In the United States, there are various stakeholders and factors involved in the administration dimension of the healthcare system. The multiple-payer system, insurance coverage, medical billing, and requirements for eligibility vary significantly, costing healthcare providers additional efforts and costs linked to administration (Jiwani, Himmelstein, Woolhandler, & Kahn, 2014). The aforementioned activities are collectively referred to as Billing and Insurance-Related (BIR) activities. From the perspective of the healthcare provider, BIR activities consist of functions related to interaction with payers (Jiwani et al., 2014). These include claim filing, obtaining prior authorization, and administration of managed care. From the payer angle, most of the functions of administration relate to billing, with only a tiny proportion spent on issues related to care (Jiwani et al., 2014). BIR costs are also increased by the profiting of insurers from the healthcare system. The above costs, which affect the availability and accessibility of healthcare to various groups in the country, informed the institution of Medicare and Medicaid programs, as well as the Affordable Care Act (ACA).
There are a number of requirements considered for eligibility for Medicare, a federal health insurance program, as outlined by the United States Department of Health and Human Services (HHS, 2014). Generally, Medicare is for people aged sixty-five years or older and is available to younger people if they have a disability and/or a renal disease that necessitates dialysis or transplant. Specifically, Medicare is categorized into four parts, each with its own set of requirements. Part A is concerned with Hospital Insurance and provides coverage for a hospital stay, nursing facilities after discharge from hospital, and home healthcare (Aoughsten, Johnson, Kuruvilla, & Bionat 2015). Part B pertains to Medical Insurance and consists of laboratory costs, medical supplies and equipment, routine doctor costs, and physical therapy (Aoughsten, et al., 2015). Part C concerns healthcare recipients enrolled in Medicare-approved private health plans (Aoughsten, et al., 2015). Part D pays some costs of prescription drugs (Aoughsten, et al., 2015). There are different conditions for being eligible for either part or category.
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For people at aged least sixty-five years, the eligibility for premium-free Part A is generally dependent on whether their spouses paid Medicare taxes for a period no shorter than a decade. It both requirements are met, one qualifies for Part A. However, if the latter condition is not met, a sixty-five-year-old can still qualify for premium-free Part A if they are under retirement benefits from either the Railroad Retirement Board or Social Security; if they are eligible for benefits from either but have yet to file for them; or, if their spouse was in government employment that covers Medicare (HHS, 2014).
If a 65-year-old or his/her spouse did not pay Medicare taxes during their employment, he/she is allowed to buy Part A if he/she has a permanent residence or citizenships of the United States. People aged below 65 years may benefit from Part A without paying premiums if they are kidney transplant or dialysis patients, or if they have entitlement to Railroad Retirement Board or Social Security disability benefits for two years (HHS, 2014). While most people are not required to pay premiums for Part A, everyone who wants Part B must pay a premium for it. The premium for Part B is deducted monthly from Civil Service Retirement check, Railroad Security check, or Social Security check, and for those who do not get any of the three payments, Medicare sends them a bill for their Part B once every three months (HHS, 2014). Since the start of the year 2006, all people with Medicare, irrespective of their health status, income, or use of the prescription drug have coverage for a prescription drug.
On the other hand, Medicaid, a state and federal health program, has qualification requirements that are based on family size and income. All over the United States, Medicaid provides coverage for certain low-income families, people, and children, as well as old people and people living with disabilities, while in some states, it provides coverage for adults whose income falls below a certain level (HHS, 2017). From the United States government healthcare.gov website, one can find out if one's state is expanding its Medicaid. For states that are expanding it, people can qualify on the basis of their income level alone. For households whose income falls below 133 percent of the federal poverty level, members automatically qualify (Medicaid & CHIP, 2019). As the requirements change continually, people who have not qualified for Medicaid previously may qualify under new rules. Requirements for eligibility under new rules may be found out by visiting the Medicaid website for one’s state or by filling out applications in the Health Insurance Marketplace (HIM). Requirements for qualification of Medicaid may be different at different times.
Medicaid patients have been impacted by the institution of the Affordable Care Act (ACA) in a variety of ways. As intended, the ACA Medicaid expansion seems to ameliorate inequality based on income as concerns the accessibility of healthcare with regards to financial status. It has resulted in follow-up care being more affordable and in lessened worries about medical bill paying; and reduced the uninsured population and increased met medicals needs that would otherwise not have been realized among very low-income communities (Kino, & Kawachi, 2018). In sum, ACA Medicaid expansion has strengthened the poor’s healthcare safety net.
However, increased accessibility does not necessarily mean increase utilization, particularly when it comes to preventative services. According to Kino and Kawachi (2018), while ACA Medicaid has appreciably improved accessibility, it has not served to improve the use of Medicaid services to a high enough degree to alleviate preexisting disparities related to income inequality. ACA Medicaid may have increased healthcare affordability but low-income households and individuals still face additional impediments not directly related to actual healthcare needs. The barriers include inflexible work schedules, inadequate knowledge, and inability to arrange childcare in order to receive screening services (Kino & Kawachi, 2018). Time and cost of traveling are still unaffordable to the poor.
The ACA has also impacted Medicare from the recipients’ perspective. It has lowered the cost of prescription drugs, reduced or stabilized monthly premiums, and improved care in terms of access and quality (Aoughsten et al., 2015). The ACA has also reformed how payments are made in Medicare. This has changed the approach to the reimbursement of healthcare providers and health institutions, the result of which has been that more focus is placed on the healthcare quality received (Aoughsten et al., 2015). This has led to good reimbursement rates being tied to good practice, something that has benefited healthcare recipients. The ACA is also enacting new programs aimed at lowering the rates of fraudulent claims, which is translating to the enhancement of Medicare overall.
Apparently, Medicare and Medicaid have increased the accessibility and availability of healthcare to populations that would otherwise be financially constrained. Healthcare has become reasonably affordable to low-income communities. This has further been enhanced by the institution of the Affordable Care Act. However, members of low-income communities still find it costly to travel for healthcare. They also tend to have inflexible work schedules, which prevents them from seeking and using healthcare services. These are areas that an amendment of the ACA or an institution of a new act can ameliorate. Additionally, the federal government should make it mandatory for all states to expand Medicaid to get rid of geographical and jurisdictional impediments to access.
References
Aoughsten, J., Johnson, S., Kuruvilla, M., & Bionat, S. (2015). The effect of the affordable care
act on Medicare: Opportunities for advanced practice nursing. Nurse Leader , 13 (3), 49-53.
HHS (2014). Who is eligible for Medicare? Health and Human Services . Retrieved
https://www.hhs.gov/answers/medicare-and-medicaid/who-is-elibible-for-medicare/index.html
HHS (2017). Who is eligible for Medicaid? Health and Human Services . Retrieved
https://www.hhs.gov/answers/medicare-and-medicaid/who-is-eligible-for-medicaid/index.html
Jiwani, A., Himmelstein, D., Woolhandler, S., & Kahn, J. G. (2014). Billing and insurance-
related administrative costs in United States’ health care: synthesis of micro-costing evidence. BMC Health Services Research , 14 (1), 556.
Kino, S., & Kawachi, I. (2018). The impact of ACA Medicaid expansion on socioeconomic
inequality in health care services utilization. PloS One , 13 (12), e0209935.
Medicaid & CHIP. (2018). Medicaid expansion & what it means for you. Healthcare.gov .
Retrieved from https://www.healthcare.gov/medicaid-chip/medicaid-expansion-and-you/
