I) Healthy Insurance in the U.S.a. Insurance is pooling of risk b. Types of health care:i. Beveridge Model: health insurance is public-financed by taxes (like libraries/police) many/most hospitals are public and users don’t get doctor bills. Government limits treatments and charges to keep costs down [UK, most of Scandinavia, HK, Spain, Cuba]ii. The Bismarck Model: insurance paid for by employers and employees, but plans are non-profit, tightly regulated, and must cover everyone. Despite private doctors/hospitals costs are kept low/down [Germany, France, Belgium, Switzerland, Japan]iii. The National Health Insurance Model: private providers however payment comes from universal public insurance program (government run). Costs low because of non-profit, and single payer can negotiate low drug prices-but also b/c treatments may be limited and waits may be longiv. The Out-of-Pocket Model: much of the world, including developing countries1. Public insurance (single-payers): Beveridge model (public providers), national health insurance model (private providers)2. Private insurance (not single-payers): Bismarck model (but w/major government regulation) [private providers], and no insurance: out-of-pocket modelc. The US is a mix of all the above:i. Veterans getting healthcare through the veterans’ health administration1. Beveridge Model (public-public)ii. For employed adults getting healthcare through employers1. Bismarck Model (private-private)iii. For the uninsured, tough luck1. Out-of-pocket Modeld. US Healthcare: most expensive and worst performing (Khazan, 2014)i. Commonwealth fund report compared 11 countries healthcare systems (US, UK, NZ, Australia, Canada, and 6 European countries)ii. Most expensive: US spends 17.7% of GDP on healthcare (other countries= 7-11%); US has highest per capita health expenditures ($8,508)iii. Worst performing: US scores high on ‘effective care’ but ranked worst inefficiency, equity, healthy lives, and cost-related barriersII) Obamacarea. Single-payer healthcarei. Refers to universal health care systems where costs are paid by a single, public (government) systemii. Some countries (Canada, Taiwan) are considered pure single-payer systemsiii. Other countries have a combination of public and private payers (or regional rather than national public payers)b. Health insurance b/t jobsi. How do Americans b/t jobs get health insurance?1. OPT1: Pay for COBRA insurance (up to 18 months post-job loss) but very expensive, must pay full cost of former employer’s insurance and admin fee (2017 avg: $569/month=singles and $1595/month=families)2. OPT2: Pay out-of-pocket (even more expensive)3. OPT3: sign up for short-term (1-year plans) w/limited benefits4. OPT4: sign up for Medicaid if eligible5. OPT5: none/uninsuredc. Germany’s healthcarei. All residents of Germany are required by law to have health insuranceii. 87% have statutory HI1. Nonprofit firms offer same mandated coverage but compete with eo by offering optional perks (covering costs of exercise classes/travel vaccines)2. Costs 14.6% of gross income, split evenly b/t employee and employers3. Unemployed, students, retirees alsoiii. Others have highly regulated private insuranced. Obamacare Goals/Timeline (Kliff)i. Obamacare= Patient Protect and Affordable Care Act (ACA/ PPACA)ii. Main goal: increase # of Americans covered by health insurance and decrease of HCiii. 03/2010 signed into law -> indiv. Mandate upheld by supreme court in 06/2012 (Medicaid expansion=optional) ->exchanges opened 10/2013 -> indiv. Mandate went in effect (01/2014) -> indiv. Mandate repealed (12/2017) effective (2019)e. Main features of Obamacare:i. Individual mandate: individuals must get minimum essential coverage/ pay a fee at tax timeii. All plans must cover minimum benefits w/ no $ limits on 10 essential health benefits (ER care, hospital stays, lab services, maternity care, mental health/substance abuse treatment, preventive care, pediatric care)iii. Guaranteed issue: insurance companies cannot deny coverage/charge more based on pre-existing conditionsiv. Employer mandate: business w/50+ full time employees must provide insurance (effective 2015-2016)v. 26 is when young adults can’t stay on parent’s planvi. Expansion of Medicaid in states choosing to acceptvii. Marketplace (exchanges): through HC.gov/ state-run w/ some people eligible for subsidiesf. Tax penalties: increased from 2015-2016 (not qualified for insurance for year anddon’t qualify for exemption)g. Bronze covers 60%, silver 70%, gold 80%, platinum 90% of medical costsh. Tax penalties=smaller than actual cost of insurance (for those not eligible for waivers; reason why many choose to pay penalties and not insurancei. Democratic states expanded Medicaid/ alternative plan; republican states did notj. Evaluating Obamacare: successes (Cliff 2017, Sanger-Katz 2017)i. 17-20 million more people have HI1. # of uninsured in US dropped (48.6->31 million)2. % uninsured dropped by 40% in Medicaid expansion states- but only 10% in non-expansion statesii. Made American more financially secure (medical debt is #1 cause of bankruptcyiii. Reduced inequality (a redistributive law)iv. HI more comprehensivev. Reduced federal deficitvi. Some insurance companies, pharmaceutical companies, and hospitals= flourishing because ACA provides them with new costumersk. Evaluating Obamacare: Failuresi. Health insurance is still very expensiveii. HC system remains complex and confusingiii. Can’t always keep your plan/doctor1. Overregulation (insurance companies, employers, and individuals)2. Too much govmt spending3. Employer mandate can discourage job growth (employers don’t want to hit 30h/week cut off for getting insurance)l. Too soon to tell if people=healthier, if law contributed to slowdown in HC spending, if hospital care/quality improvedIII) Immigrant Healtha. Immigrant health paradox: immigrants face challenges such as language barriers, financial difficulties and discriminationi. Despite difficulties immigrants tend to have better health and mortality profiles than native born=health paradox (markides)ii. Immigrant health advantages= reduced w/time in host country and disappear by next gen. ; due to part to changes in health behaviors and acculturation processes (process which individual adopts, acquires, and adjust to a new cultural environment)b. Immigrant/ethnic enclavesi. Some scholars propose immigrant/ethnic enclaves are protective of health because they