1997

covers children in poor families, but above medicaid

increased % with increased income

national income tax

less % with increased income

Insurances.  experience more so than community

fringe benefits

sales tax, out of pocket pay

flat %

state income tax

combined burdon of all taxes for HC.

Provider-Insurer pact.

BC/BS run by hospitals.

insurance pays blank check

employers pay b/c good economy

tension develops

economy wend bad, purchasers complained.

 (purchaser-> regulator)

insurers impose "utilization review"

MD competes for PT, gov pays less for health spending.

revolt of purchasers

troubled economy, raising HC

businesses favor HMO over FFS

employers made employees pay for part of HC

DRG lowered medicare hospital costs

since more poor, more medicaid

"selective contracting": TP contracts with MD

Provider-/-insurer

era for HMOs

purchasers had the power

1997 balanced budget act stopped medicare inflation

Consolidation: Big HMO eats little HMO

most hospitals systemize, and for profit

managed care falters

less HMO, more PPO

hospitals joined, and demand more $ from HMO

Raising drug prices

PPOs less $, so more popular b/c more choices

"consumer driven Health Plan"

employer gives employee a coupon

results in wide variation in HC

Medicare

1965

65 or older, disabled, end stage renal

administered by CMS

financed by payroll taxes

hospital, skilled nursing, home health, hospice

ICF (long term care) not cover

deductible over benefit period

free from SS

medigap can help

financed by premiums and general revenues

physicians and outpatient tests

has premiums

deductables, co-insurance

voluntary

recently prescriptions

medigap can help

drug benefits

private plans supply, and bear the risk

patient chooses the provider

all providers have = coverage

traditional: medicare+ Rx plan

Medicare Advantage (c).  A+B=PPO/HMO

Deductible (pay 100%)

patient pays 25%

Patient pays 100% (donut hole)

Patient pays 5% (catastrophic drug coverage)

MTM

Targets who?

who makes the decisions?

targets: chronically ill, on many part D drugs, with anual drug cost over 4,000

Plan decides: disease state, reinbursement, providers

categorical means test

payed for by state and gov.  (gov 50%-83%)

can cover ICF

1.) private marketplace works

2.) individual should retain choice

3.) science and technology works

4.) vulnerable groups should be protected

Hill Burton Act

when

what

when: 1940s

What: gov gave money for hospitals to expand

what is:

reimbursement Incentive?

public utility

National health insurence?

reimbursement incentive: DRG

public utility: an authority sets the rates for providers

national health insurance: gov insurance, private still exists

15%

80% are in working families

• Insurance companies pay rebates if their costs or profits are to high
• some services must be free by TP and medicare
• small businesses will get tax breaks to help buy insurance for workers
• lifetime limits not allowed
• Must buy insurance

• can't turn kids down for pre-existing conditions
• high-risk pool subsidized by government for the "un-insurable"
• insurers can't turn you down or charge you more if you are sick

• Medicaid expanded
• health insurance tax credit  if lose job or no coverage by employer
• if you cant get coverage at work, you can go to an exchange

• health plans must report expenditures, clinical services, administrative services, quality, and other costs
• provide rebates to consumers
  

• 2011 cover free annual wellness checkup and prevention plan 
• no copay for preventative services rated A or B by Preventative Service Task Force
• pay hospitals less for preventative readmissions and hospital acquired conditions.
  

Medicare Timeline

2010

2011

2013

2014-2019

2020

2010: part D enrollees in gap get $250 rebate

2011: part D enrolees in gap get 50% off brand

phase-in generics covered in gap

2013: Phase-in coverage of brands

2014-2019: catastrophic coverage threshold ↓

2020: enrolees pay 25% for drugs in gap

High Risk Pool

eligibility

gov subsidized premiums

Eligibility: us Citizens/legal immigrants, pre-existing conditions, uninsured ≥ 6 months

2014 onward

Medicaid expansion

• 133% of federal poverty level
• covers non-medicare eligible adults under 65 with no children
• makes state coverage more standardized
• eligibles guaranteed "essential health" coverage through exchange
• states get 100% funding 2014-2016

• Premium credits to help people buy coverage through exchanges
• 133%-400% poverty lvl
• employees covered under employer not eligible.

 Exeption: employer plan doesn't have actual value of at least 60%, or employee share of premium >9.5% of income.

employers must offer coverage

starting 2014 employers ≥