Module Components

• Overview

Topics

• Definitions
• Case Study
• Structure and Financing
• U.S. Public Health System

Nurs 467 - Public Health Nursing

Module 5: Healthcare Delivery

Structure and Financing

Structure

The US healthcare system has many components that often operate independently from each other.

If you live in Curtis Bay, you may go to a private physicians’ practice on Pennington Avenue for a preventive visit, have blood drawn at Bay Clinical Laboratories in nearby Brooklyn, pick up medications at the Ritchie Pharmacy in Brooklyn, and go to Harbor Hospital if you need surgery.

We haven’t even discussed dental care, nursing homes, and mental health. In other words, our healthcare delivery system is a multilevel industry that operates via a complex set of interactions between consumers, providers, payers, employers, and the government. Unfortunately, this complex system does not distribute goods and services equitably across the country and among populations. Too often it depends on who, if anyone, is paying the bills.

Financing

Payment for health-related services in the US occurs in one of three ways.

Private Insurance
This often is offered (and partially paid for) by employers, or people can purchase their own private insurance plan offered by companies like Blue Cross/Blue Shield, Aetna or Cigna. You (or your employer) pay the insurance company and then the insurance company pays for some or all of your care. Sometimes you are responsible for paying the service provider (doctor, lab, hospital) directly, depending on your plan. The cost-sharing can be complicated, see the Definitions page for more information. Before the Affordable Care Act, the private insurance industry was wholly unregulated, meaning insurers could do things like charge women higher rates than men and refuse to pay for “pre-existing conditions”, or conditions that were present prior to obtaining the insurance plan.

Public Insurance
This includes Medicare and Medicaid and is paid for by our taxes. Medicare is the public insurance plan for adults over the age of 65 and some disabled people. Medicare is paid for entirely by the federal government. Medicaid is the public insurance plan for people with low income levels and is paid for with a combination of federal and state dollars. Both Medicare and Medicaid often require cost sharing but at more affordable levels.

In Maryland, once a resident enrolls in Medicaid, he or she must then choose a Managed Care Organization (MCO). There are nine to choose from, each offering different access to hospitals, providers, pharmacies, etc. Please view this comparison chart of the nine MCOs in Maryland.

Out of Pocket
This means that you do not carry an insurance plan of any kind and must pay service providers their fees directly. This can be prohibitive because insurance companies and the government are able to negotiate lower prices with service providers, whereas you as an individual often cannot. For example, if you have Cigna insurance and you go to a lab for bloodwork before meeting your deductible, you may have to pay $35 for a blood test because that is the amount that Cigna agreed on with the lab. If you have no insurance, the lab will charge you their full price, which can be significantly higher.

Affordable Care Act (ACA)

The video that you watched gives excellent detail on the ACA. Here is a summary of four major concepts to focus on:

• Employer mandate: this means companies of a certain size must offer affordable health insurance benefits to their full-time employees.
• Marketplace: this is often called the “exchange”. It is a virtual place where state residents can compare insurance plans that are available for individuals and families that are not able to take advantage of employer insurance, for whatever reason. There are strict rules that insurance companies must follow if they want to offer plans on a state’s exchange site.
• Individual mandate: this was the rule that required all individuals to carry health insurance or pay a penalty. It has since been repealed.
• Medicaid expansion: this gave states the option to receive additional funding to expand Medicaid availability to a larger portion of the population.

How do we compare with other countries?

As you saw in the video, we spend the most per person on healthcare and have worse outcomes than most developed countries. Our life expectancy is lower, our infant mortality rate is higher and we rank in the top 10 countries for cardiovascular death rates. Think about the structure and financing of healthcare offered in other countries, like Great Britain’s National Health System. What are the major differences that you see? Could we do something similar here in the US?