Chapter 3 Textbook Notes
Chapter 3 Textbook Notes SPHU 3010
Popular in Foundations of Health Care Systems
Popular in Public Health
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This 7 page Class Notes was uploaded by Cara Macdonald on Wednesday September 14, 2016. The Class Notes belongs to SPHU 3010 at Tulane University taught by Arthur Mora in Fall 2016. Since its upload, it has received 3 views. For similar materials see Foundations of Health Care Systems in Public Health at Tulane University.
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Date Created: 09/14/16
History of the U.S. Healthcare System (Chapter 3) • Pre-industrial era: o Practitioners visit house s § Quacks, faith healers, homeopaths, snake -oilers, midwives, salesmen • Snake oil, cocaine drops, etc brought by traveling salesmen • Charged generally low fees which were paid out of pocket § Word-of-mouth and self-prescriptions § There was no science yet in medicine to prove other treatments • Barbers and surgeons frequently shaved and bled with the same razors § Miasma theory of diseas e: • If there was an odor, it meant disease was spreading a. Was coincidentally true § Dependant on oneself and family for surviva l § Lack of knowledge § No infrastructure for healthcare, most systems were managed on a local level • What structure we did have wasn’t real healthcare • No real hospitals- had almshouses, homes for the poor, asylum s . All these places ended up being shelters→ institutionalized and removed people from society instead of treating and returning them a. For those unlucky enough to fall sick without family to take care of the m b. Conditions were crowded, unsanitary, unethical and inhuman e c. Services were only provided to the poor/disabled d. Had terrible reputations because of these reasons o Post-industrial Era § What changes occured to get us where we are today? • Science of medicine confirm ed what the MDs knew . Homeopathic, faith and snake -oil healers fell behind without science to back up their treatments a. Confidence in the medical system increased, knew no limits yet § Federal government funneled billions of $$ into academic medical research b. Supreme Court upholds and confirms medical authorit y in physicians graduating from reputable medical college § Highest court qualifies a legitimate system § Medical colleges advocated for these physician s § Enrollment increased § Transition to an Urban Society • Industrialization shifted the workplace from the home to somewhere other than the home . Concentrated areas of population a. Apartment dwelling, often alone tenant -dwelling § Individualized: lose family support § If you got sick, you had no one to care for yo u § Conditions were somewhat deplorable § BUT this fueled the opportunity for further legitimization in the field of healthcare • Improvement in hospitals removed the stigma against them . Advent of antiseptic surger y § Previously, 50/50 prospect of surviving a sur gery § Antiseptics saw this risk drop exponentiall y a. Anesthesia § Prior to its advent, amputations occurred without anesthesia or painkillers § Further reduced the stigma against hospitals b. Hospitals began to keep records • Kept track of effective treatments § Statistics proved if a treatment was effective or not § Saw improvement in the performance of the hospital • Rise of Insurance o Cost of hospital treatments increased, were no longer affordable o Black Tuesday stock market crash left hospitals empty § Had no cash coming in from lack of patient s o Baylor University Hospital Insurance Pla n: § $6/year guaranteed up to 21 days of hospitalizatio n § $6/year gave peace of mind, was worth the small price for the high risk o Blue Cross/ Blue Shield began guaranteeing their empl oyees health insurance o WWII wage freeze exempts health insurance o Women were pulled into the workforce § Lack of employees to fulfill business -government contracts § Factories took employees from other factories • Government contracts became more expensive, lost money • Implemented a wage freeze § Companies started offering health insurance to incentivize employees • Institutionalized attainment of health care • Elderly was major group left out of healthcar e o Jobless, had no employee benefits o Many presidents have aimed for universal healthcare, but failed o Kennedy insisted on providing healthcare for the elderly § 1960 revived effort to enact hospital insurance for the aged § Congress responded by enacting Kerr-Mills Program: • Distributed federal funds to states willing to pay health care providers to care for the indigent aged . Later expanded to cover indigent disabled § After his assassination, wave of emotion left people obligated and inspired to carry out the tenets of his campaign o LBJ: those who have plenty should give to those who have non e § Abundance of wealth in our country had to be shared § Enactment of the US “great society” made an opportune time to renew effort to enact national health insuranc e § BUT conservatives and the American Medical Associati on (AMA) cited the nation’s oversupply of hospitals and desired to return to a physician-centered delivery system § Congress compromised between the two and expanded on Kerr-Mills: • President’s proposal for hospital insurance for the elderly became Medicare Part A • Republican proposal for physician insurance for the aged became Medicare Part B • The AMA’s effort to expand Kerr -Mills became Medicaid • Medicaid: not a single national program, but collection of 50 state-administered programs providing health insurance to low -income residents o Each state’s eligibility rules, benefits and payment schedules for Medicaid are different § Richer states have more generous eligibility rules o The federal government contributes between 50 -78% of Medicaid costs § During late 1980s, Congress imposed rules to increase state coverag e • Number of children insured nearly doubled in the next 8 year s • Medicaid expansion was the federal government’s main strategy to reduce the uninsured population § During early 1990s, President Clinton proposed to require that employers offer health insurance to their employee s • Proposal failed, but states were given more autonomy and flexibility in Medicaid requirements § 2 trends dominating Med icaid policy: • Encouragement or requirement of managed care delivery systems • Growth in Medicaid enrollees ended, a slow decline began . Probably due to federal welfare reform in 198 6 § People receiving Aid to Families with Dependent Children (AFDC) stopped being automatically enrolled in Medicaid a. Welfare recipients now had to apply separately for Medicaid § Millions didn’t know they even qualified § To reverse this decrease in enrollees, state and federal officials undertook some change s • Simplified eligibility proces s • Simplified eligibility rule s • Expanded outreach and education . By mid-1998, enrollment began to increase again § Unfortunately, growth in enrollment has lead to higher costs for prescription drugs, services for the disabled, and long -term care • Prompted cost-containment efforts in every state . Most popular option was effort to control rising cost of pharmaceuticals, through either leveraged buying (purchasing pools) or limits on access (formularies) § Recently, the ACA expanded on Medicaid eligibility further, requiring states to expand coverage to a higher percentage of federal poverty level • Medicare: provided health insurance to segments of the population not general ly covered by the mainstream employer -sponsored health insurance syste m o Differs significantly from Medicaid; Medicare is: § A social insurance program provided benefits to the aged and disabled regardless of income § Administered by federal officia ls and the private insurers they hire § Funded primarily by the federal government plus beneficiary copayments and deductibles § Limited benefit package that excludes much preventive care, long -term care, and until 2006, prescription drugs outside the offic e • Medicaid offers a much more generous array of benefits o Began in 2 separate parts: § Medicare part A: covers inpatient hospital care • Financed primarily by a 2.9% payroll tax . Revenue contributed originally exceeded program’s expenses, but surplus $$ were e xploited for bills, etc. a. Eventually, provider reimbursement had to be cut • All beneficiaries automatically receive part A coverag e • As the program recovered its debt, a change in insurance politics sparked 3 different responses : . Emphasized the need to undo some provider reimbursement cuts a. Argued against new spending measures on behalf of either provider or beneficiary b. Fiscal conservatives: proposed that any surplus remain in the Trust Fund to be used in future years • Congress chose to undo some cuts in pr ovider reimbursement . The cuts were widely considered too harsh, and Congress proposed 2 giveback initiatives to reimburse providers § Medicare part B: covers outpatient care • Voluntary program for a monthly premiu m • 95% of beneficiaries choose to enroll in part B § Medicare part C: Allows private health insurance companies to provide Medicare benefits (private prescription drug plans) for beneficiaries who wish to stay in fee -for-service Medicare § Medicare part D: ben eficiaries can receive outpatient drug coverage through a managed care plan, assuming they decide agains t a private prescription plan • Republicans maintained that the plan would provide significant coverage to millions of seniors • Democrats argued that the initiative gives too little to needy seniors and too much to health maintenance organizations, big businesses and pharmaceutical industry • COME BACK TO THIS PART • The remaining uninsured: o Millions were still uninsured, mostly from families with members s elf-employed or employed in small businesses § States with unionized industrial/manufacturing bases were likely to have fewer uninsured o Dramatic increase in uninsured occured during mid 1990s - an era of economic growth, low unempoyment and small rises in h ealth care costs § Accelerated in ecconomic downturn of early 2000 s § Best explained by the decline in number of americans with employer - sponsored private health insurance due to: • Increased share of insurance bill paid by employee s • Elimination of coverage fo r spouses and children • Elimination of retiree health coverage • Hiring of more part -time workers, avoiding need to offer health insurance • Job growth in service and small business sectors (notoriously low - paying jobs that don’t offer insurance ) § Employer-sponsored health insurance mandate was reinvigorated but failed yet again: • Faced vehement opposition from business community • Opponents argued that mandate would be too costly and would force employers to eliminate jobs • After its collapse, policymakers focu sed on reforms in 3 structural areas: . Small business employers often couldn’t afford to provide health insurance to employees a. Employees of small businesses/people who are self employed earn too little to purchase insurance b. People at high risk medically were often excluded completely from the individual insurance market § By late 1990s, focus on insurance reforms were shifted toward programs that expanded health insurance for children (a sympathetic group by bipartisan agreement) • Congress enacted Children’s Health Insurance Program (CHIP ) . States can use CHIP funds to liberalize Medicaid eligibility rules a. Simplifies Medicaid enrollment for both client and state • Early enrollment in CHIP was disappointing because: . Eligible families didn’t know they were eligible a. Complicated application proces s b. Stigma associated with government insurance programs • However, improved outreach lead to a rise in enrollmen t . Democrats proposed significantly increased funding a. Congressional Republicans opposed, arguing expnasion would undermine the nation’s private insurance system b. Political battle continued until President Obama’s inauguration § He almost immediately signed for the expansion, and CHIP enrollment continued to increase § Despite groiwng numbers of enrollees in Medicaid and CHIP, number of uninsured kept rising • Bipartisan debate continued: democrats for further expansions, republicans against • Obama decided to push hard for comprehensive health reform legislation to: . Reduce number of uninsured a. Pay for such coverage without adding to the natio’s budget deficit b. Slow the rising cost of health care more generall y c. Encourage more efficient and higher -value health care system • Several obstacles stood in his way: . Interest groups (i.e. employers, insurers, hospitals, doctors) a. America’s political institutions/veto system made it almost impossible to enact • Obama needed to develop a new strategy: . Declared health reform to be his top domestic priority a. Urged health reform’s enactment d uring his first year b. Delegated task of developing reform plan to congressional leaders o Congress enacted the Patient Protection and Affordable Care Act of 2010 (ACA) § Mandates that nearly all americans have some form of health insurance § Requires state Medicaid programs to provide coverage to all persons with incomes below 133% federal poverty level § States encouraged to create “insurance exchange” system in which the uninsured and small-business community could purchase more affordable coverage § Requires that employers with more than 50 full -time employees either provide coverage or pay a penalty to federal gov’t § Private insurance companies are required to comply with federal regulations eliminating discrimination against persons with pre existing conditions • 4 Key Characteristics of the Policy Process: o Each health program or problem domain typically has a relatively distinct policy subsystem: § Consists of actors from public or private sectors who are routinely and “actively concerned” about a policy problem or issue § Each policy subsystem tends to be distinctiv e o The fragmented nature of America’s governing institutions makes it difficult to translate majority preferences into major policy decision s in the health arena o Implementation is a critical part of the policy process, markedly affecting who gets what from federal health program s o Establishment of health programs reconfigures policy subsystems and broader political factors in ways tha t affect program durabilit y § Medicaid is often seen as highly vulnerable to program erosio n, but has actually thrived over the decades • Opposition to Medicaid expansion still existed, especially in the Republican party o Reagan’s arrival in the White House unleashed an effort to revamp and retrench Medicaid o George H.W. Bush also set to pare the progra m o Representative Henry Waxman of California fended off the retrenchment initiatives and laid the foundation for substantial Medicaid growth: § Played a significant role in establishing Medicaid’s Disproportionate Share Hospital program : • could direct money to hospitls that served uncommonly high numbers of the uninsured and Medicaid enrollees • Secured the passage of legislation that required all states to cover children younger than 6 and pregnant women in poverty . Federal and state Medicaid spending grew substantially between 1981-1992 • Medicaid Waivers: o Congressional delegation of authority to the executive branch to permit states to deviate from the ordinary requirements of law. Medicaid waivers assume two basic guises: § Demonstrations • Gives the federal executive broad discretion to experiemnt with alternative state approaches to Medicaid § Targeted initiatives focused on long -term care o Clinton administration provoked an outpour of Meidcaid waivers § Among the factors leading federal and state Medicaid outlays to more than double during this period o Presidents employ waivers to overcome barriers to adaptation and innovation rooted in the bias of American governance • Supreme Court decision in 2012 made state participation in Medicaid expansion voluntary rather than required o Movement over time toward a more positive social construction of Medicaid enrollees § Reducing its image as “welfare medicine” § Emerging as a program for working people and as a safety net for middle - class individuals needing long -term care o As republicans took control of the House of Representatives, they have passed budget resolutions that would repeal the AC A and convert Medicaid to a capped block grant with reduced funding
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