Understanding the Role of Medicaid in the US Health Care System - Research Paper Example

?Understanding the Role of Medicaid in the U.S. Health Care System Introduction A plan to provide every individual with health care coverage is now being implemented through the use of the Medicaid program and its expansion. The new Affordability Care Act, signed this previous March has provisions within to expand the entire Medicaid program. Logistics of this have been worked out and new policies have been implemented. The goal of providing every American individual with health care coverage may soon be realized by the United States, however; these additional coverage effects are already being felt though the program is just beginning. Medicaid is attempting to make cutbacks where it may in most States to conserve as the price of health care continues to rise. It is not known how these two factors will balance out without leaving either State or federal government further in health care debt. The affordability care act has had much opposition, primarily from the republican sector of government. Individual provisions of the act, aside from the Medicaid aspect, have been challenged in courts across the country though none have been successful thus far. The Medicaid expansion act that is included has been received favorably for the most part by individual States, with the federal government picking up cost increases for this, however; representatives are arguing against this in the long term. Body Medicaid is a Government funded health care program or benefit that a certain segment of the population can qualify for. Medicaid provides health care coverage to the population that it serves1. Medicaid was founded in the late fifties and early sixties while the United States was focused on providing health care to the senior population. Congress was approached with three choice programs in 1964, all aimed at helping the elderly with health care. The first, a hospital insurance program based on Social Security, the second a voluntary physician services program and third, an expansion of the Kerr-Mill program which already offered health care to the low income elderly2.Surprising to everyone Congress adopted all three. The first was to be known as Medicare, part A, the second was Medicare part B, and the third known as Medicaid. At the time Medicaid was seen to be a very minor piece of the Social Security Legislation and much less important than Medicare. At that time the importance of Medicaid was much less significant and coverage was provided to a much smaller percentage of the population. The entire program was formulated in a very different way than the program we currently are used to and the primary goals of this legislation were to improve of the Medicare program for our senior population. Medicaid was set up initially to serve elderly individuals and has since grown exponentially to serve so many more than that. Medicaid serves pregnant women, women with children, elderly individuals whose Medicare does not cover them fully, those blind or disabled, those already on public assistance or AFDC, indigent individuals, children whose parent qualifies, foster and adopted children and individuals or families who meet income guidelines. Income guidelines are a set amount of income that an individual can make or a group of individuals such as a family of four between them and be considered for Medicaid. These guidelines are decided at both the State and Federal level, with the Federal income guidelines being flexible in that the State can use more flexible guidelines though the State cannot decrease the amounts, they can only increase them. Essentially this means that at the State level Medicaid income guidelines can only be altered in a way that is favorable to recipients. By 1967 thirty-seven states had implemented Medicaid programs.Before this time States had minor programs which would offer some assistance though they were State specific with very few federal guidelines. The Medicaid program was still tailored by States, though now it had federal requirements and conditions as well. Currently all states are involved in the Medicaid program3, though each state may extend the program for more services if they decide. Services such as fertility care or other specialized services may be covered should a State decide to add them provided the cost sharing to the Federal government is not increased. Federal eligibility standards for Medicaid are different than those that vary by State. Eligible populations include pregnant women who are at 133% of the poverty level, infants whose mothers were on Medicaid when they were born are covered up to age one, at which time they are covered through age 5 at the 133% poverty level and over age 5 at 100% poverty level3. These are the eligibility standards which each State is required to use though they may use though states may choose to make their eligibility more flexible. Other eligible groups include those who receive SSI, children who are adopted or are in foster care, and those with low income who are also eligible for Medicare. Other populations are also covered with federal matching funds. Infants and pregnant women who are at 185% poverty level, parents who have eligible children, those receiving Medicare whose incomes are too high, those whose medical expenses are deemed high in relation to their income, those who have disabilities but would lose eligibility with income, women who are low income and uninsured having breast or cervical cancer can be covered for cancer treatment, and through the Children’s Health Insurance Program children can be covered at 200% the federal poverty guidelines3. The major thing that is different in most States is the income guidelines. In New York a single healthy person must make less than $708.00 per month to qualify for Medicaid if they do not qualify through any of the Federal eligibility guidelines1. A family of four who qualify in no other way can qualify if their income is less than $1220.00 per month. There are alternatives to Medicaid though most alternatives are at the community level. New York offers a number of different insurance programs such as Family Health Plus, which is designed for those who are still economically challenged but do not fall within the income guidelines or other qualifications to receive Medicaid1. New York also offers the Medicaid Excess Income Program, designed for those whose incomes are too high to qualify for Medicaid. This program focuses on those under 21 and over the age of 654. Most places will have County Health Departments, some offering a handful of free services while using a sliding scale for other services. Disease or condition specific groups offer varying assistance usually in the Community for those with no insurance or Medicaid. Some Communities have volunteer health care centers which use different criteria to screen individuals for service. Veterans can be seen at the Veteran’s Administration facilities without any coverage. Though there are many programs it is still unfortunate to find an individual who does not qualify for any of them. The services that Medicaid covers can vary by State. In New York Medicaid covers most acute care services such as visits to the Doctor or as an outpatient of a medical facility. Medicaid also covers many practitioners’ services such as dental, midwives, optometry and psycholog.Prescription drug benefits are provided. Physical therapy, occupational therapy, speech and hearing therapy are covered. Items such as dentures, eyeglasses, hearing aids, wheelchairs and prosthetics are covered5. Diagnostic services such as lab work are covered. Should you need care in your home there is coverage as well as hospital coverage. Several things that are excluded specifically are podiatry, surprising considering the link between diabetes and foot neuropathy, chiropractic services, and religious non medical health care institutions. Currently States and the Federal Government share the cost of Medicaid through a formula which determines who pays what. The Federal Government pays at least 50% for each State and the remainder is determined by several factors 1.Those States having lower per capita income receive higher matching funds to foot the Medicaid bill. The formula used is called the ‘Federal Medical Assistance Percentages’ Matching rates from October 2011 through Sept 30, 2012 show that few States receive 50% but most are higher than that with Kentucky (71.18%) and Mississippi (74.18%) being the highest6. New York is in the low few that are matched at 50%. This percentage represents the amount of the Medicaid bill that is matched and paid by Federal government. With New York at 50%, the Federal government matches the Medicaid bill by 50%, and both the State and the Federal government pay half. Medicaid costs continue to rise while most States are attempting to reduce Medicaid spending in these economic times. Programs are being removed, services no longer fully covered, and larger gaps are being made between those who have health coverage and those who do not. In attempting to contain costs associated with the Medicaid program 17 States have reduced benefits 7. These cost containment actions come in the form of increased copays, eligibility cuts, long term care changes, and reduced services with New York among them. Eligibility cuts have been made in three States, making it harder to get Medicaid in the first place for those that need it. Eligibility cuts come in the form of decreased income allowances and larger family size allowances before benefits can be approved. Medicaid spending is influenced by the amount of services used, volume of those enrolled in the program and the price of the services. Medicaid is very much like any health insurance program except that during a recession there are a much greater amount of people that qualify for the program. This is an obvious statement. Medicaid makes a huge difference in the lives of those who need it and receive it. The Medicaid program covers some of our most vulnerable population, low income pregnant women, already at high risk due to low socioeconomic status, elderly, disabled, infants and children have come to depend on this program for medical care. Some would not seek or receive medical care without Medicaid. Removing Medicaid for many would be a catastrophe. Cutbacks are already being felt by some with reduced programs, benefits, stronger eligibility requirements and a decreased amount of providers who will accept Medicaid. The Medicaid program has enabled patients to have access to preventative, acute and long term care. Medicaid finances over 40% of live births! The Patient Protection Act and the Affordable Care Act was passed on March 23, 2010 with a primary goal of improving access to health care services through insurance system reforms8 . Immediate improvements in American health care and an increase in the number of people with insurance9 are the Act’s essential features, though there are many individual elements of the act that address specific issues. This legislation became necessary as a result of the Nation’s critical health care situation. Health care that is unaffordable, citizens with no insurance, an aging population with increased health care needs and a high percentage of American citizens living at or below poverty rates contributed to this necessity. This was primarily a democratic statute, passing the Senate without the Republican vote and getting through the House of Representatives with a high percentage of republicans voting against it. Navigating the health care system without a continuum of care can result in misinformation, increased spending, unnecessary services utilized, all leading to increased costs which always have the trickledown effect, with less services being covered by Government programs or tighter eligibility rules 10. The ACA contains provisions designed to lay the foundation for a healthcare delivery system that integrates care across settings and providers. A research study involving comparing and contrasting different methods and modalities of treatment has been implemented; effectiveness and outcomes combined with appropriateness of treatments are to be reported on by an independent panel in an effort to reach this goal. Insurers would now be required to offer essentially the same coverage and benefits to each of their insured, despite preexisting conditions or individual factors. The ACA has other provisions included to make sure our health care facilities are properly staffed in today’s nursing shortage. School scholarships, loan and tuition forgiveness programs and grants all designed to attract, retain, and graduate new nursing staff11 are included in the Statute. States will be receiving 100% federal funding for this between 2014 and 2016. The Federal coverage decreases only very slightly after that. States have the option to expand eligibility to childless adults but will receive their regular FMAP until 2014. Those enrolled in the Medicaid Children’s Health Insurance program will now not see an eligibility increase until year 2019 and can be eligible at 133% the poverty level.This is the federal matching amount mentioned earlier. The ACA expanded Medicaid to all those non-Medicare eligible individuals under the age of 65 with incomes up to 133% the poverty level and he ACA will require Medicaid to maintain the current income eligibility limits for children in Medicaid and in the Children’s Health Insurance Plan until the year 201911 . ACA section 1902 relates to a new eligibility group for Medicaid and is one expansion option written into the Act. This group includes very low income individuals who are not otherwise eligible to receive Medicaid. That means that they must not be pregnant, over 65, enrolled in Medicare part A or B, or any of those described in other groups, such as parents, those receiving SSI or children. This particular section is designed to fill in the gap and insure those who are usually not eligible for Medicaid12. This would affect individuals or families who do have some income, enough to usually prohibit them from receiving Medicaid, though not enough income to afford health care premiums. Seniors who have not yet reached 65 without full Medicare benefits will not be eligible. This group could also include men unable to find a job or those who are underemployed. Men have long been a population ignored, due to the fact that they are frequently employed with incomes too low to afford health care but too high to qualify for Medicaid. Without other existing factors such as being of Medicare age or disabled they frequently go without insurance. With income allowances higher more men are able to work and qualify for Medicaid. Social Security Act Section 1115 Waiver gives States the ability to research improvements to their own Medicaid and CHIP programs. States may use this waiver to give individuals Medicaid who are not otherwise qualified. The waiver can also be used to cover non-Medicaid services. This program has made significant differences for those who have received Medicaid through this waiver or SCHIP, which is the Children’s Health Insurance through the use of the waiver. The waiver program is very interesting in that it is very vague and seems to be very flexible as to who can receive this, provided it does not change the budget in any way. The fact that this waiver is budget neutral is what makes the waiver successful. It cannot change or increase the budget in any way, increasing the Federal government’s FMAP. An example of the waiver program was Oklahoma’s Learn Fare program13. This was an initiative that set out to design a method on implementing a stay in school program for pregnant teenage girls. Partnered with the welfare program Oklahoma hopes to show the program as successful, thereby being implemented in other areas. Medicaid expansion and the Act altogether have many arguments against it, notably most of the Republican Party. Saying that it is unreasonable and a cost that the Federal government cannot afford at this time is the primary reasons given by the Republicans in voting against it. Despite arguments against the Act it has remained and all provisions are expected to be in effect in the next two years. Conclusion The Medicaid Expansion Act under the Affordable Care Act is an excellent beginning in health care reform, though the Affordable Care Act has its number of positive and negative factors. Political opposition, especially from the republican sector means that this Act is likely to be delayed a great deal in being fully implemented due to constitutional challenges, both by individual States and Republican representatives and sectors14. Elements included in the Act that are not Medicaid related such as the requirement of smaller employer’s to share in the cost of health care if they do not provide insurance are being battled against by activist groups and political representatives in each State. Arguments have also been made against the pre-existing condition clause in the affordable care act, pointing out that removing pre-existing clauses from insurance policies will simply cause many people to avoid buying private insurance until they have need of it, and this is an excellent argument as the Act at this time does not include any enforcement or provisions for cases such as this15. States and multiple Representatives do not believe that Federal Government should have such authority when it comes to health care, though the Federal government has been looked to for years to make changes and provide Medicaid and Medicare insurance to individuals. Despite this being the case it seems only reasonable that the Federal government have such authority, which has ultimately been decided in every case thus far against this Act. Medicaid expansion has been the least argued element of the affordable care act, possibly because the federal government is assuming much of the cost of this. If we are to ever have a single structured health care system rather than two separate distinct structures such as is the case now, with private health insurance as one and Medicaid and other government programs the second then an expansion such as thus provided is an important step. It is an important theoretical step though seeing it in action over the next five years will tell if it will be successful. Already Medicaid programs are overspent with the government matching over half of most States programs. Programs are trying to find ways to make cutbacks without being detrimental to the health care process which is impossible. Eligibility requirements have changed in three States in the last year, fewer provider’s are available who will accept Medicaid payments and the amount and type of services covered are being narrowed in some States. Medicaid expansion is a great idea and each American having some type of health insurance sounds good but the plausibility of it in today’s ever increasing health care costs remains to be seen. The ACA has many fine attributes to it and has very important objectives. Whether these meet their target and are successful will not be known for some years. Medicaid at its inception was nearly an accident and today is a huge part of the health care delivery system and Medicaid expansion has a similar chance in my opinion. In conclusion, the Medicaid program plays a large part in our Country’s health care system. Improvements to the program can only make it more successful, allowing it to serve more people. With Medicaid being a chosen option in all fifty States we are heavily vested in this program and its ability to meet the needs of those who aren’t able to get health insurance coverage due to a number of reasons. With the expanded eligibility requirements and the CHIP programs’ retained eligibility requirements Medicaid will be serving more individual that ever over the next several years and I see this increase continuing with the current economic situation as it is. Works Cited 1. "Medicaid." New York State Department of Health. Available at: . Accessed 05 Dec. 2011 2. Grogan, C, and E Patashnik. "Between Welfare Medicine And Mainstream Entitlement: Medicaid At The Political Crossroads." Journal Of Health Politics, Policy & Law. 28.5 2003; 821-858. 3. "Medicaid Home Page." NCSL Home. Available at: . Accessed 04 Dec. 2011. 4. "Medicaid Excess Income ("Spend down" or "Surplus Income") Program." New York State Department of Health. Available at: . Accessed 05 Dec. 2011. 5. "Family Health Plus." New York State Department of Health. Available at: . Accessed 05 Dec. 2011. 6. "2012 FMAP and EFMAP Notice." Office of the Assistant Secretary for Planning and Evaluation, HHS. Available at: . Accessed 05 Dec. 2011. 7. "Medicaid Cost Containment, FY2012.” Kaiser State Health Facts. Available at: . Accessed 05 Dec. 2011. 8. Hardcastle L, Record K, Jacobson P, Gostin L. Improving the Population's Health: The Affordable Care Act and the Importance of Integration. Journal Of Law, Medicine & Ethics . September 2011;39(3):317-327. 9. Reno R. REFORMING THE HEALTH-CARE REFORM. First Things: A Monthly Journal Of Religion & Public Life [serial online]. June 2010;(204):61-63. Available from: Academic Search Premier, Ipswich, MA. Accessed December 5, 2011. 10. Shugarman L, Whitenhill K. The Affordable Care Act Proposes New Provisions to Build a Stronger Continuum of Care. Generations. April 2011;35(1):11-18. 11. McNeal G. The Healthcare Reform Bill and its Impact on the Nursing Profession. ABNF Journal [serial online]. Spring2010 2010;21(2):38. Available from: Academic Search Premier, Ipswich, MA. Accessed December 5, 2011. 12. Mann, Cindy. "New Option for Coverage of Individuals under Medicaid." Centers for Medicare and Medicaid Services. Department of Health and Human Services. Available at: https://www.cms.gov/smdl/downloads/smd10005.pdf . Accessed 5 Dec. 2011 13. Harvey C, Camasso M, Jagannathan R. Evaluating Welfare Reform Waivers Under Section 1115. Journal Of Economic Perspectives [serial online]. Fall2000 2000;14(4):165-188. Available from: Business Source Premier, Ipswich, MA. Accessed December 5, 2011 14. Gable, L. (2011). The Patient Protection and Affordable Care Act, Public Health, and the Elusive Target of Human Rights. Journal Of Law, Medicine & Ethics, 39(3), 340-354. doi:10.1111/j.1748-720X.2011.00604.x 15. Gruber J. THE IMPACTS OF THE AFFORDABLE CARE ACT: HOW REASONABLE ARE THE PROJECTIONS?. National Tax Journal. September 2011;64(3):893-908. References "Medicaid Program; Review and Approval Process for Section 1115 Demonstrations." Federal Register. Available at: . Accessed 05 Dec. 2011 Baumrucker, Evelyn. "CRS Report for Congress Medicaid and SCHIP Section 1115 Research and Demonstration Waivers." Available at: . Accessed 5 Dec. 2011 DSH Policy Changes for States with Section 1115 Expansion Waivers Issued. Hfm (Healthcare Financial Management) [serial online]. March 2000;54(3):10. Available from: Business Source Premier, Ipswich, MA. Accessed December 5, 2011. Kocher R, Emanuel E, Deparle N. The affordable care act and the future of clinical medicine: the opportunities and challenges. Annals Of Internal Medicine. October 19, 2010;153(8):536-539. . Read More