MEDICARE AND MEDICAID
Introduction
Ever since the start of the 20th century, insurance coverage on health issues has remained a significant issue in the USA government. The government tried for the first time to coordinate efforts between 1915 and 1920 to create government health insurance but failed. Since the 1930s, Americans desired to have health insurance to give them protection from impulsive and disastrous medical costs. The main problem remained whether the insurance should remain publicly or privately financed. World War II saw increased private health insurance coverage. In 1950, Congress improved access to medical care for the needy through public assistance. In 1965, Congress passed legislation that established Medicaid and Medicare programs (Davis & Reynolds, 1976). Medicare responded to particular medical care requirements of the elderly, while Medicaid remained responsible for the perceived insufficiency of welfare medical care through public assistance. Medicaid involves a federal and state program that gives health coverage to low-income earners. Medicare program involves a federal program that provides health insurance to people over the age of sixty-five years old or under but with a disability no matter their level of income. The essay seeks to discuss Medicare and Medicaid
Quality Improvement Organizations
The organizations responsible for quality improvement in the health care services include a group of clinicians, health experts, and consumers aiming to improve the quality of medical care given to people with Medicare. Medicare and Medicaid are Federal government programs that seek to improve the quality of health care services for beneficiaries in the USA (Davis & Reynolds, 1976). The key role of the organizations is to improve efficiency, effectiveness, economy, and quality of services given to beneficiaries. The organizations protect the integrity of the program’s Trust Fund through ensuring that it only pays for goods and services necessary and reasonable given under suitable settings. Besides, the program protects beneficiaries through addressing personal complaints rapidly. The organizations improve healthcare and policies for beneficiaries in many ways. The organizations promote better quality for health care, better affordability, and better accessibility. The organizations’ principles help in improving quality by driving rapid change that prioritizes patients first and gives better patient care, lower costs, and better health population. The organizations improve quality by eliminating existing disparities, improving data systems and infrastructure, allowing local innovation and nurturing organizations for learning.
The organizations improve policies and health care by improving the communities’ health status through effective treatment and prevention of chronic diseases. In this case, the organizations work with physicians to give effective patient treatment to individuals with chronic diseases like stroke and heart diseases (Kline, Muldoon, Schumacher, Strawbridge, York, Mortimer & Kapp, 2017). The organizations decrease disparities by encouraging self-management education among disadvantaged communities. Besides, they assist the clinicians and physicians in practicing the utilization of electronic records fully and ensuring each patient obtains preventive health care services. The organizations encourage safe care for patients and family-centered accessible, and reliable. In this perspective, they work together with providers across the field of care to avoid healthcare-related infections in other care settings and hospitals. Consequently, they give assistance by sustaining and spreading evidence-based practices to ensure prevention and reduction of infections.
The organizations also improve policies by aiming at the prevention of health-care-obtained conditions in each patient’s safety efforts, nursing homes, and they facilitate innovation and collaboration. Besides, they promote family and patient engagement in all decisions and programs given to promote efficient, effective, and accessible health care services to the needy (Kline et al., 2017). These efforts aim at making care safer and decrease the harm caused during the delivery of care to patients. They improve policies and care by encouraging effective coordination and communication. The organizations help stakeholders organize for good coordination of transitions of care, better community access to services, better communication discharge, and improved sharing of evidence-based methods to decrease preventable patient readmissions among vulnerable individuals that witness inadequate care coordination. The organizations work with stakeholders and providers in the care environment to decrease possible serious drug reactions, overdoses, medication errors, and allergic reactions hence encourage medication management strategies. Lastly, they improve policies by making care more affordable through assisting the providers in reporting on and obtaining incentive compensation for procedures that assess the quality of clinical care, patient safety, care coordination, and caregiver and patient experience of care. Consequently, they assist hospitals and doctors in improving the quality of care, efficiency, and effectiveness of care successfully through the utilization of healthcare information technology to obtain system-wide lower costs and efficiency.
Qualifications for Medicare and Medicaid Benefits
Medicare remains available for individuals aged 65 years old and above, all people from all ages with disabilities and those with chronic renal diseases. The contains two sections that include part A and Part B. To obtain benefits under part A; one must have obtained the age of sixty-five and above. Consequently, either spouse must have worked and always paid Medicare taxes for a minimum of ten years (Lanford & Quadagno 2016). The law also indicates that one remains eligible to benefits from part A by virtue of being sixty-five years old. Additionally, one could become illegible without paying premiums if an individual receives retirement benefits from the railroad retirement board or social security. Moreover, an individual remains eligible to receive social security but has not filed them, and if a spouse possessed Medicare, covered government employment could receive such benefits without paying premiums. Individuals also qualify for Medicare benefits if an individual has an entitlement to social security disability benefits for a period of twenty-four months. Besides, patients with kidney dialysis and those in need of a kidney transplant qualify for the benefits without having to pay premiums.
On the other hand, an individual might qualify for low-cost or free care by Medicaid based on the size of the family and income. For this reason, the cover gives health care services to children and families, low-income individuals, elderly, pregnant women, and individuals with disabilities. In some areas, the services cover every individual adult that earns below a particular income category. The program covers children under the age of 18 years and pregnant women with an income of below 133% of the federal poverty line (Wang, Tsugawa, Figueroa & Jha, 2016). The programs cover those individuals that have satisfied state and federal needs concerning immigration status, residency, and documentation of citizenship for the USA.
The states have provided opportunities to modify the qualifications to serve more population that is vulnerable in the society. In this case, the 2010 Affordable Care Act allowed the programs to expand their coverage to each low-income Americans below the set age of sixty-five years. In this case, the organizations modified eligibility for children to a least 133% in terms of the federal poverty level (Wang, Tsugawa, Figueroa & Jha, 2016). Besides, the organizations have the opportunity through various states to extend eligibility for adults that earn an income at or less 133% of the poverty level. The Affordable Care Act also allows modification of the qualifications by formulating a new approach for establishing income eligibility of both Medicare and Medicaid program services through modified and Vgross income utilized to establish financial eligibility for premium tax credits, Medicaid, and cost-sharing reductions present in the healthcare marketplace. The other way of modifying the qualification to serve the population that is more vulnerable includes making it easier for such populations to apply and enroll in such programs without any obstacles. The organizations should also ensure improved awareness on the benefits of the programs to patient care and the process of enrollment hence promotes increased numbers of enrollment from vulnerable populations.
The Impact of the Affordable Care Act (ACA) on Benefits and Coverage for Medicare and Medicaid Recipients
The Affordable Act has had both negative and positive impacts on the beneficiaries of both Medicare and Medicaid. Studies indicate that recipients would benefit from the phasing down Medicare overpayments. In this case, the federal government initially paid for Medicare plan almost 14% more than the ancient Medicare for giving similar services hence costing the taxpayers nearly $1000 more on each beneficiary (Duggan, Goda & Jackson, 2017). Such extra funds enabled the programs’ plans to attract customers by providing benefits not contained in the initial Medicare. For this reason, the ACA has resulted in decreased overpayments over time; hence programs’ plans acquire payments comparable only to what they could have cost the initial Medicare to cover for the elderly. Such effects have helped save over $156 billion for a period of ten years. The other advantage of the ACA is that it does not eliminate the programs’ advantage plans or decrease the extra advantages they give beneficiaries. Therefore, the ACA enables every private insurer to choose the type of benefits to provide to beneficiaries.
Besides, the act prevents Medicare providers from charging the elderly more money than in the ancient Medicare for skilled nursing care, chemotherapy, and renal dialysis. Consequently, the ACA has benefited the beneficiaries by ensuring that the program providers spend nearly 85% of the revenue collected on elderly care and not profits. In this case, any program that spends less than the said percentage on the care for the patients could face suspension or termination hence increases accessibility, quality, and efficiency to healthcare services among beneficiaries (Duggan, Goda & Jackson, 2017). On the other hand, ACA has resulted in shrinking networks. In this case, most insurance firms offering Medicare and Medicaid covers have had cut costs during the implementation process of the ACA needs. Such an act has made beneficiaries so remain with few service providers. The other disadvantage indicates that cutting costs through ACA implementation results in uncertainties in the marketplace hence increased costs. In this case, the ACA has resulted in numerous cancellations of insurance, reduced competition, and raised costs in the marketplace. Therefore, despite the increased benefits from the Medicare and Medicaid Services, ACA has resulted in increased disadvantages to the beneficiaries.
The role of the Health care leaders in advocating for cost-effective care for vulnerable population
A health care leader should ensure the achievement of each set of goals and objectives aimed at acquiring improved health care services. The leaders should ensure that the physicians, clinicians, consumers, and other people with the responsibility of improving the quality of patient care remain committed and dedicated to work. In this case, the leader should ensure that they have the required knowledge and skills required to serve the beneficiaries. Besides, the leaders must ensure that the service providers have no other issue affecting their performance (Duggan, Goda & Jackson, 2017). For instance, the leader should ensure better compensation for the service providers or program facilitators. The leader should improve efficiency, quality, and effectiveness of the care given to the insured individuals by ensuring the available resources get to the target populations. Additionally, the leader should direct how to manage such a resource among the target individuals in the communities. The leader must play a role in ensuring mitigation and elimination of all obstacles that hinder service delivery. For instance, the leader should make enrollment procedures and qualifications easier to enable the target population to enroll for services easily and at no cost. Increased and easier enrollment could promote quality service delivery that remains effective and efficient.
Consequently, the leader must ensure adherence to the set rules and regulations set by the state and federal government. In this case, the leader must ensure the service providers have access to information technology services like internet access that would enable them to access the required information that helps them in meeting the set goals and objectives of the program (Duggan, Goda & Jackson, 2017). Access to information could help them learn new ways to ensure cost-effective methods to the beneficiaries. The leaders should also ensure that the organization invests more in research on a new way to ensure effectiveness, efficiency, and quality in care to the beneficiaries.
Conclusion
Medicaid entails health care programs that provide health care services to low-income earners in America. Medicare is a federal government program that provides healthcare services to sixty-five years old and above individuals in the USA but has an exception to those with disabilities. The organizations ensure patient quality care by improving the health status of the communities by effectively treating and preventing chronic diseases. They decrease disparities by promoting self-management education on the population. Those who qualify for Medicare include persons aged 65 years old and above and those with disabilities and chronic renal diseases. The size of the family and income levels determines who qualifies for Medicaid services. The ACA has resulted in decreased overpayments and restricted the service providers from overcharging the elderly. The ACA has also created market uncertainties leading to increases in costs. The healthcare leader should ensure the guidance of the services providers and resources within the organizations to ensure effective service deliveries to the beneficiaries.
References
Davis, K., & Reynolds, R. (1976). The impact of Medicare and Medicaid on access to medical care. The role of health insurance in the health services sector (pp. 391-436). NBER.
Duggan, M., Goda, G. S., & Jackson, E. (2017). The effects of the Affordable Care Act on health insurance coverage and labor market outcomes (No. w23607). National Bureau of Economic Research.
Kline, R. M., Muldoon, L. D., Schumacher, H. K., Strawbridge, L. M., York, A. W., Mortimer, L. K., … & Kapp, M. C. (2017). Design challenges of an episode-based payment model in oncology: the Centers for Medicare & Medicaid Services Oncology Care Model. Journal of Oncology Practice, 13(7), e632-e645.
Lanford, D., & Quadagno, J. (2016). Implementing ObamaCare: The politics of Medicaid expansion under the affordable care act of 2010. Sociological Perspectives, 59(3), 619-639.
Wang, D. E., Tsugawa, Y., Figueroa, J. F., & Jha, A. K. (2016). Association between the Centers for Medicare and Medicaid Services hospital star rating and patient outcomes. JAMA internal medicine, 176(6), 848-850.