Health Law Creation - Answers Federal Statutes dominate
Arises from authority to "tax and spend" and "regulate interstate commerce" (Article 1 of the US
Constitution)
Entitlement - Answers a type of financial help provided by the government for members of a
particular group
Medicare and Medicaid - Answers Two very large entitlement programs that provide health care and
services.
Combined they serve more than one third of the US population.
Medicare - 60 million beneficiaries
Medicaid - 70 million beneficiaries.
Medicare - Answers Federal social insurance program.
Managed by Centers for Medicare and Medicaid Services (CMS).
Anyone 65 years or older is eligible.
On SSDI > 24 months.
ESRD patients who have been on dialysis for three months. (added by Nixon)
Those with ALS
Paying for Medicare - Answers 40 %from general fund.
Rest from Medicare taxes, premiums, deductibles, SS taxes, etc...
Medicare Part A - Answers No premium for most.
Covers hospital stays and short term rehab (after $1300 deductible).
Covers some home health.
Covers 100% of hospice care including meds, staff, equipment in hospice
Will pay first 90 days of a hospital stay. Co-pay of about $300/day after day 60.
Also offers 60 "lifetime reserve" days beyond the 90. Co-pay of about $600/day for these.
Medicare Part B - Answers Premium-based (most pay about $100/month).
Covers MD visits.
Preventive care.
Durable medical equipment (walker, shower chair, ect.)
Ambulance service.
$183 annual deductible then Medicare pays 80%, patient pays 20%
Medicare Part C - Answers AKA Medicare Advantage
Basically, a highly regulated but private replacement for Parts A and B.
Coverage and premiums vary.
Not generally something lower income patients enroll in due to costs
Medicare Part D - Answers Large expansion of Medicare passed in 2003 under President Bush.
Prescription drug plan. Cost estimate $92 billion in 2018
$400 annual deductible.
Avg $40/mo
̴ premium. Varies with plan, income.
Pays 75% of drug costs, up to $2970 per year (now $3700 per year).
Then nothing until costs reaches $4750 at which point Medicare pays 95%.
Donut Hole (the hole between what Medicare D will pay for and what the pt has to pay for)
ACA trying to close that hole by raising the amount Medicare D will pay
Medicaid - Answers Federal health insurance program for certain low-income and disabled
individuals.
Funded jointly by federal and state governments (50-80% federal).
Managed by states.
Eligibility largely determined at state level.
25% of all children covered by Medicaid.
50% of all Medicaid recipients are children.
Account for only 20% of cost.
Medicaid Eligibility - Answers Highly Variable
For adults, usually based on % of FPL (federal poverty level)
FPL is $12K for one adult. $20K for family of 3.
Examples:
,AL - Parents - 18%; Childless adults - 0%.
32 states expanded Medicaid thru ACA, 138% for parents and childless adults.
NC - Parents - 44%; Childless adults - 0%.
Who is eligible? - Answers Those with low a income and are:
Children
Pregnant
Adult with dependent children
Disabled
Blind
States may apply to CMS to expand coverage to other groups. Some do, some don't.
What does Medicaid cover? - Answers Hospital
MD visits
Rx
Vision
Dental
Home health
Nursing home care (60% of this population receive Medicaid benefits)
Children's Health - Answers Children's Health Insurance Program (CHIP).
Covers about 8 million children who do not qualify for Medicaid.
Jointly funded by Federal and State governments.
Coverage similar to Medicaid.
Costs capped at 5% of family income.
Patient Protection and Affordable Care Act (ACA) - Answers Passed into law in 2010.
Most provisions in effect by 2014.
ACA Provisions - Answers Individual mandate - all individuals must purchase health insurance or pay
penalty (with exceptions for religion or financial hardship).
Businesses with more than 50 employees must offer health insurance or pay penalty.
Small businesses receive tax credits for offering health insurance to employees.
ACA Court Challenges - Answers Constitutionality of law challenged by an independent business
group.
Supreme Court heard case in 2012.
Upheld most elements of law, including individual mandate.
King v Burwell (2015) - challenged subsidies in states that use federal exchange.
SCOTUS did strike down this important provision... - Answers Mandated Medicaid expansion by
states.
States opting out of expansion will have residents in an insurance "gap" comprised of non-disabled,
non-elderly adults under 138% FPL but over state Medicaid threshold.
Changes in coverage under ACA - Answers In 2012, about 50 million Americans uninsured.
By 2015, down to about 30 million.
By 2019, that number may be down to 25 million.
The latest tax bill brings this estimate into question
Changes under ACA - Answers Childless, non-disabled adults easier access to health care.
As of 2014, Medicaid reimbursement on par with Medicare.
No lifetime coverage limits.
No pre-existing condition denials.
No pre-existing condition cancellations.
May stay on parents policy until 26 yrs old.
Individual Mandate Tax Penalty - Answers 2017 = $695 per person and $347.50 per child per year | or
2.5% of your income
In December of 2017, President Trump signed a tax bill that repeals the individual mandate penalty.
Doesn't go into effect until 2019...
Will likely cause a decrease in insurance enrollment
Who else lacks health insurance? - Answers Answer: Mostly, those who can't afford it. 16% of non-
elderly population.
Why does that matter?
, Lower life expectancy.
More chronic illness.
Higher hospitalization rates.
More ED visits.
More entitlement use (Medicaid, SSI Disability).
Fewer days going to work.
What about the small business - Answers Employers have been leaving the (employee sponsored
insurance (ESI) system for years.
2000 - 69% of employers offered ESI.
2010 - 59% of employers offered ESI.
ACA provides tax credits to small businesses (< 50 employees) to subsidize ESI. 15% tax credit plus
deduction of premiums.
What about the large business - Answers Wal Mart is the largest private employer in the US.
Approximately 2 million employees.
Average wage is $13.38/hour (full time).
One third are part time ($10.58/hr)
Supported ACA passage.
But. . .in 2011, Wal Mart initiated "annual review of insurance eligibility."
- Sometimes part time employees can get more affordable insurance through ACA exchange....
Why do we have to allocate resources - Answers Growing costs
Scarcity of resources
Resource allocation methods - Answers Rationing
Patient
Cost
Physician
How do we decide who gets what? - Answers Triage- a system of sorting patients based on severity
and urgency
Need
Cost
Outcomes
Utility
Ethical principles - Answers Respect for persons
Autonomy: Person has control over themselves
Beneficence: Working for the good
Justice: Number one way you determine who gets what, who needs it most
Health Disparities - Answers "differences in access to or availability of facilities and services."
(National Institute of Health, 2009).
Avoidable vs Unavoidable
Acceptable vs Unacceptable
If there is a health disparities that are avoidable and unacceptable then they have to be fixed
Resource utilization - Answers "The registered nurse utilizes appropriate resources to plan and
provide nursing services that are safe, effective and financially responsible." (ANA Standards of
Practice, 2016).
Evidence based practice
Quality Improvement
Cost effectiveness analysis
SA node intrinsic rate - Answers 60-100 times per minute
AV node intrinsic rate - Answers 40- 60 times per minute
When does atrial repolarization occur? - Answers During ventricular depolarization and is hidden in
the QRS complex
How do you get a positive deflection - Answers An electrical current flowing toward a positive pole
will produce a positive deflection
How do you get a negative deflection - Answers An electrical current flowing toward a negative pole
will produce a negative deflection
How do you get a biphasic deflection - Answers An electrical current flowing away from both a
negative and a positive pole will produce a biphasic deflection