An Introduction to Health Care and Health Policy in the United States Foundations For Community Health Workers (2009) Editors: Berthold, T., Miller, J., and Avila-Esparza, A. San Francisco: Jossey-Bass Chapter Six An Introduction to Health Care and Health Policy in the United States

What you will learn, part 1 What is a health care system Health care systems in the US How we pay for health care Health insurance programs Medicare Medicaid

What you will learn, part 2 State Children’s Health Insurance Program (CHIP) Who provides health care services How health care providers work together Challenges to the US healthcare system How healthcare providers (don’t) work together Politics for changing healthcare policy

What is a health care system? Organize and pay hospitals, health professionals, drug manufacturers, and others for delivery of services Provide preventative care to stay healthy and quality medical care when sick Ensure equal access to healthcare Coordinate care among clinics, hospitals, doctors, and other healthcare providers through centralized systems

U.S. health care systems Only industrialized economy without universal health care Complicated and uncoordinated mix of services with few common goals and no central leadership Influence and control comes from different sources such as governments, employers, and insurance companies 16% of the economy is spent on health care Factors that contribute to cost are population growth, longer life span, and expensive services

How do we pay for health care? Half of all health care dollars come from local, state, and federal taxes Support programs such as Medicare, Medicaid, and the State Children’s Health Insurance Program (CHIP) Other half comes from private sectors, mostly employers

Health insurance programs Private health insurance Goal is to spread the financial risk for an unexpected event Consumers pay a monthly premium for coverage Important to determine access and quality to health care services Employer-based health insurance 60% of the people with this type of health insurance Majority of people who are uninsured are employed but do not receive benefits from their employer

Does not cover long term care, dental, or vision services Medicare Federally funded and administered program that provides medical care to the elderly Part A- covers health care, nursing facilities, hospice care, and home health care Part B- covers cost of physicians services, outpatient care, and other medical services that Part A does not Part C- known as Medicare+ choice or Medicare advantage Part D- the newest part of the Medicare program, and now covers prescription drugs Does not cover long term care, dental, or vision services

Medicaid Helps some but not all low-income individuals and families Federal and state funded - administered by each state Individuals and families who are eligible for Medicaid: Pregnant women and families with income below 133% of Federal poverty level Recipients of Supplemental Security Income (SSI) and recipients of adoption or foster care assistance U.S. citizens or permanent residents Services are hospital stays, nursing home care, preventive care, family planning, labs, and x-rays Majority of funds pay services for the elderly who are low income

State Children’s Health Insurance Program (CHIP) Funded by Federal and State funds and administered by each State Services provided by each State are well-baby, and well-child care, immunizations, and emergency services Most States provide a comprehensive benefit package and some States include vision and dental services

Who provides health care services? Hospital care Wide range of care from primary care to specialty care Out patient clinics and inpatient services A hospital stay costs $3,000 a day, plus the cost of services Physician care Physicians do not work for hospitals – admitting privileges People with insurance see a primary care doctor most often Community health center care More then 6,000 community health centers in the US Affordable and accessible source of healthcare Non-profit outpatient care intended to serve the neediest

How health care providers (don’t) work together Physician group practices, hospital chains and managed care plans work together in pieces Pieces of the U.S. healthcare system do not fit together CHWs are a vital piece in the healthcare system Provide health education to individuals, families, and communities Link people to healthcare services and resources Navigators and advocates that access quality healthcare services for individuals and their families

Challenges to the U.S. healthcare system Providers of healthcare such as doctors, hospitals, and pharmaceutical companies resist changes Focus is on advanced and expensive technology to treat diseases rather than than prevention Process for changing public policies is slow with checks and balances Despite these challenges, efforts for healthcare equity continue at state, local, and Federal levels

Politics for changing healthcare policy Stakeholders with different interests and views try to influence healthcare systems and policies These stakeholders include: Individuals, families, and communities Physicians Hospitals Insurance companies Business Labor unions Pharmaceutical companies

Words to know Health care system Private health insurance Employer-based health insurance Medicare Medicaid State Children’s Health Insurance Program (CHIP)