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Chapter 7

The Health Care System

Three Models of Health Care: The Medical Model

Focus on diagnosis and cure
Care in hospital, doctor’s office, nursing home
Drugs, surgery rehabilitation
Physicians control most treatment
Little focus on prevention or community-based care

Three Models of Health Care: The Social Model

Focus on person’s ability to function in the social world
Health is more than the absence of disease
Focus on functional capacity
Health care mostly takes place in community

Three Models of Health Care: The Health Promotion Model

Focus on disease prevention and reduced disability
With support, some can regain lost abilities
Improving fitness and well-being

Figure 7.1 Hospital Discharge Rates, 2006

The U.S. Health Care System Today

History of Health Care for Older People
Few options until mid 1960s
About ½ older people had health insurance
Medicare program passed by Congress 1965
AMA opposed Medicare at the time
Called it socialized medicine
Feared government control of physicians fees

The U.S. Health Care System Today
Medicare

Part A
Hospital Insurance
Funded by payroll tax
Eligibility
Benefits: 4 kinds of care
Part B
Supplemental Medical Insurance

The U.S. Health Care System Today
Medicare

Funded by
Eligibility
Benefits
Part D (2006)
Prescription Drug Discount Card
Has reduced some costs for some older people

Figure 7.2 How Is the U.S. Health Care Dollar Spent?

National Health Expenditures, United States, 2007

Figure 7.3 Number of Medicare Beneficiaries, 1970–2050

Figure 7.4 Total Medicare Expenditures 1970–2008

Figure 7.5 Medicare Costs as a Share of Gross Domestic Product

Table 7.1 Medicare Payments, Original Medicare Plan

Selected Medicare Services, 2004

The U.S. Health Care System Today
Medicaid

Began 1965
Serves low income Americans, all ages
Funded by federal and state governments
Eligibility
Income and asset limits
Income and asset limits different for each state

NOTE p. 10 Ch 8 typo in 3rd paragraph “ople” for “people”

Figure 7.6 Where the Medicaid Dollar for the Elderly Goes, 2002

Figure 7.7 Funding for Long-Term Care, 2004

The U.S. Health Care System Today
Other Health Care Plans

Employer Sponsored Plans
Medigap
Intended to reduce out-of-pocket costs due to gaps in Medicare coverage
Long Term Care Insurance
Vary widely in coverage and services
Strong interest in buying LTC insurance

NOTE p. 10 Ch 8 typo in 3rd paragraph “ople” for “people”

Figure 7.8 Total Health Expenditures as a % of Gross Domestic Product

And Per Capita Health Expenditures in U.S. Dollars, by Selected Countries: 2006

The Cost of Care

Since 1960 US leads developed nations in health care spending
Costs expected to increase
Federal, state, local governments paid nearly half the total health care bill in 2000
Rising health care costs explain most government spending on older people

Figure 7.9 Out-of-Pocket Health Care Costs

As a Share of Income of Elderly Medicare Beneficiaries

The Rising Personal Cost of Health Care

Amount paid by individuals has increased, despite federal payments
Older people pay high out-of-pocket costs
About 9% no coverage except Medicare
Few have long term care insurance
Results

Public Dissatisfaction & Health Care Reform

Cost of care is high; weak return on cost
Health Care Reform: National Legislative Action 2010
Gains & Losses for Medicare Beneficiaries
Summary of the Legislation
Structural Flaws in the System

Institutional Care

Insurance does not provide substantial nursing home benefits
Medicare
Medicaid
Must spend down to qualify
Private Long Term Care Insurance
Only pays about 45% of costs

Table 7.2 Long-Term Care Expenditures for the Elderly

By Source of Payment, 2004

Long Term Care: Community-Based Services

In-Home care and Assisted Living
Better community-based care accounts much of the decline in nursing home placement
Olmstead Decision (1999)
Types of HCBS

Long-Term Care

Long-Term Care Insurance: A Good Bet?
Adult Day Care
Respite Services
Home Health Care Programs
Changes in Funding to Control Costs

Long Term Care: Managed Care

Medical Care Settings
Some cost control
Capitated payments
Interdisciplinary approach
Early LTC planning
Keeps track of health records
Some focus on rehabilitation

Disease Prevention & Health Promotion

Prevention catching on in United States!
Examples
No smoking in restaurants
Magazines on fitness
Salads and low fat items in fast food restaurants
Water and air quality standards

Beyond Fitness and Personal Health Promotion

Typical health promotion efforts:
Should also
Account for the social and economic contexts of sickness
Account for environmental contexts
Promotion and prevention must have impact on the production of illness

Future Issues in Health Care

Availability
Existence of services; “no-care zones”
Accessibility
Can people get the services that do exist?
Coordination
Case management needed
Need for integrated system