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AHS330_F10_u10_PDF - Public Policy and Health Policy Public...

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Unformatted text preview: Public Policy and Health Policy Public policy - Authoritative decisions made in legislative, executive, or judicial branches of government intended to direct or influence the actions, behaviors, or decisions of others Decisions, usually developed by government policy makers, for determining present and future objectives pertaining to the health care system AHS 330 Health Policy Chap. 21, PLB 11/09/10 AHS 330 - Fall 2010 - Unit 10 – Cahn, 1998 1 11/09/10 – Ex. Medicare Part B Categorical involvement AHS 330 - Fall 2010 - Unit 10 Part Part of Executive branch of government Granted “statutory” authority to implement bill once it is passed Two types of “tools” to implement laws types of tools to implement laws – Regulate – Allocate President can appoint heads of these agencies Federal Register – Ex. Medicare Part A 11/09/10 2 Role of Bureaucracies (Regulators) When Does the Government Make Government Policy Decisions? Market forces break down Health and welfare of the citizenry at stake – U.S. Constitution Voluntary involvement AHS 330 - Fall 2010 - Unit 10 3 11/09/10 AHS 330 - Fall 2010 - Unit 10 4 Five Basic Types of Regulatory Policies Types of Public Policy Market entry Regulatory – Government prescribes and controls behavior of particular target group, i.e. FDA, Nursing home standards, nuclear facilities, environmental Allocative - Direct provision of income, services, or goods to certain groups or individuals, i.e. grants, loan paybacks, tax benefits – CONs Rate or price-setting controls price– DRGs Provider quality controls – JCAHO MarketMarket-preserving – Status quo Social Social regulation – To achieve social good) 11/09/10 AHS 330 - Fall 2010 - Unit 10 5 11/09/10 AHS 330 - Fall 2010 - Unit 10 6 1 Principal Features of US Health Policy Allocative Allocative policies are generally used when the government feels they do not have direct authority to require something Government as subsidiary to the private sector Fragmented, incremental, and piecemeal reform reform Pluralistic and interest group politics Decentralized role of the states Impact of presidential leadership – For example- you can’t require a physician to examplepractice in rural area, but you can offer loan practice in a rural area, but you can offer loan forgiveness forgiveness to influence them to go to a rural area Two types of allocative policies – Distributive – society in general – Redistributive – takes money from one group and gives it to another 11/09/10 AHS 330 - Fall 2010 - Unit 10 7 11/09/10 Fragmented, incremental, and piecemeal reform Government as subsidiary to the private sector Health care is not a right of citizenship Private sector plays a dominant role Government fills the gaps in the private sector Government’s bureaucracy 11/09/10 AHS 330 - Fall 2010 - Unit 10 8 AHS 330 - Fall 2010 - Unit 10 Little coordination between federal, state, and local governments Incremental: Medicaid Example, adding CHIPS CHIPS Fragmented – numerous congressional committees 9 11/09/10 AHS 330 - Fall 2010 - Unit 10 10 Federalism Decentralized role of the states Role of Federal Government – “We the people of the United States, in order to form a more perfect union, establish justice, insure domestic tranquility, provide for the common defense, promote promote the general welfare, and secure the blessings of liberty to ourselves and our posterity, do ordain and establish this Constitution for the United ordain and establish this Constitution for the United States States of America.” – Preamble to the Constitution States manage the Medicaid programs, oversee licensing of practitioners and hospitals, and regulate insurance companies companies Should state’s have more control? Role of State Government – 10th Amendment: “The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.” Role of Local Government 11/09/10 AHS 330 - Fall 2010 - Unit 10 11 11/09/10 AHS 330 - Fall 2010 - Unit 10 12 2 Health Care Should be Available to Everyone Even if They Cannot Afford It? Trust in the Government Don't Know 2% Disagree 4% Agree 94% Northwest Life, 1990 11/09/10 AHS 330 - Fall 2010 - Unit 10 13 11/09/10 AHS 330 - Fall 2010 - Unit 10 14 11/09/10 AHS 330 - Fall 2010 - Unit 10 16 The Role of Pluralistic and Interest Groups in Politics Heavy influence on policy formulation Often bills are actually written by these interest groups and introduced by a Congressman allied with these organizations For successful passage of a bill, a coalition of bill interest interest groups are needed to support a bill – Often a bill changes the status quo, and the status quo benefits a lot of organizations and they do not want change Interest groups are part the the “Iron Triangle” and there influence is both revered and loathed 11/09/10 AHS 330 - Fall 2010 - Unit 10 15 Historical Perspective – 19th century Karl Marx “A healthy workforce is a more productive workforce” Bismarck of Germany (1880s) - introduced social security legislation national accident and health insurance and old-age pensions that ended whatever revolutionary designs Socialists may have had. History of Health Policy and National Health Insurance 11/09/10 AHS 330 - Fall 2010 - Unit 10 17 11/09/10 11/09/10 AHS 330 - Fall 2010 - Unit 10 18 3 Historical Perspective – 1900-1917 1900- Great Depression and private health insurance New Deal programs, Social Security Act, NHI 1939 National Health Bill (Wagner, Murray, and Dingel Bill) Truman, Fair Deal, Hill-Burton HillCold war and anti-communism and antiantiantisocialism Workman’s compensation State government health insurance proposals Change in AMA leadership AMA Post WWI prosperity “roaring 20’s” 11/09/10 AHS 330 - Fall 2010 - Unit 10 19 Historical Perspective – 1950 1968 AHS 330 - Fall 2010 - Unit 10 20 Rapid growth of Medicare costs led to policy focus on expenditures Wide range of proposals, “players” included – Dellums – Kennedy/Griffith – Nixon – Carter – Long/Ribicoff Long/Ribicoff – None of these passed – Medicare and Medicaid – AFDC AHS 330 - Fall 2010 - Unit 10 11/09/10 Historical Perspective – 1968-1978 1968- Time of prosperity coupled with a new sense of social conscience Kennedy proposed many social programs Kennedy’s assassination in 1963 opened 1963 the the door for Johnson’s Great Society Great Society 11/09/10 Historical Perspective – 1920-1950 1920- 21 11/09/10 AHS 330 - Fall 2010 - Unit 10 22 Historical Perspectives – 1980s Reagan and Bush initiated no new proposals, theory of private competition Did expand some existing programs (Medicaid for children) (Medicaid for children) Focus still on cost containment 1990’s - present – DRGs, RBRVS, etc 11/09/10 AHS 330 - Fall 2010 - Unit 10 23 11/09/10 AHS 330 - Fall 2010 - Unit 10 24 4 National Health Insurance: Reasons for Interest 1992 Presidential Election Rising costs Gaps in present health insurance coverage in services and populations Geographic mal-distribution of personnel mal distribution of personnel and and facilities Access to service by ability to pay, social class, age group, and geography Anticipated impact of national health insurance on population health status • • Clinton’s Clinton’s Platform Clinton’s Clinton’s Health Security Act • • • 11/09/10 AHS 330 - Fall 2010 - Unit 10 25 11/09/10 AHS 330 - Fall 2010 - Unit 10 26 27 11/09/10 AHS 330 - Fall 2010 - Unit 10 28 Clinton’s Health Security Act Universal Coverage All Citizens Coverage - Provided by Employer Plan or purchased through th alliances alliances and subsides Benefits - Federally defined minimum coverage 11/09/10 Choice -Choice of plans rather than choice of provider Financing - Payroll taxes Employer & employee contributions Other Programs Eventually folded in other federal programs AHS 330 - Fall 2010 - Unit 10 Problems With The Clinton Plan Lacked of freedom of choice Loss of jobs Costs Increased bureaucracy 11/09/10 AHS 330 - Fall 2010 - Unit 10 29 11/09/10 AHS 330 - Fall 2010 - Unit 10 30 5 Health Insurance Portability and Accountability Act of 1996 Success of Health Insurance Portability & Accountability Act Preexisting Conditions Provisions Guaranteed Coverage in the Individual Market Coordinated Fraud and Abuse Program Administrative Simplification Medical Savings Account Demonstration Project Tax Benefits for Long-Term Care Insurance, LongAccelerated Death Benefits, and Viatical Settlements 11/09/10 AHS 330 - Fall 2010 - Unit 10 Example of Incremental Health Care Reform Coordinated effort to maintain and strengthen the health care coverage of currently insured individuals Prevents “job lock” for employees who want to change jobs or start their own business 31 Shortcomings of the Health Insurance Portability & Accountability Act of 1996 11/09/10 AHS 330 - Fall 2010 - Unit 10 32 Why No NHI before now? “The squeaky wheel gets greased” Although aiding Americans who are currently insured, the Act does nothing to help the uninsured acquire insurance TimeTime-limited exclusions prevent employees who are actively receiving medical treatment (but have not been insured for 12 consecutive months) from moving to another job insurance company without either personally financing or suspending medical treatments PrePre-existing condition protections only apply to individuals who have experienced less than a 63 day loss in health care coverage while switching jobs or insurers 11/09/10 AHS 330 - Fall 2010 - Unit 10 33 11/09/10 AHS 330 - Fall 2010 - Unit 10 34 Top Issues for American Public 11/09/10 AHS 330 - Fall 2010 - Unit 10 35 11/09/10 AHS 330 - Fall 2010 - Unit 10 36 6 Alternative Delivery Systems Current system (pluralistic) OneOne-payer (Canadian style) Truly government run system (England) “Pay or Play” or Play Medical Savings Accounts/Tax Credits/Vouchers Tax employer sponsored health plans and use money to cover uninsured Health Security Act (Clinton’s 1992 proposal) 11/09/10 AHS 330 - Fall 2010 - Unit 10 37 Considerations Regarding NHI 11/09/10 Considerations Regarding NHI Who should be covered? Should patients share in costs? How should plan be financed? What role should private insurance companies and state governments play? What role should consumers have? role should consumers have? How should hospitals, physicians and other providers be paid? What provisions should be made for quality controls? What types of delivery forms should be emphasized? – Income – Employment basis – Voluntary vs. Compulsory – Equity it What services should be covered? – Preventive – Essential – Lower cost – Special cases/services? 11/09/10 AHS 330 - Fall 2010 - Unit 10 38 AHS 330 - Fall 2010 - Unit 10 39 11/09/10 40 AHS 330 - Fall 2010 - Unit 10 Support/Oppose Current Reform Proposals As of right now, do you generally support or generally oppose the health care proposals being discussed in Congress? Is that strongly or somewhat? Recent Health Care Reform Initiatives: Obama’s Health Care Plan Care Plan Strongly support 28% TOTAL Democrat Independent Republican Somewhat support 18% 52% 23% 20% 4% Somewhat oppose 9% Strongly oppose 33% 6%9% 16% 10% 9% 14% 38% 66% Note: “Depends on which proposal (vol.)” responses for total=3% and “Don’t know/Refused” responses for total=9%. Not shown for party breaks. Source: Kaiser Family Foundation Health Tracking Poll (conducted March 10-15, 2010) 11/09/10 AHS 330 - Fall 2010 - Unit 10 41 11/09/10 AHS 330 - Fall 2010 - Unit 10 42 7 Top Reasons for Support Top Reasons for Opposition I’m going to read some reasons people give for supporting the proposed health care legislation. After I read each one, please tell me if it is a major reason, a minor reason, or not a reason why you yourself support the legislation. I’m going to read some reasons people give for opposing the proposed health care legislation. After I read each one, please tell me if it is a major reason, a minor reason, or not a reason why you yourself oppose the legislation. AMONG THOSE WHO SUPPORT HEALTH CARE PROPOSALS, percent who say each is a MAJOR reason for supporting: To make sure people can get and afford health insurance coverage The legislation gives government too big a role in the health care system 88% 80% Too much of the process took place behind closed doors & involved too much deal-making To reform insurance company practices such as making sure they have to sell policies to people with pre-existing health conditions 73% The legislation takes the wrong approach to reform 84% 73% We can’t afford to pay for health care reform right now To bring down the cost of health insurance and health care 72% 81% To strengthen the country’s long-term economic situation 67% To help fill the coverage gap, or doughnut hole, in Medicare’s prescription coverage Health care reform is distracting from other priorities, like the economy and jobs 62% The legislation doesn’t go far enough in expanding coverage or controlling costs Source: Kaiser Family Foundation Health Tracking Poll (conducted February 11-16, 2010) 11/09/10 11/09/10 AMONG THOSE WHO OPPOSE HEALTH CARE PROPOSALS, percent who say each is a MAJOR reason for opposing: 65% 49% Source: Kaiser Family Foundation Health Tracking Poll (conducted February 11-16, 2010) 43 AHS 330 - Fall 2010 - Unit 10 11/09/10 AHS 330 - Fall 2010 - Unit 10 44 Health Care Reform… Is Now the Right Time? Which comes closer to describing your own views? Given the serious economic problems facing the country… 80% 60% 62% 61% 62% 59% 61% 56% 40% 34% 37% 34% 37% 35% 39% 53% 42% 57% 55% 58% 54% 54% 39% 41% 41% 36% 20% 39% It is more important than ever to take on health care reform now We cannot afford to take on health care reform right now 0% Oct08 Dec08 Feb09 Apr09 Jun09 Jul09 Aug09 Sep09 Oct09 Nov09 Dec09 Jan10 Note: Asked of half sample in Nov09 and Jan10. “Don’t know/Refused” responses not shown. Sources: Kaiser Family Foundation polls 11/09/10 AHS 330 - Fall 2010 - Unit 10 Pew Research Center for the People and the Press, Jan. 25, 2010 45 11/09/10 11/09/10 AHS 330 - Fall 2010 - Unit 10 46 Patient Protection and Affordable Care Act of 2010 (Obama Health Care Plan) Signed into law on March 23, 2010 Individual and employer mandates Expansion Expansion of Medicaid State Health Insurance Exchanges Health Insurance Exchanges Premium and cost sharing credits Tax penalties for not obtaining insurance (and not supplying it for employees) *** All of this all MAY be repealed (or left unfunded) in the upcoming Republican congress 11/09/10 11/09/10 Pew Research Center forAHS 330 - Fall 2010 - Unit 10 the People and the Press, Mar. 18, 2010 47 11/09/10 AHS 330 - Fall 2010 - Unit 10 48 8 Obama Health Care Plan Support 11/09/10 AHS 330 - Fall 2010 - Unit 10 Reasons to Favor the Obama Health Care Plan 49 Take place within the 6 months of enactment No lifetime or annual limits on dollar value or specific covered benefits for group and individual plans No group or individual plan may rescind coverage unless a covered individual commits fraud or intentionally misrepresents facts. Coverage of preventive health services without cost sharing Extension of Dependent Coverage – If a plan has dependent coverage, it must expand coverage to unmarried children up to age 26 AHS 330 - Fall 2010 - Unit 10 – No later than May 24, 2010, Secretary shall establish a temporary high-risk pool program establish temporary high risk pool program until until Jan. 1, 2014 Administered by State or non-profit private plan, nonstate or plan must submit application, and agree to use contract funding State must not reduce amount expended for other highhigh-risk pools in previous year 51 11/09/10 AHS 330 - Fall 2010 - Unit 10 52 Health Insurance Market Reforms Qualified High-Risk Pool High– Provide coverage for all eligible individuals with no preexisting condition exclusion – Provide coverage where insurer’s share of total allowed cost in not less than 60% and has out-ofout-ofpocket costs not greater than IRS code (either $1000/$2000 or $5000/$10,000 individual and family) – Individuals must be citizens or lawfully present, not covered under creditable coverage during previous six months, have a pre-existing precondition AHS 330 - Fall 2010 - Unit 10 50 Immediate access to uninsured with preexisting conditions Immediate Actions to Preserve and Expand Coverage 11/09/10 AHS 330 - Fall 2010 - Unit 10 Immediate Actions to Preserve and Expand Coverage Immediate improvements 11/09/10 11/09/10 53 Prohibition on Pre-existing condition Preexclusions Fair Health Insurance Rates – rates in individual and small group markets can only vary vary by individual vs. family, rating area (states determine), age (3:1), tobacco use (1.5:1) Guaranteed Availability – Guaranteed issue in both individual and group market can only be restricted by open enrollment periods 11/09/10 AHS 330 - Fall 2010 - Unit 10 54 9 Health Insurance Market Reforms Health Insurance Market Reforms Guaranteed Renewability – Once an insurer offers insurance they must renew or continue coverage at the option of the plan sponsor or individual. Prohibiting Discrimination based on Health Prohibiting Discrimination based on Health Status Status – No rules for eligibility can be based on health status, medical condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability, disability, or any other health status related factor. 11/09/10 AHS 330 - Fall 2010 - Unit 10 55 Health Promotion and Disease Prevention – rebates for wellness programs, fitness club memberships, preventive care, smoking cessation, etc. – Wellness program demonstration projects No discrimination against providers – but reimbursement can vary based on quality or performance measures No waiting periods longer than 90 days 11/09/10 Qualified Health Plans AHS 330 - Fall 2010 - Unit 10 57 Essential Benefits Package AHS 330 - Fall 2010 - Unit 10 11/09/10 AHS 330 - Fall 2010 - Unit 10 58 Plans may choose to cover abortion services or to exclude them. No public funding for abortion based on federal law Abortion in community health insurance option Bronze (60% of actuarial value) Silver (70% actuarial value) Gold (80% actuarial value) Platinum (90% actuarial value) (90% actuarial value) – Must assure compliance with federal law and prove that no federal funds pay for a defray the cost of abortion services or pay for tax credits or cost-sharing costreductions – Plans must segregate funding if they provide abortion services – Does not pre-empt existing state laws pre- Catastrophic plan – does not provide coverage until individual meets $5,000 OOP, covers at least 3 primary care visits, individual must be younger than 30 or has hardship certification ChildChild-only and dental-only plans dental11/09/10 Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental heath and substance abuse disorder services Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care Coverage of Abortion Services Levels of Coverage – – – – 56 Essential Health Benefits Certified or recognized by the exchange Provides essential health benefits package Offered by insurer licensed in state, that agrees to offer at least one silver and one gold plan Agrees to charge same premium whether plan is offered on exchange or directly from issuer or agent 11/09/10 AHS 330 - Fall 2010 - Unit 10 59 11/09/10 AHS 330 - Fall 2010 - Unit 10 60 10 Individual Responsibility Employer Responsibility Individuals are required to ensure that they and all dependents are covered under minimum essential coverage beginning in 2013 Penalties: $695 in 2016 or Penalties: $695 in 2016 or 2.5% of household of household income, income, indexed for COLA after 2016 Exemptions for financial hardship, religious objections, American Indians, uninsured less than 3 months, premiums are more than 8% of income, or individual has income below tax filing threshold 11/09/10 AHS 330 - Fall 2010 - Unit 10 61 Employers with more than 50 employees will be fined $2000 per full-time employee fullif don’t offer coverage If employee receives tax credit employer If employee receives tax credit, employer must must pay $3000 for each employee receiving tax credit 11/09/10 AHS 330 - Fall 2010 - Unit 10 62 Small Business Tax Credit Small business with less than 25 employees and avg. annual wages < $50K may receive a tax credit to cover plan Full credit for firms with < 10 employees and avg. wages of $25K or less Phases out as firm size and avg. wage increase 11/09/10 AHS 330 - Fall 2010 - Unit 10 63 11/09/10 AHS 330 - Fall 2010 - Unit 10 64 11/09/10 AHS 330 - Fall 2010 - Unit 10 65 11/09/10 AHS 330 - Fall 2010 - Unit 10 66 11 Policy Research Organizations NEXT WEEK Test Review – No live class????? Final in two weeks Unit 10 Quiz Kaiser Family Foundation National Conference of State Legislatures Assessing the New Federalism -Urban Institute Commonwealth Fund Commonwealth Fund AcademyHealth Families USA Agency for Healthcare Research and Quality CDC/NCHS 11/09/10 AHS 330 - Fall 2010 - Unit 10 – Multiple Choice and True/False Questions Covering Assigned Textbook Chapters Unit Covering Assigned Textbook Chapters, Unit 8 PowerPoint PowerPoint Slides, & Lecture Speaker Quiz Unit 10 Discussion Question – Comment on a 200 word discussion question and post a 50 word response to another student’s blog 67 11/09/10 68 AHS 330 - Fall 2010 - Unit 10 12 ...
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