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Week 9 - Part 2: Health Care Delivery in the United States

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Ashley Conway

on 29 June 2017

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Transcript of Week 9 - Part 2: Health Care Delivery in the United States

Week 9 - Part 2: Health Care Delivery in the United States
Why do people become public health and health care professionals? Although there may be as many answers to this question as people asked, most students of public health, medicine, nursing, or other health care related fields share the altruistic ideal to help others and make a contribution to society.

Whatever your profession and your reasons for choosing it, you will be practicing within the health care system of the country you work in. And, as you will learn, the health care system determines how health care is delivered.
On the surface, the health care delivery system in the U.S. is straightforward....
A provider can be an institution (e.g. hospital, clinic, private practice) or individual (e.g. physician, nurse, therapist, social worker) providing a health related service (e.g. preventative, curative, therapeutic, rehabilitative) in a public or private setting.
The individual seeking or receiving health care services. Patients may also be referred to as clients, consumers, or other terms.
How the health care services are paid for. May be public or private. Private insurance may be paid for by an employer or by the individual. Uninsured individuals may pay for care "out of pocket" or may rely on "charity care" at an institution. Some care is provided by public health agencies or non-governmental organizations.
Patients receive services from providers which are paid for by insurers within a system of regulations, licensing requirements, and laws.
Chapter 13 in the text presents a history of U.S. health care delivery; a picture of how the current system is structured; how the system functions; and an explanation of health care reform. I think the authors do a good job of tackling a big issue in less than 60 pages, so I encourage you to read the entire chapter even though the content may seem dry and technical. What I know from my career of providing health care and in public health is that understanding the system you are practicing in - especially who is paying for it and what they expect - is of paramount importance in reaching desired outcomes.

What about those of you who don't think you will have a career in health care? Well, everyone needs health care at some time! Knowledge about the health care system can make a difference in whether your experience in getting the care you need is a good one or a bad one.

Kaiser Foundation. Health Reform Explained Video: "Health Reform Hits Main Street" (9:05)
Kaiser Family Foundation, Health Reform:
But in reality the health care delivery system is highly complex and can be difficult to understand - even for health care professionals!

If you or a family member have had to navigate the health care system for a serious illness or an illness that was difficult to diagnosis and treat, then you may understand this first hand. From finding the right provider, to getting medical records from one place to another, to dealing with insurance - it can be a daunting process, especially if you are already sick and worried.

This lecture isn't going to present most of the material contained in Chapter 13, rather it will present the health care delivery system in a different way - often with the help of video.

The objective is to familiarize you with key concepts and issues so that you will have a foundation of knowledge and understanding about health care delivery for your future studies. For instance, when you hear the acronym ACA, you will know what it is and its importance in health care delivery.

Beveridge Model
Named after the social reformer who designed Britain's National Health Service. In this system, health care is provided and financed by the government through tax payments, just like the police force or the public library. This model is used in
Great Britain, Spain, most of Scandinavia, New Zealand, Hong Kong, and Cuba.
Bismark Model
Named for the Prussian Chancellor Otto von Bismarck, who invented the welfare state as part of the unification of Germany in the 19th century. It uses an insurance system -- the insurers are called "sickness funds" -- usually financed jointly by employers and employees through payroll deduction. This model is used in
Germany, France, Belgium, the Netherlands, Japan, Switzerland, and, in part, Latin America.
National Health Insurance Model
This system has elements of both Beveridge and Bismarck. It uses private-sector providers, but payment comes from a government-run insurance program that every citizen pays into. Since there's no need for marketing, no financial motive to deny claims and no profit, these universal insurance programs tend to be cheaper and much simpler administratively than American-style for-profit insurance. This model is used in
Canada, Taiwan, and South Korea.
Out-of-pocket Model
Only the developed, industrialized countries -- about 40 of the world's 200 countries -- have established health care systems. Most of the nations on the planet are too poor and too disorganized to provide any kind of mass medical care. The basic rule in such countries is that those able to pay get medical care (called out-of-pocket); those who can't stay sick or die. This model is in play in regions of
Africa, India, China and South America...
Health care around the world...
...4 different models
The U.S. health care system is fragmented and has parts of each of the 4 systems in it
Did you say the
United States?!
The four models should be fairly easy for Americans to understand because we have elements of all of them in our health care system. When it comes to treating veterans, we're Britain or Cuba. For Americans over the age of 65 on Medicare, we're Canada. For working Americans who get insurance on the job, we're Germany.

For the
15 percent of the population
who have no health insurance, the United States is Cambodia or rural India, with access to a doctor available if you can pay the bill out-of-pocket at the time of treatment or if you are eligible for "charity care" (also called uncompensated care). Whether charity care is offered or not, what it covers, and who is eligible is determined by the individual states.

The United States is unlike other capitalist democracies because it maintains so many separate systems for separate classes of people.

Source: T.R. Reid. The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care
- T.R. Reid
PBS, FRONTLINE. Trailer: Sick Around the World. (0:30)
The documentary you will be watching this week examines the health care systems of five capitalist democracies around the world - Japan, Taiwan, Switzerland, Great Britain, and Germany - all have health care systems that provide health care for everyone. They have higher life expectancies, lower infant mortality rates, and spend less money than the U.S. for health care. What lessons can the U.S. learn about health care from other countries?

As you watch the video consider what system (including the current U.S. system) you would choose for the U.S. Don't worry about how popular your choice would be politically... pretend you have the power to choose!

How do you think the need for private insurance might affect your choice of a job and your future career path. For instance, if you wanted to do international aid work for a couple of years as a volunteer - what would you do for health care?

At the end of the video the president of the Swiss Federation asserts that "Everyone has the right to health care". Do you agree or disagree?

What do you think the implications of the 4 models are for public health?

Watch the video "Sick Around the World" (56:19). You can find the link on the Week 9 page in Sakai.
That's about 58 million Americans
to the enactment of ACA)
You may want to check out the Week 9 graded discussion assignment before you view this presentation or watch the video.
NBC News on medical bankruptcies

The sources for the information on medical bankruptcies in the previous slides are from a study from Harvard University and a study published in the peer-review journal, the American Journal of Medicine. However, not everyone accepts these findings and dispute that people go bankrupt from medical bills.

Sally Pipes, the president of of the Pacific Research Institute, wrote
"the alleged link between health costs and bankruptcy is about as real as the tooth fairy. The overwhelming body of research shows that medical costs play little or no role in the vast majority of U.S. personal bankruptcies".

As you may know from current presidential race, health care is a highly contentious issue in the U.S. and there is a steady stream of conflicting information about it. As a student and as a consumer, you will have to decide for yourself what is credible and what isn't. Remember to think like a journalist!

62.1% of all bankruptcies have a medical cause
Most medical debtors were well-educated and middle class; 3/4 had health insurance
The share of bankruptcies attributable to medical problems rose by 50% between 2001 and 2007
Himmelstein, et al. Medical Bankruptcy in the United States, 2007: Results of a National Study. American Journal of Medicine.
T.R. Reid asks representatives from the five countries highlighted in "Sick Around the World" if individuals in their countries ever go "medically bankrupt".

What is medical bankruptcy? Medical bankruptcy occurs when debt incurred by health care costs is the cause of personal bankruptcy. This debt is different from other debt because is is not the fault of the debtor and cannot be avoided.
Medical bankruptcy...
Of course, not everyone agrees...
The Daily Conversation. Obama Clearly Explains "ObamaCare". (7:30)

Despite very different ideologies about health care, there IS agreement that our current health care system is unsustainable.

As a health care workforce policy analyst for the N.J. Department of Labor, in 2011 I coordinated a council of high-level representatives from health care organizations throughout New Jersey including public agencies, private hospital systems, non-profits, foundations, and professional associations.

Without exception, there was agreement among Council members that the trajectory of health care in the U.S. (this was prior to the implementation of the ACA (also called Obamacare) was unsustainable - the system was broken and needed to be fixed.

No one doubts that the fix will be difficult and even painful (remember, change is difficult). But agreement on what the change should look like is, arguably, the most difficult part of the process.

You are on your career journey in a time of incredible change: technology is advancing at a dizzying pace; our understanding of disease is deeper (think CTE); there is an ongoing shift from acute care in hospitals to community-based care; and the health care system itself is transforming.

It is the health care system that determines who gets care, where they get it, who the care givers are, and what the quality of that care is! The system of health care delivery greatly impacts public health, medical research, and even the education system of future health care practitioners and public health professionals.

Despite political forces opposed to health care reform, the Accountable Care Act (ACA) is the law of the land and - by ruling of the Supreme Court - is moving forward.
If health care reform is confusing to you - you aren't alone. Laws are complex and a law that covers an entire system is bound to be ... well, big!

The Affordable Care Act is the nation’s health reform law enacted in March 2010.

The law consists of two pieces of legislation: the Patient Protection and Affordable Care Act (PPACA), enacted on March 23, 2010, and the Health Care and Education Reconciliation Act (HCERA), enacted on March 30, 2010. Jointly they are referred to as the Affordable Care Act or ACA.

The law’s most controversial component, known as the “individual mandate,” requires all Americans to purchase health insurance or pay a “shared responsibility payment” to the government.

On the day the law was enacted, 26 states, several individuals, and others sued to have the law struck down as a violation of the Constitution’s Commerce Clause, which gives the federal government the power to regulate commerce between the states.

The case was heard by the Supreme Court of the United States (SCOTUS) and the Court acknowledged that the mandate “is plainly designed to expand health insurance coverage,” and noted that “taxes that seek to influence conduct are nothing new”—for example, the taxing of cigarettes to discourage smoking. A majority of the Court upheld the individual mandate clearing the way for implementation of the ACA. At least temporarily.

ObamaCare, health care reform, ACA... I'm confused!
- American Public Health Association. (2013) ACA Policy.
- Kaiser Family Foundation. (2012) A Guide to the Supreme Court’s Affordable Care Act Decision.
- Wegman, Jessie. Understanding the Supreme Court Ruling. The Daily Beast.
According to fact checkers at the Washington Post - around 40,000 pages (if all of the regulatory fine print is counted). This is to be expected in any large and complex governmental undertaking (WP).
For your assignment this week you will be reading the Accountable Care Act.

So, how big is the ACA?
Do you support the ACA?
Do you oppose it?
Are you unsure?
Here's how the President explains health care reform...
What does the ACA mean for public health?
National Association of City and County Health Officers (NACCHO). The Affordable Care Act and Public Health. (9:08)
As you watch the interview with Dr. Choucair, notice how his vision of how the ACA will impact public health in Chicago fits with the core public health functions.
Rosenbaum, Sara. (2011) The Patient Protection and Affordable Care Act: Implications for Public Health Policy and Practice. Public Health Reports, Association of Schools of Public Health.

Learn more about the ACA and public health:
1. Read Chapter 2 and Chapter 13 in the text

2. View both Prezi lectures (on public health organizations and health care delivery)

3. Read the Rosenbaum article

4. View "Sick Around the World"

5. Begin the Week 9 graded discussion

Ashley Conway
Principles of Public Health
Fall 2016
Bloustein School of Planning and Public Policy
Rutgers University
Just kidding! Watch the videos...
This is the trailer for the documentary you will be watching.

U.S. Health Care Costs and Outomes
The U.S. spends more on health care than any other county in the world.
Are Americans healthier?
and the United States.
Medical Homes
In your studies you may hear the term "medical home". What does it mean and what are the implications of the medical home model for health care consumers and practitioners?

In 2007, the major primary care physician associations developed and endorsed the Joint Principles of the Patient-Centered Medical Home. The model has since evolved, and today the PCPCC actively promotes the medical home as defined by the Agency for Healthcare Research and Quality (AHRQ).

The 2010 Patient Protection and Affordable Care Act (PPACA) contains various provisions that support implementation of the medical home model including new payment policies, Medicaid demonstrations, and the creation of Accountable Care Organizations – which are similar to medical homes, on a larger scale.

The medical home is best described as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system, and is a philosophy of health care delivery that encourages providers and care teams to meet patients where they are, from the most simple to the most complex conditions. It is a place where patients are treated with respect, dignity, and compassion, and enable strong and trusting relationships with providers and staff. Above all, the medical home is not a final destination instead, it is a model for achieving primary care excellence so that care is received in the right place, at the right time, and in the manner that best suits a patient's needs.

- National Conference of State Legislators
- Patient-Centered Primary Care Collaborative

MedicalHomeforAll. What is a patient-centered medical home? (5:58)
Nearly all young people can now stay on their parents' plan until age 26, even if they're married, financially independent and no longer live with their parents. Young adults who are offered coverage through their own jobs can choose that plan or stick with their parents' plan if they prefer.

What does this mean for you?
What's in a name?
Just about everyone calls the Affordable Care Act "Obamacare" — even the White House. But is President Obama returning to his old stance that the health-care law should not have his name attached to it?
At a fundraiser in Potomac, Md., Monday night, Obama backed off the term that his administration shunned, and then embraced.

"First of all, in five years it will no longer be called Obamacare, because when something is working, they’re definitely not going to — there will be a whole renaming process similar to National. (Laughter.) I don’t know if it will be “Reagancare,” but it will definitely be — it will be something different," Obama told the crowd.
(For those of you outside the Washington area, Obama was referring to Washington National Airport, which was renamed Reagan National Airport in 1998).

Obama halted himself before getting out a full thought, but he signaled that Republicans won't want to attach his name to a law that, according to him, is successful. "because when something is working they’re definitely not going to," he said before shifting.

The term "Obamacare" was first coined by conservative Republicans as derogatory slang for a law they vehemently opposed. It was a fresh spin on "Hillarycare," which Republicans nicknamed Bill Clinton's failed attempt at health care reform in the 1990s — legislation that Hillary Clinton played a significant role in crafting.

The White House distanced itself from the term, referring to the law by its proper name — the Affordable Care Act — or health-care reform. But as the name stuck, the White House shifted and tried to own the term.
"You want to call it Obamacare — that's okay, because I do care," Obama said at a 2012 fundraiser. The White House also touted the term on Twitter, asking supporters to send tweets with the hashtag #ilikeobamacare.
"On Obamacare, Republicans spent hundreds of millions branding Obamacare as a negative, and we believe we can turn that to our advantage,” said Stephanie Cutter, a spokeswoman for Obama’s campaign, told The Post in 2012. “The term is incredibly popular with the president’s supporters, who will fight to the end to defend the law after 70 years of work to pass health reform.”

But language matters — a lot. And the difference between calling the law Obamacare and the Affordable Care Act is palpable, at least according to polls. According to a CNBC poll released last year, 46 percent of people said they were opposed to Obamacare; 37 percent said they were opposed to the Affordable Care Act. However, more people polled said they supported Obamacare than the Affordable Care Act. In Kentucky, a Marist poll conducted for NBC News found that 57 percent of people polled said they were opposed to Obamacare, while a plurality of people said they had a favorable impression of Kynect, the state health exchange.

"Call it something else, and the negatives drop,” Marist pollster Lee Miringoff told NBCNews.com. However, the White House has previously said something along the lines of Obama's comments on Monday. In 2012 — before the law was upheld by the Supreme Court — senior Obama adviser David Plouffe said Republicans might wish they hadn't branded the law with Obama's name. "I'm convinced at the end of the decade, the Republicans are going to regret turning this [into] 'Obamacare,'" Plouffe told CBS News.

- Katie Zezima, Washington Post, May 20, 2014

Obama: "In five years it will no longer be called Obamacare."
What have you heard?
Is the ACA a success or a failure?
Congressional Budget Office (CBO) is a federal agency within the legislative branch of the United States government that provides budget and economic information to Congress.
Wall Street analysts and health care experts say the law helped the industry financially by providing new customers to insurers and new paying patients to hospitals.
Of the 7.3 million people who signed up for private insurance through online exchanges during the first enrollment period, 85 percent qualified for federal subsidies that decreased the cost of their premiums.
Most experts say there is not enough data yet on the entire population to determine whether the law is improving the nation’s health.
In December 2012 Governor Christie vetoed an attempt to create a state-run exchange in New Jersey, citing uncertainty over the cost to the state.

However, in February [2013], the Governor agreed to expand Medicaid under the federal law, putting him at odds with many in his party.

“Accepting these federal resources will provide health insurance to tens of thousands of low-income New Jerseyans, help keep our hospitals financially healthy and actually save money for New Jersey taxpayers,” he said at the time.

The Governor went on to say that has no regrets that he decided against setting up a state health care exchange under the Affordable Care Act, saying he's glad the program's "failure" is not his responsibility.

- Interview with NJ 101.5 FM on 11/26/2013

101.5 FM. (11/2013) Gov. Christie calls Obamacare a "train wreck". (0.26)
Of course, not everyone agrees....
New Jersey
- New York Times
Do you know your sources?

American Journal of Medicine
Harvard University
Pacific Research Institute

The Federal Poverty Guidelines are a simplification of the poverty thresholds used for administrative purposes — for instance, determining financial eligibility for certain federal programs. They are issued in January of each year in the Federal Register by the Department of Health and Human Services (HHS).
What is Medicaid? And why is it so important to the Affordable Care Act?
Investopia. (2014) Medicaid vs. Medicare. (2:08)
Gov. Chris Christie (R) on June 28, 2013, signed a state budget that includes $227 million for Medicaid expansion in the state. However, he vetoed legislation that would have made the expansion permanent in the state.
Why are health care exchanges and subsidies so important?
On March 4, 2015 the Supreme Court will heard oral arguments in King v. Burwell, the latest challenge to Obamacare. This case involves the insurance exchanges created by Obamacare and the IRS’s interpretation of a provision of the law that authorizes tax credits for health insurance purchased through an exchange “established by the state.” When 36 states chose not to establish their own exchanges, the federal government stepped in and created federally run exchanges in those states. The IRS then extended the tax credits for insurance purchased through the federally run exchanges – an interpretation [that the plaintiff argues] directly violates the language of the law. The Supreme Court has been asked to decide whether the IRS’s interpretation may stand.

- Heritage Foundation

The case is not easy to understand so here is a short video that explains King v. Burwell:

New York Times. (2/15/2015) Obamacare 2015: The Two Americas of Health Care. (1:48)
New Jersey residents receiving subsidies for health insurance:

Share of population less than 65 receiving subsidies:

A web site that I often use to vet organizations is SourceWatch, sponsored by the Center for Media and Democracy. Many governmental agencies, non-profits, associations and other groups are listed in SourceWatch. You can get the back-story of organizations including who the funders are, which often tells you what the group's agenda is. Try searching for the Pacific Research Institute on SourceWatch.
SourceWatch: http://www.sourcewatch.org/index.php/SourceWatch
Why is the ACA called "Obama Care"?
What are FPGs?
It is a sad irony that the states with the most poverty and the most uninsured citizens are the states that have chosen not to take advantage of federal subsidies to expand Medicaid coverage :-(
This means that while you are in school or starting out in a new career you can stay on your parent's health care plan (if they have one) and will have more flexibility about choosing a job, taking advantage of a volunteer opportunity, or continuing on in your academic pursuits. :-)
One other giant thing that the ACA does...
Children's Defense Fund. (2012) Affordable Care Act Fact: Pre-existing Conditions Covered. (2:18)

It is almost unthinkable that insurance companies were able to refuse to cover a person because of a pre-existing condition. This was "business as usual" before the ACA was enacted. The ACA makes it illegal to refuse coverage to an individual because of an illness or condition that they already have. :-)
Yes, I'm biased for the ACA - and here's why...

Although the ACA is far from perfect, like science - it can be improved upon. Many of the constraints that make it imperfect were put in place by a Congress that was against the ACA (as you saw in the map of states that refused expanding Medicaid). But despite those challenges, the ACA has made a huge difference in access to health care in the U.S.

When I was the coordinator of a clinic in Newark for persons living with HIV/AIDS, health care coverage was a constant struggle - it took so much of our already limited resources to fight insurance companies who refused to cover our patients' "pre-existing conditions" or refused to pay for new, life-sustaining treatment therapies that we prescribed.

Knowing that a patient will likely die because of lack of health care coverage is a Terrible burden for health care providers to bear. My hope for those of you who aspire to be physicians, nurses, PAs, NPs, community health workers, social workers, health educators, or public health practitioners is that access to health care will be the norm rather then the privilege of some in your practice.
That's it for this week's presentations. See you in your discussion group!
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