Insurance Regulation in the United States: an Overview for Business and Government

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Percent of federal poverty level and eligibility category e. Basic acute care coverage, some preventive; high cost sharing, no prescription drugs. Comprehensive for both acute and chronic care plus institutional long-term care for the elderly, disabled, and mentally retarded; nominal cost sharing. Hypertension, osteoporosis, chronic obstructive pulmonary disease, asthma, diabetes, heart disease, and stroke.

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Medicare is percent federally financed and operated, health care services are delivered almost entirely through the private sector. The Medicare population carries a heavy burden of chronic illness never resolved conditions with continuing impairments that reduce the functioning of individuals —78 percent of Medicare beneficiaries have at least one. Medicaid or actuarial equivalent of largest managed care plan in state; some cost sharing. Comprehensive chronic and acute care, including long-term institutional care; minimal cost sharing.

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Acute care coverage; no cost sharing for active duty personnel in military treatment facilities; some cost sharing for purchased care in civilian sector. Acute care, public health services, dental services, nutrition, community health, and other services. Psychosis, substance abuse, heart failure, chronic obstructive pulmonary disease, pneumonia, chest pain, neuroses, arteriosclerosis, and digestive disorders. Childbirth, orthopedic injuries, chest pain, pneumonia, congestive heart failure, asthma, and depression. Medicare beneficiaries with three or more chronic conditions account for the bulk of program expenditures see Figure The most prevalent diagnoses in persons aged 65 and over—high blood pressure, osteoporosis, chronic obstructive pulmonary disease, asthma, diabetes, heart disease, and stroke—are all chronic illnesses requiring medical management over extended time periods and multiple settings Medical Ex-.

A person with physical impairment is someone reporting difficulty performing three or more activities of daily living. The fastest-growing sectors in Medicare in terms of spending though not the largest proportion of total program spending have been home health, skilled nursing facilities, and hospice care, reflecting a shift in demand toward more chronic care.

Medicaid serves about 42 million people who are poor and who require health care services to achieve healthy growth and development goals or meet special health care needs. The program covers low-income people who meet its eligibility criteria, such as children, pregnant women, certain low-income parents, disabled adults, federal Supplemental Security Income SSI recipients low-income children and adults with severe disability , and the medically needy non-poor individuals with extraordinary medical expenditures who meet spend-down requirements generally for long-term care.


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There is a good deal of variability across states in the maximum income for eligibility. Unless otherwise indicated, data in this section are based on Centers for Medicare and Medicaid Services, a. Medicaid is administered and financed jointly by the federal government and the states, although the federal government pays for over 50 percent of aggregate program expenditures U. Government Printing Office, There is a good deal of variability in methods of health care delivery and financing across states.

Medicaid programs rely extensively on private-sector health care providers, managed care plans, and community health centers to deliver services and, to a lesser degree, state, county, or other publicly owned facilities or programs.

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Nationwide, over half of the total Medicaid population is enrolled in Medicaid managed care arrangements. Institutionalized, disabled, dually eligible, and elderly beneficiaries are most likely to receive services through FFS payment arrangements. The majority of Medicaid beneficiaries are children 54 percent , most under the age of 6 see Figure Each year, over one-third of all births in the United States are covered by Medicaid.

Over half of Medicaid expenditures are for long-term care services, with the majority going to institutional long-term care providers Centers for Medicare and Medicaid Services, a. While coordinated collection of Medicaid data from the states is lacking, other data sources indicate a substantial prevalence of chronic condi-.

NOTE: Disabled children are included in the aged, blind and disabled category. Designed as a joint federal-state program, SCHIP was created in to provide health insurance to poor and near-poor children through age 18 without another source of insurance. Approximately 4. Some states. Unless otherwise indicated, data in this section are based on Department of Health and Human Services, SCHIP operates as a block grant program to the states. States have the option of creating SCHIP programs as Medicaid expansions, as separate programs, or as combined programs i.

Most states rely on managed care arrangements as their primary mechanism of service delivery for both healthy children and those with special health care needs. VHA was established in as a separate division within the Veterans Administration to meet the health care needs of U. Eligibility is triaged according to the available budget; those with compensable, service-connected disabilities are assigned the highest priority Veterans Administration, a.

VHA serves as a payer of last resort for treatment not related to service-connected disabilities that is provided through VHA facilities. Each VISN contains 7 to 10 hospitals, 25 to 30 ambulatory care clinics, 4 to 7 nursing homes, and other care delivery units Kizer, Most clinical and administrative staff are employees of VHA. Generally, the VHA population is older, low-income, and characterized by high rates of chronic illness see Table Approximately 19 percent of the total VHA population sought inpatient and outpatient mental health services including those related to substance abuse in Van Diepen, a.

TRICARE provides services to active-duty military personnel, their dependents, retirees under the age of 65 and their.

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At the core of the program is a direct care system of military treatment facilities MTFs , which provide most of the care delivered to active-duty personnel and over half of that provided to TRICARE beneficiaries overall. There is an MTF located at most major military facilities in the United States and abroad, each operated by one of the military services. TRICARE also has regional contracts with private-sector health plans to provide active-duty personnel with certain services not available through MTFs and to serve other beneficiaries.

Lastly, since the Gulf War, a great deal of attention has been focused on early detection of risks associated with the activities and settings of deployment e. In addition to force health protection, the service needs of other TRICARE beneficiaries, mostly active-duty dependents, are sometimes described as basically babies and bones Jennings, IHS, an agency within the Department of Health and Human Services, is responsible for providing health services to members of federally.

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The discussion in this section is based on data provided by Indian Health Service, IHS currently provides health services to approximately 1. The provision of these health services is based on treaties, judicial determinations, and acts of Congress that result in a unique government-to-government relationship between the tribes and the federal government. IHS, the principal health care provider, is organized as 12 area offices located throughout the United States.

These 12 areas contain health care delivery facilities operated by IHS and tribes, including: 49 hospitals; health centers; and health stations, satellite clinics, and Alaska village clinics. Poverty and low education levels strongly affect the health status of the Indian people. Approximately 26 percent of American Indians and Alaska Natives live below the poverty level, and more than one-third of Indians over age 25 who reside in reservation areas have not graduated from high school.

Common inpatient diagnoses include diabetes, unintentional injuries, alcoholism, and substance abuse. This section highlights two important trends: the increase in chronic care needs and expectations for patient-centered care. Trends in the epidemiology of health and disease and in medical science and technology have profound implications for health care delivery. Chronic conditions defined as never resolved conditions, with continuing impairments that reduce the functioning of individuals are now the leading cause of illness, disability, and death in the United States and affect almost half the U.

Most older people have at least one chronic condition, and many have more than one Administration on Aging, Fully 30 percent of those aged 65—74, and over 50 percent of those aged 75 and older report a limitation caused by a chronic condition Administration on Aging, The proportion.

Thus, the majority of U. This trend is strongly reflected in the government health care programs. In the Medicare and VHA programs, most of the beneficiaries have multiple chronic conditions. Diseases such as asthma, diabetes, hypertension, cancer, congestive heart failure, and mental health and cognitive disorders are important clinical concerns for all or nearly all of the programs.


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The increasing prevalence of chronic illness challenges systems of care designed for episodic contact on an acute basis Wagner et al. Hospitals and ambulatory settings are generally designed to provide acute care services, with limited communication among providers, and communication between providers and patients is often limited to periodic visits or hospitalizations for acute episodes. Serious chronic conditions, however, require ongoing and active medical management, with emphasis on secondary and tertiary prevention. The same patient may receive care in multiple settings, so that there is frequently a need to coordinate services across a variety of venues, including home, outpatient office or clinic setting, hospital, skilled nursing facility, and when appropriate, hospice.

There is mounting evidence that care for chronic conditions is seriously deficient. Fewer than half of U. Health care is typically delivered by a mix of providers having separate, unrelated management systems, information systems, payment structures, financial incentives, and quality oversight for each segment of care, with disincentives for proactive, continuous care interventions Bringewatt, For individuals with multiple chronic conditions, coordination of care and communication among providers are major problems that require immediate attention.

There are many efforts under way to develop new models of care capable of meeting the needs of the chronically ill. For example, Healthy Future Partnership for Quality, an initiative in Maine now in its fifth year, enrolls insured individuals from leading health plans and the state Medicaid program and uninsured individuals covered by a 10 percent surcharge on the fee for each insured participant and paid by insurance companies with chronic illness in an intensive care management program that provides patient education, improved access to primary care and preventive services, and disease management Healthy Futures Partnership.

It involves 1, patients, half of whom participate in home monitoring using devices that read blood sugar, take pictures of skin and feet, and check blood pressure , intensive education on diabetes, and reminders and instructions on how to manage their disease. The changing clinical needs of patients have important implications for government quality enhancement processes. These processes and the health care providers they monitor should be capable of assessing how well patients with chronic conditions are being managed across settings and time.

This capability necessitates consolidation of all clinical and service use information for a patient across providers and sites, a most challenging task in a health care system that is highly decentralized and relies largely on paper medical records. Patient-centered care is respectful of and responsive to individual patient preferences, needs, and values and ensures that patient values and circumstances guide all clinical decisions Institute of Medicine, Informed patients participating actively in decisions about their own care appear to have better outcomes, lower costs, and higher functional status than those who take more passive roles Gifford et al.

Most patients want to be involved in treatment decisions and to know about available alternatives Guadagnoli and Ward, ; Deber et al. Yet many physicians underestimate the extent to which patients want information about their care Strull et al. Patient-centered care is not a new concept, rather one that has been shaping the clinician and patient relationship for several decades. Authoritarian models of care have gradually been replaced by approaches that encourage greater patient access to information and input into decision making Emanuel and Emanuel, , though only to the extent that the patient desires such a role.

Some patients may choose to delegate decision making to clinicians, while patients with cognitive impairments may not be capable of participating in decision making and may be without a close family member to serve as a proxy. Patients may also confront serious constraints in terms of covered benefits, copayments, and ability to pay discussed below under benefits and copayments.

Principle of Patient Autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. The current focus on making the health care system more patient-centered stems at least in part from the growth in chronic care needs discussed above. Effective care of a person with a chronic condition is a collaborative process, involving extensive communication between the patient and the multidisciplinary team Wagner et al.

Patients and their families or other lay caregivers deliver much if not most of the care. Patients must have the confidence and skills to manage their condition, and they must understand their care plan e.

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For many chronic diseases, such as asthma, diabetes, obesity, heart disease, and arthritis, effective ongoing management involves changes in diet, increased exercise, stress reduction, smoking cessation, and other aspects of lifestyle Fox and Gruman, ; Lorig et al. Pressures to make the care system more respectful of and responsive to the needs, preferences, and values of individual patients also stem from the increasing ethnic and cultural diversity that characterizes much of the United States.

Although minority populations constitute less than 30 percent of the national population, in some states, such as California, they already constitute about 50 percent of the population Institute for the Future, A culturally diverse population poses challenges that go beyond simple language competency and include the need to understand the effects of lifestyle and cultural differences on health status and health-related behaviors; the need to adapt treatment plans and modes of delivery to different lifestyles and familial patterns; the implications of a diverse genetic endowment among the population; and the prominence of nontraditional providers as well as family caregivers.

Although there has been a virtual explosion in Web-based health and health care information that might help patients and clinicians make more informed decisions, the information provided is of highly variable quality Berland et al. Some sites provide valid and reliable information. There are also notable efforts to provide consumers with comparative quality information on providers and health plans.

These efforts are discussed further in Chapter 5. There is little doubt, however, that we are embarking on a long journey to determine how best to make valid and reliable information available to diverse audiences with different cultural and linguistic capabilities Foote and Etheredge, In general, communication with consumers is enhanced through the use of common terminology, standardized performance measures, and reporting formats that follow common conventions.