In the United States, Medicare is the program supports people over age 65 with medical care. It also provides support for persons with certain disabilities and people of all ages who have kidney failure. Medicaid is a state administered program that provides medical support for a broad range of people. However, each state administers Medicaid individually and this creates inconsistencies in the program across the country. There are specific rules for judging just how much money someone receiving Medicaid can make and be eligible. In addition, there are separate rules for people in nursing homes and children with disabilities who live at home. There is a long list of regulations that explain who is eligible for which services. The Patient Protection and Affordable Care Act of 2012 (also known as the Affordable Care Act and “Obamacare”), included various changes to Medicare and Medicaid—including changes to eligibility, payments, and enrollment.
Keywords Americans with Disabilities Act (ADA); Baby Boomers; Contractors; Fraud; Lobbyists; Medicare; Medicaid; Providers; Socialized Medicine; Upcoding
Medicaid and Medicare are two of the most enduring social programs in United States history, providing different services to different groups of people. The eligibility rules for Medicaid have been criticized as confusing. Medicaid is a state administered program and its rules vary across states. That can present a significant problem to someone enrolled in Medicaid that moves across state lines. The 2012 Patient Protection and Affordable Health Care Act (ACA) included some changes in Medicaid enrollment procedures.
President Lyndon Johnson was responsible for the creation of Medicare and Medicaid in 1965 (Berkowitz, 2008). Since then, both programs have undergone a variety of changes. The passage of the ACA in March 2013 followed decades of debate over health care reform in the United States at all levels of government. ACA supporters believe the legislation would go a long way to address the millions of Americans without health insurance coverage.
The push to create a national health plan began almost a century ago. In the beginning, Medicare was thought of as a "sickness insurance program." There were concerns that large segments of the population, especially laborers, who could not afford to pay their medical bills. While Medicare was in its planning stages, the American Medical Association (AMA) opposed a national plan from the start. "The AMA, in common with many Americans, thought of medical care as largely a private transaction between a medical practitioner and a patient. There was no need for the State to intervene in this relationship" (Berkowitz, 2008, p. 82). It was not until President John F. Kennedy began the push for a national health care plan in 1961 that Medicare received significant political support (Berkowitz, 2008). However, the bill introducing Medicare was defeated in 1962. Many legislators felt the initiative lack support in the private sector. According to Berkowitz, New York Senator Jackob Javits was one of those politicians who continually lobbied for the private sector to be given continued consideration in new health care legislation.
Important to Javits' proposals and to other alternatives offered at the time was the notion of choice. Representative John Lindsay (R-NY) proposed that consumers be given a fundamental choice. They could either accept government health insurance, to be run by the states, or a private health care plan. If they chose the private health plan, they would receive an increase in their social security benefits (Berkowitz, 2008, p. 86).
The modern iteration of Medicare is far more complicated than it was in its original form. There are four sections to Medicare: A, B, C, and D. Sequentially, they cover:
• Hospital insurance,
• Medical insurance,
• Advantage plans
• Prescription drug coverage.
According to Leavitt & Weems, the federal government describes Medicare Advantage Plans as follows:
Medicare Advantage Plans are health plan options (like HMOs and PPOs) approved by Medicare and run by private companies. These plans are part of the Medicare Program and are sometimes called "Part C" or "MA plans." Medicare pays an amount for your care every month to these private health plans. Medicare Advantage Plans must follow rules set by Medicare. Medicare Advantage Plans aren't supplemental insurance (Leavitt & Weems, 2008, p. 38).
Throughout the late twentieth and early twenty-first century, the Medicare program continued to provide the health insurance required by seniors and persons with disabilities while at the same time trying to contain costs. However, high demand and market competition helped cause private and public health care costs in the United States to surge.
In 2003, Part D of Medicare was instituted. Part D, Medicare’s prescription drug plan, had been in the planning stages for almost four decades(Berkowitz, 2008).
Medicaid was developed almost simultaneously to Medicare. In the 1950s, the federal government created a welfare category for people who were poor and a category for those with permanent disabilities. Like Medicare, Medicaid became law in 1965. However, it was initially only a supplemental program. It later developed into a far more significant health insurance program (Berkowitz, 2008). By 2002, all states mandated that families who were under the Federal Poverty Line (FPL) with children under the age of 19 were eligible for Medicaid (Rowland, 2006).
Since its inception, many states have chosen to provide services under Medicaid that go beyond federal guidelines. This choice has led to the expansion of Medicaid and its increased importance in the health care field: "These expansions, coupled with the enactment of welfare reform in 1996 that replaced the AFDC program, transformed Medicaid to a broad-based health insurance coverage program for low-income children" (Rowland, 2006, p. 65).
Historically, Medicaid has been a program that provides health insurance coverage for people who live on low incomes. In 1997, the federal government expanded Medicaid by creating the State Children's Health Insurance Program (SCHIP). This allows states to receive federal money in order to expand Medicaid (if they wish to do so), or to create a separate fund for uninsured children whose families are ineligible for Medicaid because their income exceeds the limit for Medicaid (Rowland, 2006).
Medicaid also provides health care for pregnant women who live on low incomes. They assist with pre- and postnatal care and delivery. "Reducing financial barriers to accessing necessary health services has been integral to Medicaid's role as the source of health coverage for the low-income population" (Rowland, 2006, p.67).
Abuses of Medicare
Both Medicare and Medicaid have been fraught with difficulties since their inception. In 2006, the government unveiled new initiatives to control abuse and waste in both programs (Scott & Tabuena, 2006).
Extensive research has been conducted into issues of fraud in the Medicare program. The program involves hundreds of millions of dollars and millions of people. According to Berek & Shetterly, "Medicare is an attractive target for other reasons besides its size; for example, it pays higher-than-market rates for some services. Another major problem is limited administrative capacity to prevent fraud" (1996, p. 113). These authors also state that approximately 10% of all Medicare funding is lost to waste, fraud and abuse.
Becker, Kessler and McClellan (2005) suggest that there is definitely 'anecdotal' evidence to support concerns over fraud in both Medicare and Medicaid. They list some of the ways that patients and providers can defraud the system; billing for treatments that never took place, billing for services by individual when it should be as a group billing; and (one of the more insidious) changing the person's actual illness to something far more complicated and serious which warrants a higher billing. Some call this 'upcoding.' One of the primary issues in the field of researching abuse is the need for hard evidence. In the...
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