US Healthcare Policies and Delivery Systems
Where does healthcare financing come from?
​
Healthcare finance is such a big topic and core component of health systems that there are various hands that finance it in the US. Healthcare financing issues have been contributing factor to the evolution of healthcare. Personal payment has changed to financing through health insurance by the employer and employee at the workplace. Progression towards governmental funding has turned healthcare finance into a multifaceted system. One that is governmentally financed through social security or general taxation and supplemented by private or non-governmental organizations and personal out-of-pocket spending.
Mechanisms of Financing Healthcare
-
government through general revenue, taxes and social insurance contributions
-
private insurance premiums
-
direct out of pocket payments
Government
Private Health Insurance
The government’s various roles in healthcare financing can be considered as a mosaic of individual programs. These programs consist of reimbursement, direct payments to vendors, grants, matching funds, and subsidies. The government uses programs such as Medicare and Medicaid and State Children's Insurance Program. These programs are meant for those who would otherwise not be able to afford other means of affording healthcare and are unable to utilize the other mechanisms of healthcare finance. The downfalls are access to care due to coverage issues.
Any Health insurance plan that is not run by the federal or state government. This insurance is most commonly offered by an insurer to exchange a set of benefits for a payment in the form of a specified premium and can be purchased from your employer, a state or federal marketplace, or a private marketplace. Consumers are able to choose or shop insurance packages that best meet their preferences. Packages are offered at group or individual basis. Managed care organizations are synonymous to private healthcare. These consist of HMOs, PPOs and a POS plan. Private health insurance is costly and many cannot afford the premiums. Coverage and access can be concerns.
​
​
​
​
​
Direct Out-of-Pocket Payments
Direct out-of-pocket payments are made by patients to private providers at the time a service is rendered. Medical care expenses that aren't reimbursed by insurance that include deductibles, coinsurance, and copayments for covered and uncovered services. A major access barrier that contributes to high costs is unregulated direct charges.
​
​
​
Legislation Passed in 2019
​
According to Govtrack, "
This bill alters several Medicaid programs and funding provisions.
For example, the bill temporarily extends the applicability of Medicaid eligibility criteria that protect against spousal impoverishment for recipients of home- and community-based services.
The bill also establishes a state Medicaid option to provide for medical assistance with respect to coordinated care provided through a health home (i.e., a designated provider or team of health-care professionals) for children with medically complex conditions. States must determine payment methodologies in accordance with specified requirements; payments also temporarily qualify for an enhanced federal matching rate."
​
According to Govtrack, "
This bill alters several Medicaid programs and funding mechanisms. Specifically, the bill
makes appropriations through FY2024 for, and otherwise revises, the Money Follows the Person Rebalancing Demonstration Program; allows state Medicaid fraud control units to review complaints regarding patients who are in noninstitutional or other settings; temporarily extends the applicability of Medicaid eligibility criteria that protect against spousal impoverishment for recipients of home and community-based services; temporarily extends the Medicaid demonstration program for certified community behavioral health clinics; repeals the requirement, under the Medicaid Drug Rebate Program, that drug manufacturers include the prices of certain authorized generic drugs when determining the average manufacturer price (AMP) of brand name drugs (also known as a "blended AMP"), and excludes manufacturers from the definition of "wholesalers" for purposes of rebate calculations; and increases funding available to the Medicaid Improvement Fund beginning in FY2021."
​
According to Govtrack, "This bill reauthorizes through FY2024 the Emergency Medical Services for Children Program, which is a grant program administered by the Health Resources and Services Administration. The program focuses on improving emergency health care for children who are seriously ill or injured."
​
According to Govtrack, "This bill (1) temporarily extends the Medicaid demonstration program for certified community behavioral health clinics, and (2) reduces funding available to the Medicaid Improvement Fund beginning in FY2021."
​
According to Govtrack, "
It is known as a continuing resolution (CR) and prevents a government shutdown that would otherwise occur when FY2020 begins on October 1, 2019, if the 12 regular appropriations bills that fund the federal government for FY2020 have not been enacted.
The CR funds most projects and activities at the FY2019 levels with several exceptions that provide funding flexibility and additional appropriations to various programs.
Additionally, the CR extends several programs that are scheduled to expire at the end of FY2019, including
several health programs, the National Flood Insurance Program, the Temporary Assistance for Needy Families (TANF) program and related programs, several authorities related to immigration, the Calfed Bay-Delta Authorization Act, the Department of Education's National Advisory Committee on Institutional Quality and Integrity, the Export-Import Bank of the United States, and the U.S. Commission on International Religious Freedom. The bill also includes a provision that permits the Department of Agriculture to continue making payments to farmers affected by retaliatory tariffs by accelerating reimbursements to the Commodity Credit Corporation for certain net realized losses sustained in FY2019"
​
​
Potential/Pending Legislation
​
According to Govtrack, "This resolution urges the Department of Justice (DOJ) to cease its efforts against the Patient Protection and Affordable Care Act (PPACA) and reverse its position in Texas v. United States. (On March 25, 2019, DOJ submitted a letter to the appellate court agreeing with the lower court's decision that PPACA should be struck in its entirety)."
​
S. 1895: Lower Health Care Costs Act
​
​
According to Govtrack, "To amend the Internal Revenue Code of 1986 and title XI of the Social Security Act to extend appropriations and transfers to the Patient-Centered Outcomes Research Trust Fund and to extend certain health insurance fees for such transfers, and for other purposes."
​
H.R. 1781: Payment Commission Data Act of 2019
According to Govtrack, "To amend titles XVIII and XIX of the Social Security Act to provide the Medicare Payment Advisory Commission and the Medicaid and CHIP Payment and Access Commission with access to certain drug payment information, including certain rebate information."
​
​
To amend titles XVIII and XIX of the Social Security Act to provide the Medicare Payment Advisory Commission and the Medicaid and CHIP Payment and Access Commission with access to certain drug payment information, including certain rebate information.
References
Health. (n.d.). Retrieved from https://www.govtrack.us/congress/bills/subjects/health/6130.