Exam 2 Short Answers Flashcards
What are the basic characteristics/features of the insurance system in the US? Does the ACA change these basic characteristics/features?
Private insurance market: system of private health insurance companies to provide coverage to individuals and families, these companies offer various plans with different levels of coverage and premiums
Employer-sponsored insurance: many Americans receive health insurance through their employers, this is a significant source of coverage for individuals and families
Government programs: US government operates several health insurance programs, including Medicare and Medicaid that offer coverage to specific populations who may not have access to private insurance
Individual mandate
Pre-ACA: no requirement for individuals to have health insurance, however, those who did not have coverage may face penalties when filing taxes
Post-ACA: one of the most significant changes brought by the ACA was the individual mandate, which required most Americans to have coverage or pay a penalty. This was intended to increase the number of people covered and spread risk across a broader population
Other ACA changes: ((expanded coverage, implemented consumer protections, created new avenues for obtaining insurance))
- Creation of health insurance exchanges: markets where individuals and small businesses can shop for and purchase insurance plans, exchanges offer a range of plans often with subsidies to help lower income individuals afford coverage
- ACA prohibits insurance companies from denying coverage to individuals with pre-existing conditions or charging them higher premiums, the goal of this was to ensure that individuals with health issues could still obtain coverage
- Medicaid expansions: ACA allowed states to expand their Medicaid programs to cover more low-income individuals and families, however, not all states chose to expand Medicaid
- Essential health benefits: ACA required all health insurance plans to cover essential health benefits like preventative care, maternity care, prescription drugs
Which premium assessment method does ACA rely on in the marketplaces? Community Rating or Experience Rating? Why?
Community rating
Insurance companies can’t vary premiums based on factors such as an individual’s health status, medical history, or gender. Instead, premiums are based on factors like age, geographic area, family size, tobacco use
This ensures that individuals with pre-existing conditions or higher healthcare needs can’t be charged significantly higher premiums, making insurance more accessible and affordable for a broader range of people
Community rating promotes fairness and accessibility in the insurance market, preventing discrimination to align with the ACA goals of expanding coverage and providing protections for consumers in the healthcare system
(Before the ACA) Which groups had difficulty obtaining health insurance in the US? In other words, as Bodenheimer and Grumbach (B&G) discuss, who were the uninsured before the 2010 ACA reforms? Were these groups able to get insurance coverage after the ACA?
Unemployed individuals: people not covered by employer-sponsored plan often struggled to afford coverage on their own, especially if that had pre-existing conditions or limited financial resources
Low-income individuals and families: couldn’t afford health insurance premiums even if they were available, and also, Medicaid eligibility criteria varied by state which left some low-income individuals without access to coverage
- ACA expansion allowed states to cover move low-income individuals and families and provided affordable coverage to millions of previously uninsured individuals
People with pre-existing conditions: diabetes, cancer, health disease etc. patients often faced difficulty in individual insurance market because insurers could deny coverage or charge prohibitively high premiums based on an individuals health status
- Guaranteed issue: ACA prohibited insurance companies from denying coverage or charging higher premiums based on preexisting conditions
Young adults: people who aged out of their parents insurance plans or entered the workforce without access to employer-sponsored coverage
- ACA allowed young adults to stay on their parents health insurance plans until the age of 26, providing coverage option for those transitioning into adulthood
Minority groups: certain minority groups including racial and ethnic minorities faced disparities in access to coverage and services due to various socio-economic factors and systemic inequalities
ACA aimed to reduce number of uninsured individuals by addressing the barriers to coverage faced by vulnerable populations
What are the differences and similarities between HMOs and PPOs?
Both types of managed care plans, meaning various mechanisms are used to manage and control healthcare costs, utilization, and quality
- HMOs offer lower costs and more comprehensive coverage for in network care but have stricter restrictions on provider choice and out of network coverage. PPOs have higher costs and require more out of pocket expenses for out of network care, but offer more flexibility in provider choice
Both cover essential healthcare services like doctors offices, preventative care, hospital stays, and prescription drugs
Provider networks
- HMOs have more restricted network of healthcare providers, usually need to have a PCP within the network and all medicare care goes through them, referrals to see providers required
- PPOs have larger network of healthcare providers, no PCP necessary, can see any doctor inside or outside of network, but will pay less if staying in network
Costs
- HMOs have lower premiums and lower out of pocket costs, but have to pay a lot if you go out of network
- PPOs have higher premiums and out of pocket costs, but more flexibility in choosing healthcare providers, including out of network options
Referrals and prior authorization
- HMOs require referrals from PCP to see specialists, prior authorization needed for certain procedures or treatments
- PPOs don’t need referrals to see specialists, and prior authorization requirements are less strict
Coverage for out of network care
- HMOs don’t cover out of network care unless in emergency, will have to pay full cost yourself
- PPOs provide coverage for out of network care, but you’ll pay more in coinsurance or deductibles compared to in network care
Flexibility
- HMOs less flexible in terms of choosing healthcare providers and require you to coordinate care through PCP
- PPOs more flexible in choosing providers and accessing care without referrals
Which groups oppose managed care plans and why? What happened as a result of this backlash/opposition? What happened to managed care?
Patients: dissatisfaction due to restrictions on choice of healthcare providers, perceived delays in accessing care, and concerns about the quality of care received within network constraints
Healthcare providers: criticize reimbursement practices, which often involve negotiating discounted rates for services and implementing utilization management techniques that can interfere with clinical decisions
Legislative and regulatory changes: aimed at addressing managed care issued including mandates for coverage of certain services, requirements for external appeals processes, and greater oversight of plan operations
Consumer protections: enhanced disclosure of plan terms and coverage limitations, as well as mechanisms for addressing grievances and appealing coverage denials
What kinds of insurance marketplaces/exchanges are there and why? Who can go to these marketplaces and buy insurance? What kinds of plans are offered in the insurance marketplaces/exchanges? Do they cover all medically necessary services at 100% actuarial value? How do the premiums get calculated? Who gets the subsidies?
What kinds of marketplaces/exchanges?
- State based exchanges: operated by individual states and offer health insurance plans to state residents, states have flexibility to tailor their exchanges to their specific healthcare needs and demographics
- Federal marketplace (healthcare.gov): for states who choose not to establish their own exchanges, the federal government operates the marketplace through healthcare.gov, residents of these states can still access and purchase health insurance plans through the federal exchange
- State-federal partnership exchanges: some states choose to partner with the federal government to operate their exchanges, these partnerships allow states to retain some control over aspects of the exchange while leveraging the federal platform for enrollment and administration
Who can go?
- Only people who do not have access to employer-sponsored health insurance and who do not qualify for public programs like medicare and medicaid
- Small businesses can use the marketplace to offer health insurance options to their employees
What kinds of plans?
- The plans have to adhere to certain standards set by the ACA, which include coverage of essential health benefits like hospitalization, prescription drugs, preventative care, and maternity care
- Bronze, silver, gold, platinum
Do they cover all services at full value?
No, they don’t have to. Plans are categorized into the metal tiers based on their actuarial value
How do premiums get calculated?
- Various factors, including the level of coverage (the metal tier), age, location, and tobacco use of enrollee. - Generally, older individuals and those living in higher-cost regions will pay higher premiums
Who gets subsidies?
- Lower income individuals and families
- Premium tax credits: income between 100 and 400% of FPL to lower cost of monthly premium payments
- Cost-sharing reductions: incomes between 100-250% of FPL to reduce out of pocket expenses like deductibles, copayments, and coinsurance
What is the insurance rationale for creating an “individual mandate” and “guaranteed issue” as part of the ACA?
Bans many crueler practices that private health insurance companies used over the years
Individual mandate required most Americans to have health insurance coverage or pay a penalty, rationale was to encourage healthier individuals to participate in the insurance market.
- Without the mandate, there was a risk that only sicker individuals would purchase insurance, leading to adverse selection and higher premiums
- By requiring everyone, including healthy individuals, to have coverage, the individual mandate aimed to spread the risk pool more broadly. Helps to stabilize premiums by ensuring that the costs of caring for those with high healthcare needs are shared among a larger group of people
Guaranteed issue: before ACA, insurance companies could deny coverage to individuals with pre-existing conditions or charge them higher premiums. This practice left many people with chronic illnesses or medical histories unable to obtain affordable coverage
- Guaranteed issue prohibits denying coverage or charging higher premiums, which increased insurance access, promotes principle of healthcare equity and helps to ensure people with preexisting conditions have access to the care that they need
According to Reading 8, by Schwab, R., Swindle, R. and Giovannelli, titled “State-Based Marketplace Outreach Strategies for Boosting Health Plan Enrollment of the Uninsured”, what kinds of outreach strategies were used in the state-based marketplaces (SBMs) to promote health insurance take-up among the uninsured? Which ones were more effective?
Targeted advertising/enrollment campaigns: employed advertising campaigns across various media channels to raise awareness about the availability of health insurance coverage through the marketplace and to educate the uninsured about their coverage options and enrollment process
Community outreach and events: enrollment fairs and info sessions to engage directly with uninsured people, provided opportunities for in person assistance with enrollment, as well as education and outreach about the benefits of health insurance coverage
Navigator and assistance programs: provide personalized assistance to people seeking coverage, these programs trained and deployed navigators and assisters to help uninsured individuals understand their coverage options, complete the enrollment process, and navigate any challenges they encounter
Successful:
Strategies that involved direct, personalized assistance and community-based outreach events were often cited as more effective in reaching and enrolling uninsured individuals
What does a “successful” or “resilient” insurance marketplace look like? According to Reading 7 by McDonough, Massachusetts has been successful in covering more of its residents than any other state. How did Massachusetts manage to do this? What kinds of lessons can be learned from Massachusetts?
High enrollment: high percentage of its population enrolled in health insurance coverage, indicates that the marketplace is effectively reaching and engaging with its target population
Accessible coverage: ensures coverage options are accessible to all residents, including those with pre-existing conditions or lower incomes. This involves implementing policies such as guaranteed issue and premium subsidies
Financial stability: financially stable with balanced risk pool and sustainable premiums, requires a mix of healthy and less healthy enrollees to spread the cost of healthcare across the population and prevent adverse selection
Quality coverage: meets healthcare needs of its enrollees, includes access to a broad network of healthcare providers, comprehensive benefits, and effective care coordination
Massachusetts:
- Individual mandate
- Subsidies to help low income families, expanded medicaid (masshealth) to cover even more low income residents
- Massachusetts health connector: an exchange where individuals and small businesses can compare and purchase health insurance plans, connector facilitated enrollment in coverage and provided a centralized platform for accessing subsidies and other assistance
- Collaboration and bipartisanship: policymakers, providers, insurers, consumer advocates worked together to develop and implement comprehensive reforms that garnered broad support
Lessons learned from MA
- Implementing an individual mandate can encourage broad participation in the insurance market and help stabilize premiums
- Providing subsidies and expanding Medicaid eligibility can make coverage more affordable and accessible to low income individuals and families
- Establishing a state based exchange or marketplace can streamline enrollment and facilitate access to coverage options and financial assistance
- Collaboration and bipartisanship are crucial for enacting and sustaining meaningful healthcare reforms
Which factors explain the record high marketplace enrollment in 2023? Do Biden administration policies help or hurt enrollment?
- Expanded subsidies: Biden admin implemented changes to ACA premium tax credits, making them more generous and available to a wider range of people, this could have made coverage affordable for many more people, leading to increased enrollment
- Enhanced outreach and enrollment efforts: raising awareness about coverage options and encourage enrollment
- Economic factors: changes in the economy, such as job losses or changes in employment status due to covid may have led more people to seek coverage through the marketplace
- Stabilization of the insurance market: stable premiums and insider participation increasing consumer confidence
- Policy continuity: Biden admin’s commitment to preserving and strengthening the ACA may have provided sense of stability and confidence
Biden
Helped: expanding premium credits and outreach make it more affordable and accessible, and the support for ACA increases confidence
What happened in the three separate Supreme Court cases [The National Federation of Independent Business v. Sebelius (2012) and King v. Burwell (2015) and Texas v. United States? How was the ACA implementation impacted as a result?
The National Federation of Independent Business v. Sebelius
- Supreme Court upheld majority of the ACA, including the individual mandate
- The court ruled that the federal government couldn’t penalize states that chose not to expand medicaid, leading to a situation where medicaid expansion became optional for states
King v. Burwell
- Supreme court upheld ACA provision of subsidies provided to individuals purchasing health insurance through the federal exchange
- Case centered on whether the language of the ACA limited subsidies to state-run exchanges
Court’s decision ensured that individuals in states that didn’t set up their own exchanges could still access subsidies
Texas v. United States
- Several states challenged the constitutionality of the ACA after Congress reduced the penalty for not having health insurance to zero dollars
- Argument was that without a financial penalty, the individual mandate could no longer be considered a tax and thus was unconstitutional;
- Additionally, plaintiffs argued that since the individual mandate was inseparable from the rest of the ACA, the entire law should be invalidated
The Supreme Court ruled in a 2021 that plaintiffs did not have standing to challenge the individual mandate as it stood, but left the door open for states to challenge other provisions of the ACA, ruling does not directly impact ACA’s implementation, but it kept the law intact for the time being, but it still faces challenges
Texas v. United States
Texas v. United States
- Several states challenged the constitutionality of the ACA after Congress reduced the penalty for not having health insurance to zero dollars
- Argument was that without a financial penalty, the individual mandate could no longer be considered a tax and thus was unconstitutional;
- Additionally, plaintiffs argued that since the individual mandate was inseparable from the rest of the ACA, the entire law should be invalidated
The National Federation of Independent Business v. Sebelius
The National Federation of Independent Business v. Sebelius
- Supreme Court upheld majority of the ACA, including the individual mandate
- The court ruled that the federal government couldn’t penalize states that chose not to expand medicaid, leading to a situation where medicaid expansion became optional for states
King v. Burwell
King v. Burwell
- Supreme court upheld ACA provision of subsidies provided to individuals purchasing health insurance through the federal exchange
- Case centered on whether the language of the ACA limited subsidies to state-run exchanges
Court’s decision ensured that individuals in states that didn’t set up their own exchanges could still access subsidies
Who can enroll in Medicare and how? What is covered under Part A, Part B, Part C and Part D and Medigap?
Eligibility
- Individuals 65 and older qualify if they or their spouse have worked and paid medicare taxes for at least 10 years
- People under 65 who have certain disabilities or end-stage renal disease or ALS
Enrollment
- Initial enrollment period: starts 3 months before 65th bday month, ends 3 months after
- General enrollment period: runs from Jan 1 to March 31 each year, coverage beginning in July
- Special enrollment periods: certain situations like losing employer coverage or moving to a new area
Part A hospital insurance
Part B medical insurance
Part C Medicare advantage
Part D prescription drugs
