Medicare and Medicaid

Medicare and Medicaid are highly sensitive topics in health care, economic, and political worlds. This paper will explore the models of reimbursement and the effects the same have to patients and healthcare providers.

A Brief History of Both Medicare and Medicaid

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Medicare and Medicaid are joint federal and state programs that have defined the American healthcare system for more than half a century. President Lyndon B. Johnson on the 30 of July in 1965 signed into law legislation that led to the formation of Medicare and Medicaid programs. 19 million people were covered. According to the Center for Medicare and Medicaid Services (2015), the process of having the programs was kickstarted by General Thomas Parran who was a surgeon. It was his suggestion that national health insurance should be introduced and it should prioritize social security beneficiaries.

Initially, Medicaid provided assistance in the form of medical insurance to people who were receiving cash assistance. As time progressed, Congress made changes to Medicare and Medicaid. For instance, in 1972, Medicare got an expansion to cover the disabled, senior citizens who opted to be under Medicare coverage, and people requiring dialysis or a kidney transplant. In 2003, the Medicare Prescription Drug Improvement and Modernization Act initiated the biggest changes to the programs. Private health plans were accommodated if approved and were known as Medicare Advantage Plans (Center for Medicare and Medicaid Services, 2015). The Children’s Health Insurance Program (CHIP) was initialized in 1997 to cater to the health insurance and preventive care for more than 11 million uninsured children in America. In 2010, the Affordable Care Act (ACA)  was enacted and brought Health Insurance Marketplace into action where consumers were allowed to enroll in private health insurance schemes. 

Populations Intended to be Served by Medicare and Medicaid

According to the Population Reference Bureau (2017), Medicaid has the most health coverage than any other program in the US. Currently, Medicaid and Medicare cover a large group, which includes low-income families, pregnant women, people with disabilities despite their age, and people who need long-term care. Medicare and Medicaid provide a leeway for states to tailor their own Medicare and Medicaid programs to serve people in their states better, and as such, there are huge variations in service offered from one state to the other. By the end of March 2017, 74 million Medicaid and Children’s Health Insurance Program (CHIP) enrollees were actively covered. 

The table below indicates that children and youth are the most covered population segment representing about a half of all people who are covered, while senior citizens account for only 11%, and the disabled and institutionalized adults account for 14%. Women who have delivered under the program are a paltry 2%. CHIP is intended to cater to children whose parents are not eligible for Medicaid.

Category of ParticipantNumber in 2015PercentCumulative Percent
Child/Youth (under age 19)30,419,90245.845.8
Ages 65 and Older7,155,40110.856.6
Disabled (ages 19-64)8,781,32713.269.8
Institutionalized (ages 19-64)380,5170.670.4
Recent Mother (ages 19 and older)1,040,1931.671.9
Working Full Time Year Round (ages 19-64)4,678,1427.079.0
Working Part-Time or Part-Year (ages 19-64)3,319,8115.084.0
Other10,641,44716.0100.0
TOTAL Means-Tested Public Health Insurance66,416,740100.0

Source Population Reference Bureau (2017)

Expansion of Medicaid in the State of Delaware

The State of Delaware was among the very first states to expand health insurance coverage to state residence after 1965. The expansion was mostly aimed at covering residents with low incomes. Through the Affordable Care Act (ACA), Delaware was able to adopt Medicaid expansion. According to Norris (2018), after the enactment and adoption of ACA, the state of Delaware increased its enrollment in Medicaid and CHIP by 11%, an increase of 25,000 people. As a consequence, the uninsured rate in the state reduced from highs of 9.1% in 2013 to 5.4%  four years later in 2017. 

For an individual in the State of Delaware to qualify for the Medicaid Program, one has to have some specified characteristics. For instance, Norris (2018) outlines that children who are less than a year and are born into families with income levels less than 212% of the federal poverty levels (FPL) are eligible. Further, children who are between 1 and 5 years and their families earn less than 142% of the FPL are eligible. The income level for children between 6 and 18 years and in families earning less than 133% of FPL get eligible. Pregnant women with family incomes less than 212% of FPL are eligible and parents with family income of up to 138% of FPL are eligible, and the same is applicable to childless, non-elderly adults. Individuals with diabetes are also eligible. 

Reasons that States Choose Not to Participate in Medicaid Expansion

Different states have different reasons for rejecting the expansion of Medicaid. One of the most prevalent reasons, as Valdmanis (2015) elaborates, many states are cautious with the programs since they do not want to engage in programs that limit access to quality healthcare and at the same time diminish state budgets. They argue that the programs add people to Medicare or Medicaid, yet there are no cost controls and reforms necessary to accommodate such a bulging number. 

Other state administrators feel that the programs are political tools that are left active for any given federal administration. If adopted, such claimants say that the program will only be active for the period of time that the occupant in White House remains. As such, they do not want to be accused of playing politics with poor people’s health. The instability of healthcare policies as described by Clinton and Sances (2018) give reasons to many of the resistant states to put a halt on the programs. 

In a sense, Medicaid expansion is a precursor for increased costs of healthcare. Due to the low reimbursements that characterize Medicaid patients, healthcare providers prefer to treat patients with private health insurance who are likely to pay more. As such hospitals will prefer to accommodate patients with private insurance to offset the gaps that come with working with Medicaid patients. Further, the concept of reducing private health insurance is a bother to many state administrators. According to Gruber and Simon (2008) Medicaid expansion is estimated to reduce private coverage by 60%, which further reduces economic activity in states. An expansion of Medicaid replaces the people who were already in private coverage. 

Role of a Nurse when Interfacing with Medicare and Medicaid Recipients

As a professional, it is not prudent to be keen when it comes to who settles the bill for patients. Patients have a right to quality care and if a nurse is in a position to deliver, one should expedite the same. On the other hand, nurses are also economic agents who have to face the economic world anyway. This brings in the idea of feeling shortchanged when dealing with publicly insured patients. To outrun such a predicament, it is my opinion that nurses should see it as their duty to provide healthcare to all, it is altruistic, and part of their social responsibility. 

References

Center for Medicare and Medicaid Services. (2015). CMS’ program history: Milestones 1937-2015. Retrieved from https://www.cms.gov/About-CMS/Agency-Information/History/Downloads/Medicare-and-Medicaid-Milestones-1937-2015.pdf

Clinton, J. D., & Sances, M. W. (2018). The politics of policy: The initial mass political effects of Medicaid expansion in the states. American Political Science Review, 112(1), 167-185.

Gruber, J., & Simon, K. (2008). Crowd-out 10 years later: Have recent public insurance expansions crowded out private health insurance?. Journal of health economics, 27(2), 201-217.

Norris, L. (2018). Delaware and the ACA’s Medicaid expansion. HealthInsurance.org. Retrieved from https://www.healthinsurance.org/delaware-medicaid/

Population Reference Bureau. (2017). Majority of People Covered by Medicaid, and Similar Programs, are Children, Older Adults, or Disabled. Retrieved from https://www.prb.org/majority-of-people-covered-by-medicaid-and-similar-programs/Valdmanis, V. G. (2015). Factors affecting well-being at the state level in the United States. Journal of Happiness Studies, 16(4), 985-997.

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