Complexities of the US Private Insurance System – You are part of an international health conference where health professionals from around the world have gathered. Your role is to provide a greater understanding of the history and current standings of the U.S. healthcare system. The first day of the conference focuses on the history of healthcare.

The Complexities of the US Private Insurance System

HE002: History of the U.S. Healthcare System

Write your responses where it reads “Enter your response here.” Write as much as needed to satisfy the requirements indicated. Each item contains the Rubric which will be used to evaluate your responses.

A.      Evolution of the U.S. Healthcare System

  • Part A: Describe the critical historic events since World War II (after 1945) that have influenced U.S. healthcare evolution. Provide ONE topic per paragraph (5 separate paragraphs).
  • Part B: Read the scenario (below), and then respond to the instruction that follows.

Scenario: You are part of an international health conference where health professionals from around the world have gathered. Your role is to provide a greater understanding of the history and current standings of the U.S. healthcare system. The first day of the conference focuses on the history of healthcare. You will have a friendly debate with Germany and Canada on how healthcare has evolved.

Create a table that presents the similarities and differences of the healthcare systems among the U.S., Germany, and Canada. Pertinent information should include but is not be limited to:

  • Total population
    • Gross national income per capita
    • Life expectancy at birth for males and females
    • Total expenditure on health per capita
    • Total gross domestic product percentage (GDP %) expenditure on health

Your Response

Employee Health Benefits

After World War II (WWII), wage and price controls were instituted on employers. As a result, employers introduced health benefits as part of compensation to attract more workers. Even though the health benefits framework was introduced to overcome the salary and price controls that had been set during WWII. However, employees tended to show disinterest in the national health insurance plan after having received a cushion against health care prices (Catlin & Cowan, 2015). Tax incentives provided to employers offering health insurance plans further advanced the employer-based health system. Employee health benefits led to extensive innovations in healthcare finance and organization that fueled the rapid growth and evolution of the health care system (Catlin & Cowan, 2015).

Medicare and Medicaid 1965

The current US healthcare system is an accumulation of different factors and events that have shaped its evolution. Critical to the system was the introduction of Medicare and Medicaid in 1965. After years of proposals for comprehensive health coverage, Medicare was introduced to cover individuals the age of 65 and over, and Medicaid focused on long-term care for the poor and disabled. As a result, there was an increase in companies offering private health insurance and specialization among doctors (Oberlander, 2015). Despite the drastic changes the coverage schemes have undergone, Medicare and Medicaid cover 16.3% and 19.6% of the American population, respectively.

Emergency Medical Treatment and Active Labor Act (EMTALA) 1985

The law made it mandatory for hospitals to treat patients in need of emergency care regardless of their ability to pay, citizenship, or even legal status. Regarded as one of the most effective and encompassing laws on nondiscriminatory access to emergency medical care and thus to the healthcare system, EMTALA shifted the costs of care for the underprivileged from states to private facilities as it provided no additional coverage for the mandated services (Rosenbaum, 2013).

Health Insurance Portability and Accountability Act (HIPAA) 1996

HIPAA, enacted in 1996, aimed at protecting individuals covered by health insurance by ensuring that health-care plans are accessible, portable, and renewable. The law also sets the standards and the methods for how medical data is shared across the U.S. health system in order to prevent fraud. HIPAA facilitated the safe and secure administration of healthcare and set in motion the development of policies and technologies inclined to safeguard the patient while also providing quality care (Edemekong, & Haydel, 2019).

The Affordable Care Act 2010

Signed into law by President Barrack Obama in 2010, the Affordable Care Act is seen to set off a series of severe reforms in the health insurance system of the U.S. Some of these reforms comprise of introduction of health insurance markets, unpriced preventive care and affordable care for persons below the age of 26 (Burstin, Leatherman & Goldmann, 2016). The Affordable Care act had to maneuver through multiple repeal votes in the House of Representatives. It is, nonetheless, signed into law finally and made active immediately after. In 2014, the Affordable Care Act came into full effect on January 1st. Some of the most essential parts of it that were made active include; proscription of the pre-existing conditions, elimination of the lifelong limitations on insurance coverage, also, individual mandate as well as Medicaid are expanded to allow individuals who can afford insurance to purchase coverage at affordable rates (Burstin, Leatherman & Goldmann, 2016).

Similarities and differences of healthcare system between America, Canada, and Germany.

InformationAmericaCanadaGermany 
Total population  About 84 percent of the total population is enclosed by either 26 percent public insurance or 70 percent private insurance (Ridic, Gleason, & Ridic, 2012).Every person is required to have health insurance (Ridic, Gleason, & Ridic, 2012).The government provides for the health insurance of all citizens (Ridic, Gleason, & Ridic, 2012).
Gross national income per capita  America’s GNI per capita As at 2018 was $62,850.00Canada’s GNI per capita As at 2018 was  $44,860.00Germany’s GNI per capita As at 2018 was $1038.74
Life expectancy at birth for males and females  78.69 years on average; 78.7 for females 78.5 for males.82. 30 years on average; 80 years for males and 84 for females81.26 percent on average; 83.5 percent for females and 78.7 percent for males
Total expenditure on health per capita  By 2018, the total expenditure on health per capita in was $11, 172.00By 2018, the total expenditure on health per capita in was $6, 448.40By 2018, the total expenditure on health per capita in was $5,011.19
Total gross domestic product percentage (GDP %) expenditure on health  Spent 17.8 percent of GDP on healthcare on healthcare in 2016 (Health Care Spending in US, Other High-Income Countries., n.d.)Spent on same year spent 11 percent on health care (Barua, Timmermans, Nason & Esmail, 2016).Spent on the same year 10.1 percent on healthcare (Barua, Timmermans, Nason & Esmail, 2016).

 

Rubric

 0 Not Present1 Needs Improvement2 Meets Expectations3 Exceeds Expectations
Sub-Competency 1: Explain how the U.S. healthcare system has evolved.
Learning Objective 1.1: Describe historic events since World War II (WWII) after 1945 that influenced the U.S. healthcare system.Description of historic events since WWII that influenced the U.S. healthcare system is missing.  Response includes vague details and/or addresses fewer than five historic events that influenced the U.S. healthcare system following WWII.   Response does not include references to academic/professional resources or the resources are not relevant.Response includes five key historic events that influenced the U.S. healthcare system following WWII (after 1945)   Response includes references to relevant academic/professional resources.Response demonstrates the same level of achievement as “2,” plus the following:   Response includes insight on some of the ramifications of one or more of these historic events.
Learning Objective 1.2: Identify the similarities and differences among healthcare systems in various countries.Identification of the similarities and differences among healthcare systems in various countries is missing.Response includes limited or incorrect similarities and differences among the U.S., Canada, and Germany regarding the total population; gross national income; life expectancy at birth; total expenditure on health per capita; and the gross domestic product percentage (GDP%) expenditure.   Response does not include references to academic/professional resources or the resources are not relevant.Response details similarities and differences among the U.S., Canada, and Germany regarding the total population; gross national income; life expectancy at birth; total expenditure on health per capita; and the gross domestic product percentage (GDP%) expenditure.   Response includes references to relevant academic/professional resources.Response demonstrates the same level of achievement as “2,” plus the following:   Response includes an interpretation of the data in two or more of the data sets.  

1.       The Complexities of the U.S. Private Insurance System

  • Describe two important historic factors that led to the development of the private health insurance industry. (1–2 paragraphs)
  • Describe two current regulations that govern private insurance. (1–2 paragraphs)

Your Response

  1. After WW2, employers began offering health insurance to their employees. However, with time, medical costs grew rapidly influencing a shift in insurance frameworks. As a result, individuals saw the need for pooling resources together and catering for the hospital bills of the sick. The move was, however, reversed with a fear of losing physician influence and income. During the 1950s, the employers who were able to pay high salaries catered for the health insurance cover for their respective employees (Conklin, 2002). This kind of insurance, at that time was tax deductible from the employer but not the employee and the practice led to the escalation of private health insurance. Insurance companies then later decided to be discriminative and refrained from providing health insurance cover to all, particularly, those that looked likely to become sick. This way, they secured their companies from suffering losses and made tremendous gains. However, advances such as the introduction of Medicare and Medicaid made coverage more accessible to low income, underserved and less privileged Americans.

Social insurance covers did not have proper professional guilds or communities. This is due to the fact that in some countries, the GDP is below 10 percent and cannot be able to fully fund the operations that carters for each individual (Gold, 2016). As such, private insurance took over and many individuals embraced it. Private insurance, for the named reasons, has managed to remain relevant across many nations even those that have stable GDPs. More often, its coverage complements public systems as they advance.

  • In order for the implementations of the targeted interventions of private health insurance to effectively take charge, states have to enact laws and regulations that limit mediocrity in it. Good examples of the restrictions imposed on the business of private health insurance include:
  • Seller Policy

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Complexities of the US Private Insurance System
Complexities of the US Private Insurance System

Governments are advised to be wary of institutions that they allow to provide private health insurance cover. Such institutions have to be fully equipped with the necessary resource and information. In addition, they have to be financially stable to run their operations without any ups and downs in order for their clients to receive optimal services always. The policies enacted on these institutions are beneficial to both firms and patients, as they insure safer markets as well as customer protection.

  1. Buyer Policy

Policy makers, in this case, are made able to regulate who has the potential to receive insurance cover and under which conditions. It is here that the breadth and the depth of the coverage is determined. Breadth in this case, concerns a

Rubric

Sub-Competency 2: Describe the development of the private health insurance industry in the U.S.
Learning Objective 2.1: Describe important historic factors that led to the development of the private health insurance industry.  Description of the historic factors that led to the development of the private health insurance industry is missing.Response vaguely describes two historic factors, describes irrelevant factors, or describes only one factor that led to the development of the private health insurance industry.   Response does not include references to academic/professional resources or the resources are not relevant.Response clearly and accurately describes two important historic factors that led to the development of the private health insurance industry.   Response includes references to relevant academic/professional resources.Response demonstrates the same level of achievement as “2,” plus the following:   Response includes insight on these historic factors that influenced the development of private health insurance.
Learning Objective 2.2: Describe current regulations that govern private insurance.  Description of current regulations that govern private insurance is missing.Response includes a vague description of current regulations that govern private insurance and/or addresses only one regulation.   Response does not include references to academic/professional resources or the resources are not relevant.Response clearly and accurately describes two current regulations that govern private insurance.   Response includes references to relevant academic/professional resources.Response demonstrates the same level of achievement as “2,” plus the following:   Response includes two to four additional regulations that govern private insurance.

2.       During the late 1950s and early 1960s, the groundwork for Medicare and Medicaid began. In 1965, during the Johnson and Truman administration, Congress passed amendments to the Social Security Act and created the Medicare and Medicaid programs. Since 1965, there have been many additions and changes to the programs.

Describe each of the following by stating the key provisions of the program, who is eligible, and when it was enacted: (1–2 paragraphs each)

  • Medicare A
  • Medicare B
  • Medicare C
  • Medicare D
  • Medicaid

Your Response

  • Medicare A

Also referred to as Medicare part B, Medicare A is an insurance cover that carters for the hospital bills or inpatient settings-like bills, for instance, trained nursing services. This type of plan, however, has not been able to carter for long-term care. The plan’s coverage also, is applied automatically to persons who are entitled to social security benefits (Berkowitz, 2005). For the unemployed or those that have no checks, registration is open for them through the social security web.

  • Medicare B

This kind of insurance covers outpatient expenses, for example, doctor visits. It has also been designed to take charge of expense on other services, for instance, ambulatory facilities, precautionary facilities, coverage on mental health, and various health equipment. In addition, a couple of prescription drugs are also included in this plan. Premiums are considerably expensive for persons whose annual income exceed $87, 000 (Berkowitz, 2005).

  • Medicare C

This kind of plan is also identified as Medicare advantage. According to its policies, the coverage that it offers should at least be equitable to the Original Medicare. Often, clients buy Medicare Advantage from the private insurance firms than from the government. Many of these kind of plan do give annual covers based on a cash at hand basis (Berkowitz, 2005). Additional, a considerable number of them give care and services cover that would have not been offered by Original Medicare.

  • Medicare D

Medicare has been structure to offer prescription drugs an insurance coverage through this plan. Members of plans A and B often enroll with plan D to receive the prescription drug services, which would have not been provided in the Original Medicare (Berkowitz, 2005).

  •  Medicaid

This is a health insurance program that is sponsored by the government. In other words, it well described as a state plan or a mutual federal program that offers health insurance covers to the less fortunate in society. Beneficiaries are expected to own a restricted amount of assets to be fully in compliance with its policies (Berkowitz, 2005). Any Medicaid coverage beneficiary is entitled to laboratory and x-ray services, home-healthcare, hospitalization, nursing amenities among many others.

Rubric

Sub-Competency 3: Describe the healthcare-related programs associated with Medicare and Medicaid.
Learning Objective 3.1 Describe Medicare Part A.Description of Medicare Part A is missing.Response vaguely or inaccurately describes key provisions of Medicare Part A, when it was enacted, and who is eligible and/or the response is incomplete.   Response does not include references to academic/professional resources or the resources are not relevant.Response clearly and accurately describes key provisions of Medicare Part A, when it was enacted, and who is eligible.   Response includes references to relevant academic/professional resources.Response demonstrates the same level of achievement as “2,” plus the following:   Response includes critical issues or other insights related to Medicare Part A.
Learning Objective 3.2 Describe Medicare Part B.Description of Medicare Part B is missing.Response vaguely or inaccurately describes key provisions of Medicare Part B, when it was enacted, and who is eligible and/or the response is incomplete.   The response does not include references to academic/professional resources or the resources are not relevant.Response clearly and accurately describes key provisions of Medicare Part B, when it was enacted, and who is eligible.   The response includes references to relevant academic/professional resources.Response demonstrates the same level of achievement as “2,” plus the following:   Response includes critical issues or other insights related to Medicare Part B.
Learning Objective 3.3 Describe Medicare Part C.Description of Medicare Part C is missing.Response vaguely or inaccurately describes key provisions of Medicare Part C, when it was enacted, and who is eligible and/or the response is incomplete.   Response does not include references to academic/professional resources or the resources are not relevant.Response clearly and accurately describes key provisions of Medicare Part C, when it was enacted, and who is eligible.   Response includes references to relevant academic/professional resources.Response demonstrates the same level of achievement as “2,” plus the following:   Response includes critical issues or other insights related to related to Medicare Part C.
Learning Objective 3.4 Describe Medicare Part D.Description of Medicare Part D is missing.Response vaguely or inaccurately describes key provisions of Medicare Part D, when it was enacted, and who is eligible and/or the response is incomplete.   Response does not include references to academic/professional resources or the resources are not relevant.Response clearly and accurately describes key provisions of Medicare Part D, when it was enacted, and who is eligible.   Response includes references to relevant academic/professional resources.  Response demonstrates the same level of achievement as “2,” plus the following:   Response includes critical issues or other insights related to related to Medicare Part D.
Learning Objective 3.5 Describe Medicaid.Description of Medicaid is missing.Response vaguely or inaccurately describes key provisions of Medicaid, when it was enacted, and who is eligible and/or the response is incomplete.   Response does not include references to academic/professional resources or the resources are not relevant.Response clearly and accurately describes key provisions of Medicaid, when it was enacted, and who is eligible.   Response includes references to relevant academic/professional resources.  Response demonstrates the same level of achievement as “2,” plus the following:   Response includes critical issues or other insights related to Medicaid.

4. The passage of the Patient Protection and Affordability Care Act (PPACA) has many different components that impact healthcare services by expanding access, lowering costs, and improving quality. Describe the following programs, which evolved from the PPACA: (2 paragraphs each)

  • Individual Mandate and Tax Implications
  • Patient-Centered Medical Home Model (PCMH)
  • Accountable Care Organization (ACO)
  • Prevention and Wellness (two programs)

Your Response

  • Individual Mandate and Tax Implications

In order to acquire relevance in the Patience Protection and Affordable Care Act (PPACA), all citizens are required to comply with the scripted policies of PPACA or alternatively be subject to tax for not doing so. This was made effective as from the year 2014. It is also considered to mark the first time in the history of America when the government decided to force its citizens into buying insurance cover. The lawsuit, on the other hand, responded by refashioning the mandate as purchase insurance cover or pay tax for failing to do so, and was supported by 26 states (NFIB, n.d.).

Looking into certain facts and considerations, there seems to be portion of individuals in America who will be exempted from the tax. In this the exempts include persons with staunch religious protests,  American Indians who receive insurance coverage from their country of origin, unregistered immigrants, individuals who have remained uninsured as long as three months, detainees serving jail terms, and the fraction of persons whose income tend be rank below the threshold (NFIB, n.d.).

  •  Patient-Centered Medical Home Model (PCMH)

In this model, patients are directly engaged to their care provider with an aim of enhancing the relationship. The care provider is expected to coordinate a team of health professionals that cooperatively remain collected and responsible for an all-inclusive assimilated health care to the patient (Hall, Holtrop, Dickinson, & Glasgow, 2017).  They should advocate, plan, and arrange quality care alongside other professional caregivers and community resources as required.

Practices within the PCMH do enhance transdisciplinary care groups that progress the coordination of caregivers as well as care management of the patient populations with the purpose of rendering top quality, efficiency and safety in patient care. Through recognition of PCMH, practices can advance the conveyance of health support, which may be advantageous to public or private enticement remunerations that recompense patient-centered care centers (Hall et al., 2017). PPACA offers sufficient federal funding to states so that they can manage the operations in care homes that serve Medicaid beneficiaries.

  • Accountable Care Organization (ACO)

These are organizations and professionals (doctors) who join hands in providing affordable care to the less fortunate. Their aim is to ensure that patients acquire the appropriate at the correct time and affordably. They practice that consciously careful that they might not duplicate services in the process. Also, when an ACO effectively operates and becomes successful, its extra funds are offered to other organizations and or persona that need it dearly (Gold, 2016). It is considered the most discussed topic in Obamacare with regards to how much it has been embraced by it. In Obamacare, every Accountable Care Organization is expected to manage at least 5,000 Medicare recipients for a period not less than three years.

It was later included in the law by the congress in order to help reduce the national deficit. The law, therefore, opens up a Medicare Shared Savings Program. Though the program, ACOs are made responsible having their providers to coordinate and raise funds by avoiding any unnecessary operations (Gold, 2016). Providers, in that regard, are made to choose between taking a risk of losing their finances while aiming for greater rewards or simply joining the program and remaining safe (Gold, 2016). 

  • Prevention and Wellness (two programs)

The public health care of the United States has been improved ever since the introduction of the of the prevention and wellness programs (CMS.gov, 2012). Through the Affordable Care Act, fresher builds and incentives that coexist in today workplaces have made work environments heathier and encouraged much more opportunities for the same.  The constituent parts of Health and Human Services (HHS), Treasury, Labor are working together to improve the conditions that favor this policy in accordance with the requirements of the ACA (CMS.gov, 2012).

In an attempt of keeping clients from unfair practices, regulations have been brought forth that will call for integrity and will demand accomplices to adhere to certain laws. In that regard, programs that are designed should be reasonably made to suit the purpose, in this case, the suggested disease (CMS.gov, 2012). Also, while designing the programs, the programmers should consider the similarly situated persons. Here, alternatives that match the prerequisites of the designed program should be made available. This is to ensure that medical conditions are not made difficult to run into the quantified health standard to anyone (CMS.gov, 2012).

Rubric

Sub-Competency 4: Describe components of the Patient Protection and Affordable Care Act (PPACA).
Learning Objective 4.1: Describe the Individual Mandate and Tax Implications.Description of the Individual Mandate and Tax Implications is missing.Response includes a vague or incomplete description of the Individual Mandate and Tax Implications and/or its purpose.   Response does not include references to academic/professional resources or the resources are not relevant.Response accurately and completely describes and states the purpose of the Individual Mandate and Tax Implications.   Response includes references to relevant academic/professional resources.  Response demonstrates the same level of achievement as “2,” plus the following:   Response explains the impact of the Individual Mandate and Tax Implications on quality and cost of healthcare.  
Learning Objective 4.2: Describe the Patient-Centered Medical Home Model.Description of the Patient-Centered Medical Home Model is missing.Response includes a vague or incomplete description of the Patient-Centered Medical Home Model and/or its purpose.   Response does not include references to academic/professional resources or the resources are not relevant.Response accurately and completely describes and states the purpose of the Patient-Centered Medical Home Model.   The response includes references to relevant academic/professional resources.    Response demonstrates the same level of achievement as “2,” plus the following:   Response explains the impact of the Patient-Centered Medical Home Model on quality and cost of healthcare.
Learning Objective 4.3: Describe the Accountable Care Organization.Description of the Accountable Care Organization is missing.Response includes a vague or incomplete description of the Accountable Care Organization and its purpose.   Response does not include references to academic/professional resources or the resources are not relevant.Response accurately and completely describes and states the purpose of the Accountable Care Organization.   Response includes references to relevant academic/professional resources.  Response demonstrates the same level of achievement as “2,” plus the following:   Response explains the impact of Accountable Care Organization on quality and cost of healthcare.
Learning Objective 4.4: Describe Prevention and Wellness programs.Description of two Prevention and Wellness programs is missing.Response includes a vague or incomplete description and/or purpose of two Prevention and Wellness programs.   Response does not include references to academic/professional resources or the resources are not relevant.Response accurately and completely describes and states the purpose of two Prevention and Wellness programs.   Response includes references to relevant academic/professional resources.  Response demonstrates the same level of achievement as “2,” plus the following:   Response explains the impact of two Prevention and Wellness programs on quality and cost of healthcare.

Reference

Barua, B., Timmermans, I., Nason, I., & Esmail, N. (2016). Comparing performance of universal health care countries, 2016. Fraser Institute.

Berkowitz, E. (2005). Medicare and Medicaid: The past as prologue. Health care Financing Review27(2), 11.

Burstin, H., Leatherman, S., & Goldmann, D. (2016). The evolution of healthcare quality measurement in the United States. Journal of internal medicine279(2), 154-159.

Catlin, A. C., & Cowan, C. A. (2015). History of health spending in the United States, 1960-2013. Centers for Medicare and Medicaid Services.

CMS.gov. (2012, December 4). The Affordable Care Act and Wellness Programs. Retrieved from https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/wellness11202012a

Conklin, T. P. (2002). Health care in the United States: An evolving system. Michigan Family Review7(1).

Edemekong, P. F., & Haydel, M. J. (2019). Health Insurance Portability and Accountability Act (HIPAA). In StatPearls [Internet]. StatPearls Publishing.

Gold, J. (2016, July 13). Accountable Care Organizations, Explained. Retrieved from https://khn.org/news/aco-accountable-care-organization-faq/

Hall, T. L., Holtrop, J. S., Dickinson, L. M., & Glasgow, R. E. (2017). Understanding adaptations to patient-centered medical home activities: the PCMH adaptations model. Translational behavioral medicine7(4), 861-872.

Health Care Spending in US, Other High-Income Countries. (n.d.). Retrieved from https://www.commonwealthfund.org/publications/journal-article/2018/mar/health-care-spending-united-states-and-other-high-income

NFIB. (n.d.). Facts About PPACA Individual Mandate. Retrieved from https://www.nfib.com/cribsheets/individual-mandate/

Oberlander, J. (2015). The political history of Medicare. Generations39(2), 119-125.

Palmer, K. (1999). A Brief History: Universal Health Care Efforts in the US” Physicians for a National Health Program. Physicians for a National Health Program.

Ridic, G., Gleason, S., & Ridic, O. (2012). Comparisons of health care systems in the United States, Germany and Canada. Materia socio-medica, 24(2), 112.

Rosenbaum, S. (2013). The enduring role of the emergency medical treatment and active labor act. Health Affairs32(12), 2075-2081.

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