US Healthcare - difference between Obama and Trump care

Obama Healthcare

The Patient Protection and Affordable Care Act, often called Affordable Care Act (ACA) or Obamacare, is a United States federal statute enacted by the 111th United States Congress and signed into law by President Barack Obama on March 23, 2010.

The term "Obamacare" was first used by opponents, then re-appropriated by supporters, and eventually used by President Obama himself. Together with the Health Care and Education Reconciliation Act of 2010 amendment, the U.S. healthcare system's most significant regulatory overhaul and expansion of coverage since the passage of Medicare and Medicaid in 1965.

The ACA's major provisions came into force in 2014. By 2016, the uninsured share of the population had roughly halved, with estimates ranging from 20–24 million additional people covered during 2016. The increased coverage was due, roughly equally, to an expansion of Medicaid eligibility and to major changes to individual insurance markets. Both involved new spending, funded through a combination of new taxes and cuts to Medicare provider rates and Medicare Advantage.

Trump Healthcare – American Health Care

The American Health Care Act of 2017 is a United States Congress bill to partially repeal the Patient Protection and Affordable Care Act (ACA), also known as Obamacare. Rejected Senate amendments would have renamed it the Better Care Reconciliation Act of 2017, Obamacare Repeal Reconciliation Act of 2017, or Health Care Freedom Act of 2017. Below is the comparison between ACA, AHA acts.

Comparison Point	Affordable Care Act (ACA)	American Healthcare Act (House bill)	Better Care Reconciliation Act (Senate bill)
Employer Mandate	Businesses with 50+ full time (or part time equivalent) employees must provide health insurance or pay a penalty.	Penalty eliminated	Penalty eliminated.
Pre-existing Conditions	Insurance companies cannot deny coverage or charge more based on pre-existing conditions.	States can set their own policies on pre-existing conditions via waiver application.	Insurance companies cannot deny coverage or charge more for pre-existing conditions but can waive ‘essential health benefits’.
Women’s Health	Women’s health coverage must be included in ACA-compliant plans.	States can remove women’s health benefits, such as maternity care, by applying for a waiver.	States can remove women’s health benefits, such as maternity care, by applying for a waiver.
Affordability Of Care	Elderly cannot be charged more than 3x a young person’s premium.	Elderly can be charged up to 5x a young person’s premium.	Elderly can be charged up to 5x a young person’s premium.
Medicaid	30+ states expanded coverage with federal support.	Federal expansion support removed by 2020; annual caps on funding available to each state.	Federal expansion support removed by 2021. Medicaid in some states would phase out sooner. Annual caps on funding available to each state
Health Savings Accounts	Limits annual contributions to $3,400 for individuals and $6,750 for families.	Increases cap on contributions to $6,650 for individuals and $13,300 for families.	Increases cap on contributions to $6,650 for individuals and $13,300 for families.
Small Business Association Health Plans	Requires association health plans to provide essential health benefits	Requires association health plans to provide essential health benefits	Allows association health plans to offer fewer benefits
Insurance Marketplaces	Created federal and state insurance online marketplaces where people can compare and shop for insurance plans	Unclear on the future of the insurance marketplaces.	Individual health insurance market would continue; Funds allocated through 2019 to stabilize insurance market.
Business Tax Impact	Created a small business tax credit. Increased taxes on insurance companies, medical device makers, and wealthy Americans.	Eliminates small business tax credit starting in 2020. Repeals taxes on insurance companies, medical device makers, and wealthy Americans.	Eliminates small business tax credit starting in 2020. Repeals taxes on insurance companies, medical device makers, and wealthy Americans.

US Healthcare Financial Spending Across all Entities

The US Healthcare system is both mix of public and private insurance. The government provides insurance coverage for approximately,

• 53 million elderly via Medicare
• 62 million lower-income persons via Medicaid
• 15 million military veterans via the Veteran's Administration
• 178 million employed by group insurance (subsidized health insurance through their employer)
• 52 million other persons directly purchase insurance either via the subsidized marketplace exchanges developed as part of the Affordable Care Act or directly from insurers.

Financial spending as percentage of GDP
The Centers for Medicare and Medicaid (CMS) reported that U.S. health care costs rose to 17.8% GDP in 2015, up from 17.4% in 2014. Increases were driven by the coverage expansion that began in 2014 as a result of the Affordable Care Act.

Financial spending Per Capita
The Centers for Medicare and Medicaid (CMS) reported that U.S. health care costs rose 5.8% to reach $3.2 trillion in 2015, or $9,990 per person.

Distribution of spending by service type
Healthcare spending in the U.S. was distributed as follows by type of service in 2014.
Hospital care 32%, Physician and clinical services 20%, Prescription drugs 10% and all other, including many categories individually making up less than 7% of spending. 

US Healthcare Industry - Various stake holders

There are six major entities,

1. Regulators and Policy Makers
2. Payers
3. Advocacy Organizations
4. Providers
5. Suppliers
6. Consumers

1)      Regulators and policy makers

       At the top of the pyramid, the federal government sets the tone for the entire system. Many other entities have been formed over the years in response to the need for control over various areas of the healthcare industry. Today, the most influential regulators include the U.S. Department of Health and Human Services (HHS), the Centers for Medicare and Medicaid Services (CMS), the Food and Drug Administration (FDA), and the Centers for Disease Control and Prevention (CDC). These entities have been charged to interpret, implement, and ensure compliance with the current laws of the United States that affect and govern the healthcare industry. The scope of regulatory influence of these entities is determined by the laws they enforce. At the state level, state legislatures, state and local governments, health departments, state medical boards, and state insurance commissions also play significant roles while functioning within federal regulations. Nevertheless, state governments have been successful in introducing unprecedented moves that go beyond federal mandates for healthcare policy; for example, Massachusetts Was able to mandate health insurance coverage for all its citizens in 2006.

2)     Payers

      Financing in the U.S. healthcare system can be broken down into payments made by the public sector (the federal government, state and local governments), the private sector (private insurers and businesses), and the consumer (out-of-pocket expenses and self-pay). Public funding of the U.S. healthcare system includes federal sources, such as Medicare and Medicaid programs, the Veterans Administration, and the U.S. Department of Defense, and state and local programs, such as Medicaid and state and local hospitals. Private funding includes out-of-pocket expenditure, private insurance, and philanthropy. As can be inferred from this list, many of these payers have other capacities and exert substantial influence in other areas of the U.S. healthcare system through policy making (e.g., CMS) or through advocacy groups and lobbying (e.g., private insurance companies).

3)      Advocacy organizations

      This category encompasses organized efforts of smaller entities in the healthcare system around a common interest that is frequently self-serving. Examples of these groups include the American Medical Association (AMA), the American Society of Clinical Oncology (ASCO), the American Hospital Association (AHA), the American Nurses Association (ANA), America’s Health Insurance Plans (AHIP), and the National Patient Advocate Foundation (NPAF).

4)      Providers

      This category includes all individuals and organizations that provide a healthcare service to the consumer. As such, it includes health practitioners, hospitals, nursing homes, and other similar entities. Although health professionals are central to the specific entity that actually provides care, hospitals, in particular, offer the environment in which care can be provided and are compensated by payers for the services provided. It is in the hospital setting that a substantial portion of healthcare resources are consumed. Individual practitioners, practice groups, general hospitals, specialty hospitals, ambulatory facilities (surgery, imaging, etc.), and integrated healthcare systems are also examples of providers.

5)      Suppliers

      This category includes pharmaceutical companies and medical equipment companies. These entities have grown to be a significant part of the healthcare system and are in fact considered industries of their own. Although suppliers are integral to the healthcare system, the nature of their business is different. Like private insurance companies, most of these organizations are for-profit and publicly traded companies and exist in a different competitive environment. Unlike the payer category, the amount of not-for-profit activity in this category is small.

6)      Consumers

      People, whether sick or healthy, are consumers of care. In the industrialized world, one would be hard pressed to find anyone who has never received any care within a healthcare system. Consumers of healthcare services are somewhat different from consumers in other sectors of the economy.
Two primary differences are
(1) healthcare consumers often have to depend on the advice of a physician in  making a health services “consumption” decision, and
(2) in most instances, the consumer is unaware of the full costs of his or her choice because of the intermediary function of payers even though there may be a significant out-of-pocket

      component of the full cost.

To know more about financial spending refers US Healthcare Financial Spending Across all Entities

Marketplace

US Health insurance exchange operated under the federal government with the provisions of the Patient Protection and Affordable Care Act (PPACA, referred as 'ACA' or 'Obamacare'), which currently serves the residents of the U.S. states. 

The exchange facilitates the sale of private health insurance plans and offers subsidies to those who earn less than four times the federal poverty line. The website Healthcare.gov assists those persons who are eligible to sign up for Medicaid, and has a separate marketplace for small businesses.

To know US healthcare entities and their role refer US Healthcare Industry - Various Stake Holders

Refer Medicaid to know more about health insurance policies for low income people.

SQL Server Column Store Index

What is a ColumnStore Index?
A columnstore index is a technology for storing, retrieving and managing data by using a columnar data format, called a columnstore.
In a columnar, all the column 1 values are physically together, followed by all the column 2 values

How Different are Column and Row Store?

In row store data are stored in the disk tuple by tuple.
Where in column store data are stored in the disk column by column.

Most of the queries does not process all the attributes of a particular relation.
For example the query
Select c.name, c.address
From CUSTOMES as c
Where c.region=‘Mumbai’;

Only process three attributes of the relation CUSTOMER.  But the customer relation can have more than three attributes.

Column-stores are more I/O efficient for read-only queries as they read, only those attributes which are accessed by a query.

Benefits of Column Store Index:

• Each page stores data only on basis of column. That give significant improve in performance when fetching selected columns from table
• One page one column data, increase the chances of high percentage of data compression because of similar data type & data for same column
• Does not physically store columns in a sorted order. Instead, it stores data to improve compression and performance
• Column Store Index by default compressed data by New Column Store Compression

Restrictions of Column Store Index with SQL Server 2012:

• Cluster ColumnStore index cannot be combined with other index types, you can use Non-Cluster index to combine it with other indexes
• Only Clustered Column index are updatable on the other side Non-Clustered ColumnStore index are read only
• Non-Clustered CloumnStore Index requires extra storage space for column copy in index
• ColumnStore index creation takes more time (1.5 times almost) than creating a B-tree index (on same set of columns) because the data is compressed
• A table can have only one ColumnStore Index and hence you should consider including all columns or at least all those frequently used columns of the table in the index
• A ColumnStore Index can only be non cluster and non unique index; you cannot specify ASC/DESC or INCLUDE clauses
• Not all data types (binary, varbinary, image, text, ntext, varchar(max), nvarchar(max), etc.) are supported
• The definition of a ColumnStore Index cannot be changed with the ALTER INDEX command, you need to drop and create the index or disable it then rebuild it
• A ColumnStore Index cannot be created on view

New Enhancements with SQL Server 2014:

• SQL Server 2014 supports Clustered ColumnStore Index whereas SQL Server 2012 supports only Non-Clustered ColumnStore Indexes
• In SQL Server 2012, As soon as you had created a ColumnStore Index on a table, the underlying table was read only, and no changes to the data were allowed. But SQL Server 2014 allowed to have updatable ColumnStore Index
• Deltastore used with clustered ColumnStore indexes only, to gain performance.

Refer below videos for more details.

Informatica Transformation Types

Transformation is a repository object that generates, modifies, or passes data. Using Informatica transformations, users can implement business logic and transform the data.

Few more details about Transformations:

• Power center designer provides a set of transformations to perform specific functions.
• Transformations in a mapping represent the operations the Integration Service performs on the data.
• Data passes into and out of transformations through ports that we link in a mapping or mapplet.
• Transformations can be Active or Passive.

• An active transformation can change the number of rows that pass  through it.
• A passive transformation does not change the number of rows that    pass through it.
• Transformations can be connected to the data flow.
• An unconnected transformation is not connected to other transformations in the mapping.
• It is called within another transformation, and returns a value to that  transformation.

The below video will describes types of Informatica transformations. And why a transformation is called an active or passive transformation

Robotic Process Automation use cases in Supply Chain Management

Supply Chain Management:

Supply Chain Management (SCM) is a management of the flow of goods and services, involves the movement and storage of raw materials, of work-in-process inventory, and of finished goods from point of origin to point of consumption.

Example: Transport and goods, e-commerce etc.

1.       Order processing and payments:

a.       Business Process: Customers place orders online, they select their desired products, enter their payment information, and receive order and shipping confirmations — all of which happens electronically. And tracking the changes in company’s database.

b.      Problem: Behind the scenes, however, many companies still depend on manual labor and paper documents to execute these transactions that accompany processing an order. This can include manually entering customer information into the company’s database, processing payments, and sending out email confirmations and order updates.

c.       RPA Usage: By automating back office tasks, RPA has the ability to reduce the need for this manual work.

2.       Automation of emails:

a.       Business Process: Maintaining regular communication between manufacturers, suppliers, transportation service providers, and customers.

b.      Problem: Effective communication within the supply chain is essential. When a shipment is delayed or an order cannot be fulfilled, as well as when orders are successfully processed and shipped, it’s important to ensure open communication between all individuals and companies to build credibility and trust.

c.       RPA Usage: RPA can be used to automate this communication, automatically triggering an email or text when an order is processed, shipped, or delayed.

3.       Procurement and inventory management processes:

a.       Business Process: Ensure the manufacturer has enough products to serve the demand.

b.      Problem: Manufacturers and suppliers need to be able to carefully monitor their inventory levels in order to ensure they have enough products and serviceable to meet demands.

c.      RPA Usage: Software robots can monitor inventory, generate notifications when levels are low, and reorder products when levels go below a set threshold. In addition, real-time reporting provided by RPA can be used to determine optimal inventory levels based on previous needs and modify levels based on patterns in demand.