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Based on the readings discuss how the health s

Based on the readings discuss how the health system can motivate individuals to adopt behaviors that prevent most chronic diseases and illnesses.

Please make sure all responses are in your own words. Quality posts will utilize a source to support their statements. Please use APA format and be sure to cite the source if one is used.

Chapter 4

Medical Insurance and Access to Care

Processes For Thinking About the U.S. Health Care System

“In view of the Constitution, in the eye of the law, there is in this country no superior, dominant, ruling class of citizens. There is no caste here.”

— Justice John Marshall Harlan

Lecture Overview

Principles and Applications

The Three W’s of Medicaid Insurance: Who? What? Why?

Children’s Health Insurance Program

Why Is Government Insurance Economically Necessary?

Unaffordability of Advanced Medicine

Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Medicaid insurance and access to medically necessary care. In Health care management and the law: Principles and applications (pp. 65-86). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.

Principles and Applications

As millions of Americans gain health insurance as a result of the Affordable Care Act:

(1)Affordability of coverage remains a persistent problem for some

(2)Many technological innovations and health care initiations are focused on affluent communities and are accessible mainly to people with private health insurance.

(3)Health care in the United States costs more every year:

For every one in four adults who may be without health insurance for part or all of any given year, access to quality health care is simply not affordable

The Three W’s of Government Health Insurance: Who? What? Why?

Federal Share of Medicaid Spending

Medicaid is the government health insurance program for Americans with limited means and the severely disabled.

For states that expand Medicaid insurance through the Affordable Care Act, the federal government pays 100 to 90% of the costs

Regular match rate 60%

Medicaid Expansion Map

Kaiser Medicaid

States that do not adopt the expansion will forgo substantial federal revenues:

Low income adults may fall into a coverage gap

Federal contribution varies based on state per capita householdincome relative to the national income average

The Three W’s of Government Health Insurance: Who? What? Why?

Who is Categorically Eligible for Medical Insurance?

Medicaid insurance is the principle safety net for:

Blind or severely disabled children and adults

Low income working families with children

Medicaid eligible with limited resources, who need assistance with filling gaps in their Medicare coverage

Uninsured pregnant women

Medicaid insurance does not provide coverage for everyone unless the state expanded traditional coverage

The Three W’s of Government Health Insurance: Who? What? Why?

Who is Categorically Eligible for Medical Insurance?

Disabled Medicare Beneficiaries:

1 out of 4 of the Medicaid insured are seriously disabled and receiving Medicare benefits

This population group accounts for more than 70% of the nation’s Medicaid insurance spending

Severely Disabled Children and Adults:

Medicaid insurance provides health insurance coverage for people with physical and mental disabilities and chronic illnesses.

Uninsured Pregnant Women:

Medicaid insurance provides access to prenatal care and neonatal intensive care for eligible women and their babies

The Three W’s of Government Health Insurance: Who? What? Why?

What Medicaid Insurance is Required?

There is no national consensus of the 3 W’s of Medicaid insurance:

Who is deserving of financial assistance?

What health care costs should be covered?

Why should the government be involved in the first place?

The demand for broader state accountability is a constant theme for Medicaid insurance as the 3 W’s are debated

The Three W’s of Government Health Insurance: Who? What? Why?

Coverage Issues

Controversies that remain unresolved include:

Rules for when someone may be eligible for Medicaid insurance coverage (3 month rule)

Entitlements for non citizens, if they are entitled at all, for taxpayer Medicaid insurance

Identification of what constitutes a life threatening medical event

Delivery system inequities between the uninsured/underinsured compared to those with comprehensive health insurance coverage plus the ability to pay out of pocket costs before any non life threateningtreatment is ever received

The Three W’s of Government Health Insurance: Who? What? Why?

Coverage Issues

Three Month Rule

Coverage may start 3 months prior to application for Medicaid insurance, if the individual would have been eligible during the retroactive period but:

was unaware of this opportunity, or

because the nature of their illness prevented them from seeking coverage

States seldom develop outreach programs to advise their residents of the benefits of Medicaid insurances

Coverage Issues

Lawful Permanent Residents

Most states have charity programs to provide medical assistance to residents who do not qualify for Medicaid but face extraordinary circumstances

MA Case legal residents 5 year rule

Coverage Issues

Definition Of Medically Needy:

Low income is only one test for Medicaid eligibility; assets and resources are also tested against established thresholds

The middle class is often covered when their private insurance is exhausted from medical situations:

Expenses from a catastrophic injury or illness that exceed private insurance

The medical treatments they elect are excluded from their coverage

Coverage Issues

Emergency Medical Services:

Emergency services must be life threatening to be covered by Medicaid insurance

Coverage Issues

Coverage Issues

Delivery System Inequities:

States increase Medicaid enrolments to qualify for more federal assistance rather than being given incentives to increase efficiency and higher quality

There are significant differences between states on measures of health care access, quality, costs, and outcomes

Coverage Issues

Coverage Incentives:


Accurate and comparable payment rates

Health outcomes, or whether coverage is actually improving health

Quality of health care

Should coverage be revoked if it turns out an individual experience was not life threatening?

Should there be a limit on the total amount of coverage Medicaid insurance will provide?

What should be considered life threatening?

Coverage Issues

State Waivers:

In states that chose to expand Medicaid insurance under the Affordable Care Act, all low income adults are now eligible for Medicaid health insurance that is subsidized by the federal government

A handful of states have received special permission, known as waivers, from federal regulators to take steps to improve their Medicaid insurance plans:

Indiana, Louisiana, North Carolina, Pennsylvania

Coverage Issues

Economics of the Medicaid Insured

With health insurance premiums rising more rapidly than the federal poverty level, the protection offered to the sickest and poorest Americans by Medicaid insurance has not kept pace with rising health insurance costs

Medicaid: Who? What? Why?

Access to Medically Necessary Care

While Medicaid insurance is an improvement over being uninsured, it often relegates Medicaid insured consumers to inferior health care:

Disparity in health care

Major reform of the U.S. health care system will require significant inter-governmental mandates for decades to come

Equal Access for El Paso, Inc. v. Hawkins

Equal access provision unenforceable

Paediatric Specialty Care, Inc. v. Arkansas Department of Human Services

Found an enforceable right

The Three W’s of Government Health Insurance: Who? What? Why?

Economic Inequities

Medicare/Medicaid Insured

Access problems faced by those who qualify for both Medicare and Medicaid insurance, generally referred to as being dual insured:

4 out of 10 physicians restrict access

30% of U.S. physicians refuse to accept new patients with Medicare/Medicaid insurance

Access for patients with Medicare/Medicaid insurance is most limited in urban areas

Most of the individuals who are dual insured face restrictions on access to the latest medical technologies

The Three W’s of Government Health Insurance: Who? What? Why?

Economic Inequities

Treatment of Serious Heart Conditions

The treatment of heart disease discloses clinical disparities that can only be attributable to the influence of insurance status:

80% of the hospitalizations for heart failure are patients with Medicare/Medicaid

Patients who are Medicaid insured face significantly more angina, poorer quality of life, and higher risks of hospitalizations after myocardial infarctions

Patients with Medicaid coverage are almost 50% more likely to die after coronary artery bypass surgery

The Three W’s of Government Health Insurance: Who? What? Why?

Economic Inequities

Diagnoses of Cancer

The probability of being diagnosed with late stage cancer is greater for the uninsured and Medicaid insured than it is for people with private coverage and health care

The Three W’s of Government Health Insurance: Who? What? Why?

Economic Inequities

Treatment of HIV/AIDS

The uninsured/underinsured with inadequate prescription plans complain about being denied access to the antiretroviral drugs that can prevent their immune systems from being weakened to the point of acquiring AIDS

Lack of early access is the difference between life and death from AIDS

Treatment is withheld for many uninsured Americans of limited means until it is too late for preventive care

Children’s Health Insurance Program

Created in 1997 to address the growing challenge of uninsured children:

Directed by the Centers for Medicare and Medicaid Services

Administered by the states, with broad federal guidelines, each state determines:

Administrative and operating procedures

Benefit packages

Design of its program

Eligibility groups

Payment levels for coverage

Should states be able to place limitations upon enrollment in Medicaid insurance, such as maintenance of a healthy weight, not smoking, or not abusing drugs?

Children’s Health Insurance Program (CHIP):Who is Targeted for CHIP?

CHIP is designed to provide health insurance to uninsured, low income children who:

Reside in a family with household income below 200% of the federal poverty level

Whose family has a household income 50% higher than the state’s Medicaid insurance eligibility threshold

Certain children cannot be covered under CHIP, including children who are:

Eligible for Medicaid coverage

Insured through an employer, an association, or an individual plan

Members of a family eligible for government sponsored health insurance based on employment with a public agency

Residing in an institution for those with mental illnesses

Waivers to use funds to cover adults with children exist

Children’s Health Insurance Program: Expansion of Medicaid Insurance to Higher Income Households

If a state elects to expand its Medicaid insurance using CHIP, the Medicaid insurance eligibility rules apply, including the inability to:

Enact lifetime caps

Enforce residency requirements

Establish time limits for eligibility

For states that opt for a separate child health program, certain other federal restrictions affecting Medicaid insurance eligibility are optional:

Choose to offer children one year of continuous eligibility

Enforce enrollment caps for eligible children

Have waiting lists for coverage of uninsured children

All states must establish a dual system of government insurance eligibility for children

Children’s Health Insurance Program

Limitation of Government Insurance Coverage

The federal government used to restrict the availability of CHIP to children who were not U.S. citizens

Since 2009, all children residing in the United States who meet need based requirements for participation are now eligible for coverage

Need Based Cost Sharing

States are permitted to impose different cost-sharing on CHIP

Some of the poorest insured families in America have unenforceable rights when their children are denied medical coverage

Children’s Health Insurance Program:

Middle Income Families

Families must be advised of their maximum annual cost sharing limit for each child; the state plan must describe the:

Consequences of not paying cost sharing charges

Disenrollment protections for families who cannot pay their cost sharing obligations

Methods used to determine cost sharing amounts

Should participation in CHIP be limited to children who are U.S. citizens?

Children’s Health Insurance Program

Low Income Families

Where children reside in households at or below 150% of the federal poverty line, states may not impose more than:

Nominal cost sharing fees

One cost sharing charge for all services delivered during a single office visit

One type of cost sharing for a medical service

What Health Insurance is Required for Uninsured Children?

States are required to offer medical services to eligible individuals and families that meet specified financial criteria

States cannot restrict Medicaid insurance coverage to focus on improving the health of their children

Why is Government Insurance Economically Necessary?

In a democratic society there is an economic need for the federal government to:

Seek expected utility maximization

Enhance state capacities for health insurance coverage

Help generate economic activity in the states

Maximize economic impacts on the U.S. health care system

Support a safety net

U.S. Health Care System and Safety Net

The guarantee of federal financing for Medicaid insurance enables states to respond to:

Aging population

Chaotic economic downturns

Emergencies and disasters

Increases in health care costs

Children’s Health Insurance Program

Generation of Economic Activity:

Additional tax revenues are derived from the health care jobs and household incomes generated

Economic impact of Medicaid funds is impacted because of the federal matching dollars

Health care jobs generate household income within the health care sector and throughout other sectors of the local economy due to the multiplier effect

Medicaid insurance funding to health providers supports health care jobs and household incomes

State spending on behalf of Medicaid insured consumers for health care pulls federal tax dollars into local economies

Children’s Health Insurance Program

Economic Impact on the Health Care System

Government payments to health providers, on behalf of the Medicaid insured, directly impact health providers by:

Creating household income

Promoting consumer purchases associated with the provision of health care

Supporting health care jobs

State Capacity for Health Insurance Coverage

The magnitude of economic impact from Medicaid insured consumers is dependent on:

Economic conditions of the state economy

Federal funding to the states for Medicaid insurance

Level of state funds available for Medicaid spending on health care

Unaffordability of Advanced Medicine

The United States has long prided itself in medical innovations, as the global leader in medical research and health care technology

One in four Americans cannot afford the costs required to meet their medically needed care

Prohibitive costs keep advanced medicine completely out of reach for many members of society, including the:

Low wage earners

Medicaid insured

Underinsured of limited means


This lack of access has been termed a health care crisis


Chapter 5 Medicare Insurance Reforms

Medicare Insurance Reforms

“Our current national health care system is simple: do not get sick.”

— Anonymous

Lecture Outline

Principles and Applications

Medicare Reform: Financing by Individuals or Society?

Complexity of Medicare Insurance

Structural Reform of Medicare Insurance

Reallocating Medical Treatments and Prevalence

Overhauling Medicare /

Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Medicare insurance reforms. In Health care management and the law: Principles and applications (pp. 87-97). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.

Principles and Applications (1 of 2)

The Medicare program is the second largest social insurance program in the United States, behind Social Security, offering health insurance benefits to those eligible by virtue of their Social Security eligibility

Persons eligible for Medicare insurance include:

Individuals aged 65 and over

The severely disabled

Those with end stage renal disease

While the Medicare insured make up just 17% of the U.S. population, they account for most of the U.S. health care costs

The rise in treatment prevalence (common chronic diseases) accounts for most of the spending growth in health care costs /

The sickest 25% of the Medicare-insured spend 90% of the U.S. health care dollars with an average of:

At least one hospitalization yearly

$181,800 in health expenditures yearly

5 diagnosed medical conditions

10 prescriptions

12 physicians

The key to cutting costs lies with the physicians who treat these super-users:

At least two of their chronic medical conditions were preventable

Their care is not being coordinated by their multiple providers

They are being over-treated and mistreated (polypharmacy)

Principles and Applications (1 of 2)

Medicare Reform: Financing by Individuals or Society?

Medicare insurance must be changed if it is to be sustained

Its benefits package still closely resembles the standard package available in the mid 1960s:

70% of medicare enrollees have traditional indemnity insurance at a time when less than 2% of the insured have conventional insurance

Medicare payments are not intended to cover all the medical needs of enrollees, nor should society pay for all these expenses

Only 1 in 10 individuals over 65 relies solely on Medicare insurance; the rest have:

Medicaid insurance

Employer provided coverage

Supplementary health insurance in addition to Medicare

Indeminty Insurance Plans: different than policies offered bby HMOs, PPOs because it allowes you to obtain medical care wehre you choose providing compensation for a set portion of the cots. IT does not force you to choose a primary care doctor and you can self refer to specialisist. Very simliar to Fee-for service

Complexity of Medicare Insurance Part A: Hospital, Skilled Nursing, Home Health, and Hospice Care

Medicare Part A covers hospital insurance

Pays for almost ¼ of benefits spending:

Most of the Medicare insured do not pay premiums for this benefit, because they have already paid it through their payroll taxes

Part A does not cover custodial or long term nursing care, and consumers must meet certain eligibility criteria for home health and hospice care

The home health care benefit is available to individuals certified by their physicians as homebound

The Medicare hospice benefit is available only to individuals whose physicians have certified their expected mortality is less than six months away

Complexity of Medicare Insurance Part B: Physician, Outpatient, Home Health Care, and Preventive Services

Medicare Part B covers physician visits, outpatient visits, preventive services, and some home health visits

Most people pay a monthly premium for this insurance:

Medicaid insurance may subsidize premiums based on income eligibility, which varies by state

Services are provided on a medically necessary basis

No coinsurance or deductible is charged for an annual wellness visit or for preventive services

Complexity of Medicare Insurance Part C

Medicare Advantage

Medicare Part C refers to Medicare Advantage, where the federal government pays a fixed amount per member per month to private insurance companies that then coordinate and finance care

Consumers can select from a variety of private managed care plans and enroll in:

Health maintenance organizations

Preferred provider insurance

Private fee for service plans

Special needs plans

Medicare Advantage has doubled its enrollments in the past decade

Complexity of Medicare Insurance-Part C: Medicare Advantage Coverage

Medicare’s Special Needs Program

Restricted to dual eligible Medicare/Medicaid insurance consumers residing in long term care facilities

Serves about 1.2 million consumers

Complexity of Medicare Insurance-Part C: Medicare Advantage Coverage

Administrative Complexity of Medicare Advantage

With private/public sector complexity, the federal government has no way to monitor access, use, or performance for the over 165 million consumers enrolled in Medicare Part C

Medicare Advantage insurance plans are not required to:

Have Medicare review of services

Negotiate fees

Report quality measures

The increase in competition generated by higher payments to Medicare Advantage has not translated into better benefits for consumers

Complexity of Medicare Insurance Part D: Medicare Prescription Drug Coverage

Medicare Part D prescription plans generally have at least two economic objectives:

(1)Allow the health care system to improve the overall delivery of health care to the Medicare-insured

(2)Relieve the financial burden on those who have trouble affording prescription drugs

While the prescription drug program has value, it does not begin to address either of these economic objectives:

It shows how public perceptions, or misconceptions, can unduly influence decisions about health risks

Example of health policy based not on a rational response to health risks, but rather on misperceptions of risks

Complexity of Medicare Insurance – Part D: Medicare Prescription Drug Coverage (1 of 2)

The drug plan, while providing coverage at the lower and upper ends of expenditures, allows for a coverage gap in the middle:

Donut hole coverage

The drug benefit is not catastrophic coverage above a deductible, but rather:

75% coverage for a range of expenses, after a modest deductible (or, most of the donut), then

100% cost-sharing for beneficiaries (or, the donut hole with zero coverage), before

A return to 80% donut coverage (or, the rest of the donut)

Medicare Part D reduces coverage for people with high expenses to offer coverage for people with low expenses:

Provides most consumers with a return on their premium

Patient Assistance Programs

For enrollees covered by Medicare Part D, the medical products industry offers patient assistance programs that provide drugs outside the Part D benefit without any cost to the Medicare program

Most manufacturers have a data-sharing agreement with the federal government to help coordinate prescription use with plans providing Medicare prescription coverage

Medicare Part D benefit coverage has reduced the load on patient assistance programs, enabling the medical products industry to expand these programs to individuals with complex needs and high costs

Complexity of Medicare Insurance – Part D: Medicare Prescription Drug Coverage (2 of 2)

Complexity of Medicare Insurance – Supplemental Insurance Coverage

Medicare has high cost arrangements, no limit on out-of-pocket spending, and a coverage gap in the Part D prescription drug plan

Employer-sponsored health insurance, Medicaid insurance, and Medigap overlay each of the four types of Medicare

Help with cost-sharing requirements and benefit gaps

Medigap is a supplemental insurance offered through private insurers.

Takes care of medical expenses not covered by Medicare

Most of the Medicare-insured have some sort of supplemental coverage

Structural Reform of Medicare Insurance (1 of 2)

It is important to gather more evidence about the implications of either paying less to Medicare Advantage or other changes in entitlement to make the Medicare system more fiscally responsible

Little attention is being drawn to the:

$65 trillion the United States needs to make Medicare whole

$1 billion that private insurers get in profit subsidies from Medicare Advantage plans each year

$1 trillion in unfunded health care obligations for health care retirees

Discussion generally centers on increasing payroll taxes or the premiums for Medicare insurance

How to control the growth of Medicare?

Structural Reform of Medicare Insurance (2 of 2)

United States v. Lahey Clinic Hospital, Inc.

Demonstrates the problems that may arise under single-payer systems without competition

Physicians could not compete for laboratory services and receive lower rates

Obtaining more revenue for the Medicare program does not solve the issue of long-term sustainability until unnecessary spending like the Lahey case is controlled

Medicare puts a price tag on consumer’s health, perhaps even their lives

Reallocating Medical Treatments and Prevalence

Given the higher costs of Medicare Advantage, with no discernible improvement in the quality of its managed care, there may be many opportunities to cut its services, with little minimal adverse impact on consumers

The money saved could then be allocated where it may provide more efficient benefits:

Advertising expenditures are expanding but better quality care does not come from advertising.

The rise in treatment preference, rather than rising treatment costs, accounts for most of the spending growth

“This person’s life expectancy is only so many years, so this procedure is not worth the cost”

Overhauling Medicare

There is a general consensus on several overhauls of the Medicare system:

Increase payroll taxes and premiums for medicare insurance to those who can afford to pay more

Mandate that profit subsidies from Medicare Advantage be returned to consumers in the form of reduced premiums or additional benefits

Monitor quality use and performance for all the Medicare-insured

Require more competitive bidding for medical services reimbursed by Medicare insurance

Overhauling Medicine

Everyone pays for hospitalization insurance through payroll taxes, but physician payments for prescription drug benefits are voluntary:

Perhaps those who are better off should pay higher premiums

Medicare is an inadequate health insurance plan in the sense that it does not protect against long hospital stays or catastrophic expenses

The least likely to purchase supplemental Medicare coverage are financially distressed consumers with complex needs