el sistema de salud de eeuu

7/27/2019 El Sistema de Salud de EEUU

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El Sistema de Salud de EEUU

El sistema de Salud en EEUU no es universal. En el coexisten los dos tipos de sistemas de

aseguramiento: El privado y el pblico (Medicare, Medicaid, Children's Health Insurance Program,

and the Veterans Health Administration). Los empleados trabajadores y profesionales menores de

65 aos, no tienen ningn tipo de acceso a un seguro mdico pblico, y por ende deben elegirentre las distintas opciones que proporcionan las compaas privadas, as solo pueden tener un

seguro sanitario privado y este pueden obtenerlo de slo dos formas: pagndoselo ellos mismos o

bien a travs de sus empleadores. Sin embargo no todos los empleadores ofrecen planes de

seguro sanitario, y eso explica el gran nmero de personas no asegurados, sumado a que la

prdida del empleo significa entonces, la perdida de la cobertura de salud.

Al 2011 la estimacin de gasto per cpita en salud se estimaba en $8,608 (World HealthOrganization), y de acuerdo al censo del 2010 (US Census Bureau), la poblacin no aseguradarondaba el 16,3%. Esto corresponde a alrededor de 40 millones principalmente jvenes o personasque no califican como pobres, pero cuyos ingresos son apenas superiores a los de la lnea depobreza oficial.

Tipos de Prestaciones y cobertura:

PBLICOS:

El gobierno federal es proveedor directo de servicios de salud para el personal militar, los excombatientes

con discapacidades vinculadas con el servicio (veteranos), los indios y nativos estadounidenses y los

presidiarios de las prisiones federales. Tambin se encarga de los ancianos y los pobres a travs de los

programas conocidos como Medicare, Medicaid y SCHIP

Medicare

.
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Se financia en general mediante una combinacin de impuestos a los sueldos, ingresos generales y primas

que pagan los beneficiarios.


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Medicare tiene cuatro partes: la Parte A, que proporciona seguro de hospital; la Parte B, que proporciona

seguro mdico complementario, la Parte C, que permite que las Partes A y B sean prestadas mediante

planes de salud privados y la parte D que se refiere a la cobertura de medicamentos.

La Parte A (pagada en gran parte mediante impuestos sobre generales) ayuda a pagar la atencin dehospitalizacin, hospitales de acceso crtico (establecimientos pequeos que proporcionan servicios

limitados ambulatorios y de hospitalizacin a personas en zonas rurales), establecimientos de enfermera

calificada, atencin en hospicios y algo de atencin domiciliaria.


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La Parte B, que actualmente tiene una prima de cerca de US$50/mes (ajustada anualmente), ayuda a pagar

los mdicos, los servicios complementarios de pacientes ambulatorios y algunos otros servicios mdicos que

la Parte A no cubre, como los servicios de los fisioterapeutas y terapeutas ocupacionales y atencin

domiciliaria, cuando son mdicamente necesarios.

La Parte C, conocida como Medicare+Choice, les da a los beneficiarios la oportunidad de inscribirse en

planes de salud privados. La idea que sustenta esto fue ofrecer una eleccin adicional a los ancianos as

como promover la competencia entre los planes de salud para reducir los costos para este grupo de

poblacin.

La Parte D corresponde al seguro para medicamentos recetados que se encuentra disponible para todos los

beneficiarios de Medicare con una prima adicional. La cobertura Parte D es opcional y adems de brindarle

cobertura para medicamentos recetados, garantiza la cobertura de los insumos necesarios para inyectarse

insulina

Existe una variedad de planes de coberturas para medicamentos operados por empresas privadas, pero,

todos deben cumplir con las normas establecidas por el gobierno federal y entregar como mnimo un plan

estndar definido.

EL PLAN ESTNDAR

El Costo total anual de medicamentos es la cantidad total de dinero que cuestan sus medicamentos

recetados, sin importar quin los paga.


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Como se puede observar en la tabla, el plan estndar tiene un tope parcial anual de US$2250. Una

vez que se supera ese tope de costo total, la persona deber pagar todas sus recetas hasta que el costo total

anual alcance los US $5,100. A partir de ese momento, comienza la cobertura catastrfica y el plan cubre el

95% del costo de sus medicamentos hasta el final del ao calendario.

Medicaid

Medicaid, por su parte, es un programa enfocado en la atencin de los pobres. Sus costos sonasumidos conjuntamente por los gobiernos federal y estatal, de manera que los porcentajes de

financiacin y los paquetes bsicos varan segn los resultados de la negociacin entre ambosniveles de la administracin pblica.Medicaid es un programa de seguro de salud financiado en forma conjunta por el gobierno federal y los

gobiernos estatales y se dedica a algunos sectores de la poblacin de bajos ingresos y necesitados. Cubre a

aproximadamente 36 millones de personas, incluidos nios, ancianos, ciegos, discapacitados y otros que

renen los requisitos de encontrarse en una situacin precaria en trminos socioeconmicos y es el

programa ms grande que presta servicios mdicos y relacionados con la salud a las personas ms pobres

del pas.

El programa Medicaid vara considerablemente de un estado a otro, as como en un mismo estado en

diferentes perodos, pero el gobierno federal requiere que se presten ciertos servicios bsicos a todos los

inscritos en el programa. El lmite mximo de permanencia en el programa es de un mximo de 5 aos.

Federal law specifies a set of mandatory services that states must cover for the traditionalMedicaid population. Most Medicaid beneficiaries are entitled to receive the mandatory services

listed below, subject to a determination of medical necessity by the state Medicaid program or a

managed care plan under contract to the state: Physicians services Hospital services (inpatient

and outpatient) Laboratory and x-ray services Early and periodic screening, diagnostic, and

treatment (EPSDT) services for individuals under age 21 Federally-qualified health center (FQHC)

and rural health clinic (RHC) services Family planning services and supplies Pediatric and family

nurse practitioner services Nurse midwife services Nursing facility services for individuals 21 and

older Home health care for persons eligible for nursing facility services Transportation services

States have flexibility to cover many additional services that federal law designates as

optional.Many of these optional services are particularly vital for persons with chronic

conditions or disabilities and the elderly. Examples include prescription drugs (which all statescover), personal care services, rehabilitation services, and habilitation services. Notwithstanding

their optional designation in statute, the fact that states choose to cover many of these services

in their Medicaid programs is evidence that they are widely considered to be essential for

the Medicaid population. Nonetheless, when states are under severe budget strains, as in therecent economic recession, optional benefits like dental services for adults are particularly

vulnerable to cuts, despite their importance and the well-documented adverse health


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consequences of reduced access to care. About one-third of total Medicaid spending is

attributable to optional services.23

Medicaid is a joint federal-state program that provides health coverage or nursing home coverage

to certain categories of low-asset people, including children, pregnant women, parents of eligible

children, people with disabilities and elderly needing nursing home care. Medicaid was created to

help low-asset people who fall into one of these eligibility categories "pay for some or all of their

medical bills."[26]

There are two general types of Medicaid coverage. "Community Medicaid" helps people who have

little or no medical insurance. Medicaid nursing home coverage pays all of the costs of nursing

homes for those who are eligible except that the recipient pays most of his/her income toward the

nursing home costs, usually keeping only $66.00 a month for expenses other than the nursing

home.

Having limited assets is one of the primary requirements for Medicaid eligibility, but poverty alonedoes not qualify people to receive Medicaid benefits unless they also fall into one of the defined

eligibility categories.[27]According to the CMS website, "Medicaid does not provide medicalassistance for all poor persons. Even under the broadest provisions of the Federal statute (exceptfor emergency services for certain persons), the Medicaid program does not provide health careservices, even for very poor persons, unless they are in one of the designated eligibility

groups."[27]In 2010, thePatient Protection and Affordable Care Actexpanded Medicaid eligibilitystarting in 2014; people with income up to 133% of thepoverty linequalify for coverage, including

adults without dependent children.[28][29]However, theUnited States Supreme Court ruledthat theFederal government must make participation in the expanded Medicaid program voluntary, and

several state governments have declared that they will not participate.[30

Medicaid covers mo re than 62 mil l ion Americans, or 1 in every 5. Medicaid

beneficiaries include lowincome individuals of all ages, including newborns, children andparents, pregnant women, individuals with diverse physical, developmental, andintellectual disabilities and mental illnesses, and poor elderly and disabled Medicarebeneficiaries, including many with longterm care needs. Half the people with HIV whoare in regular care are covered by Medicaid.11 The program plays a particularly large rolefor certain subpopulations who are disproportionately likely to be poor and who lackaccess to private coverage due to their low income or health status (Figure 4).
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CHIP (Childrens Health Insurance Program)

Este programa est orientado a ofrecer atencin mdica gratis o a bajo costo a los nios menores de 18

aos, si cumplen con ciertas condiciones de ingreso familiar (bajos ingresos, pero no tan bajos como para ser

beneficiarios de MEDICAID). Todos los estados tienen un programa de seguro de salud para nios y

adolescentes. Este seguro paga las consultas mdicas, los medicamentos recetados, la hospitalizacin y

otros servicios de atencin mdica.

The State Children's Health Insurance Program (SCHIP) now known more simply as

the Children's Health Insurance Program (CHIP)[1] is a program administered by theUnitedStates Department of Health and Human Servicesthat providesmatching fundsto states forhealth

insuranceto families with children.[2]The program was designed to cover uninsured children infamilies with incomes that are modest but too high to qualify forMedicaid.

Like Medicaid, SCHIP is a partnership between federal and state governments. The programs are

run by the individual states according to requirements set by the federalCenters for Medicare and

Medicaid Services. States may design their SCHIP programs as an independent program separate
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from Medicaid (separate child health programs), use SCHIP funds to expand their Medicaid

program (SCHIP Medicaid expansion programs), or combine these approaches (SCHIP

combination programs). States receive enhanced federal funds for their SCHIP programs at a rate

above the regular Medicaid match.

By February 1999, 47 states had set up SCHIP programs, but it took effort to get children

enrolled.[6]That month, the Clinton administration launched the "Insure Kids Now" campaign,designed to get more children enrolled;[21]the campaign would fall under the aegis of theHealth

Resources and Services Administration. By April 1999, some 1 million children had been enrolled,

and the Clinton administration set a goal of raising the figure to 2.5 million by 2000.[22]

States with separate child health programs follow the regulations described in Section 42 of the

Code of Federal Regulations, Section 457. Separate child health programs have much more

flexibility than Medicaid programs. Separate programs can impose cost sharing, tailor their benefit

packages, and employ a great deal of flexibility in eligibility and enrollment matters. The limits to this

flexibility are described in the regulations, and states must describe their program characteristics in

their SCHIP state plans. Out of 50 state governors, 43 support SCHIP renewal.[23]Some states

have incorporated the use of private companies to administer portions of their SCHIP benefits.These programs, typically referred to asMedicaid managed care, allow private insurance

companies or health maintenance organizations to contract directly with a state Medicaid

department at a fixed price per enrollee. The health plans then enroll eligible individuals into their

programs and become responsible for assuring SCHIP benefits are delivered to eligible

beneficiaries.

InOhio, SCHIP funds are used to expand eligibility for the state's Medicaid program. Thus all

Medicaid rules and regulations (including cost sharing and benefits) apply. Children from birth

through age 18 who live in families with incomes above the Medicaid thresholds in 1996 and up to

200% of the federal poverty level are eligible for the SCHIP Medicaid expansion program. In 2008,

the maximum annual income needed for a family of four to fall within 100% of the federal povertyguidelines was $21,200, while 200% of the poverty guidelines was $42,400.[24]

Other states have similar SCHIP guidelines, with some states being more generous or restrictive in

the number of children they allow into the program.[25]With the exception of Alaska, Idaho, North

Dakota and Oklahoma, all states have a minimum threshold for coverage at 200% of the federal

poverty guidelines. North Dakota currently has the lowest at 160%. New York currently has the

highest at 400% of the federal poverty guidelines.[26]SCHIP Medicaid expansion programs typically

use the same names for the expansion and Medicaid programs. Separate child health programs

typically have different names for their programs. A few states also call the SCHIP program by the

term "Children's Health Insurance Program" (CHIP).

States are allowed to use Medicaid and SCHIP funds for premium assistance programs that helpeligible individuals purchase private health insurance. As of 2008 relatively few states had premium

assistance programs, and enrollment was relatively low. Interest in this approach remained high,

however.[27]

In August 2007, the Bush Administration announced a rule requiring states (as of August 2008) to

sign up 95% of families with children, earning 200% of the federal poverty level, before using the

funds to serve families earning more than 250% of the federal poverty level. The federal
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government said that 9 out the 17 states that offer benefits to higher-earning families were already

compliant. Opponents of this rule argued that signing up higher-income families makes lower-

income families more likely to sign up, and that the rule was incompassionate toward children who

would otherwise go without medical insurance.[28]

Veteran Health Administration

The Veterans Health Administration (VHA) is the component of theUnited States Department of

Veterans Affairs(VA) led by theUnder Secretary of Veterans Affairs for Health[3]that implements

the medical assistance program of the VA through the administration and operation of numerous

VA outpatient clinics,hospitals,medical centersand long-term healthcare facilities (i.e.,nursing

homes).

The VHA division has more employees than all other elements of the VA combined.

The VHA is distinct from the U.S.Department of DefenseMilitary Health Systemof which it is not a

part.

Overall Evaluation[edit]

"Patients routinely rank the veterans system above the alternatives, according to the American

Customer Satisfaction Index." In 2008, the VHA got a satisfaction rating of 85 for inpatient

treatment, compared with 77 for private hospitals. In the same report the VHA outpatient care

scored 3 points higher than for private hospitals.[15]

"As compared with the Medicare fee-for-service program, the VA performed significantly better on

all 11 similar quality indicators for the period from 1997 through 1999. In 2000, the VA outperformed

Medicare on 12 of 13 indicators."[16]

A study that compared VHA with commercial managed care systems in their treatment of diabetespatients found that in all seven measures of quality, the VHA provided better care.[17]

ARAND Corporationstudy in 2004 concluded that the VHA outperforms all other sectors of

American health care in 294 measures of quality; Patients from the VHA scored significantly higher

for adjusted overall quality, chronic disease care, and preventive care, but not for acute care.[13]

A 2009Congressional Budget Officereport on the VHA found that "the care provided to VHA

patients compares favorably with that provided to non-VHA patients in terms of compliance with

widely recognized clinical guidelines particularly those that VHA has emphasized in its internal

performance measurement system. Such research is complicated by the fact that most users of

VHA's services receive at least part of their care from outside providers."[6]

VA Mental Health Services[edit]

The percentage of veterans seen at the VA with a mental illness was 15 percent in 2007. Trends

show that the percentage of veterans with mental illnesses will continue to increase. The VA has

directed its attention to this growing trend and is making mental health care for veterans a priority.

For example, the VA allocated an extra 1.4 billion dollars per year to the mental health program

between 2005 and 2008. They also implemented a five-year Mental Health Strategic Plan to
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expand and improve the mental health program. The status of the Mental Health program in 2006

was evaluated as a part of Mental Health Strategic Plan.[18]The results are as follows:

Quality of care at the VA was shown to be better than the private sector. The VA had a

higher level of performance then the private sector for 7 out of 9 indicators. In fact, they

"exceeded private plan performance by large margins.[19]"

Patients did not indicate improvement in their conditions. However, they had a very

favorable opinions of their care.[18]

Healthcare for Women Veterans[edit]

With the population of Women veterans projected to rise from 1.6 million in 2000 to 1.9 million

in 2020, the VA has been focusing on integrating quality women's medical services into the VA

system.[20]However, studies show that 66.9 percent of women who do not use the VA for

women's services consider private practice physicians more convenient. Also, 48.5 percent of

women do not use women's services at the VA due to a lack of knowledge of VA eligibility and

services. This study indicates that the VA still has room for improvement with convenience and

education regarding women's medical services.[21]

Physicians[edit]

Doctors who work in the VHA system are typically paid less in core compensation than their

counterparts in private practice. However, VHA compensation includes benefits not generally

available to doctors in private practice, such as lesser threat of malpractice lawsuits, freedom

from billing and insurance company payment administration, and the availability of the

government's open source electronic records systemVistA.[15]

Initiatives[edit]

The VHA has expanded its outreach efforts to include men and women veterans and homeless

veterans.

The VHA, through its academic affiliations, has helped train thousands of physicians, dentists,

and other health professionals. Several newer VA medical centers have been purposely

located adjacent to medical schools.

The VHA support for research and residency/fellowship training programs has made the VA

system a leader in the fields ofgeriatrics[1][2],spinal cord injuries[3],Parkinson's disease[4],

andpalliative care.

The VHA has initiatives in place to provide a "seamless transition" to newly-discharged

veterans transitioning fromDepartment of Defensehealth careto VA care for conditionsincurred inIraqorAfghanistan.

TheVeterans Health Administration Office of Research and Development's research into

developing better-functioningprostheticlimbs, and treatment ofPTSDare also heralded. The

VHA has devoted many years of research into the health effects of the herbicideAgent

Orangeused bymilitaryforces inVietnam.
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In October 2012, the VHA announced a new goal "to care for and heal our wounded Veterans.

In addition to repairing their damaged bodies and minds, VA has embarked on a unique

campaign to repair their crumbling intimate relationships.

Eligibility for benefits[edit]

By Federal law, eligibility for benefits is determined by a system of eight Priority Groups. Retireesfrom military service, veterans with service-connected injuries or conditions rated by VA, andPurple

Heartrecipients are within the higher priority groups.

Veterans without rated service-connected conditions may become eligible based on financial need,

adjusted for local cost of living. Veterans who do not have service-connected disabilities totaling

50% or more may be subject to copayments for any care they received for nonservice-connected

conditions.

Eligibility for VA dental care and Community Living Center care are much more restricted. For VA

dental care the veteran must have a 100 percent service-connected disability rating, Have a

service-connected compensable dental disability or condition, Former prisioner of war, or be in the

Vocational Rehabilitation and Employment Program (Chapter 31). VA providesnursing

homeservices to Veterans through three national programs: VA owned and operated Community

Living Centers (CLC), State Veterans' Homes owned and operated by the states, and the

community nursing home program. Each program has admission and eligibil ity criteria specific to

the program. Nursing home care is available for enrolled Veterans who need nursing home care for

a service-connected disability, and those rated 60 percent service-connected and unemployable; or

Veterans or who have a 70 percent or greater service-connected disability. VA provided nursing

home care for all other Veterans is based on available resources. Reservists andNational

Guardsmenwho were called to active duty by a Federal Executive Order qualify for VA health care

benefits.[24]

In 2010, there were 1 million veterans receiving disability pensions. 25% of these were Vietnamveterans with the disability ofadult-onset diabetes. More Vietnam veterans are being compensated

for diabetes than any other disease.[25]

Tricare

(styled TRICARE), fo rmer ly kn own as th eCivilian Health and Medical Program of the UniformedServices ('CHAMPUS), is a health care program of theUnited States Department ofDefenseMilitary Health System.[1]Tricare provides civilianhealth benefitsformilitary personnel,military retirees, and theirdependents, including some members of theReserve Component. TheTricare program is managed by Tricare Management Activity (TMA) under the authority oftheAssistant Secretary of Defense (Health Affairs). Tricare is the civilian care component of

theMilitary Health System, although historically it also included health care delivered in the militarymedical treatment facilities.

Tricare's options[edit]

Tricare Standard[edit]

Tricare Standard provides a similar benefit to the original CHAMPUS program and is available to

retirees from the Active Component, retirees from the Reserve Component age 60 or older, and
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their eligible family members. Under Tricare Standard, beneficiaries can use any civilianhealth care

providerthat is payable under Tricare regulations. The beneficiary is responsible for payment of an

annualdeductibleandcoinsurance, and may be responsible for certain otherout-of-pocket

expenses. There is no enrollment fee for Tricare Standard.

Tricare Extra[edit]

Tricare Standard beneficiaries can elect to use the Tricare Extra option by using a civilian health

care provider from within the regional contractor's provider network. In this way, Tricare Extra

represents apreferred provider organization(PPO). When using Tricare Extra, the beneficiary's

coinsurance amount is reduced by at least five percentage points. There is no fee for use of the

Tricare Extra benefit other than the coinsurance.

Tricare Prime[edit]

Tricare Prime is ahealth maintenance organization(HMO) style plan available to active duty

personnel, retirees from the Active Component, retirees from the Reserve Component age 60 or

older, and their eligible family members. Under Tricare Prime, beneficiaries must choose aprimary

care physicianand obtain referrals and authorizations forspecialty care. In return for theserestrictions, beneficiaries are responsible only for smallcopaymentsfor each visit (retirees and their

families only). There is an annual enrollment fee for Tricare Prime for military retirees and their

family members. There is no enrollment fee for active duty military and their family members.

US Family Health Plan[edit]

US Family Health Plan, a Tricare Prime-sponsored health plan option, is made available by

nonprofit health care providers in the Northeast U.S., Southeast Texas/Southwest Louisiana, and

the Puget Sound region of Washington state.

Tricare Reserve Select (TRS)[edit]

Tricare Reserve Select is a premium-based health plan that active status qualified National Guardand Reserve members may purchase. The classification is sometimes referred to as Tricare

Reserve Component (RC). It requires a monthly premium and offers coverage similar to Tricare

Standard and Extra for the military member and eligible family members. It has a partial premium

cost sharing arrangement with DoD similar to civilian private or public sector employer plans,

although typically at a lower cost than civilian plans. The program coverage is available world wide

to Selected Reserve (SELRES) members of both theTitle 10USC Federal Reserve Components

(Army Reserve,Navy Reserve,Air Force Reserve,Marine Corps Reserve),Title 14USC Federal

Reserve Component (Coast Guard Reserve) and theTitle 32National Guard (Army National

GuardandAir National Guard) in a drill pay (also known as "paid") status. As of February 2008,

retired Reserve Component personnel under the age of 60, actively drillingIndividual Ready

Reserve(IRR) personnel in a non-paid status, or actively drilling Volunteer Training Unit (VTU)personnel in a non-paid status do not qualify for TRS. IRR and VTU members are eligible for

reinstatement under TRS is they return to a SELRES status. Reserve Component personnel who

are also Federal civil servants (to include Army Reserve Technicians and Air Reserve Technicians

(ART) in the Army Reserve, Army National Guard, Air Force Reserve and Air National Guard) and

eligible for the Federal Employee Health Benefit Program (FEHBP) are also excluded from TRS.

Retired Reserve Component personnel and eligible dependent family members become eligible

Tricare Standard, Tricare Extra or Tricare Prime on the service member's 60th birthday in the same
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://en.wikipedia.org/wiki/United_States_Army_Reservehttp://en.wikipedia.org/wiki/Title_10_of_the_United_States_Codehttp://en.wikipedia.org/w/index.php?title=Tricare&action=edit&section=7http://en.wikipedia.org/wiki/US_Family_Health_Planhttp://en.wikipedia.org/w/index.php?title=Tricare&action=edit&section=6http://en.wikipedia.org/wiki/Copaymenthttp://en.wikipedia.org/wiki/Medical_specialisthttp://en.wikipedia.org/wiki/Primary_care_physicianhttp://en.wikipedia.org/wiki/Primary_care_physicianhttp://en.wikipedia.org/wiki/Health_maintenance_organizationhttp://en.wikipedia.org/w/index.php?title=Tricare&action=edit&section=5http://en.wikipedia.org/wiki/Preferred_provider_organizationhttp://en.wikipedia.org/w/index.php?title=Tricare&action=edit&section=4http://en.wikipedia.org/wiki/Out-of-pocket_expenseshttp://en.wikipedia.org/wiki/Out-of-pocket_expenseshttp://en.wikipedia.org/wiki/Coinsurancehttp://en.wikipedia.org/wiki/Deductiblehttp://en.wikipedia.org/wiki/Health_care_providerhttp://en.wikipedia.org/wiki/Health_care_provider


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manner as Active Component retirees and their eligible dependents are eligible immediately upon

retirement from active service. Qualification questions should be referred to Tricare.

Tricare Reserve Retired (TRR)[edit]

Tricare Reserve Retired is a premium-based health plan that qualified retired members of the

National Guard and Reserve under the age of 60 may purchase for themselves and eligible familymembers. Established in 2008 and opened for enrollment in 2010, it is similar to Tricare Reserve

Select (TRS), but differs in that there is no premium cost-sharing with DoD as there is with TRS. As

such, retired Reserve Component members who elect to purchase TRR must pay the full cost

(100%) of the calculated premium plus an additional administrative fee. Although open to all eligible

retired Reserve Component personnel under the age of 60, the program's principal focus is often

perceived as being focused on recent Reserve Component retirees who are self-employed or

otherwise ineligible for civilian employer provided/subsidized health insurance, especially those who

were mobilized for full-time active duty service subsequent to 11 September 2001 in support of

OperationsEnduring Freedom,Enduring Freedom, Iraqi Freedom,New Dawnand/orNoble Eagle.

Retired Reserve Component personnel who elect to participate in TRR will exit TRR when the

service member reaches age 60 and he/she and their eligible dependent family members becomeeligible for the same Tricare Standard, Tricare Extra or Tricare Prime options as Active Component

retirees and, in the case of Tricare Prime, at the same cost as Active Component retirees.

Qualification questions should be referred to Tricare.

Tricare for Life (TFL)[edit]

Tricare for Life was first incorporated as part of the then-seven regional Managed Care Support

Contracts of Tricare in May 2001. The benefit was enacted by Congress in response to growing

complaints from beneficiaries that as Medicare out of pocket costs increased a benefit was needed

to pay these costs in lieu of Tricare retirees being required to purchase Medicare Supplemental

Coverage to pay for prescriptions, physician and hospital dispensed drugs, cost shares and

deductibles. Before Tricare for Life, Tricare beneficiaries immediately lost Tricare coverage uponattaining Medicare eiligibility. This included becoming Medicare eligible due to disability. Tricare for

Life is designed to pay patient liability after Medicare payments. There is no enrollment necessary

for Tricare for Life and to be eligible, members must be Tricare and Medicare Eligible and have

purchasedMedicare Part Bcoverage. An exception to the requirement for Part B coverage exists

when the beneficiary that is Medicare eligible is the spouse of an Active Duty Service Member. In

some instances Tricare for Life is primary payer when the services are normally a Tricare benefit

but not covered by Medicare. This includes drug charges, when Medicare benefit limits are attained

and services performed outside the United States or in aVeterans Affairsfacility where Medicare

does not pay. TFL does not pay patient liability for services that are not a Tricare benefit even

though they may be paid by Medicare, such as chiropractic benefits. The policy limitations applyingto Tricare also apply to TFL and must therefore be deemed medically necessary and skilled care.

Custodial care therefore is not covered. In 2004 the Tricare for Life benefit was transferred from the

individual regional Tricare contractors. Medical claims are processed by the national Tricare Dual

Eligible Fiscal Intermediary Contractor (TDEFIC-Wisconsin Physicians Service Insurance

Corporation). Pharmacy claims are processed by the Tricare Pharmacy Contractor (Express

Scripts) and Overseas TFL claims are processed by the Tricare Overseas Program Contractor (as
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of September 2010 this will be International SOS using Wisconsin Physicians Service as their Fiscal

Intermediary partner).

Tricare Young Adult (TYA)[edit]

Tricare Young Adult (TYA) is a premium-based health care plan available for purchase by qualified

dependents who have aged out of Tricare at age 21, or age 23 for full-time college students.Dependents are eligible if they are unmarried, not eligible for Tricare coverage or their own

employer-sponsored health care coverage, and as long as their sponsor remains Tricare eligible.[4]

Eligible dependents have the option to purchase Tricare Standard/Extra health coverage on a

month-to-month basis. Purchased coverage includes medical and pharmacy benefits but does not

include dental. A premium-based Tricare Prime benefit will be available later in 2011.

The signing of the National Defense Authorization Act in January 2011 aligned Tricare with the

provisions of the 2010 Patient Protection and Affordable Care Act, and lead to the creation of

TYA.[5]

Enrollment began May 1, 2011.

Indian Health Service

(IHS) is an operating division (OPDIV) within the U.S.Department of Health and Human

Services(HHS). IHS is responsible for providing medical andpublic healthservices to members of

federally recognized Tribes and Alaska Natives. IHS is the principal federal health care provider and

health advocate for Indian people, and its goal is to raise their health status to the highest possible

level.

IHS provides health care to American Indians and Alaska Natives at 33 hospitals, 59health centers,

and 50 health stations. Thirty-foururban Indianhealth projects supplement these facilities with a

variety of health and referral services.The IHS currently provides health services to approximately 1.8 million of the 3.3 million AmericanIndians and Alaska Natives who belong to more than 557 federally recognized tribes in 35 states.The agency's annual budget is about $4.3 billion (as of December 2011).

Las personas que no califican dentro de estas categoras recurren, en su mayora, alaseguramiento privado. ste es ofrecido comnmente por sus empleadores, quienes han llegado aacuerdos con empresas particulares y pagan un porcentaje de los costos de las primas. La otraparte de la financiacin del aseguramiento privado debe ser asumida por el empleado.

SISTEMA PRIVADO

SISTEMAS PRIVADOS DE SALUDEn los Estados Unidos, los servicios de salud en gran parte son entregados por el sector privado, y

aproximadamente 70% de la poblacin del pas est cubierta por seguros de salud o autoseguros

organizados por su empleador, quienes comparten con el empleado el costo.

La ley no exige que el empleador proporcione cobertura en salud, pero ofrece ventajas tributarias para la

compra de un seguro de salud o la organizacin de un autoseguro, siempre y cuando los trabajadores

compren masivamente los planes que sus empleadores proporcionan.
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Se estima que, al menos antes de la crisis econmica, un 75% de los empleados tena cobertura de salud a

travs de su empleador. Los planes de cobertura ofrecidos por los empleadores en su mayora son opciones

con eleccin limitada de prestadores y sistemas de derivacin dirigida, a travs de organizaciones HMO, o de

Prestadores Preferentes (PPO), desplazando mayoritariamente los planes de libre eleccin basados en pagos

por prestacin.

Estas opciones dirigidas se generaron como un esfuerzo organizado, que i ncluye tanto a los aseguradores

como a los proveedores de salud, para usar incentivos financieros y medidas organizativas con el fin decontrolar el aumento de los costos.

El modelo caracterstico de atencin regulada son las HMO y los PPO se consideran una variacin del

modelo. Las HMO son organizaciones que entregan la totalidad de los servicios de salud a sus afiliados a

cambio de una mensualidad (capitacin). Para entregar las atenciones usa una red de proveedores propia o

convenida. Para el asegurado la eleccin de mdicos y hospitales se limitan a los que tienen convenios con la

HMO para prestar atencin y a menudo se requieren derivaciones para ver a un especialista. Los mdicos y

los hospitales son, en muchos casos, pagados per cpita en vez de usar la modalidad de pago por prestacin.

Las PPO es otra forma de atencin de salud administrada y es una

combinacin libre eleccin y HMO. Cuando los pacientes utilizan proveedores especficos, la mayora de sus

facturas mdicas estn cubiertas, pero tambin pueden elegir a mdicos fuera de la lista proporcionada y

recibir una cobertura menor.

CERTIFICACIN DE CALIDADLa prestacin de los servicios de salud por prestadores pblicos y privados se vigila de maneradescentralizada y voluntaria. Las autoridades estatales y locales, pueden vigilar los hospitales y consultorios

del gobierno. Los hospitales privados son autnomos por lo general, pero pasan por varias formas de

examen. Medicare tiene reglas que rigen la calidad que los hospitales deben seguir para participar en el

programa. Otras medidas de control de calidad incluyen acreditacin por las organizaciones privadas, como

Joint Comission (JCAHO) y el Comit Nacional de Garanta de la Calidad (NCQA). Los hospitales tanto

gubernamentales como privados buscan obtener la acreditacin de la JCAHO.

LOS PROBLEMAS DEL SISTEMA DE SALUDDe acuerdo a diferentes analistas, los problemas del sistema de salud norteamericano son muy amplios y

complejos, sin embargo sus fallas medulares se pueden resumir en los siguientes aspectos:

1. Baja eficiencia del sistema de salud: Estados Unidos destina alrededor del 17% de su PIB a salud aprox.(US$6700 anuales per cpita); y se estima que, de no hacer ningn cambio relevante, ese monto ser de

20% en el ao 2017, sin embargo, sus ndices de mortalidad infantil y esperanza de vida, entre otros, son

peores que los de otros pases ricos que destinan menor porcentaje de sus ingresos a salud. A manera de

comparacin, de acuerdo al OECD Health Data 2009, el ao 2007 Suecia destin el 9% de su producto a

salud y logr una tasa de mortalidad infantil de 4.4 muertes por 1000 nacidos. Estados Unidos, tuvo una tasa

de 6.6 muertes por 1000 nacidos. Tambin se observan resultados relativamente ms bajos en indicadores

tan relevantes como expectativas de vida (por ejemplo en Canad es de 82 aos y en Estados Unidos es de

76 aos), manejo de enfermedades crnicas, prevencin de patologas evitablez, entre otras.

2. Poca orientacin a la prevencin: Otro aspecto que se destaca como un factor de baja eficiencia delsistema de salud es el nfasis curativo en oposicin a lo preventivo. El pas enfrenta ndices peligrosos de

obesidad y enfermedades crnicas, pero a pesar de esto, menos del 4% del gasto total en salud se invierteen prevencin y salud pblica.

3. Alta proporcin de poblacin noasegurada: Actualmente se estima que aproximadamente 47 millones

de ciudadanos menores de 65 aos que no cuentan con cobertura mdica. Se estima que una alta

proporcin de las personas no aseguradas, tienen ingresos que le permitiran cancelar una prima mensual,

pero son rechazados en las aseguradoras por tener enfermedades preexistentes.


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A una persona con ingresos normales pero sin seguro mdico, una enfermedad peligrosa la podra llevar a la

bancarrota, que es una figura legal que acta como refugio contra los acreedores. De no declararse en

bancarrota o si su solicitud de bancarrota es rechazada por un tribunal, esa persona tendra que hacer

planes de pago de mutuo acuerdo con los mdicos, laboratorios y hospitales a los que debe dinero. Aqullos

que deciden no pagar, sufrirn una baja en la calificacin de su historial de crditos. Ese historial es muy

importante en la dinmica de la sociedad estadounidense. Sin una buena imagen en este sentido, a veces no

es posible arrendar una casa o abrir una cuenta bancaria.4. Fuerte crecimiento de los costos de salud para las personas, las empresas y el gobierno : De acuerdo alos analistas, el gasto en salud ha aumentado tres veces ms rpido que el salario promedio. Las primas se

han duplicado desde el ao 2000, con un ndice de crecimiento muy superior a los salarios, sin embargo la

cobertura real ha empeorado. De acuerdo a cifras oficiales, los gastos de bolsillo de la gente con seguro han

aumentado fuertemente, influenciados por el aumento en los deducibles y copagos de sus planes de salud.

Estos costos estn afectando a las personas y empresas, ya que impiden que los salarios aumenten. Para los

trabajadores, que dependen del seguro de salud proporcionado por su empleador, el creciente costo

significa que una mayor proporcin de su sueldo ser entregada como beneficios de salud en lugar de dinero

en efectivo del que puede disponer. Si se sigue la misma tendencia, se espera que en diez aos, el

porcentaje estimado de la compensacin total de un trabajador que se recibir en la forma de seguro de

salud ser de 26%.

5. Incentivos mal enfocados: Se piensa que uno de los mayores impulsores del aumento del costoexperimentado por los programas pblicos de salud es un esquema de relacin entre prestadores

aseguradores y pacientes errneo, que genera un aumento sostenido del gasto:

o Al pagar a los prestadores por prestacin y no por resultados no existen incentivos orientados al uso

eficiente.

o Al establecer copagos para atenciones de tipo preventivo y de control de enfermedades crnicas no se

incentiva su demanda, evitando el desarrollo de enfermedades crnicas evitables.

o La falta de informacin objetiva sobre resultados, recursos y buenas prcticas dificulta la seleccin de

prestadores ms eficientes.

REFORMA DE SALUD OBAMA

el sistema de salud de eeuu

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