In the United States, Medicaid is a government program that provides health insurance for adults and children with limited income and resources. The program is partially funded and primarily managed by state governments, which also have wide latitude in determining eligibility and benefits, but the federal government sets baseline standards for state Medicaid programs and provides a significant portion of their funding.
Medicare is a federal health insurance program in the United States for people age 65 or older and younger people with disabilities, including those with end stage renal disease and amyotrophic lateral sclerosis. It was begun in 1965 under the Social Security Administration and is now administered by the Centers for Medicare and Medicaid Services (CMS).
Medicare is the publicly funded universal health care insurance scheme in Australia operated by the nation's social security agency, Services Australia. The scheme either partially or fully covers the cost of most health care, with services being delivered by state and territory governments or private enterprises. All Australian citizens and permanent residents are eligible to enrol in Medicare, as well as international visitors from 11 countries that have reciprocal agreements for medically necessary treatment.
Prescription drug list prices in the United States continually are among the highest in the world. The high cost of prescription drugs became a major topic of discussion in the 21st century, leading up to the American health care reform debate of 2009, and received renewed attention in 2015. One major reason for high prescription drug prices in the United States relative to other countries is the inability of government-granted monopolies in the American health care sector to use their bargaining power to negotiate lower prices, and the American payer ends up subsidizing the world's R&D spending on drugs.
The term managed care or managed healthcare is used in the United States to describe a group of activities intended to reduce the cost of providing health care and providing American health insurance while improving the quality of that care. It has become the predominant system of delivering and receiving American health care since its implementation in the early 1980s, and has been largely unaffected by the Affordable Care Act of 2010.
...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as Health Maintenance Organizations and Preferred Provider Organizations.
Dual-eligible beneficiaries refers to those qualifying for both Medicare and Medicaid benefits. In the United States, approximately 9.2 million people are eligible for "dual" status. Dual-eligibles make up 14% of Medicaid enrollment, yet they are responsible for approximately 36% of Medicaid expenditures. Similarly, duals total 20% of Medicare enrollment, and spend 31% of Medicare dollars. Dual-eligibles are often in poorer health and require more care compared with other Medicare and Medicaid beneficiaries.
Patient dumping or homeless dumping is the practice of hospitals and emergency services inappropriately releasing homeless or indigent patients to public hospitals or on to the streets instead of transferring them to a homeless shelter or retaining them. These cases may usually require expensive medical care with minimal government reimbursement from Medicaid or Medicare. The term homeless dumping has been used since the late 19th century and resurfaced throughout the 20th century alongside legislation and policy changes aimed at addressing the issue. Studies of the issue have indicated mixed results from the United States' policy interventions and have proposed a variety of ideas to remedy the problem.
Health care in Australia operates under a shared public-private model underpinned by the Medicare system, the national single-payer funding model. State and territory governments operate public health facilities where eligible patients receive care free of charge. Primary health services, such as GP clinics, are privately owned in most situations, but attract Medicare rebates. Australian citizens, permanent residents, and some visitors and visa holders are eligible for health services under the Medicare system. Individuals are encouraged through tax surcharges to purchase health insurance to cover services offered in the private sector, and further fund health care.
In the United States, health insurance helps pay for medical expenses through privately purchased insurance, social insurance, or a social welfare program funded by the government. Synonyms for this usage include "health coverage", "health care coverage", and "health benefits". In a more technical sense, the term "health insurance" is used to describe any form of insurance providing protection against the costs of medical services. This usage includes both private insurance programs and social insurance programs such as Medicare, which pools resources and spreads the financial risk associated with major medical expenses across the entire population to protect everyone, as well as social welfare programs like Medicaid and the Children's Health Insurance Program, which both provide assistance to people who cannot afford health coverage.
Healthcare reform in the United States has had a long history. Reforms have often been proposed but have rarely been accomplished. In 2010, landmark reform was passed through two federal statutes: the Patient Protection and Affordable Care Act (PPACA), signed March 23, 2010, and the Health Care and Education Reconciliation Act of 2010, which amended the PPACA and became law on March 30, 2010.
The healthcare reform debate in the United States has been a political issue focusing upon increasing medical coverage, decreasing costs, insurance reform, and the philosophy of its provision, funding, and government involvement.
There were a number of different health care reforms proposed during the Obama administration. Key reforms address cost and coverage and include obesity, prevention and treatment of chronic conditions, defensive medicine or tort reform, incentives that reward more care instead of better care, redundant payment systems, tax policy, rationing, a shortage of doctors and nurses, intervention vs. hospice, fraud, and use of imaging technology, among others.
Healthcare in the United States is largely provided by private sector healthcare facilities, and paid for by a combination of public programs, private insurance, and out-of-pocket payments. The U.S. is the only developed country without a system of universal healthcare, and a significant proportion of its population lacks health insurance. The United States spends more on healthcare than any other country, both in absolute terms and as a percentage of GDP; however, this expenditure does not necessarily translate into better overall health outcomes compared to other developed nations. Coverage varies widely across the population, with certain groups, such as the elderly and low-income individuals, receiving more comprehensive care through government programs such as Medicaid and Medicare.
An accountable care organization (ACO) is a healthcare organization that ties provider reimbursements to quality metrics and reductions in the cost of care. ACOs in the United States are formed from a group of coordinated health-care practitioners. They use alternative payment models, normally, capitation. The organization is accountable to patients and third-party payers for the quality, appropriateness and efficiency of the health care provided. According to the Centers for Medicare and Medicaid Services, an ACO is "an organization of health care practitioners that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it".
The Center for Value-Based Insurance Design at The University of Michigan is an advocate for development, implementation and evaluation of clinically nuanced health benefit plans and payment models. Since its inception in 2005, the V-BID Center has been actively engaged in understanding the impact of value-based insurance design (V-BID) on clinical outcomes and economic efficiency in the U.S. health care system. The V-BID Center also works with employers, consumer advocates, health plans, policy leaders, and academics to promote the implementation and demonstration of value-based insurance design in health benefit plans, as well as in state and federal legislation. Co-founded by A. Mark Fendrick, MD, and Michael Chernew, PhD, the V-BID Center is based in Ann Arbor, Michigan and operates collaboratively with the University of Michigan School of Public Health, the University of Michigan Medical School, and the University of Michigan Institute for Healthcare Policy and Innovation.
Mark V. Pauly is an American economist whose work focuses on healthcare management and business economics. He is currently the Bendheim Professor in the Department of Health Care Management at the Wharton School of the University of Pennsylvania. Pauly is a former commissioner on the Physician Payment Review Commission, and has been a consultant to the Congressional Budget Office, the Office of the Secretary of the U.S. Department of Health and Human Services, the American Enterprise Institute, and served on the Medicare Technical Advisory Panel. He is also the Co-Editor-in-Chief of the Springer journal International Journal of Health Care Finance and Economics, and was formerly the Robert D. Eilers Professor from 1984 to 1989.
Elizabeth Selvin is an American diabetes epidemiologist. She is a full professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health.
Justin Brigham Dimick is an American surgeon. He is the Frederick A. Coller Distinguished Professor of Surgery and Chair of the Department of Surgery at the University of Michigan.
Mousumi Banerjee is an Indian-American statistician and singer. She is the Anant M. Kshirsagar Collegiate Research Professor of Biostatistics and Director of the Center for Healthcare Outcomes and Policy (CHOP) at the University of Michigan. Banerjee is also the executive director of the nonprofit art foundation Tagore Beyond Boundaries.
Julia Adler-Milstein is a Professor of Medicine and Director of the Center for Clinical Informatics and Improvement Research at the University of California, San Francisco. In 2019, she was named a Member of the National Academy of Medicine.
