the Public Healthy?"
-brought Public Health into the forefront -Issues including globalization, rapid travel, scientific and technological advances, and demographic changes -In-depth exploration of educational needs for improved public health and appropriately prepared public health professionals
What are the 3 human service agencies?
1. Administration for Children and Families 2. Administration for Community Living 3. Centers for Medicare & Medicaid Services (CMS)
What is a federally qualified health center (FQHC)?
A "free clinic". An example is Mary's Center in DC.
What tends to motivate philanthropic funding?
A specific disease to research; eligibility is limited to that condition/population of interest
Jane is a veteran who served in the middle east conflict. She goes to the local Veterans Administration Hospital for many of her health care needs. Health care for veterans is provided by which health care subsystem? A.Federal B.Private C.Federally Qualified health Center (FQHC) D.Philanthropic
A. Federal
A 2010 Act with three goals: increase access to care, decrease costs, and expand medicaid
Affordable Care Act
Jack is a 54-year-old male with asthma and hypertension. He visits his family doctor at the clinic yearly for a physical. He had a colonoscopy last year at the local surgery center. He has his medications refilled via a mail order pharmacy. uJack receives his health care through the A.Public health care subsystem B.Private sector C.Community health care system D.Voluntary agencies
B. Private sector
What is the name of a grant that is given by US DHHS to states to impact the health of the public as a whole?
Block grant
Other state agencies with health related responsibilities
Department of Education State Board of Licensing Environmental Health
What governmental department is the Surgeon General under?
Department of Health and Human Services
What is an example of assurance in Montgomery County?
Department of Health and Human Services in Montgomery County Provide services: screenings, family planning, mental health services, etc.
What department in Maryland implements programs?
Department of Health and Mental Hygiene
Famous nurse who proposed federally funded hospitals in the 1800s- Vetoed as "Socialized medicine"
Dorothea Dix
What essential services are included in assurance?
Enforce laws Link to/provide care Assure competent workforce Evaluate
Assurance on the federal level
Ensuring quality care: Agency for Healthcare Research and Quality (ARHQ) EBP guidelines for clinical practice Healthcare regulatory agencies- FDA, OSHA, CDC, CMS Ensuring Access to Care: Federally Qualified Health Centers (FQHC's or 'free clinics') Veteran's Administration (VA) Hospitals Ensuring Competent Workforce: Training Grants National Health Service Corps
Who runs Medicaid?
Federal and State governments; federal government provides matching funds, but it is administered by the state
Which policies guide state and local policies?
Federal policies
Who does "Safety Net" provider funding help?
For those who do not qualify for services but cannot afford health insurance, they can go to a safety net clinic. It is funded through a patchwork of funding streams/ public-private partnership.
Which health agencies may distribute accounting profits to shareholders?
For-profit
Policy development in Montgomery County
Health & Human Services Committee
Examples of Policy Development in Maryland
Health Coverage Programs: Medicaid basics Maryland Children's Health Insurance Program (MCHP) Emergency Preparedness (MEMA)
What is an example of assessment in Montgomery County?
Health Data: Healthy Montgomery
Who is responsible for implementing suggested changes?
Health and Human Services
What 3 things do local health department services depend on?
Health codes of state and locality that must be followed Needs of the community Availability of funding/ resources
What are direct services?
Healthcare services that require face to face interaction between the nurse and the client
What essential services are included in policy development?
Inform, educate, empower Mobilize community partnerships Develop policies
What is a major factor in the lack of access to care in the United States?
Lack of insurance
Which health department has direct responsibility to the citizens in a community/local jurisdiction?
Local Health Department subsystem (city or county)
Developed in the 1960s by JFK and L.B. Johnson to take care of the old, the poor and the disabled.
Medicaid/Medicare
List major public assistance programs
Medicare Medicaid CHIP SNAP WIC
Examples of indirect healthcare on the federal level (provides funding)
Medicare, Medicaid and CHIP Programs Disease monitoring and Surveillance Homeland Security Centers for Disease Control National Institutes of Health
Focus of public health
Populations: federal, state and local programs
What authority is given to the federal government in the U.S. Constitution for public health?
Promote the general welfare
Importance of "To Err is Human"
Promotes safety within the healthcare delivery system; error-proof the system
What recommendation did the Institute of Medicine Report make in 2008 for public health?
Transformation of a system (published in the HHS in the 21st Century: Charting a New Course for a Healthier America")
What is an example of something the Behavioral Risk Factor Surveillance System will track?
Trends in smoking (any behavioral trend is tracked). If the percentage of smokers goes up, more money will be put into smoking cessation programs.
What is the focus of the private health care subsystem?
the individual
Medicare buy-in proposals (taken from a required reading)
would provide those over a certain age — usually 50 — the option to buy into the program, but otherwise would leave today's health insurance system as it is.
Can a state gov't provide more than the Medicaid baseline services?
yes
