US Medicaid and Medicare program and Australian Medicare programs - Research Paper Example

? The Medicare and Medicaid programs have been applied in the US in securing medical cover for patients. These programs are good and have been very influential in ensuring the health of people who cannot afford medical care. The US programs are however structured in a way that cuts on the scope of those who are considered eligible for the program. For instance, it covers only for the aged people above 65 years, the extremely physically disabled people, those considered to be of very low income (not all), and those undergoing serious special medical conditions or procedures. This is in contrast to the Australian Medicare system which covers for all residential citizens of Australia, is comprehensive in its coverage, is flexible in terms of giving patients the chance to choose public or private hospitals to go to, and also extends the cover to the visitors from The Reciprocal Health Care Agreement countries. This paper takes a critical evaluation of the two countries’ health care cover programs and tries to make a comparison in the discussion as far as their application is concerned and considers the quality of both. Table of Contents Abstract 2 Table of Contents 3 1.0Introduction 4 2.0Evaluation and Discussion 4 3.0Conclusion 12 4.0Recommendations 13 Works Cited 14 1.0 Introduction Medicare is simply a social insurance structure that is administered by the government in the US and by the Australian government. It is aimed at providing health insuring to people that are over 65 years of age; those that are below 65 years but are physically disabled or those that exhibit congenital disability; or those that are classified under certain criteria (Coory 581-583). The system in the US almost has close resemblance to single-payer healthcare programs, although this is not. There are differences in the application of the Medicare programs between the US and the Australian governments. The main difference seems to come from the single-payer approach. Other differences come from the requirements set for enrolment in the program. While the US Medicare program targets certain age groups and the disable people or those with special needs, the Australian system seems to be all-inclusive (AHS). There is no dispute that everyone needs good health and deserves a medical insurance cover that is able to serve this purpose. However, the issues of socialism seem to crowd the decision-making process by the US government regarding this health program because historically, the US has been trying its best to cut links with socialism practices, even in issues that affect its citizens. This paper takes a keen look at the US Medicare or Medicaid programs and tries to compare this with the Australian Medicaid or Medicare programs to find out where they are similar and how the differences come in. however, whatever the differences or similarities, the importance of providing medical cover to people cannot be ignored (HHS). 2.0 Evaluation and Discussion The Medicaid program got enacted in the year 1965; just the same time the Medicare program was created in the US. This was through the Social Security Amendments of 1965. This program expanded quickly and happened to replace the other programs that had been organized under the Federal Grants to the various States within the US that had been providing medical care to many patients on welfare and those who were aged. In the US, the Medicaid program is more of an entitlement program and is jointly receiving funds from the Federal as well as the State funds. The contribution that comes from the Federal government towards every State depends heavily on the willingness shown by the State to give financing to the medical cover and in this case, a matching formula is employed. As has been seen, each of the States does design and manages its individual program but based on the rules set by the Federal government. This medical care program has been very demanding in terms of funding. For instance, in the year 2002 alone, the expenditure on Medicaid was at 258.2 billion USD (Coory 581-583). In the US, this program has been entangled in eligibility ambiguity. This is because it has not been easy for the administration to state clearly who are actually eligible for the program, what the exact services that the program covers are, and the mode of reimbursing and delivering these programs, an issue that has caused much misgivings. Something that is however clear the fact is that variability throughout the States seems to be the rule. Basing on the state programs implemented over the past years by different states, special waiver has been exercised (HJK). Differences come in the eligibility levels based on income, the type of services that are covered, and the methods as well as the amounts of cover. Interestingly, the US’s Medicaid program is targeted at poor people or those thought to have very low income, yet the program does not end up covering for all the poor people. When it comes to the children and families, there is available primary as well as acute care that is delivered most of the time through the managed care program. The elderly people and those who are found to be physically disabled are typically covered based on a fee-for-service platform. In the country, Medicaid has been seen to offer financing to many long term based care services. These services have been singled out and are for example, nursing home care as well as the services based on community that are specifically designed to give assistance to people of old age and those who are physically disabled, albeit in their homes. It is only in the recent past that some of the States have gone further and integrated the Medicaid program with the Medicare in terms of financing and also in helping to coordinate the acute and identified long term health care services for these categories of populations (CMS). In the US, there are complex issues in the Medicaid program and these have posed serious challenges to people that try to generalize the program in its application. These challenges have been experienced in cases involving eligibility, the kind of services that are to be covered by the program, the way that the program is to be financed and managed, issues to do with the main reimbursement provider, and the important role that is played by waivers given that try to expand who is eligible and also in trying to modify these services. Medicare program is like a social security program within the US. It does provide health insurance cover for old people who are of over 65 years of age, the physically disabled, and those that have been classified under the special criteria. The Medicare program within the US is more of a single-payer healthcare program, although many try to differentiate it from this. The Medicare program does fund residency training programs too for many physicians in the US. The financing of this program has been based on the payroll taxes that have been stipulated by the federal insurance contributions Act or FICA as well as the self-employment contributions Act that was enacted in 1954. Until the year 1993, there was a legislation that gave the maximum compensation that the Medicare tax got imposed in every year but this was eliminated in January 1994. To this extent, it is required for a self-employed person to pay the entire 2.9% tax that is levied on the net earnings from self-employment. For Medicare, eligibility is still an issue, although this has been structured in a way that covers people who are of age at 65 years or more and must have been legally residing in the US for a period of over 5 years and their spouses are on record as having managed to pay medical taxes for a period not less than 10 years. The other criteria targets people who are disabled physically even when they are below 65 years and this is pegged on them having receiving social security disability insurance or SSDI benefits for a period not less than 24 months. People who have certain specific medical related conditions that make them incapable of earning are also considered in this cover, for instance, those that are on dialysis or require having a kidney transplant (Kaisser). There have been serious political campaigns that aim at cutting the spending by the US government on the Medicare and Medicaid programs. This is said to be able to save over 7.6 trillion US in a period of over 10 years through the capping of spending by the federal government of up to 20.6% of its GDP. The only way to reach such a goal has been singled out as being through serious cuts on the Medicare and Medicaid programs. The driving force behind these serious proposals has been the fear that the baby boom generation is now passing its middle age and would be at an advanced age in a very short time. The effect of this ageing generation would be huge given the numbers that will be above the 65 year mark in the next few years. Many have however argued that such an enormous cut would amount to doing away with the program as a whole. But economists and proponents of the programs pose that the effects of such a cut on the economic stability at this time when the economy is still trying to get out of the recession would be serious and could have huge negative repercussions (Coory 581-583). Currently, the Medicaid program is helping in funding of health as well as long term care and the population being cared for has risen to over 55 million people who fall within the low income, severely disabled, and elderly people. The current annual cost to the US government stands at 300 billion USD. This could be one reason why many people are concerned about the sustainability of these programs (Kaisser). Some States within the US have seen the need to incorporate private companies in the administration of portions that are related to their Medicaid benefits. These Medicaid managed care programs give a chance to private companies in insurance or those that are involved in maintenance of health to directly carry out contracting with a Medicaid program of a State department and this is done at a fixed price per single enrollee. The differences between Medicare and Medicaid programs come from the level of funding. While Medicare is a social program of insurance and is fully funded by the federal government with a primary focus on the older population, Medicaid is not solely getting its funding from the federal government. The different States have to give over half of the funding in the Medicaid program and even counties are called upon to contribute in some states. The Medicaid program is also different from the Medicare system because it is means-tested and needs-based social protection or welfare program as opposed to the social insurance system. For Medicaid, eligibility is more or less determined by one’s level of income. It is thus based on the limited income as well as financial resources availability (Mascarenhas). On the other hand, the Australian system of Medicare stands out. This system has been well structured, is clear, and helps give medical cover to almost all resident Australian citizens. This has been described by many observers as one of the most successful government initiated programs across the world. The Australian government has been seen to set health policies and does put subsidies on health services that are given by the state, territory governments, as well as the private sector. The government manages to spend a total of 9.8 percent of its GDP on healthcare as opposed to over 23% spent by the US. The Australian government has managed over the years to fund universal medical care services and the costs of pharmaceuticals, besides giving financial help to all public hospitals, community-based care organizations as well as residential based aged care providers. The state and governments in the territories have managed to give various direct health related services, which also incorporates acute and mental medical services. Schooling health, maternal and child health, dental, occupational health, and disease control plus health inspection services are just among the covers given by this Australian Medicare. This seems to be a very comprehensive cover program that does not discriminate on the basis of income and age levels or even physical abilities as is the case for US’s Medicare or Medicaid programs (Mascarenhas). The local governments are also charged with the provision of health in form of environmental control like garbage collection and disposal, provision of clean water, and consistent health inspections. Furthermore, they provide personal preventive services together with home care health services. The Medicare program in Australia thus ensures that each and every Australian is able to access free medical and at times low-cost, optometric and also hospital based care. It also gives these Australian citizens a chance to make a choice on the private hospital or private health services and allied health services in some special instances. The Australian Medicare system is quite different in its application when compared to the US Medicare or Medicaid programs. This is because it is able to give free medical treatment to the public in all public health hospitals; gives free and at times subsidized treatment by doctors and specialists, together with the optometrists and dentists; and also is able to provide free treatment by those organizations that do bulk billing. It has a network of Medicare offices and information claiming services. Different from the US Medicare program that was introduced in 1965; the Australian system was initiated in 1984 as a comprehensive health care provision system. This program became effective in February 1984 after the Health Legislation Amendment Act 1983 was passed that encompassed the amendments that were made on the Health Insurance Act 1973, Health Insurance Commission Act 1973, and the National Health Act 1953. All eligible Australians who are residing in Australia have access to this free or low cost healthcare program and have the freedom to choose going private or public. Individual contribution is pegged on income levels and levies in terms of taxes or Medicare levy. Charges are not imposed on patients treated in public hospitals for patients who have been admitted. There is in existence the safety net arrangements that ensure patients in need of a high level treatment procedure are not forced to incur heavy out-of-personal-pocket expenses (Biggs). The quality of Medicare system in Australia cannot be compared to that in the US. This is because it is able to give people who are eligible access to medical treatment for free in public hospitals and to some extent subsidize charges in private hospitals. The aspect of eligibility has managed to provide pharmaceutical benefits scheme (PBS) that does cover much of the pharmaceutical prescriptions that are to be provided by pharmacies across the country. Even for those people who are not able to pass the eligibility criteria, they still could access quality medical provisions from the private hospitals as well (DHAC). People who are on visits to Australia do not qualify for this cover. However, there are exceptions granted to people from countries that are part of The Reciprocal Health Care Agreement that could access the Medicare but to a restricted level. The restrictions are based on injuries and illnesses that have been got from Australia during their stay period only and which need quick treatment first before they are allowed to leave Australia. Thus, prearranged together with elective modes of treatment is not part of their Medicare cover. RHCA is applicable to visitors from countries such as New Zealand, UK, Netherlands, Finland, Sweden, Italy, Ireland, and Malta (DHAC). Private hospitals in Australia contribute at least a third of the hospital beds and private medical practitioners have been found to give most of the medical services found outside hospitals. These coupled with the salaried doctors have the capacity to give a large part of the medical services offered. Over half of all Australians have private health insurance covers. While 43% of the entire population is covered by the hospital insurance and this caters for treatment as private patients going for public or private hospitals. 43% also possess ancillary cover that deals with non-medical services which are given to people outside the hospital settings. These include physiotherapy, dental, and spectacles’ purchases. The main headache for the Australian government has been finding a balance between the private sector and public sector involvement in the healthcare process by motivating all people to be part of the health insurance scheme, while at the same time being able to maintain or sustain its universal safety net platform for Medicare (HHS). As such, a tax rebate of over 30% is offered by the government for premiums on private health insurance. Furthermore, once the annual threshold target is met, the Extended Medical Safety Net that was introduced in the year 2004 does give help through meeting 80% of the individual medical expenses. Alternative forms of medicines have been a cause for major debate for inclusion in Australian Medicare program but have not managed to do so. However, the acupuncture has been included in the cover as long as it is provided by an approved medical practitioner (Kaisser). On the international scale, Australia has been seen working or collaborating with other countries through sharing health provision experiences, implementation of regional health policies, and on a range of many health issues. These have had the benefits of helping the country set health standards that are considered international and also promote health support. The initial platform for Medicare in Australia was based on the Medibank scheme but took different financing arrangements (DHAC). 3.0 Conclusion The role that Medicare and Medicaid play in health provision cover has been very important. However, many observers ask about the need for such a cover when insurance firms exist and could give health related covers more effectively. What these critics forget is the role that these programs play in ensuring that the citizens are equally healthy irrespective of their income, age or physical conditions. Private health insurance would only cater for those who can afford to pay health care insurance premiums as opposed to those who cannot afford. The Medicare and Medicaid programs of the United States are good but have very significant differences to the Medicare program applied by the Australian government (HJK). The first distinct difference as discussed above is the scope of people who are eligible for the program. The US programs are quite discriminatory and only assist old people past 65 years, physically disabled people, very poor Americans, and those on special medical conditions. This leaves the other groups outside the bracket. However, the Australian Medicare does cover for all resident citizens and its scope is very comprehensive. The other difference is also in terms of economics involved. While the US systems cannot cover for all the citizens, it still takes up over 23% of the country’s GDP annually. The Australian system takes only 9.8% of the GDP yet it covers all the resident citizens of Australia without discrimination. This poses a serious question on the structure, integrity and application of the US Medicare and Medicaid programs in terms of being able to meet the healthcare needs of the American people, being efficient, and effectively meeting the targets for health care service covers. Various concerns have been raised in the US over the current campaigns aimed at cutting down on the budget for Medicare and Medicaid provision. Whether these strategies are well-informed or not, will be proven with time (HHS). 4.0 Recommendations The medical cover programs being carried out by the two states are very crucial in ensuring that the health of citizens is maintained. To this extent, it will not be prudent enough for the US government to withdraw the program and leave it to private health care insurance companies. This is because the objectives of the government and those of the private insurance providers are very different; Better ways of managing the health care insurance covers need to be found so that the program runs efficiently and effectively; The US government should consider applying the extended Medicare safety net program since this has proven to be more effective in Australia. This will be able to help the patients who have to foot the medical expenses out of their pockets, a move that will reduce heavily their medical expenses; The Medicare system in Australia needs further re-evaluation so that it can be made more patient-responsive than it might be at the moment. The US government needs to borrow a leaf from the Australian system in its structuring and application of the Medicare program. This kind of benchmarking would ensure that it improves its Medicare program in terms of scope for eligibility, costs involved, efficiency, and effectiveness. Works Cited AHS. "How does Medicare Work." 18 March 2010. Medicare Australia. Accessed on 3rd December 2011, at: . Biggs, Amanda. "Medicare Background Brief." 22 April 2005. Parliamentary Library of Australia. Accessed on 3rd December 2011, at: 2011 . CMS. "Medicare and Home health care." May 2010. US. Department of Health and Human Services: Center for Medicare and Medicaid Services. Accessed on 3rd December 2011, at: . —. National Health Expenditure Data: NHE Fact sheet. 6 June 2009. Accessed on 3rd December 2011, at: . Coory, Michael D. "Ageing and Healthcare costs in Australia: a Cses of policy based Evidence." The Medical Journal of Australia (2004): 180(11):581-583. DHAC. "The Australian Health care System." September 2000. Department of Health and Aged care. Accessed on 3rd December 2011, at: . HHS. "Health Insurance Reform and Medicare." 2010. Health Reform. Accessed on 3rd December 2011, at: . HJK. "Health care Costs: a Premier key information on health care costs and their Impacts." March 2009. Henry J. Kaisser Foundation. Accessed on 3rd December 2011, at: . Kaisser. "The Medicaid: A Premier." July 2005. The Kaisser Commission. Accessed on 3rd December 2011, at:. Mascarenhas, Alan. Global Post. 30 May 2010. Accessed on 3rd December 2011, at: . Read More