PHLT 412 TAMU EXAM 2

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RISK OF HEALTH INSURANCE IN THE US

-"sickness" insurance in European countries -Blue Cross, Blue Shield and other commercial insurance carriers -Medicare and Medicaid -Factors led to rising healthcare cost -Fee-for-service (FFS) -Health Maintenance Organization Act of 1973

KEY FAILED ATTEMPTS AT NATIONAL HEALTH REFORM

-1912 Progressive Party candidate Teddy Roosevelt supported social insurance platform included health insurance -1915 American Association for Labor Legislation proposal for working class health insurance -President Truman supported national health reform upon taking office, won re-election on national health insurance platform in 1948 -President Nixon initial health reform proposal in 1969 and revised proposal in 1972 -President Clinton Health Security Act in 1993

AFFORDABLE CARE ACT (ACA)

-EMPLOYER MANDATE: employers with 50 or more employees must provide affordable health insurance or pay a penalty -insurance is affordable if it has an actuarial value of at least 60% or is not more than 9.5% of an employees's income -penalty is per employee after first 30 employees

MANAGED CARE: UTILIZATION CONTROL TOOLS

-GATEKEEPR: managed care organization uses a primary care provider to make sure only necessary and appropriate care is provided -UTILIZATION REVIEW: managed care organization reviews and approves or denies services requested by provider -CASE MANAGEMENT: managed care organization manages and coordinates patient care

The Right to Personal Privacy

-Griswold v. Connecticut (1965) -Roe v. Wade (1973) -Planned Parenthood of Southeastern Pennsylvania v. Casey (1992) -Stenberg v. Carhart (2000) -Partial Birth Abortion Ban Act of 2003 -Gonzales v. Carhart (2007)

THE AFFORDABLE CARE ACT (ACA)

-INDIVIDUAL MANDATE (REPEALED); -most people have to purchase health insurance or pay a penalty starting in 2014 -exemptions for certain populations based on affordability -CONTROVERSY: too much governmental interference in private lives? constitutional? -STATE HEALTH INSURANCE EXCHANGES/MARKETPLACES: -American Health Benefit Exchanges for individuals -Small Business Health Options program for small businesses -must offer essential health benefits -four cost levels for plans based on actuarial value (bronze, silver, gold, platinum)

MANAGED CARE: COST CONTAINMENT TOOLS

-PERFORMANCE BASED SALARY BONUSES AND WITHHOLDS: -provider receives a salary as a managed care organization employee -salary is subject to bonuses or withholds -DISCOUNTED FEE SCHEDULE: -provider accepts less than fee-for-service rates to participate in managed care network -CAPITATED PAYMENT: -provider receives a per member/per month payment for all services rendered within scope of practice

PPACA

-Patient Protection and Affordable Care Act (2010) -111th Congress -March 23, 2010 -One of the goal: health insurance coverage expansion -health care quality -PH Practice -health disparities -community health centers -health fraud and abuse -long-term care -make health care more accessible to people

INDIVIDUAL RIGHTS AND HEALTH CARE: A GLOBAL PERSPECTIVE

-US does not guarantee health care as a fundamental right -other countries address health or health care rights in their constitutions: however, does not guarantee that the right will be recognized or enforced

THE PATIENT PROTECTION AND AFFORDABLE CARE ACT (PPACA)

-Why did the ACA pass when so many prior attempts had failed? -commitment and leadership -learned lessons from past failurs -politcal pragmatism -"a reasonable and logical way of doing things or of thinking about problems that is based on dealing with specific situations instead of on ideas and theories"

TYPES OF SOCIAL DETERMINANTS

-access to high quality educational opportunities -access to medical care services -access to social media and other technologies -availability of community-based resources and opportunities for recreational activities -availability of resources to meet daily needs -culture -language/literacy -public safety -residential segregation -social norms and attitudes -socioeconomic conditions -transportation options

ESSENTIAL HEALTH BENEFITS

-ambulatory patient services -emergency services -hospitalization -maternity and newborn care -mental health and substance use disorder services, including behavioral health treatment -prescription drugs -rehabilitative and habilitative services -laboratory services -preventative and wellness services and chronic disease management -pediatric services, including oral and vision care

BASIC INSURANCE TERMINOLOGY

-beneficiary: the person or entity you name in a life insurance policy to receive the death benefit. -premium: the amount a business or individual pays regularly to maintain health insurance coverage -deductible: the amount patients must pay out of their own pocket before their health insurance policy begins contributing to the cost of their care -cost-sharing: a requirement that insured patients pay a portion of their medical costs either as co-insurance or as a fixed co-payment

WHAT DETERMINES HOW HEALTHY WE ARE?

-built environment -civic engagement -culture -early childhood experiences -education -employment/income -environment: air, water, toxins -food security/nutrition -health care: physical/mental -housing -land use policy -social support -transportation -working conditions

ACA FINANCING HEALTH REFORM

-changes to medicare provider reimbursement -changes to medicare advantage reimbursement -medicare part A increases for high earners -changes in medicare part D subsidies -changes in medicare employer subsidy -changes in disproportionate share payments -increase medicaid prescription drug rebate paid by manufacturers -income tax code changes -health industry fees -tax on high cost health insurance plans

HIAP (health in all policy) STRATEGY

-collaborative governmental approach to health improvement by incorporate health consideration into an array of policy decisions, and by engaging governments and other stakeholders in a multi-sector approach to shaping the economic, physical, and social environments in which people live, work, and play

POINT OF SERVICE PLANS (POS)

-combines features of HMO and PPO -pays providers with capitation or other risk sharing arrangement -has a provider network; beneficiaries may use out-of-network provider for designated services -has a gatekeeper to control and coordinate care

INDIVIDUAL RIGHTS IN A PUBLIC HEALTH CONTEXT

-constitution EMPOWERS government to act in the name of public health but does not require it to do so -"NEGATIVE CONSITITUION": the constitution does not require government to provide any services, public health or otherwise -this approach to constitutional law derives from the fact that the constitution is phrased mainly in negative terms -DeShaney v. Winnebago County Department of Social Services -Town of Castle Rock, Colorado v. Gonzales

3. The right to be free from unlawful discrimination when accessing or receiving health care

-discrimination based on race/ethnicity, SES, disability, age, and gender -Civil Rights Act of 1964: Title VI Nondiscrimination in federally assisted program: prohibits discrimination on the basis of race, color and national origin -American with Disabilities Act (ADA)

HEALTH AND HEALTH CARE DISPARITIES

-disparities in health and health care are a systematic and deeply challenging problem in the US -differences in health and health care between population groups: what is health disparity? what is healthcare disparity? what is health equity?

4 BROAD DETERMINANTS OF HEALTH

-factors that contribute to a persons current state of health -biological -psychosocial -behavioral -social

1. Rights related to receiving services explicitly provided under health care, health financing, or health insurance laws

-for example, rights under: -EMTALA: emergency medical treatment and labor act -Medicaid -Patient Protection and Affordable Care Act (PPACA)

POLICE POWERS

-government authority to require individual conformance with established standards of conduct -standards are designed to promote and protect the public's health, safety, and to permit government control of personal, corporate, and other private interests

PROBLEMS WITH PPACA

-increasing premium and deductible -lacking insurance option, decreasing insurer participation -president trump and republican party intend to repeal and replace ACA

INDIVIDUAL RIGHTS IN A PHLT CONTEXT: BALANCING APPROACH

-individual private right vs. phlt and welfare of all -what might be the appropriate legal trade-offs between private rights and phlt and welfare

DIFFICULTY OF REFORM IN THE US

-individualistic culture -dislike of big government -lack of consensus -federal system rules and structure make it difficult to achieve major reform -states generally home to social welfare issues -powerful interest groups against national health reform -path dependency

NO DUTY TO TREAT PRINCIPLE

-individuals have no legal right to health care services or to public health insurance -health care providers have no general legal duty to provide care

SETTING PREMIUMS

-insurance companies set premiums to cover most of their expenses -EXPERIENCE RATING: -based on health status and claims in prior years -also referred to as medical underwriting -COMMUNITY RATING: -based on factors unrelated to previous use of medical care, such as geography or age -all persons in the community rating system pay the same amount

TIMELINE OF HEALTH INSURANCE IN THE US

-late 1800s-early 1900s: european social insurance movement resulted in the creation of "sickness" insurance throughout many countries -1929: Blue Cross established its first hospital insurance plan at Baylor University -1939: Blue Shield Began -1954: Internal Revenue Service declared that employers could pay health insurance premiums for their employees with pre-tax dollars -1965: Medicaid and Medicare were created

BENEFITS ON MLPs

-limited research -from small-scale studies: -impact on patient health and well-being -financial impact on partners and patients -impact on knowledge and training of health providers

MANAGED CARE

-managed care integrates the provision and payment of health care services -ideally, managed care contains costs while providing necessary and high quality health care services -some fear that managed care companies provide fewer services than necessary or lower quality services to save money

MEDICAL-LEGAL PARTNERSHIP (MLP)

-many "life circumstances" issues are unfixable by healthcare providers alone -improve social conditions via civil legal assistance -MPL includes both medical and legal professionals -creates and interconnected care system that focuses on the whole patient, including the ways in which myriad social conditions factor into individual and population health

LEGAL ISSUES

-medical underwriting -Health Insurance Portability and Accountability Act of 1996 (HIPAA): -HIPAA-covered group plans may not exclude or limit otherwise qualified individuals due to pre-existing conditions -HIPAA-covered group plans may not charge different premiums based on identified health factors to similarly situated individuals -state laws on medical underwriting vary

PRIVATE INSURANCE MARKET CHANGES

-no pre-existing condition exclusion -dependent coverage to age 26 -preventative services without cost sharing -prohibitions against lifetime and annual coverage limits -no rescission without fraud -new appeals process -premium rate reviews -guaranteed issue and renewability -rate variation limits -essential health benefits -wellness plans -some plans may be grandfathered in and not subject to all of these changes

PREFERRED PROVIDER ORGANIZATION (PPO)

-pays provider on a discounted fee schedule -beneficiary may use -in or -out-of-network providers

HEALTH MAINTENANCE ORGANIZATION (HMO)

-pays providers a salary or capitation -beneficiaries may only use in-network providers -HMO coordinates and controls receipt of service

UNCERTAINTY AND RISK

-people choose to be insured due to uncertainty and risk -insurance companies are concerned about uncertainty and risk because they are businesses that need to cover the cost of their expenditures -asymmetric information -uncertainty and risk may lead to adverse selection: unhealthy people over-select a particular plan, making the plan more expensive

PREMIUM AND COST SHARING SUBSIDIES

-premium tax credits available for individuals who purchase insurance in an exchange and have income between 133%-400% of poverty -cost sharing subsidies available for individuals who purchase insurance in an exchange and have income up to 250% of poverty -to qualify, must be a US citizen or legal resident, not eligible for any type or public insurance, and not have access to employer-sponsored insurance

JACOBSON VS. MASSACHUSETTS (1905)

-public health powers must be exercised in conformity with four standards in order to pass constitutional muster: -public health necessity -reasonable means -proportionality -harm avoidance

2. Rights concerning freedom of choice and freedom from government interference when making health care decisions

-right of individual patients to make informed decisions about the scope and course of their own care -right to refuse treatment -Canterbury v. Spence -Information that must shared with patient

SOCIAL DETERMINANTS OF HEALTH

-social conditions into which people are born and that may affect their daily lives and overall well-being as they move through various stages of life -"the conditions in which people are born, grow, live, work, and age" (WHO)

INSURANCE COVERAGE OVERVIEW

-the US does not have a single national health insurance program that covers the entire population -ACA expanded the health insurance coverage -of those with insurance, most obtain coverage through their employer -as of the 4th quarter of 2017, 12.2% of the US adults, were without health insurance -access to healthcare services -understand how providers, suppliers, employers, states, and others respond to changes in health insurance market -insurance carriers design their insurance product, employers and individuals choose whether to/what type of health insurance to purchase

RIGHT TO CRIMINAL LEGAL REPRESENTATION

-the government is required to provide legal counsel to all federal defendants who are unable to afford their own attorneys (6th Amendment) -Gideon vs. Wainwright (1963)

HEALTH REFORM

-there have been numerous health reform attempts in the US -prior ti 2010, all attempts at national health reform to create universal or near-universal coverage have failed -some success at the state level

CIVIL LEGAL ASSISTANCE

-there is no right to the assistance of a lawyer in CIVIL matters --immigration status, domestic violence, disability law, family law, housing needs, public benefits --varied by state laws -civil legal aid or civil legal services --promote strategies to address the severe gap in access to both criminal and civil justice for low-income and vulnerable populations

5 WAYS LAW SHAPE LIFE CIRCUMSTANCES AND HEALTH

1. design and perpetuate social conditions 2. transformed behaviors and prejudices into distribution of well-being among populations 3. determinative of health through under-enforcement 4. determinative of health through interpretation 5. structure direct responses to health-harming social needs

4 KEY PROVISIONS OF PPACA

1. individual mandate (repealed) 2. employer mandate 3. health insurance exchange 4. expansion of medicaid

INDIVIDUAL RIGHTS AND THE HEALTH CARE SYSTEM: CATEGORIZE HEALTH CARE RIGHT IN 3 WAYS

1. rights related to receiving services explicitly provided under health care, health financing, or health insurance laws 2. rights concerning freedom of choice and freedom from government interference when making health care decisions 3. the right to be free from unlawful discrimination when accessing or receiving health care