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Oct 30, 2023
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out of pocket payments, individual insurance, employer sponsored insurance, government-financed insurance. Include a sentence about which method is least effective, in your view, and why.
Out of pocket payments: when patient pays money directly to the medical care (treatments) in the hospital or clinics (provider) without insurance. Individual insurance: this refers to people buying their own private health insurance plan, patient pays regular-based fee to the insurance provider, called premium. By paying your healthcare provider, your insurance company assists in covering some of the cost of your medical care.
Employer sponsored: many employers offer healthcare coverage to their employees paying a premium for the insurance plan; so this is a part of benefit package comes from employer. Government-financed insurance: certain groups are covered in full by government-funded insurance programs, such as Medicaid for low-income people and Medicare for elderly, guaranteeing that care is available to vulnerable groups.
Paying out of pocket is, in my opinion, the least successful approach since it puts a financial barrier in the way of people's access to healthcare. Cost concerns frequently cause people to postpone or forego critical medical treatment, which can ultimately result in worse health outcomes and higher healthcare expenses.
The passage you've provided outlines some of the key changes that the Affordable Care Act (ACA) brought to the U.S. healthcare system:
1.
Employer Mandate
: Under the ACA, employers with 50 or more full-time employees are required to offer health insurance coverage to their employees. If they do not provide this coverage and at least one of their employees receives financial assistance for coverage through the health insurance exchanges, the employer is subject to a fee. This mandate was introduced to encourage employers to continue offering health insurance and ensure that employees have access to coverage.
2.
Coverage for Young Adults
: The ACA mandated that private health insurance plans must allow young adults to remain on their parents' policies up to the age of 26. This provision was intended to provide extended coverage for young adults, including college students, who might not have their own employer-based insurance yet.
3.
Preexisting Condition Protections
: The ACA prohibits insurance companies from denying coverage or charging higher premiums based on preexisting conditions. This change provides essential protection for individuals with existing health issues, ensuring they can access insurance coverage.
4.
Premium Cost Restrictions
: The ACA limited the variation in premium costs within
insurance plans. Insurance companies are allowed to charge a maximum of three times the
premium rate for the same benefit package, regardless of the individual's age. This change
aimed to make insurance more affordable and equitable.
These provisions of the ACA were implemented to increase access to healthcare, improve consumer protections, and enhance the overall functioning of the U.S. healthcare system.
The law aimed to make insurance more accessible and equitable for a broader range of individuals and families.
Premium Cost Restrictions: The ACA limited the variation in premium costs within insurance
plans. Insurance companies are allowed to charge a maximum of three times the premium rate for the same benefit package, regardless of the individual's age. This change aimed to make insurance more affordable and equitable.
ChatGPT
The passage describes a key provision of the Affordable Care Act (ACA):
Premium Cost Restrictions
: The ACA set limits on how much insurance companies can vary the cost of premiums for the same type of benefit package based on an individual's age. Specifically, insurance companies are allowed to charge a maximum of three times the premium rate for the same set of benefits, regardless of how old the individual is. This rule was implemented to achieve two main objectives:
1.
Affordability
: By capping the premium cost differences based on age, the ACA aimed to make health insurance more affordable for individuals of all age groups. Prior to this rule, older individuals often faced significantly higher premiums due to their age, which
could make insurance unaffordable for some.
2.
Equity
: The goal was also to promote fairness and equity in health insurance pricing. By limiting the age-based premium variations, the ACA sought to ensure that younger and older individuals had more comparable premium costs for the same level of coverage.
In summary, this provision was intended to create a more equitable and affordable health insurance system by narrowing the price gap for individuals of different ages while offering the same benefits.
In 2012, Bud Carpenter was self-employed. To pay the $800 monthly premium for his individual health insurance policy, he had to work extra jobs on weekends, and the $5,000 deductible meant he would still have to pay quite a bit of his family’s medical costs out of pocket. Mr. Carpenter preferred to pay these costs rather than take the risk of spending the
money saved for his children’s college education on a major illness. When he became ill with leukemia and the hospital bill reached $80,000, Mr. Carpenter appreciated the value of
health insurance. Nonetheless he had to feel disgruntled when he read a newspaper story listing his insurance company among those that paid out on average less than 60 cents for health services for every dollar collected in premiums. ышьзду цщквы
ChatGPT
The scenario you've described illustrates some of the challenges and dilemmas that individuals can face when it comes to health insurance. Here are a few key points to note:
1.
High Premiums and Deductibles
: Bud Carpenter had to work extra jobs to pay for his individual health insurance policy, and he still had a substantial deductible to meet. This highlights the financial strain that many people experience due to the high cost of healthcare and insurance.
2.
Financial Risk vs. Health Insurance
: Bud Carpenter chose to pay for health insurance even with its high costs because he wanted to mitigate the financial risk associated with a major illness. This reflects a common dilemma individuals face – balancing the cost of insurance with the risk of medical expenses.
3.
Healthcare Costs
: The hospital bill of $80,000 for his leukemia treatment underscores the significant expenses associated with medical care, especially for serious conditions. Even with insurance, out-of-pocket costs can be substantial.
4.
Insurance Payouts
: The frustration expressed by Mr. Carpenter regarding his insurance company paying less than 60 cents for every dollar collected in premiums reflects concerns about the efficiency and transparency of the health insurance industry.
This scenario highlights the need for a robust and accessible healthcare system that addresses the financial burden of healthcare for individuals and families. It also underscores the importance of understanding the terms and conditions of health insurance policies, including their coverage and cost-sharing aspects.
n 2014, Bud Carpenter signed up for individual insurance for his family of four through Covered California, the state exchange set up under the Affordable Care Act. Because his family income was 200% of the federal poverty level, he received a subsidy of $1,373 per month, meaning that his premium would be only $252 per month for a silver plan with Kaiser Permanente. His deductible was $2,000. Insurance companies were no longer allowed to deny coverage for his preexisting leukemia.
ChatGPT
Bud Carpenter's experience in 2014 demonstrates some of the key provisions and benefits of the Affordable Care Act (ACA) in the United States:
1.
Subsidies
: Bud Carpenter received a significant subsidy through Covered California because his family income was at 200% of the federal poverty level. Subsidies under the ACA were designed to make health insurance more affordable for lower and middle-income individuals and families, reducing their monthly premium costs.
2.
Preexisting Condition Protections
: The ACA implemented regulations that prohibited insurance companies from denying coverage or charging higher premiums based on preexisting conditions. In Bud's case, he could obtain insurance coverage even with a preexisting condition like leukemia, which was a significant improvement in consumer protection.
3.
Standardized Plans
: Bud was able to purchase a silver plan from Kaiser Permanente with a $2,000 deductible. The ACA standardized insurance plans into metal tiers (bronze, silver, gold, and platinum), making it easier for consumers to understand and
compare their coverage options.
Overall, Bud Carpenter's experience reflects the ACA's efforts to expand access to healthcare, increase consumer protections, and provide financial assistance to those with lower incomes to make health insurance more affordable. These changes were significant steps in the U.S. healthcare system to improve coverage and reduce barriers to obtaining insurance.
what is a deductible ChatGPT
A deductible is a specific amount of money that an individual must pay out of their own pocket before their health insurance plan starts covering the costs of their medical expenses. In other words, it's the portion of healthcare expenses that you are responsible for before your insurance kicks in to share the costs.
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For example, if you have a health insurance plan with a $1,000 deductible, and you incur $5,000 in covered medical expenses, you would need to pay the first $1,000, and your insurance would cover the remaining $4,000.
Deductibles are designed to help control insurance costs and are often set as an annual amount. They can vary widely depending on the type of insurance plan and policy. Plans with lower premiums typically have higher deductibles, and plans with higher premiums tend to have lower deductibles. The choice of a plan with a higher or lower deductible depends on an individual's financial situation and healthcare needs.
. The ACA established federal and state-based insurance exchanges to assist people seeking individual coverage to shop for insurance plans meeting the federal standards. Insurance companies are no longer able to deny coverage for medical conditions that existed prior to the purchase of the insurance. The benefit packages offered by plans in the
exchanges vary depending on whether individuals purchase a low-premium bronze plan with high out-of-pocket costs, a high-premium platinum plan with lower out-of-pocket costs,
or intermediate silver or gold plans (Kaiser Family Foundation, 2013) (Table 2–2). The contentious politics of the ACA are discussed in Chapter 15.
ChatGPT
The text you've provided describes some key provisions of the Affordable Care Act (ACA), also known as Obamacare, in the United States. Here are the main points:
1.
Establishment of Insurance Exchanges
: The ACA established both federal and state-based health insurance exchanges (Marketplaces) where individuals and families can shop for and purchase health insurance plans that meet federal standards. These exchanges were created to make it easier for people to compare and purchase health insurance, increasing transparency and accessibility in the insurance market.
2.
Prohibition of Coverage Denials for Preexisting Conditions
: One of the significant changes brought about by the ACA is that insurance companies are no longer allowed to deny coverage or charge higher premiums based on preexisting medical conditions. This is a crucial consumer protection, ensuring that people with existing health issues can still obtain insurance coverage.
3.
Variety of Benefit Packages
: Plans offered on the exchanges come in different metal tiers, including bronze, silver, gold, and platinum. These tiers represent the level of coverage and cost-sharing. For example, bronze plans typically have lower premiums but higher out-of-pocket costs, while platinum plans have higher premiums but lower out-of-
pocket costs. Consumers can choose plans based on their budget and healthcare needs.
4.
Controversies Surrounding the ACA
: The text mentions that the politics of the ACA have been contentious. The ACA's passage and implementation sparked political debates, legal challenges, and policy discussions. Chapter 15 likely goes into more detail about the challenges and controversies surrounding the ACA.
The ACA was a significant piece of healthcare reform legislation in the United States, aiming to expand access to healthcare, improve consumer protections, and make health insurance more affordable for a broader population. It had a substantial impact on the healthcare landscape in the country.
With employment-based health insurance, employers pay a portion of the premium that purchases health insurance for their employees (Fig. 2–3). However, this flow of money is not as simple as it looks. The federal government views employer premium payments as a
tax-deductible business expense. The government does not treat the health insurance fringe benefit as taxable income to the employee, even though the payment of premiums could be interpreted as a form of employee income. Because each premium dollar of employer-sponsored health insurance results in a reduction in taxes collected, the government is in essence subsidizing employer-sponsored health insurance. This subsidy is
enormous, estimated at $280 billion in 2018. ЫШЬЗДУ
ChatGPT
The passage you've provided highlights some key aspects of employment-based health insurance in the United States:
1.
Employer Contributions
: Many employers in the United States offer health insurance as part of their employee benefits package. In this system, employers typically pay a portion of the premium for their employees' health insurance plans. This contribution
helps make health insurance more affordable for employees.
2.
Tax Treatment
: The federal government treats employer premium payments as a tax-deductible business expense. This means that employers can deduct the cost of providing health insurance for their employees from their taxable income. In other words, it
reduces the amount of income subject to taxation for the employer.
3.
Tax Benefits for Employees
: Additionally, the government does not treat the value of the health insurance provided by the employer as taxable income to the employee. In essence, this means that employees do not have to pay income tax on the value of their employer-provided health insurance. This is known as a "tax-free fringe benefit."
4.
Government Subsidy
: The combination of tax benefits for employers and employees results in a substantial government subsidy for employer-sponsored health insurance. This subsidy is significant, amounting to billions of dollars annually. In 2018, it was estimated at $280 billion.
This tax treatment and subsidy have been a fundamental aspect of the U.S. healthcare system, with the goal of encouraging employers to offer health insurance to their employees. It has also been a subject of debate and discussion in healthcare policy, with some advocating for changes to the system to make healthcare more equitable and cost-
effective.
Tax Treatment: The federal government treats employer premium payments as a tax-
deductible business expense. This means that employers can deduct the cost of providing health insurance for their employees from their taxable income. In other words, it reduces the amount of income subject to taxation for the employer. Tax Benefits for Employees: Additionally, the government does not treat the value of the health insurance provided by the employer as taxable income to the employee. In essence, this means that employees do not have to pay income tax on the value of their employer-provided health insurance. This is known as a "tax-free fringe benefit." Government Subsidy: The combination of tax benefits for employers and employees results in a substantial government subsidy for employer-sponsored health insurance. This subsidy is significant, amounting to billions of dollars annually. In 2018, it was estimated at $280 billion. SIMPLE WORDS
ChatGPT
In simpler terms:
1.
Tax Treatment for Employers
: The government allows employers to subtract the money they spend on providing health insurance to their employees from their total income before calculating taxes. This means they pay fewer taxes because they're spending on health insurance for their employees.
2.
Tax Benefits for Employees
: The government doesn't consider the value of the health insurance provided by the employer as part of the employees' income. So, employees don't have to pay income taxes on the value of their employer-provided health insurance. It's like getting a tax break.
3.
Government Help
: Because both employers and employees get tax benefits for health insurance, the government ends up spending a lot of money to support this system. In 2018, this support was estimated to be a massive $280 billion.
This tax system encourages employers to offer health insurance to their employees, but it also costs the government a lot of money.
he new dynamic was called experience rating
. (The following discussion of experience rating can be applied to individual as well as employment-based private insurance.)
Healthy Insurance Company insures three groups of people—a young healthy group of bank managers, an older healthy group of truck drivers, and an older group of coal miners with a high rate of chronic illness. Under experience rating, Healthy sets its premiums according to the experience of each group in using health services. Because the bank managers rarely use health care, each pays a premium of $600 per month. Because the truck drivers are older, their risk of illness is higher, and their premium is $700 per month. The miners, who have high rates of black lung disease, are charged a premium of $800 per month. The
average premium income to Healthy is $700 per member per month.
Blue Cross insures the same three groups and needs the same $700 per member per month to cover health care plus administrative costs for these groups. Blue Cross sets its premiums by the principle of community rating. For a given health insurance policy, all subscribers in a community pay the same premium. The bank managers, truck drivers, and mine workers all pay $700 per month.
Community rating
achieves this redistribution in two ways:
1.
Within each group (bank managers, truck drivers, and mine workers), people who become ill receive benefits in excess of the premiums they pay, while people who remain healthy pay premiums while receiving few or
no health benefits.
2.
Among the three groups, the bank managers, who use less health care than their premiums are worth, help pay for the miners, who use more health care than their premiums could buy.
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Таким образом, принцип медицинского страхования, который заключается в
распределении медицинской помощи в большей степени в соответствии с человеческими потребностями, а не исключительно в зависимости от платежеспособности, ослабляется рейтингом опыта Многие коммерческие страховщики не стали продавать полисы таким группам высокого риска, как горняки, в результате чего Blue Cross остался с пациентами из группы высокого риска, которые платили относительно низкие страховые премии. Чтобы выжить в конкуренции со стороны коммерческих страховщиков, у Blue Cross не было другого выбора, кроме как искать более молодые и здоровые группы, отказавшись от рейтинга сообщества и снизив страховые премии для этих групп. Таким образом, многие планы Blue Cross и Blue Shield перешли на рейтинг опыта. Без рейтинга сообщества пожилые и больные группы населения становились все менее и менее способными позволить себе медицинскую страховку.
Приобретая медицинскую страховку, человек не знает, перейдет ли он внезапно из состояния хорошего здоровья в состояние болезни. Таким образом, внутри группы
люди готовы рискнуть, заплатив за медицинскую страховку, даже если они ею не воспользуются. Однако среди различных групп
здоровые люди не имеют экономического стимула добровольно платить за рейтинг сообщества и субсидировать другую группу более больных людей. Вот почему рейтинг сообщества не может выжить в рыночно-конкурентной системе частного страхования
However, if a patient is well insured and the cost of care causes no immediate fiscal pain, the patient will use more services than someone who must pay for care out of pocket
. In addition, particularly before the advent of fee schedules, h
ealth care providers could increase fees more easily if a third party was available to foot the bill.
Thus health insurance was originally an attempt by society to solve the problem of unaffordable health care under an out-of-pocket payment system, but its very capacity to make health care more affordable created a new problem. If people no longer had to pay out of their own pockets for health care, they would use
more health care; and if health care providers could charge insurers rather than patients, they could more easily raise prices, especially during the era when the major insurers (the Blues) were controlled by hospitals and physicians. The solution of insurance fueled the problem of rising costs. As private insurance became largely experience rated and employment based, persons who had low incomes, who were chronically ill, or who were elderly found it increasingly difficult to afford private insurance.
This passage outlines the key features of Medicare and Medicaid, two important
government healthcare programs in the United States:
1.
Medicare
:
Medicare Part A
: Provides hospital insurance for elderly individuals. It is mainly financed through social security taxes paid by both employers and employees.
Medicare Part B
: Covers physician services for the elderly. It is funded by federal taxes and monthly premiums paid by Medicare beneficiaries.
Medicare Part D
: Introduced in 2003, it offers prescription drug coverage for Medicare beneficiaries. The funding for Part D comes from a combination of federal taxes and monthly premiums paid by the beneficiaries.
2.
Medicaid
:
Medicaid is a state-administered program designed to provide healthcare coverage for low-income individuals and families.
It is jointly funded by both federal and state governments, with the federal government providing a significant portion of the funding.
Medicaid plays a crucial role in offering healthcare services to economically disadvantaged populations.
3.
Medicare Part A
:
Coverage
: Provides hospital insurance to elderly individuals.
Funding
: Mainly financed through social security taxes, which are contributed by both employers and employees. These taxes go into a trust fund that supports Part A's hospital insurance.
4.
Medicare Part B
:
Coverage
: Covers physician and outpatient services for the elderly.
Funding
: Supported by federal taxes and monthly premiums paid by Medicare beneficiaries. These premiums help finance the coverage of physician services.
5.
Medicare Part D
:
Coverage
: Medicare Part D, introduced in 2003, specifically offers prescription drug coverage to Medicare beneficiaries.
Funding
: Part D is funded through a combination of federal taxes and monthly premiums paid by the beneficiaries themselves. These
funds are used to provide access to prescription medications for eligible individuals.
Учитывая большие франшизы, доплаты и пробелы в страховом покрытии, бенефициары Medicare нуждаются в дополнительной страховке. В 2016 году 30% бенефициаров имели дополнительное пенсионное страхование от
своей предыдущей работы, 29% приобрели дополнительную частную страховку, 22% были зарегистрированы как в Medicare, так и в Medicaid, а 19% не имели дополнительного страхования. Те бенефициары, у которых не было дополнительного страхования, заплатили в среднем 5806 долларов США в виде личных расходов Session 7 Fisher Doctrone vs Marine
To federal agencies to give expertise – where applying them
Any judge can decide that federal agency and оспорить их expertise Government powers applied with laws Vs FDA (learning public health professionals ) –more expertise than federal judges (a lot more instability) what can be litigated; In Colorado (stampers- reverse abortion with progesterone ) – scientifically it is false – pre-exercise to religion to share their belief – want to be able to reach abortion; Church says (it is deception) can government see the deception? Related to pregnancy , intimate (American society of reproductive medicine) do not need to wait 6 month that infertile that insurance doesnot pay; non –
traditional families can have children (sooner) How much money matters in American healthcare ? Money is the main;
Commercial insurance and public insurance ( way that divides subject matter) ; Even if health insurance – sold for money
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Remarkable shift – massive debate – in Addordable care act –dsocialised insurance – most democratic politics were saying that it is human right (health insurance) True human right principle (health – is a human right – not healthcare); Public shifted perception – most significant people – republicans ( have an access healthcare) Having money in pocket – providers (suppliers)
Individual medical care
Finance – medical provider – patient Specifically in healthcare Public health only 5.4%; comparing to hospital care 30.8%; Were not enough public health workers; not paid; do not have leadership; Public health emergency;
Prove that Public health needs more money !!!
Medicaid – for long –term –care (not Medicare) How money drives US healthcare – health insurance Is nessecary – it is expensive – Germany ( very utilitarian)
Redistributed Putting money then when sick taken Government has a role in commercial insurance ( in private insurance) – hidden (complicated) Why we rely on insurance? Things when they will occur; predict that it will occur (health; life; worker’s insurance; renter’s; car; home insurance; fire and accident insurance) to expensive;
Managing and redistributing financial risk; (sharing risk) Health insurance Increases purchasing power negotiate with health provider; It is instead financing Traditionally, you pay premium ; We will help to pay and then you don’t use it (can went goals) recoop ; ressitribution (between people)
Regularly recouping ( healthcare in any given 5 year period ) when and why? Healthcare insurance rather than traditional insurance; Increase purchasing power ; trade of (benefit packages, sponsors, plan) also to manage it(management function) – rationing care; Risk ( is a probability of care – magnitude of harm can be high ) •
To avoid harm, reduce the probability
or magnitude
of potential harm (or both)
•
Insurance = transfer of risk + distribution of risk - insurance does not prevent
harm, it reduces the cost
of harm (monetary loss)
1920s – employer-based health insurance 1930s – SSA; Blue Cross for hospitals 1940s – prepaid group health plan “radical”; Truman’s failed proposal for single-payer national health insurance; rise of nonprofit Blue Cross/Blue Shield
1960s – market for private health insurance in place; Medicare & Medicaid (LBJ)
1970s – Nixon legislation encouraging & regulating HMOs
1980s – integration; cost-containment (DRGs, capitation)
1990s – Hillary-care fails; HIPAA & CHIP passed
2000s – ESI and Medicare increasing costs; steeply rising rates of uninsured; rising health care costs > Part D (Medicare drug benefit)
2010 >> ACA (“Obamacare”)
When we are paying federal taxes we supporting Medicaid and Medicare;other government programs; provided charitavble care (proportion to existence of community) Employer (recompense of work) Out –of pocket (self-pay – premium) Within insure (premium ) again – regular fee – just to have insurance contract
Deductible (until insurance kicks inn) before health insurance starts to pay Copayments (you pay whenever you go) healthcare provider; (do you really need to go) engaging – because you have insurance; Economist theory (rendering itself – not should be barriers for the care) •
Private Insurance – gait keeper (historically private transactions) no obligations to treat; legally – are you able to pay? You potential patient and doctor;
•
Phycisian ethical rules ( as health care provider) payd by hospital not obligatory to provide treatment •
Access to healthcare Insured
Private Insurance
Employer Sponsored Insurance (ESI)
Nongroup (Individual) or small group plan (usually through Health Insurance Exchange/Marketplace)
Marketplace
Public Insurance
Medicare
Medicaid
Other government program (VA, Indian Health Service, Federal Employees Health Benefit Program)
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•
Employer sponsored
•
Individual policies— Health Insurance Exchanges (“Marketplace”)
•
Public Insurance
•
Medicare—
federal •
Medicaid
—federal and state partnership
•
Public provider
•
Veterans Administration—
federal
•
Public hospitals and clinics
—state and local
•
Community Health Centers—
NGOs and federal grants
•
Indian Health service
—Nations and federal money
•
Private provider
•
Private not-for-profit or for profit hospitals, nursing homes, pharmacies, etc.
•
Physicians, dentists, therapists, other individuals in private practice
•
Pharmaceutical and device manufacturers
1. Community rating
: population-based pricing – pays equal the same amount •
early forms of insurance coverage (BC/BS)
•
ACA Marketplaces
2. Experience rating
: based on individual or group predicted need for medical services ( decide certain group
less or more expensive – according this) •
employer sponsored insurance calculated by accounting for the risk of the entire group
•
small group and individual plans pre-2014 (pre-ACA)
Elderly people does not have insurance (covers certain people) Risk pool (whole country) Community rating - everybody whose is contributing health insurance – distributed; Orange the same amount (terminally ill) same amount
Looking for yellow and exclude (experience rating) – Pre-existing conditions until they need it; Adverse selection would make to expensive ;
Everybody needs to pay inn
Being a female cost more (pregnancy ) cost for health insurance; All need to be;
Insurers prefer experience rating; Money matters in every direction; paying reasonable cost of care; •
Fee for service (pay the reasonable cost of care)
•
Capitation (pre-set payment per insured person
)
•
Global budget (pre-set payment per service
)
•
“Value based care” (post-care determination based on outcomes of care)
•
payment amounts
and methods
affect access, quality, and equity
The
Health Insurance Portability and Accountability Act of 1996
(HIPAA) is a federal law that required the creation of national standards to protect
sensitive patient health information from being disclosed without the patient's consent or knowledge.
Document of immigrants excluded purposefully;
You born – you should have coverage (slide 21) Affordable care Act in 2014 (elected Obama – lost a lot of jobs – can’t pay for insurance Inherently exclusionary Never had goal to law exept Medicare; How to get access to healthcare? No matter who you are should get insurance; Phenomena of Medicaid exist less advertising (only exchange ) even most vulnerable population (TEXAS, ARIZONA, Oklahoma, Florida)
To date,
41 states (including DC) have adopted the Medicaid expansion and 10 states have not adopted the expansion
.
(
We first identified all states that had not expanded Medicaid by January 2019:
Alabama, Florida, Georgia, Idaho, Kansas, Maine, Mississippi, Missouri, Nebraska, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, and Wyoming
.)
Sebellius case Several states in the United States have chosen not to expand their Medicaid programs under the Affordable Care Act (ACA), despite the option provided by the federal government. The decision not to expand Medicaid can be attributed to a combination of political, financial, and ideological factors. Here are some common reasons why certain states have not expanded Medicaid:
Political Ideology: In some states, political leaders oppose the ACA on ideological grounds. They view the expansion of Medicaid as a component of the ACA and resist its implementation based on their opposition to the broader healthcare law.
Budgetary Concerns: State governments have to contribute a portion of the funding for Medicaid expansion, even though the federal government
covers the majority of the costs. Some states are concerned about the long-term financial commitments associated with Medicaid expansion and are reluctant to take on these costs.
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State Sovereignty: Some states argue that they should have the autonomy to decide how to manage their healthcare programs and are wary of what they perceive as federal government overreach.
Political Gridlock: In certain states, political disagreements between the executive and legislative branches have hindered the expansion of Medicaid. This can result in legislative gridlock that prevents the passage
of expansion bills.
Uncertainty About Federal Funding: Concerns about the future of federal funding for Medicaid expansion can deter some states from adopting the program. They worry that federal support may change in the future.
Partisan Politics: In some cases, partisan politics have played a role, with political parties taking opposing positions on Medicaid expansion. This can lead to a lack of consensus on whether to expand the program.
Public Opinion: In states where there is strong public opposition to the ACA, political leaders may be less inclined to expand Medicaid, fearing political repercussions.
Alternative Approaches: Some states have pursued alternative approaches to expanding healthcare access without adopting the traditional Medicaid expansion. For example, they may implement smaller-scale programs or seek waivers to customize their Medicaid programs.
It's important to note that the decision to expand Medicaid or not can have significant implications for access to healthcare for low-income
individuals in a given state. The debate over Medicaid expansion continues in many states, and it remains a subject of political and policy discussions.
Federal tax policy subsidizes both employer and employee to purchase ESI
pre-tax purchase of ESI premium - benefits those with highest income most
Pre-ACA: group plans based on employment
Post ACA: not much difference - employer ‘mandate’ for firms with 50+ employees (not small employers)
Employers like Wallmart – relying on health insurance; •
Goal: simplify; create uniform minimum benefits; more equitable
•
Insurance Market(s) Reforms
•
No upper limits on coverage
•
Young adult coverage on family plans (up to 26) – not all universities provide insurances
•
Essential health benefits [EHB] (mandatory) •
Individual mandate (zero to out) how ACA – incentivized(stimulated)
•
Employer responsibility •
If 50+ employees but don’t offer coverage then fine of $2000 per employee >30 if any employee has premium support in Exchange-based purchase of insurance
•
Tax subsidies if small firms offer coverage
100000 dollars (cancer, injury) that need so much coverage in one year; Blue Shield and Blue Cross; Dentist cash business; offers eye and dental – offers its own programs; Full time employee >50 Part-time employees (do not need to pay health insurance) •
Trick question! Must know which provision in the law
•
Regulating ESI •
COMMERCE and TAXING Powers ( Congress shall have power … Article 1 section 8) •
Regulating individual and small group markets
•
COMMERCE power
•
Exchanges
•
SPENDING (grants to states, federal exchange) to start exchanges ; TAXING (subsidies to purchase insurance); COMMERCE (regulating qualified health plans) powers
•
Individual Mandate (
The individual mandate is a provision within the
Affordable Care Act
that required individuals to purchase
minimum essential coverage
– or face a tax penalty – unless they were
eligible for an exemption.
)
•
TAXING power
•
Medicaid Expansion •
SPENDING power
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Patient make sometimes make consumer decisions, but they are not consumers; Deductibles (it is one way, how premiums rise) – shifting into deductibles (1000 or more; high deductible plan) Employers put deductibles (more masking true rise of cost)
Self – funded plans – only employees pays – ARISA (HEALTH INSURANCE REGULATION) Affect of regulating (EMPLOYER SPONSORED PLANS);
Special plans (Trump administrations) specifically undermined ACA Bayden don’t see them for complaint plans; “Th[e] myth of shared responsibility makes any reform that removes employers from health care much more
difficult to enact. If workers and their families continue to believe that they can get a substantial fringe benefit like health insurance at no cost to themselves, they are less likely to consider alternatives.”
WHAT ARE THE ARGUMENTS FOR AND AGAINST CONTINUED RELIANCE ON ESI? WHAT ARE CHALLENGES AND SUCCESSES? PROS AND CONS? TAKE 5 MINUTES TO DISCUSS WITH YOUR NEIGHBOR AND BE READY TO DISCUSS WITH THE CLASS.
Can n’t afford COBRA – feredal law says employers should provide health insurance; keep till year; charge +2% administrative costs; Economic or moral ethics
Family (hard to navigate) Administrative burden (insurance) for employers; It is too complicated; no regulation can exist; Low income families can be burden for government; Covering till 26 year; 1.
Group Coverage
: ESI provides group coverage, which often results in lower premiums and better coverage options for employees due to the pooling of risk. Large group plans can negotiate better rates
with healthcare providers.
2.
Fringe Benefit
: Health insurance as a fringe benefit is a strong incentive for employees to remain with their current employers. It can help with employee retention and recruitment.
3.
Tax Benefits
: ESI is tax-advantaged. Premiums paid by employers are typically tax-deductible, and the value of health insurance provided to employees is not considered taxable income, reducing the financial burden on both employers and employees.
4.
Administrative Efficiency
: ESI is often administratively efficient
for employers, as they can handle insurance enrollment and administration for their workforce in one place.
Arguments Against Continued Reliance on ESI (Cons):
1.
Job Lock
: ESI can lead to "job lock," where employees feel trapped in their current jobs because they fear losing their health insurance if they change employers. This can limit career mobility and entrepreneurship.
2.
Inequity
: The ESI system can create disparities in coverage. Those who don't have access to employer-sponsored insurance, such as part-time or self-employed workers, may face challenges in obtaining affordable coverage.
3.
Lack of Portability
: ESI coverage is not portable. When people change jobs, they may face a gap in insurance coverage or need to adapt to new plans, leading to disruptions in care.
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4.
Costly for Employers
: Offering ESI can be expensive for employers, especially small businesses. It can strain their budgets and limit their ability to invest in other aspects of their companies.
Challenges and Successes:
One of the challenges is that the ESI system is closely tied to employment. This can create vulnerabilities, especially during economic downturns when people lose their jobs and, subsequently, their health coverage.
A success of ESI is that it provides a reliable source of coverage for a significant portion of the population, contributing to overall healthcare access.
The Affordable Care Act (ACA) introduced reforms to make it easier for individuals to obtain coverage outside of ESI through health insurance exchanges, offering subsidies for low-income individuals and
expanding Medicaid. These changes aimed to address some of the challenges associated with ESI.
The COVID-19 pandemic highlighted some of the vulnerabilities of
ESI, particularly when individuals lost their jobs and, with them, their health insurance. This has spurred renewed discussions about healthcare reform in the United States.
The debate over whether to continue relying on ESI is complex and touches on issues of healthcare access, job mobility, and the financial burden on employers. Any potential reforms would need to carefully weigh the pros and cons to ensure that Americans have access to affordable and high-quality healthcare.
Individual health coverage
Pre-ACA
: available individual plans too expensive for low to medium income, old, and sick people; plans often not comprehensive
Post-ACA
: can purchase on Exchanges (Marketplace) for comparison shopping among standardized plans
After you paid, money in a bank account; inaccessible to the most amount;
Subsidized < 1
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