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87 Cards in this Set

  • Front
  • Back
What is health?
-physical, mental, and social well-being (broad definition)
-absence of disease/infirmity=good health
Population health
The overall health of a group. How to measure population health:
1. infant mortality
2. life expectancy
3. mortality rates
4. morbidity (illness) rates:
-disease incidence=# of new cases
-disease prevalence=% of population w/ disease
What measures are commonly used in evaluating health strategies and policies?
1. Outcome:
a. change in mortality/morbidity rates
b. change in life yrs/quality
2. Input
a. medical interventions
b. behavior
3. Resource-related
a. program costs
b. cost-effectiveness
c. net benefits
How has mortality risk changed over 20th century?
1900-1920: Pasteurization, cleaner water, sewer systems
1918: Upward spike w/ WWII: influenza pandemic
1930-1940: Drugs, penicillin
1940-1980: steady; 1980s increase=AIDS
What produces health?
1. Environment
2. Lifestyle choices
3. Social Environment
4. Biological
5. Medical Care
Wealth and health
Nature of Causality?
a. Usual assumption: wealth-->health
b. health-->wealth
c. latent effects
What are the implications of health/wealth causality for public policy?
with equal access to health care, individual's stress due to socio-economic status is reduced, thus increasing health..etc.
What is the role of the prenatal environment?
birth health/weight causes:
-smoking, alcohol, malnutrition, chronic health of mom, etc.
What has been the government's response to the prenatal environment?
WIC-effective program
-encouraging breastfeeding in mothers and thus health in mothers and children
What are the rationales for public policy to reduce smoking?
1. Information as a public good
2. Information asymmetry
3. Externalities
4. Intrapersonal externalities
Rivalrous good
consumption by one consumer prevents simultaneous consumption by another consumer
Nonrivalrous good
can be consumed by one consumer without preventing simultaneous consumption
excludable good
possible to prevent people who haven't paid from not using the good
nonexcludable good
not possible to prevent people who haven't paid from using the good
smoking=nonrivalrous and nonexcludable
externalities make it public policy problem
search goods
can assess full quality before you make purchasing decision
experience goods
can't assess full quality beforehand; i.e. smoking, restaurants
External costs on society by smoking
1. Work loss
2. Medical costs (borne by others)
3. Social security
4. Productivity Loss
5. Second hand smoke
6. Littering
Intrapersonal externality
choosing to smoke=imposing externality on yourself
What are possible policy interventions to reduce smoking?
1. Taxes
2. PSAs
3. Advertising

Basically, propaganda
What are the health risks of smoking?
1. Cancer
2. Cardiovascular disease
3. Respiratory disease
4. Prenatal problems
5. Burn deaths
6. Secondhand smoke
What are the social costs of smoking?
Adults (men and women): Productivity costs + medical expenditures=Just medical expenditures for infants alone (neonatal)
Why do people smoke?
Most popular from 1950-late 70s
-more common amongst: lower income, 18-24 yr olds, mid educated, american indians

1. Information lacking
2. Risk perception: youth thinks they're invincible and adults perceive low risk
3. Behavior-perpetuated by possible addiction?
Attempts to quit smoking & smokers' self-perception
-Most people say they have slight physical and slight psychological addictions (as opposed to weak or strong)
-46% of people tried to quit 2-5x, all of whom said they had a strong addiction
How is obesity defined?
Greater than or equal to a BMI of 30. (Overweight=25-29)
What are the trends in obesity?
-rapidly increasing in both men and women of all ages
-adults and children aline
-more men have become overweight, but more women have become obese
-strangely, english speaking countries have increased rates; countries where meals are considered social gatherings/more food prepared at home (most european countries, obesity rates have not risen as sharply as in US, UK, Australia and Canada)
Is obesity a "moral panic"?
-Epidemic-rapid increase in the prevalence (% of ppl w/ disease, not # of new instances) of condition [narrower definition includes communicability of disease].
-Mortality by BMI "U-shape graph"; underweight just as likely to die as obese; lowest risk of mortality b/t 21-28 (some of which includes overweight)
-BMI not necessarily accurate measure of health
What do we know about the risks and costs of obesity?
-Deaths attributable to obesity=generally (not perfectly) increase with increasing BMI.
-Years of life lost: Increased w/ BMI for white men, not as drastic for white women (pregnancy, menopause?)
-->How to estimate cost of illness:
1. Identify diseases caused by obesity.
2. Estimate health $ and calculate population-attributable fractions
3. Estimate the total health $ assoc. w/ each disease
4. Estimate share of health burden attributable to obesity using PAFs.

Basically, PAFs relate obesity to health care costs.
How does obesity affect labor market outcomes?
Look this up..

-Absenteeism/health of workers
-Worker productivity
-Income costs
-Taxes
How does obesity compare to smoking/drinking in terms of costs of health care?
-Much higher
-Health care services highest for obesity than others
-Medication highest for aging, obesity second
-Only time smoking trumps is respiratory disease
-Heart disease: much higher related to age
Is there as strong a rationale for obesity being a policy problem as there is for smoking?
Rationales: 1. Externalities for smoking=obvious; for obesity=not so much, except for costs on health care system (depends on how closely we think obesity relates to morbidity)
2. Info as a public good: incentive? none for cigarette sellers; obesity? uncertain about strength of health risks, thus rationale for gov't funding of research.
3. Info asymmetry: Food sellers know more about its quality than consumers/Smoking cos. (once) knew more about cig contents than consumers
4. Intrapersonal Externalities: smoking at one point in life will prob continue because of addiction; this doesn't necessarily apply to obesity

--Different from smoking in that the obese population is not the minority; how policymakers view obese people will affect policy's nature and legitimacy; depends if we view obesity as character flaw, lack of info, etc.
relationship between obesity and morbidity
Does obesity cause morbidity or the other way around? Latent factors also matter.
1. Certain diseases may make it difficult to exercise (morbidity-->obesity)
2. Latent factors?
-Genetics
-Technology->sedentary lifestyle-->heavier and more diseases (contributes to both)

--Relate current obesity to current disease status, Policy that causes people to lose weight but not necessarily get healthier; Increased risk of morbidity than obesity alone
Will obesity become a political problem?
-Probably. Look at all these other dumb flashcards.
Obesity: public health risks that determine how an issue is portrayed/whether or not government intervention is warranted?
1. Is risk voluntary or involuntary?
2. Is risk universal?
--individual choice or environmental factors?
--If environmental, is it knowingly created by someone?
--Government intervention is more likely when risk is:
1. from environment
2. created knowingly
3. universal
4. involuntary
Policy options for obesity
1. Disclosure (increased info)
2. Tort liability (force fast food cos. to do certain things)
3. Surveillance
4. Reg. food marketing
5. Increase taxes on unhealthy food
6. School/workplace policy
7. Built environment zoning
8. Food prohibitions

-Think of advantages and disadvantages.

Main disadvantages: infringement on liberal economy, personal choice, freedom of speech, etc.
What kinds of private health insurance are available?
1. Group and individual
2. Non-profit
3. Commercial
4. HMO
5. self-insured provider types
6. Indemnity (fee-for-service
7. Managed care
-HMO (health maintenance orgs)
-IPA (independent practice assoc.)
-PPO (preferred provider orgs)
-POS (point of service)
8. Medical savings accounts w/ high deductible insurance
Non-profit Insurance provider
i.e. Blue Cross, Blue Shield
Commercial Insurance
Type of private insurance; paid for by the client’s employer, union, by the client and employer sharing the cost, or by the client.
HMOs (Health Maintenance Organizations)
Unlike traditional indemnity insurance, an HMO covers only care rendered by those doctors and other professionals who have agreed to treat patients in accordance with the HMO's guidelines and restrictions in exchange for a steady stream of customers.
Self-Insurance
bear your own risk, feasible for really large companies; hire insurance company to administer claims
Indemnity (fee-for-service)
-insurance companies pay fees for the services provided to the insured people.
-Offers the most choices of doctors and hospitals.
-person pays premium, deductible, and then shares bill w/ insurance co after deductible amt. is reached

-creates moral hazard for doctors
-doctor knows insurance will pay for any service
-studies show doctors' procedures are dependent upon individual's insurance/$$
Managed Care
don't rely primarily on paying individual physicians, rather, change environment so services delivered are removed from the payments received
HMO/Staff model
employee of HMO, difficult to keep right mix of physicians
Independent Practice Association
private practicers who agree to participate in HMO at fixed rate; physicians enter contract with the IPA which in turn contracts with the HMO. This model is an example of an open-panel HMO, where a physician may maintain their own office and may see non-HMO members.
Preferred Provider Orgs
list of physicians you can use at negotiated price. Limits who you can go to, but physicians charge less per visit for those in the program

managed care organization of medical doctors, hospitals, and other health care providers who have covenanted with an insurer or a third-party administrator to provide health care at reduced rates to the insurer's or administrator's clients.

-generally doesn't have copay, instead has deductible and coinsurance

-generally least expensive for individual b/c they pay first dollars
Market Provision (self-funded fee-for-service) Health Care
People pay out of pocket for their own health care expenses. Control over utilization but bad for access b/c not everyone can afford it.
Mutual Aid Societies
People band together, pay dues; society provides aid (usually replacement of lost wages for missing work) i.e. Moose Club

-Moral hazard problem, formed committees to check that people were actually sick
Charity Health Care
many hospitals started by churches, gave reduced rates to those who couldn't afford care, formalized
Premium
The amount the policy-holder pays to the health plan each month to purchase health coverage.
Deductible
The amount that the policy-holder must pay out-of-pocket before the health plan pays its share. For example, a policy-holder might have to pay a $500 deductible per year, before any of their health care is covered by the health plan. It may take several doctor's visits or prescription refills before the policy-holder reaches the deductible and the health plan starts to pay for care.
Copayment
The amount that the policy-holder must pay out of pocket before the health plan pays for a particular visit or service. For example, a policy-holder might pay a $45 copayment for a doctor's visit, or to obtain a prescription. A copayment must be paid each time a particular service is obtained.
Adverse Selection
the tendency for only those who will benefit from insurance to buy it; unhealthy people are more likely to purchase health insurance because they anticipate large medical bills; has to do w/ risk pooling and the idea that the needy will be disproportionally represented.
Moral Hazard
when one party takes increased risks or abuses the system because of the way the system is structured.
Government subsidies for health insurance
In U.S., come from taxes
Private health insurance
(as opposed to Gov't health insurance) Insurers provide, if they can get around moral hazard. (proving sickness)
Government mandated insurance
I.e. mandated car insurance
Gov't supplied health-insurance for target groups
i.e. disabled, children, low-income; insuring only a segment of the population
Direct gov't supply (delivered by public employees)
i.e. Veterans Association; medical service to veterans provided by government-employed physicians; some gov't programs for STDs, mental health, nursing homes, etc.
Direct gov't provision (single payer systems)
provides care by paying private providers thru central "pot of $" (Canada and UK)
Direct gov't provision (gov't as purchaser)
gov't provides its own health insurance plan (Canada and UK)
What are the factors affecting health care policy change?
1. Economic development: as countries become wealthier, they elect to have universal health care
2. Political Culture: different societies=people have diff tastes for gov'ts role; but policy can affect public tastes as well.
3. Interest Group-Organized groups in society will determine HC, but these interests must be mediated thru institutions (like conventions, norms)
Hacker's view of health care policy and the factors that influence it
1. Administrative capacity: needed for large gov't role, when states are weak they are constrained in types of policies they can implement
2. Federal and Unitary states differ:
-More veto points in federal systems; much easier to make policy in parliamentary systems
3. Electoral system: single-member districts vs. PR
-Canada: language cleavages, more turning of parties b/c of provincial and nat'l parties
Path dependency
small decisions at one time may dramatically affect long-term policy; often large fixed costs in introducing policy.
What political factors led the U.S. to target gov't health insurance on the elderly and the poor?
-They vote
-thought they could make it an extension of soc. security (not seen as welfare)
-Worthy: they have worked their entire life
-Needy: employer med insurance coverage end at retirement age
Medicare A
-just hospital, every retiree qualifies
-Medical insurance paid w/ premium from those who sign up (voluntary program)
What are the factors affecting health care policy change?
1. Economic development: as countries become wealthier, they elect to have universal health care
2. Political Culture: different societies=people have diff tastes for gov'ts role; but policy can affect public tastes as well.
3. Interest Group-Organized groups in society will determine HC, but these interests must be mediated thru institutions (like conventions, norms)
Hacker's view of health care policy and the factors that influence it
1. Administrative capacity: needed for large gov't role, when states are weak they are constrained in types of policies they can implement
2. Federal and Unitary states differ:
-More veto points in federal systems; much easier to make policy in parliamentary systems
3. Electoral system: single-member districts vs. PR
-Canada: language cleavages, more turning of parties b/c of provincial and nat'l parties
Path dependency
small decisions at one time may dramatically affect long-term policy; often large fixed costs in introducing policy.
What political factors led the U.S. to target gov't health insurance on the elderly and the poor?
-They vote
-thought they could make it an extension of soc. security (not seen as welfare)
-Worthy: they have worked their entire life
-Needy: employer med insurance coverage end at retirement age
Medicare A
-just hospital, every retiree qualifies
-Medical insurance paid w/ premium from those who sign up (voluntary program)
-60 days of hospital service per "spell"
-home care, outpatient diagnostic service w/ copay, some psych
Medicare B
-part of Medicare paid by tax revenue
-Medical services (as opposed to hospital services of part A)
-Includes: office visits, surgery, consultation, outpatient services (all w/ copay)
Medicare today
-strengthened state grants to provide
-stability
-single payer, but operated thru existing health system
Medicare history pre-'65
-Failed efforts to obtain nat'l health insurance
-revolt within AMA-Drs opposed natl insurance
-'64: Democrats in Congress tried to subsidize private insurance:
1. Hospital care for elderly
2. Grants to states to provide med. care
3. Republicans wanted voluntary medical insurance by fed.subsidy
1965 Medicare
-program construction: New Deal, Committee on Econ. Security=social safety net for elderly but forewent federal intervention in health insurance
-Truman-Fair Deal: proposed nat'l health insurance. Coalition in congress emerging to block this; strong lobbying by AMA
-Wilbur Mills: Put together package he thought would let Medicare go forward but prevent its uncontrolled expansion
Medicare '66-'94
-Bipartisan stability
-1960s:
1. Dialysis added to Medicare
2. Veterans Assoc. and disabled added to Medicare
-1988: Medicare Catastrophic Coverage Act-made hospital days unlimited for medicare; progressive; broadened coverage, people who could afford to pay more had to; eliminated coinsurance
Medicare 1995-present
Reconsideration of Wilbur Mills' plan
-'97: Balanced Budget Act: decreased reimbursement rate to doctors
-'03: Medicare Modernization Act added drug coverage (Medicare Part D); Controversial; pitted right and left together against center
Medicaid today
1. Health coverage for the poor/disabled
2. Increased long-term care assistance; nursing homes
3. Medicare recipients who needed help w/ copay
4. States administer program w/ about 60% of $ from Fed. gov't and 40% from the state.
-Medicaid=causing $ probs for state gov'ts, scrimping in other areas of budget like education etc.
Medicare: 1980s
(during bipartisan stability)
-1989: Catastrophic Bill=protected amt. of elderly couple's income until one used up private coverage and went to a nursing home; increase monthly premium esp. for wealthy
-led to grassroots uprising of elderly
-because the program cost more than expected + increased senior opposition=congress reversed itself
factors affecting the 1988 medicare legislation
-Included drug coverage but only lasted one year because insurance is less valuable for more frequent, cheap events and more valuable for infrequent, expensive events; issue=income vs. health
Factor affecting Medicare policy
-constituency for state's eligibility requirements=middle class families, Congress sometimes must intervene
National Bipartisan Commission on the future of Medicare
fewer workers per retiree to fund medicare.
-studied issue and made predictions
-options for recipients to choose Managed Care plan (?)

Remaining question:
Are MC providers overpaid?
Look at donut hole slide, medicare legislation
-you reach deductible, split copay w/ insurance co until certain price-->[donut hole] you pay 100% for certain range of costs-->reach certain price and you pay a much smaller copay (in case of catastrophy)

subsidized a little-->not at all-->a lot;
confusing, but makes sense economically
Medicaid History
-created in 1965
-federal gov't funds for states, state administers Medicaid
-drug rebate additions to Medicaid '90, '91, '93
-'97: Balanced Budget Act: SCHIP
-STABLE
-unlike medicare, means-tested and social welfare program
-most states use managed care programs now
Medicare Timeline
* 1960 — PL 86-778 Social Security Amendments of 1960 (Kerr-Mill aid)
* 1965 — PL 89-97 Social Security Amendments of 1965, Establishing Medicare Benefits
* 1988 — PL 100-360 Medicare Catastrophic Coverage Act of 1988
* 1997 — PL 105-33 Balanced Budget Act of 1997
* 2003 — PL 108-173 Medicare Prescription Drug, Improvement, and Modernization Act
POS
combo of HMO and PPO, members don't make decision about type of service until after the fact
UK's Health Care
Gov't provides hospital, purchases health care, etc. Health care becomes like another part of gov't, individual does not have much say. Therefore, universal.
Canada's Health Care
Private hospitals, drs, etc. You receive services. When it's all said and done, they bill Canadian gov't. That $ comes from taxes. More options than UK.