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     BY : Neel, Nick, Karissa & Rachel
Some statistics to start with
 What are the different ways of getting
 Some problems associated with each of
 these ways of getting insurance
 Privacy issues
 Political effort to reform our system – some
 bills that have been passed
 and proposed
 Ethical issues
The Dilemma of Uninsured
  Nearly 44 million Americans are uninsured
  The number of uninsured has increased by
  4.6 million between 2001-2004(growth =
  Half of these uninsured are between the
  ages of 19-34
  Young (60% under age 34) – this mainly includes
  students who are in college
  Only 20% of the uninsured are unemployed
  Only 23.7% lack a high school diploma
  73.7% are native born
 These numbers show that most of the uninsured
 Americans have a high school diploma and have
 jobs. This means that lack of education and
 unemployment aren’t a big factor affecting the
 growth of the # of uninsured Americans.
 Majority of these uninsured are also students and
 this is because once they reach a certain age they
 aren’t covered under their parents’ insurance. And
 they can’t get their own insurance because they
 are too busy to find a full-time job.
 HMOs – private and through
 Supplemental Insurance
 Student Insurance
 Stands for Health Maintenance Organization
 It is basically a prepaid health plan providing
 comprehensive care to members through designated
 Almost 30% of the Americans are enrolled in HMOs
 Unlike traditional insurance HMO sets out guidelines
 under which doctors can operate
 Is either offered to you through your employers or
 can be purchased privately
 Is comparatively cheaper than traditional insurance –
 requires a monthly premium
HMOs (contd….)
   There are 2 reasons as to why HMOs cost less:
a.) It is able to provide better and more affordable
   insurance by contracting with specific care providers
   and dealing with he amounts of patients.
b.) It reduces costs by eliminating treatments that it
   views as unnecessary and by focusing on long term
   health of the patients.
  Patients get to choose a primary care physician, who
  then negotiates with the HMO about what kind of
  care and treatments are required by a patient
  Examples include Blue Cross, Aetna, Blue Shield,
 It is a federal health insurance program for
 people ages 65 and older, people with
 disabilities and people with permanent
 kidney failure
 Paid for by the money of the taxpayers
 Involves insurance through various HMOs
 It is a combination
 of 4 different parts.
Medicare (contd…)
 Part A covers inpatient care which includes
 hospital and nursing facility stays – no premium
 required since the patients or their spouse paid
 medicare taxes.
 Part B covers outpatient care and doctor’s
 services – requires a monthly premium – if Part B
 isn’t purchased at the time of enrollment, the
 premium will go up every year thereafter.
 Part C is called Medicare + Choice and is basically
 extra insurance through an HMO.
 The last part, called Part D deals with prescription
 drug coverage
 Available to only certain low-income
 individuals and families who fit into a
 category defined by federal and state law
 State administered program
 Depending upon your state, you might be
 asked to pay a premium.
 Expenses are covered by taxpayers’
 Is like an extra insurance which may be
 purchased by individuals whose insurance
 doesn’t cover all the major benefits.
 Is cheaper because it is not a major
 insurance, only a supplemental insurance.
 It only provides limited benefits
 Offered to students by their colleges and
 You need to be a full-time student
 Requires the payment of a premium
 Is comparatively cheaper and offers most
 of the benefits
 Students are encouraged to use the
 healthcare facilities on campus
Problems with the Healthcare
 Does not cover long-term care
   Medicare coverage provides for 30 days
   of SNF (Skilled Nursing Facilities)
   coverage following a hospitalization
   Decreased rates of coverage beyond 30
   days; coverage rapidly runs out
   Many elderly and almost all young people
   requiring long-term care services are
 Prescription Coverage
    Limit as to the amount of coverage
        Affects people who take medication regularly
          – People who depend on prescriptions are more
            likely to go without the medications they need for
            periods of time
          – An estimated 85 percent of Medicare's 40 million
            beneficiaries suffer from at least one chronic
          – People who rely on a number of maintenance
            drugs, such as those with heart and respiratory
            problems, Alzheimer's disease, or arthritis, are
            likely to be most severely affected by the gaps in
            the drug benefit
Medicare Part D
 Three tiered system based on drug types
    Some medications are now less affordable
    Encourages drug substitution
        New side effects, different efficacy
    Some drugs are no longer covered
        i.e. Benzodiazepines
 Before the new entitlement, most had virtually all
 their medications covered fully by the states.
    Tens of thousands of indigent patients were told
    to get prior authorization, pay a large initial
    deductible, or make substantial co-payments for
    regularly used medicines they previously received
    at no cost

 Health care costs higher for Medicaid
 patients than for general population
   Treatment costs for elderly are more
   expensive than costs for other patients
 Medicaid programs must often be cut
 because an open-enrollment policy
 must be kept

 Based on Income and Assets
   Elderly have no income
     Elderly with assets must spend down their
     assets month-by-month until eligible for
   Assets include cars, homes, etc.
     Gifts given to applicants within 2 years of the
     application date counts towards total assets
     regardless of intention

 Most people are ineligable
   Most dual earning families working full
   Most disabled children
   Adults who are non-disabled without
   children, yet poor
   People with conditions that could be
     i.e. HIV patients
 In the past five years, private health
 insurance premiums have risen 73 percent
 Usually the number of doctors a patient can
 see and which tests he or she can get is
    Often a patient must see a "gate keeper"
    doctor who determines whether
    consultations with specialists are
    necessary and therefore reimbursable
    Usually covers bare minimum care
 The doctors say that the managed-care
 system prevalent in America today
 influences doctors to make medical
 decisions based on financial considerations
     Stresses cost cutting over cures
     Penalizes doctors for recommending
     certain tests, treatments and consultations
     with specialists
     may actually reward them for withholding
 Managed-care companies are denying
 essential mental health services
   Cost-cutting is leading to worsening
   psychiatric problems
   Companies are not paying for long term
   Managed-care companies have financial
   incentives to deny psychiatric care to the
   very patients whose health interests they
   are supposed to protect
Rutgers Health Insurance
 Basic Full Time Student
   $5000/illness or injury
   Additional coverage of $50000 or $100000
   Last January an international student suffered
   from encephalitis and slipped into a coma
     Hospital costs - $33000/day
     Has incurred over a million dollars in medical
     Doctors want to move her to a rehabilitation clinic, but
     the hospitals are reluctant to take her because she is
     at this point uninsured
Possible Beneficial Procedures
 Tomography (PET)
 scans are beginning to
 be used in association
 with cancer therapies
    Gives a more
    accurate reading
    than CT scans alone
    Estimated mean
    cost per scan of
    $1,800 to $1,900
Possible Beneficial Procedures
 Genetic Testing for hereditary breast or
 ovarian cancer
   Earlier treatment and assessment could help
   greatly combat deadly disease
   Sequencing tests cost several thousand dollars
   Labor intensive
   Most insurance companies only offer the test
   after you or a close relative is diagnosed with
   breast/ovarian cancer
Privacy Issues
Privacy Act 1988
 Personal information shall not be collected
 by a collector for inclusion in a recorder in
 a generally available publication unless:
       – For a lawful purpose directly related to a function or
         activity of the collector
       – The information is necessary for or directly related to
         that purpose

 Personal information to be used only for
 relevant purposes

 Limits on use of personal information
Disclosures Without Your
 Public health activities
 Research purposes
 Government purposes
 Organ or tissue donation/transplant
 Determination of compensation
Non-medical Use of Health Data

 Health insurance and pharmaceutical
 Regulation of health care
 Health care professionals as police
 Increased government
 interventionism and concentration
Online Access to Medical Records

 With all the new technology it is
 easier to gain access to other
 people’s records

 We will need to develop acceptable
 procedures for the following:
    -Back up data
    -Who conducts audits?
According to HIPAA, a patient’s consent is not

  When emergency care is needed
  When a provider is required by law to administer
  When substantial communication barriers exist
  and, in a professional’s judgment, the
  circumstances infer the individual’s consent;
  For a provider with an indirect treatment
  relationship to provide services (e.g., laboratories);
  For a health plan to use the information for
  treatment, payment, or healthcare operations; and
  For a clearinghouse to use the information for
  treatment, payment, or healthcare operations.
Specific Privacy Issue

 A woman has filed a lawsuit against
 Emory Healthcare after she
 underwent surgery there with
 instruments that had been exposed to
 a fatal disease similar to the human
 version of mad cow disease.
The Ethics Of It All….
(3 main issues)
 Privacy
         How private is our information really?
         Not ethical to disclose personal medical issues to the public

          Companies that provide no insurance or unaffordable
          insurance to their employees
           Costs of insurance just keep increasing with no
          The issue of not providing healthcare to people who really
          need it
          Not covering much needed medical procedures
Already Instated Healthcare Reform Bills
 Canada Healthcare Act (2005)

          $1 Billion Home Care Transfer fund established to
           build a national platform for home care services

          all Canadians will have access to essential mental
           health, post-acute and palliative care regardless of
           where they live

          ensure that the necessary community based services
           are integrated within the health system

          the important preventive, health promotion and
           maintenance functions of home care will continue to
           be part of the continuing care envisioned by
Healthcare Reform Bills (cont’d)

 Small Business Health Fairness Act (2005)
          Enables small businesses to band together through
           trade associations to purchase coverage for their

          regulated by the Employee Retirement Income Security
           Act of 1974 (ERISA) - exempt from state health
           insurance mandates and regulations

          significantly expanded access to health coverage for
           uninsured Americans” by giving small businesses
           improved bargaining power and relief from costly state

Healthcare Reform Bills (cont’d)

Healthcare Choice Act of 2005
         Introduced May12, 2005 – last reviewed Feb. 16, 2006 –
          placed on Union Calendar

         would allow individuals and families to purchase health
          insurance that is offered in other states

         legislation would allow insurance companies to sell their
          products across state lines, under specified conditions,
          without generally being subject to the mandates and
          regulations of other states

         would broaden the health insurance market and bring
          more competition to the marketing and purchasing of
          health insurance for millions of Americans

Most Recent Healthcare Reform Bills
  Fair Share for Healthcare Act – New York (3/20/06)
         covers large businesses – those with more than 100
          workers, and building services at office buildings over
          100,000 square feet and residential buildings with 50
          units or more

            ensures that large businesses pay their fair share for
             workers' health benefits

            sets a minimum amount that large businesses must
             spend on employees’ health benefits

            The Fair Share Threshold – covered business
             provide non-supervisory workers with health benefits
             worth at least $3/hr.
                    If cost of health insurance goes up, benefits
                      do not go down
       Healthcare Reform Bills (cont’d)
Massachusetts Health Care Reform (April 4, 2006)
       The first state to require that all of its citizens have some form
      of health insurance

         Single adults making $9,500 or less a year will have access to
         health coverage with no premiums or deductibles

         Those living at up to 300 percent of the federal poverty level,
         about $48,000 for a family of three will be able to get health
         coverage on a sliding scale also with no deductibles

         Fines of more than $1,000 a year by the state for people able
         but unwilling to purchase health insurance

         $295 per employee annual fee for companies who do not offer
         health insurance
                 What Can We Do to
                 Make a Difference?
                 (Our Proposed Bill)
 The Fair Health Act
        All employers must offer and pay a
         major percentage (80%) of health

        All employees offered insurance must
         work a minimum of 32 hrs./wk.

        Increased documentation of health
         insurance coverage

Danky, James Prof. Medicaid (Lecture). University of Wisconsin.
Connolly, Ceci. “Drug Benefit Disparities Cited Those With Chronic Conditions Will Pay More, Study Says”.
      Washington Post. April 19, 2005.
Hubbard, Allan B. “The Health of a Nation”. New York Times. April 3, 2006.
Avorn, Jerry, M.D. Part “D” for “Defective” — The Medicare Drug-Benefit Chaos. New England Journal of Medicine.
      Volume 354:1339-1341, No. 13. March 30, 2006.
Goleman, Daniel. “Critics Say Managed-Care Savings Are Eroding Mental Care”. New York Times. January 24,
Juweid, M.D., Malik E. and Bruce D. Cheson, M.D. Positron-Emission Tomography and Assessment of Cancer
      Therapy. New England Journal of Medicine. Volume 354:496-507, No. 5. February 2, 2006.
Fergus, Kathleen, MS, CGC. Breast and Ovarian Cancer: Considering Genetic Testing.
Guzowski, Stephanie. “Uninsured and uncertain: Bills pile up for Mason Gross cellist in a coma; peers plan benefit
      concert”. Daily Targum. January 26, 2006.
Critical Coverage: Benzodiazepines under Medicare Part D. Medicare Rights Center. June 2005.

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