1. Ramnik Dhaliwal, MD/JD PGY-2 EM/IM Residency Hennepin County Medical Center

4. Sources Of FundsPercentage of TotalAmount Per Person Total “Private” 52% $8,459 Total Govt (Medicare, Medicaid, VA&DOD) 48% * US Population of 310 million, from US Office of the Actuary, National health Projections, http://www.cms.gov/NationalHealthExpenData/

5. Top 10 % Approx 64% of spending Total USTop 1%Next 9%11-49% People (millions) 310328124 Health Care spending (millions) 2,624,400582,6171,112,746845,057 Average per person $ 8,459187,80939,8556,810

6. Birth of The Blues Blue Cross In 1929 Baylor University offered 21 days of hospital care to 1500 Dallas area teachers who paid $6 a year Blue Shield Around 1900 mine and logging owners in the Pacific Northwest paid medical service bureaus for care of workers Government Sponsored Health Care July 30, 1965 Lyndon Johnson signs Social Security Act creating Medicare and Medicaid First Medicare enrollee, Former President Harry S Truman Blue Cross and Blue Shield merged in 1982 and is now an association of 39 separate franchisees providing insurance to more than 1/3 of Americans

7. Insurers Profits Patients Risk pooling Providers Increased demand and regular payment

8. Medicare: Federal In partnership with states Medicaid Children’s Health Insurance Health Insurance portability standards, quality standards in long term care facilities, Clinical Lab Improvement

9. A social insurance program which acts as a single payer for health insurance for people who qualify To Qualify: Legal residents of the US for at least 5 years and over 65* Or: On Social Security Disability for at least 24 months or Receive disability pension from Railroad Retirement Board and meet certain criteria or Have ALS, or Have permanent kidney failure requiring dialysis or a kidney transplant. * If neither you nor your spouse has paid income tax for at least 40 quarters you may have to pay a monthly premium

10. Medicare Part A Inpatient hospital stays Including room, food, tests and doctor fees Brief stays in a skilled nursing facility Part B Covers physician and outpatient services Premium payment by beneficiaries $96.40 per month in 2009 Medicare Advantage “Part C” A combination of parts A and B allows them to be administered by private companies Part D: Prescription Drug plans, only provided through private insurance companies that have contracts with government.

11. Direct Medical Education Wages and benefits for US residents $ 2.7 billion in 2008 ž Indirect Medical Education Subsidy to teaching hospitals that provide residency education $ 5.7 billion in 2008 ž Has been frozen since 1996

12. Means-tested, needs-based health insurance program for eligible individuals and families with low incomes and resources Jointly funded by the states and federal government, and is managed by the states In 2008 49 million persons enrolledž About 1/2 of those receiving benefits are children 2010 spending $419 billion, Approx 57%coming from federal funds Accounts for approx 17% of states general fund spending

13. Created in 1997 Provides matching funds to states for health insurance for children in families with income modestly above the Medicaid eligibility ž $40 billion spent over first 10 years

14. M edicaid expansion to 138% of the federal poverty level ($15,415 for an individual and $31,809 for a family of four in 2012) for individuals under age 65 The creation of health insurance exchanges Regulation to prevent health insurers from denying coverage to people for any reason, including health status, and from charging higher premiums based on health status and gender; The requirement that most individuals have health insurance beginning in 2014; and The penalties to employers that do not offer affordable coverage to their employees, with exceptions for small employers. Florida filed lawsuit challenging the constitutionality of the individual mandate and the Medicaid expansion; Was joined by 25 other states.

16. š ACOs? Accountable Care Organizations Part of ACA New form of payment delivery system Meant to improve quality Bend the Cost Curve

17. Washington State Denies Medicaid Payments –Use final diagnosis to decline payment –Ignores Federal Prudent Layperson Standard –Jeopardizes access to care –EMTALA SUCCESS: Governor halted program Adoption of Best Practices