Medicare and Medicaid Review

The availability of affordable health insurance is a major prerequisite for maintaining an adequate level of healthcare access across various populations. The United States does not have a universal healthcare insurance system, whereas private and employer-sponsored forms of insurance dominate the market. Nevertheless, the country has two effective federal programs that cover vulnerable individuals. One of them is Medicare created for people 65 years old and older, and another one is Medicaid that provides coverage for people with limited incomes and assets. This paper will overview both Medicare and Medicaid and discuss the role of a nurse when interfacing with people enrolled in these programs.

Program Overview

Medicare

Attempts to create a national health insurance system qualifying all Americans were undertaken since the time of Roosevelt’s presidency. Nevertheless, the idea was partly realized merely in 1965 when Medicare was established. The program’s creation was supported by the findings of a study indicating that 56% of US citizens, aged 65 and older, were not covered (Anderson, 2019). The situation has drastically changed when Medicare took effect and, within just one year, 19 million individuals signed up for Plans A (inpatient services) and B (outpatient services) combined (Anderson, 2019).

Over the years, the program was exposed to several changes and modernizations. Firstly, younger individuals with long-term disabilities were allowed to enroll in Medicare in the 1970s (Anderson, 2019). In the 1980s, coverage for home health and end-of-life services was included in the program, and the limits for total out-of-pocket expenses were added (Anderson, 2019). Other significant alterations were the inclusion of optional prescription drug benefits and the extension of program benefits for the members of impoverished populations (Anderson, 2019).

Lastly, in 2015, Congress passed the MACRA that modified coverage plans with a purpose to minimize over-utilization of medical services and changed the way practitioners are paid under Medicare (Norris, 2019). As stated by Cotton et al. (2016), as a result of these policy shifts, Medicare premiums have significantly increased. Nevertheless, this alteration is expected to improve healthcare quality since doctors are now paid for value rather than quantity of rendered services.

Medicaid

Medicaid was enacted the same year as Medicare yet, compared to the latter program that covered older individuals, is focused on providing coverage for “low-income children deprived of parental support, their caretaker relatives, the elderly, the blind, and individuals with disabilities” (“Key milestones,” 2005, p. 1). Additionally, coverage for pregnant women and children (0-6 years old) was offered as a state option in the 1980s and mandated afterward (“Key milestones,” 2005). Overall, each state now runs Medicaid-funded programs for different eligible population groups and the funds became available to them starting from January 1, 1966 (“Key milestones,” 2005).

Similar to Medicare, Medicaid was subject to several modifications and expansion of benefits. However, the most important one took place along with the enactment of the Affordable Care Act (ACA). The ACA provision suggested Medicaid eligibility expansion with the purpose to include previously uninsured low-income individuals (Grant, 2014). For instance, before this, nonelderly adults without children were not eligible for coverage even if they lived in poverty. According to Lee and Porell (2018), the ACA provided them with a chance to access healthcare and improve health outcomes.

Besides that, Medicaid expansion is financially beneficial for the states as “federal funding would cover approximately 93% of the cost of insuring new populations, with states responsible for only 7%” (Grant, 2014, p. 203). However, as of today, 14 states have not adopted the initiative yet.

Florida is one of the states that refused to expand Medicaid. Baker and Hunt (2016) note that decisions regarding expansion are usually correlated with states’ dominant political ideologies. While “most Democratic-led states [are] moving quickly in support of expansion,” “most Republican-led states [are] rejecting expansion or delaying a decision” (Baker & Hunt, 2016, p. 1882). As part of their opposition to the initiative, Republican state leaders often refer to Medicaid as “a ‘broken program’ that has negative budgetary impacts, expands federal control, and encourages dependence on the state” (Baker & Hunt, 2016, p. 1882).

Instead, some of those states that postpone the adoption of expansion encourage cost-sharing and healthy behavior initiatives aimed to emphasize the personal responsibility of individuals for their health outcomes (Baker & Hunt, 2016). Such decisions may result in the further inability of lower-income people to access necessary services, whereas Medicaid expansion, on the contrary, aims to eliminate this problem.

Nurse’s Role

Senior patients and lower-income individuals are members of two vulnerable populations. It means that, compared to other people, they have more complex healthcare needs, whereas their abilities and resources necessary to meet those needs are limited (Bliss & While, 2014). This definition implies that to coordinate and provide high-quality care for Medicare and Medicaid beneficiaries, nurses must know both their health-related and social needs.

Besides that, by MACRA requirements, nurses must strive to provide care cost-effectively. They should focus on improving the quality and value of care while aiming to reduce the number of readmissions and hospitalizations. According to Oliver, Pennington, and Rantz (2014), in hospitals where APRNs work within the full scope of their practice, the achievement of these favorable outcomes becomes facilitated.

It means that advocacy for fewer restrictions of APRNs practice may be beneficial not only for practicing nurses but also for Medicare/Medicaid patients. Another thing that nurses may do to improve care for Medicare/Medicaid beneficiaries is the promotion of community-integrated care. This task requires the development of networks, partnerships, and interprofessional teams (Bliss & While, 2014). Since community-integrated care targets multiple factors at once, it may allow addressing the needs of vulnerable populations with or without insurance in a more comprehensive manner.

References

Anderson, S. (2019). . Medicare Resources. Web.

Baker, A. M., & Hunt, L. M. (2016). Counterproductive consequences of a conservative ideology: Medicaid expansion and personal responsibility requirements. American Journal of Public Health, 106(7), 1181-1187.

Bliss, J., & While, A. E. (2014). Meeting the needs of vulnerable patients: The need for team working across general practice and community nursing services. London Journal of Primary Care, 6(6), 149-153.

Cotton, P., Newhouse, J. P., Volpp, K. G., Fendrick, A. M., Oesterle, S. L., Oungpasuk, P., … Sebelius, K. (2016). Medicare Advantage: Issues, insights, and implications for the future. Population Health Management, 19(S3), S1-S8.

Grant R. (2014). The triumph of politics over public health: States opting out of Medicaid expansion. American Journal of Public Health, 104(2), 203-205.

Key milestones in Medicare and Medicaid history, selected years: 1965-2003. (2005). Health Care Financing Review, 27(2), 1-3.

Lee, H., & Porell, F. W. (2018). . Medical Care Research and Review. Web.

Norris, L. (2019). When is Medicare open enrollment? Medicare Resources. Web.

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