The November 2019 issue of the American Journal of Public Health (AJPH

1. The November 2019 issue of the American Journal of Public Health (AJPH) had a special section on Financing Health Care in light of the current political discourse. The articles (6 are required readings and 2 are optional) provide different perspectives on the single- and multiple-payer systems proposed by or advocated for by the different political parties and presidential candidates.
   These articles, along with your other readings this week, collectively form the basis of your individual Assignment 6. Feel free to consult with additional resources to support your position. Your 600-800 word essay should include:
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   Introduction
   Arguments for a single-payer system
   Arguments against a single-payer system
   Your well-supported opinion on what the next approach is for health care reform in the United States.
   References (this week’s textbook and article readings are sufficient, but feel free to add more)
   Below are few definitions to guide your readings. These definitions are extracted from the Editorial to the special section in the AJPH November issue (p. 1482):
   Single payer refers to a health system that is financed by a single entity; in its common usage, that single entity is government. Government is the payer for services, and such payments are financed by taxes, but there is no implication that government employs the providers or actually owns or operates the health system. There still may be intermediaries between the government as payer and the provider… In its “purest” form, in a single- payer system, health care services are paid for only by the government; in the case of Medicare, beneficiaries also contribute to payments through premiums.
   Multiple payer refers to a health system that is financed through more than a single entity, one of which may include government. Private health insurance companies participate in multiple-payer systems, with financing through individual premiums paid directly by beneficiaries, employers, and, in some cases, government.
   Whether a health care system is single or multiple payer does not in and of itself define the system in terms of coverage. Universal coverage means simply that all people within a particular jurisdiction have health insurance, be it single or multiple payer. Universal coverage requires governmental mandate; however, the form of that mandate may be through either single or multiple payer or a hybrid model.
    Health care in the United States is currently a unique hybrid, multiple-payer system, but with elements of single payer (i.e., Medicare, although beneficiaries also contribute through premiums), publicly subsidized private payers (e.g., employer-sponsored health insurance), socialized medicine (e.g., Department of Veterans Affairs, in which government is both the payer and the employer), and self-pay (i.e., out of pocket).

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Chapter 10

Health Reform

in the United

States

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Chapter Overview

• Discusses the history of health reform in the
United States and details the key provisions
of the Affordable Care Act (ACA)

• Focuses on:
– Previous attempts at national health reform
– Why health reform is difficult to achieve
– The passage and provisions of the ACA

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Health Reform

• There have been numerous health reform
attempts in the United States.
– Prior to 2010, all attempts at national health reform

to create universal or near-universal coverage have
failed

– Some successes at the state level

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Health Reform—Difficulty of Reform
in the United States

• Individualistic culture
• Dislike of big government
• Lack of consensus
• Federal system rules and structure make it

difficult to achieve major reform
• States generally home to social welfare issues
• Powerful interest groups against national health

reform
• Path dependency

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Health Reform—Key Failed Attempts
at National Health Reform

• 1912 Progressive Party candidate Teddy Roosevelt
supported social insurance platform that included
health insurance

• 1915 American Association for Labor Legislation
proposal for working-class health insurance

• President Truman supported national health reform
upon taking office, won re-election on national health
insurance platform in 1948

• President Nixon: initial health reform proposal in
1969 and revised proposal in 1972

• President Clinton Health Security Act in 1993

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The Affordable Care Act
(1 of 3)

• Why did the ACA pass when so many prior
attempts had failed?
– Commitment and leadership
– Learned lessons from past failures
– Political pragmatism

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The Affordable Care Act
(2 of 3)

• Individual mandate—most people have to
purchase health insurance or pay a penalty
starting in 2014
– Exemptions for certain populations and based on

affordability
– Penalty for individual mandate repealed in 2017 Tax

Cut and Jobs Act
• Controversy

– Too much government interference in private lives?
– Constitutional?

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The Affordable Care Act
(3 of 3)

• State Health Insurance Exchanges
– American Health Benefit Exchanges for

individuals
– Small Business Health Options program for small

businesses
• Effectively ended in 2018; may be revised

– Must offer essential health benefits (abortion
compromise)

– Four cost levels for plans based on actuarial value

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ACA: Premium and Cost Sharing
Subsidies

• Premium tax credits available for individuals who
purchase insurance in an exchange and have income
between 133% and 400% of poverty

• Cost-sharing subsidies available for individuals who
purchase insurance in an exchange and have income
up to 250% of poverty

• To qualify, must be a U.S. citizen or legal resident,
not eligible for any type of public insurance, and not
have access to employer-sponsored insurance

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ACA: Employer Mandate

• In 2014, employers with 50 or more employees
must provide affordable health insurance or
pay a penalty.
– Insurance is affordable if it has an actuarial value

of at least 60% or is not more than 9.5% of an
employee’s income.

– Penalty is per employee after first 30 employees.

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The Affordable Care Act (ACA)
(1 of 2)

• Private insurance market changes
– No preexisting condition exclusion
– Dependent coverage to age 26
– Preventive services without cost sharing
– Prohibitions against lifetime and annual coverage

limits
– No rescission without fraud
– New appeals process
– Premium rate reviews

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The Affordable Care Act (ACA)
(2 of 2)

• Private insurance market changes (cont.)
– Guaranteed issue and renewability
– Rate variation limits
– Essential health benefits
– Wellness plans

• Some plans may be grandfathered in and not
subject to all of these changes

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ACA: Financing Health Reform
(1 of 2)

• Changes to Medicare provider reimbursement
• Changes to Medicare Advantage

reimbursement
• Medicare Part A increases for high earners
• Changes in Medicare Part D subsidies
• Changes in Medicare employer subsidy

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ACA: Financing Health Reform
(2 of 2)

• Changes in disproportionate share payments
• Increase Medicaid prescription drug rebate

paid by manufacturers
• Income tax code changes
• Health industry fees
• Tax on high-cost health insurance plans

• Slide Number 1

Chapter Overview
Health Reform

• Health Reform—Difficulty of Reform in the United States
• Health Reform—Key Failed Attempts at National Health Reform
• The Affordable Care Act�(1 of 3)
• The Affordable Care Act�(2 of 3)
• The Affordable Care Act�(3 of 3)
• ACA: Premium and Cost Sharing Subsidies

ACA: Employer Mandate

• The Affordable Care Act (ACA)�(1 of 2)
• The Affordable Care Act (ACA)�(2 of 2)
• ACA: Financing Health Reform�(1 of 2)
• ACA: Financing Health Reform�(2 of 2)

Rubric Detail
A rubric lists grading criteria that instructors use to evaluate student work. Your instructor linked a rubric to this
item and made it available to you. Select Grid View or List View to change the rubric’s layout.

Exemplary Proficient
Needs
Improvement

Poor

Name of
local public
health
department

10 (10.00%)

–

10 (10.00%)

Name of
health
department
fully and
clearly
identified.

0 (0.00%) – 0
(0.00%)

–
0 (0.00%) – 0
(0.00%)
–
0 (0.00%) – 0
(0.00%)

Name of
health
department is
not identified.

Website 10 (10.00%) –
10 (10.00%)

Website of
health
department is
clearly
identified with
a functional
link.

0 (0.00%) – 0
(0.00%)
–
0 (0.00%) – 0
(0.00%)
–
0 (0.00%) – 0
(0.00%)

Website of
health
department is
not included.

Public
health
services

36 (36.00%) –
40 (40.00%)

Two services
are clearly
identified with
the correct
corresponding
core function
and essential
public health

service.

32 (32.00%) –
35.6 (35.60%)

Two services
are clearly
identified with
1-2 incorrect
corresponding
core function
/ essential
public health
service.

26 (26.00%) –
31.6 (31.60%)

Only one
service is
clearly
identified with
the correct
corresponding
core function
and essential
public health

0 (0.00%) – 25.6
(25.60%)

No service is
clearly
identified with
the correct
corresponding
core function
and essential
public health
service.

Name: Week 3 – Discussion Board
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Grid View List View

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service. service. public health
service.

service.

Reflection –
Overall
impression

22.5 (22.50%) –
25 (25.00%)

Student
directly
addresses
main
question(s) or
issue(s) and
adds new
insight to the
subject not
provided in
lectures,
readings, or
class
discussions.

20 (20.00%) –
22.25 (22.25%)

Student
directly
addresses
main
question(s) or
issue(s) but
does not add
much new
insight into
the subject.
That said, it is
clear that the
student has
learned a
great deal in
class and is
able to
communicate
this
knowledge to
others.

16.25 (16.25%)
– 19.75
(19.75%)

Student
attempts to
address main
question(s) or
issue(s), but
fails. The
student has
retained some
information
from the
course, but
does not fully
understand its
meaning or
context and
cannot clearly
convey it to
others.

0 (0.00%) – 16
(16.00%)

Post does
NOT address
main
question(s) or
issue(s), and it
is obvious that
student has
not retained
any
information
from the
course.

Writing and
organization

9 (9.00%) – 10
(10.00%)

Post is
coherently
organized and
the logic is
easy to follow.
Writing is
clear, concise
and
persuasive.

8 (8.00%) – 8.9
(8.90%)

.Post is
generally well
organized and
most of the
argument is
easy to follow.
Writing is
mostly clear
but may lack
conciseness.

6.5 (6.50%) –
7.9 (7.90%)

Post is
somehow
poorly
organized and
difficult to
read – barely
flows logically
from one part
to another.
Writing lacks
clarity and
conciseness.

0 (0.00%) – 6.4
(6.40%)

Post is poorly
organized and
difficult to
read – does
not flow
logically from
one part to
another.
Writing lacks
clarity and
conciseness.

Grammar
and spelling

4.5 (4.50%) – 5
(5.00%)

There are no
spelling or
grammatical
errors and
terminology is
clearly

4 (4.00%) – 4.45
(4.45%)

There are only
a few minor
spelling or
grammatical
errors, or
terms are not

3.25 (3.25%) –
3.95 (3.95%)

There are
several
spelling
and/or
grammatical
errors;

0 (0.00%) – 3.2
(3.20%)

There are
many spelling
and/or
grammatical
errors;
technical

clearly
defined.

terms are not
clearly
defined.

errors;

technical
terms may
not be
defined or are
poorly
defined.

technical
terms may
not be
defined or are
poorly
defined.

Name:Week 3 – Discussion Board
Exit