Access in the United States and International Model of Delivery

HCR 210 Ethics for the Healthcare Professional Week 6 – Access in the United States and International Model of…and Delivery why should we care? Question Do all citizens deserve to have access to healthcare? Learning Objectives: • Understand ethical principles relating to the underlying challenges of finding a way to provide affordable access to health care for all United States residents • Review various models of health care delivery throughout world and compare with the current and proposed models in the United States America’s Healthcare System Healthcare Reform in America (Very) brief history of U.S. Healthcare system: • Debate over national health insurance policies have been ongoing since the 1900s • Around this time, other countries would introduce and implement government-controlled healthcare services and/national health insurance • U.S. policymakers debated creating a national health insurance plan but the proposed bills never passed Healthcare Reform in America • Social Security Act of 1935 o President Theodore Roosevelt’s answer to the question of National Health Insurance o Private for-profit insurance companies thrived and employer-based health insurance became the new norm Healthcare Reform in America • Medicare and Medicaid amendments to the Social Security Act in 1965 o President Lyndon B. Johnson Medicare: health insurance for people with disabilities and people >65 years old Medicaid: health insurance for impoverished people with children The Iron Triangle Medicare and Medicaid provided health insurance to many people, however also contributed to skyrocketing health costs Cost Quality Access Health Insurance Overview Voluntary/Private health insurance Government funded health insurance Subsidies via ACA marketplace Employer sponsored individually purchased Self-funded plan HMO PPO PSO (or other hybrid) HDHP Social health Insurance Public welfare health insurance (Medicare) (Medicaid) Healthcare Reform in America Gaps in Medicare/Medicaid • Medicare and Medicaid also leaves gaps for people who are either not old enough or not poor enough to qualify Gaps in free market health insurance • Free market health insurance leaves gap for people who are not employed, people who have employers that do not offers health insurance, or people who are self-employed Healthcare Reform in America • The Patient Protection and Affordable Care Act (ACA or “Obamacare”) was passed in 2010; technically was not completely phased in until 2020 • In 2010 >16% of Americans did not have health insurance 4 Main Goals of ACA: 1) Providing new consumer protections 2) Improving quality and lowering cost 3) Increasing access to affordable care 4) Holding insurance companies accountable Providing New Consumer Protections • Insurance companies cannot deny coverage for children based on preexisting conditions • Insurance companies cannot deny coverage for adults based on pre-existing conditions • Insurance companies cannot charge higher rates because of gender or health status • Prohibits insurance companies from setting an annual or lifetime dollar limits on coverage • Prohibits insurance companies from denying coverage because of technical or other errors on the original insurance application Improve Quality, Lower Cost • All new health plans must cover certain preventative services without charging deductible, co-pay, or co-insurance • Establishes Center for Medicare & Medicaid Innovation to test new ways of improving care and reducing cost • Establishes Community Care Transitions Program to help Medicare beneficiaries avoid hospital readmissions Increasing Access to Affordable Care • Young adults can stay on their parents’ plan until they turn 26 • Employer mandate – businesses with 50 or more employee must provide health insurance for at least 95% of their employees • Health insurance marketplaces – can be created by individual state for run by federal govt; allows individuals to purchase health insurance with govt subsidies if they qualify • Insurances that participate in the marketplace must cover “essential health benefits” • Expands Medicaid coverage (adults without children) Hold Insurance Companies Accountable • 85% of all premium dollars collected by insurance companies for large employers must go towards healthcare services and healthcare quality improvement • 80% for individuals and smaller employers • Eliminates additional Medicare costs from Medicare part C Cons • Increased premiums on health insurance • Some insurance companies cancelled private health insurance plans as they didn’t cover essential benefits • Increased taxes on Americans • Increased federal debt • ? Reduced employee hours • Some employers found it more cost effective to pay the penalty rather than offer health insurance America’s Healthcare System • America’s current healthcare system is a mixture of 3 main models: o Private insurance is required for all by individual or employer mandate (Bismarck model) o Government owns and provides all healthcare services (Beveridge or National Health Service model) o Government provides health insurance (National Health Insurance model) America’s Healthcare System State Government Federal Government State vs Federal Government State Government responsibilities: • Licensing of healthcare professionals • Inspection and licensure of healthcare facilities • Oversight of local departments • Implementation/enforcement of federal regulation • Monitor community to identify health problems • Develop policies to support community health Federal Government responsibilities: • Creating legislation • Acting when health threats span more than one state, or the solution may be beyond the jurisdiction of the state • Assisting states when their expertise or resources are not adequate to respond to public health emergencies Question Do you believe the government has a right to regulate healthcare? A. Yes, but it should be state government – less regulation B. Yes, but it should be federal government – more regulation C. No, healthcare should be a pure free market Key Terms Do you believe the government has a right to regulate healthcare? A. Yes, but it should be state government – less regulation B. Yes, but it should be federal government – more regulation C. No, healthcare should be a pure free market If you answered the above… Libertarianism: Value individual’s freedom and private property. Typically in support of smaller local and state governments over federal government. • Example: Healthcare is a privilege; individuals should be able to decide what level of healthcare they want to purchase o State governments can choose to participate in Medicaid expansions o Each state can choose how to implement Medicaid plans Question Do you believe healthcare is a right or a privilege? A. Right B. Privilege America’s Healthcare System Do you believe healthcare is a right or a privilege? A. Right B. Privilege If you answered the above… Egalitarianism: Everyone is created equal; everyone deserves the same treatment regardless of SES. Typically in support of more federal regulations. • Example: Healthcare is a right; everyone deserves access to the same quality of healthcare o Federal government should create a national health insurance for all people Question Rights guaranteed by the U.S. Constitution include: • Constitutional Rights (life and liberty) • Bill of Rights (freedom of speech, right to bear arms, prevents soldiers from occupying homes, prevents unreasonable search and seizures, double jeopardy, due process, trial by impartial jury, bars cruel and unusual punishment, bars excessive bail and fines) What is missing? HCR 210 Ethics for the Healthcare Professional Farzana Sarder, MS, PA-C Access to Affordable Care …and why should we care? Question The concept that one’s individual freedom and right to private property is a principle of which social justice perspective? A. Egalitarian B. Libertarian Distributive Justice and Politics Determining what is fair when deciding how to divide benefits and burdens • • • • Justice is fairness Society has a duty to help those who are in need People in higher SES have a duty to help those who are in lower SES • • Autonomy is the most important aspect of deontology People have a right to choose to help if they want to, but they should not be forced People who are in need should either help themselves or convince others to help them What Do You Think? Who is entitled to healthcare? Most people said they believe healthcare is a right What care should be universally covered? A. Everything including elective procedures B. Everything except elective procedures C. Basics such as primary care and preventative care, as well as emergency medicine D. Emergency medicine only Question: Do you think the government has a right to regulate health insurance and healthcare? A. Yes B. No A For-Profit Healthcare Industry EpiPen price hike under Congressional scrutiny by CBS A For-Profit Healthcare Industry A For-Profit Healthcare Industry Who gets left behind? What happens if drug prices keep increasing? Number of Uninsured Americans What Do You Think? How much of healthcare should be a burden of society, the government, or the individual? • Should the government pay for the healthcare of its citizens? • Are people in higher SES obligated to pay for the health of people in lower SES? Ethical Principle: Distributive Justice Ethical Principle: Distributive Justice Healthcare is highly politicized Distributive Justice and Politics The Affordable Care Act has shown how divisive Americans feel in regards distributive justice in healthcare. In 2016, 43% Americans viewed the ACA favorable and 46% viewed it unfavorably. However, 47% thought the ACA should not be repealed, and 28% thought it should only be repealed after there is a replacement plan. What Has Happened to the ACA? Former President Trump’s attempts to “repeal and replace” have been unsuccessful, however he did change the ACA in several ways: • Removed the fee in the individual mandate • States are now able to add “work requirements” to Medicaid • Stopped paying subsidies to insurance companies (previously in place to encourage insurance companies to reduce premiums and participate in the Health Insurance Marketplace) • Increased “skinny plans” • Decreased funds to healthcare.gov Distributive Justice and Politics In addition to differing political views among democrats and republicans, healthcare lobbyists also influence how the U.S. healthcare system works. Distributive Justice and Politics Who gets caught in the middle in between all of the politics surrounding healthcare? International Model of Delivery …and why should we care? Question: Do you believe the healthcare system in the United States is one of the best in the world? A. Yes B. No The Costs of Healthcare Percentage of GDP Spent on Healthcare, 2018 U.S. spends the most on healthcare. Infant Mortality Infant mortality in the U.S. (5.8 in 1000) is higher than OECD average (3.0 in 1000). Life Expectancy Life expectancy in the U.S. (78.8) is lower than OECD average (80.6). United States Versus Other Countries United States Versus Other Countries Netherlands Netherlands ranks first in healthcare access. What do they do? Australia Australia ranks first in healthcare outcomes and administrative efficiency. What do they do?• • • • • Publicly funded governmental health insurance (Medicare) Services include outpt services, hospital care at public hospitals, partial coverage at private hospitals, discount on prescription drugs Can also purchase private health insurance for uncovered services or to receive higher quality healthcare services “Two-tier” system Criticism: longer wait times, ethical concerns that public health services are lower in quality than private health services Japan Japan has the highest life expectancy. What do they do? • • • • Statutory health insurance system - social insurance o Mandatory employment based o Residence based for non-employed individuals Public Social Assistance Program - public welfare insurance Both social and public welfare insurance are managed by the government Private plans are also available for supplemental insurance Discussion What do you think are some of the causes of the U.S. health care system’s apparently low performance with respect to access, equity, and health care outcomes? Discussion In your opinion, are any of the reasons you have identified ethically defensible? Please give your reasons as to why they are (or are not) and specify the ethical theories and principles involved. Questions? Assignment Quiz 2 due Sunday at 11:59 PM AZ time