Medicare and Medicaid Paper

Medicare and Medicaid are government insurance programs for providing access to healthcare by covering vulnerable populations, including older adults aged 65 years and over, people with chronic conditions and disabilities, and those with low income. The major purpose of these insurance Acts is to promote access to quality care by reducing care costs and fostering affordability.

Medicare and Medicaid

Although Medicare and Medicaid insurance programs have been responsible for improved access to quality care and increased health coverage since their enactment in 1965, these policies inadvertently created challenges for Americans since many people straddle both programs.

According to Elmaleh-Sachs et al. (2020), Medicare and Medicaid programs brought about the concept of dual-eligible, where older adults with disabilities and low-income qualify for the two programs. In this case, federal Medicare insurance covers perception drugs, acute care services, and primary care while Medicaid insurance covers long-term service and support.

Although the two insurance programs increase the probability of accessing quality and affordable care, they can lead to fragmented and uncoordinated care when integration measures are insufficient. Therefore, this paper describes the importance of quality improvement organization (QIO), how to modify Medicare and Medicaid qualifications to serve more people, the impacts of the Affordable Care Act (ACA), and the advocacy role of a nurse leader.

The Quality Improvement Organization (QIO) and how the QIO Improves Policies and Healthcare for Medicare Beneficiaries

Quality improvement organizations (QIOs) are groups of healthcare quality experts, consumers, and healthcare professionals collaborating in an organized manner to improve the quality of care delivered to Medicare Beneficiaries. According to the Centers for Medicare and Medicaid [CMS] (2020), QIOs work under the direction of the Centers for Medicare and Medicaid Services (CMS) to support various programs, including Beneficiary and Family Centered Care (BFCC) and Quality Innovation Network (QIN).

The major focus of BFCC programs is to help Medicare beneficiaries in exercising their right to high-quality care. In this sense, Beneficiary form and Family Centered Care-Quality Improvement Organizations (BFCC-QIO) review complaints regarding the quality of care and help to improve care effectiveness, economy, and efficiency (Centers for Medicare and Medicaid Services, 2020). Further, these QIOs address complaints about the quality of care and provide reviews that seek to enhance care quality, efficiency, and effectiveness.

On the other hand, Quality Innovation Network (QIN)-QIOs encourage the implementation of data-driven initiatives that enhance patient safety, improve care coordination, and bolster community health. Quigley et al. (2019) contend that Quality Improvement Organization Program’s 14 quality innovation networks (QINs) bring Medicare beneficiaries, communities, and providers together to encourage the integration of data and information into processes for improving patient safety and care coordination.

QINs are private organizations working with regional communities and care providers to promote the implementation of quality improvement initiatives to reduce adverse events such as hospital-acquired infections (HAIs) and medication errors.

Further, the Centers for Medicare and Medicaid Services (CMS) tasks QINs with the responsibility to improve the quality of resident-centered care and safety and reduce antipsychotic use in hospitalized residents (Quigley et al., 2019). These strategies represent how Quality Improvement Organizations (QIOs) improve care quality for Medicare beneficiaries.

The Qualifications for Medicare and Medicaid Benefits. How can qualifications be modified to serve more people who are considered a vulnerable population?

In 1965, the US Congress enacted Medicare and Medicaid Acts as a strategy for providing insurance coverage to the elderly, people with disabilities, and those from low-income families. Although the formation of Medicare and Medicaid services aimed to address health inequalities and promote care affordability and quality, the two programs primarily relied on different traditions and premises for eligibility and benefits.

According to Shi & Singh (2019), Medicare had uniform national standards for eligibility and benefits. In this sense, anyone aged 65 or older is eligible for Medicare. In 1973, the federal government expanded Medicare to cover two other categories of people: nonelderly disabled people receiving Social Security for at least 24 months and people with end-stage renal disease in need of dialysis or kidney transplant.

Further, the government added a coverage option under Medicare Part C in 1993 and a prescription drug benefit under Part D in 2003. The broader eligibility criteria for Medicare means that the program is not means-tested or confined to people who satisfy a specific financial threshold.

Unlike Medicare, Medicaid is a means-tested program because only people of low income are eligible for this insurance coverage. Shi & Singh (2019) argue that states have the autonomy to establish the income criteria for Medicaid because they are responsible for financing the program with matching funds from the federal government according to each state’s per capita income (p. 67).

Initially, the eligibility criteria for Medicaid accommodated people with income at or below 438% of the federal poverty line (FPL). However, the Affordable Care Act (ACA) of 2010 provided opportunities for states to extend eligibility to adults with income at or below 133% of the federal poverty line. This strategy is aimed at reducing coverage gaps and addressing the problem of uninsurance and underinsurance among low-income individuals and families.

Although Medicare and Medicaid have significantly reduced the rate of uninsurance and underinsurance while improving care quality and affordability, some sections of the vulnerable populations remain within the coverage gap. For example, low-income individuals and families in states that do not expand Medicaid. According to Garfield et al. (2021), adults who are in the coverage gap have income above their state’s eligibility for Medicaid and below the poverty thresholds eligible for tax credits through the ACA’s marketplace.

The viable options for addressing the coverage gap include providing additional incentives for non-expansion states, encouraging non-expansion states to build on the current infrastructure used in states that have expanded Medicaid, and extending financial assistance for coverage by extending marketplace premium subsidies to individuals in the coverage gap (Rudowitz et al., 2021).

Equally, it is essential to encourage non-expansion states to expand Medicaid to revise Medicaid eligibility criteria. These strategies can enable states to modify insurance qualifications to address the problems of underinsurance, uninsurance, and coverage gaps.

The Impact of the Affordable Care Act (ACA) on the Benefits and Coverage for Medicare and Medicaid Recipients

Before the enactment of the Patient Protection and Affordable Care Act (ACA) in 2010, Medicare and Medicaid beneficiaries grappled with various challenges, including inaccessible coverage premiums and an increased likelihood to fall under the coverage gap due to high-income thresholds for Medicaid eligibility. As a result, the enactment of ACA led to multiple benefits that significantly reduced the rates of uninsurance and underinsurance.

Ercia (2021) contends that the Affordable Care Act resulted in various positive impacts on patient coverage and access to care. These benefits include expanding the publicly funded Medicaid program, establishing the Health Insurance Marketplace, and enforcing an individual mandate that prompted eligible people to have federally approved health insurance coverage.

Firstly, Medicaid expansion was a profound approach to revising the income eligibility criterion to cover adults with annual incomes of up to 138% of the federal poverty level (FPL) from the previously enacted 438% income threshold. Although states had the autonomy to decline the implementation of the Medicaid expansion provision, this approach increased insurance coverage and greatly impacted care delivery.

Secondly, the establishment of the Health Insurance Marketplace for individuals and small businesses enabled them to purchase private health insurance (PHI) (Ercia, 2021). Finally, enforcing an individual mandate that required eligible people to have federally approved health insurance coverage strengthened the role of Medicare and Medicaid beneficiaries in reducing the coverage gap and improving care accessibility and utilization.

Although the Affordable Care Act (ACA) is a landmark policy for improving insurance coverage and care quality, it resulted in some disadvantages for Medicare and Medicaid beneficiaries. These shortcomings and challenges include high premium costs and the proliferation of high deductible health plans.

Currently, the pre-existing condition clause is not operational, meaning payers must cover the costs of patients with serious health concerns. This factor causes payers to increase their premium prices to cover all extra expenditures. In turn, increased premium plans increase out-of-pocket expenses incurred by Medicare and Medicaid beneficiaries.

My Role (s) as a Healthcare Leader as it Applies to the Practice of Advocating for Cost-Effective Care for Vulnerable Populations

Vulnerable communities and populations grapple with unfavorable social determinants of health (SDOH) that compromise their ability to access, afford, and utilize healthcare services. Williams et al. (2018) contend that socially and economically disadvantaged populations are susceptible to public policies and can benefit from health programs that aim to improve social conditions that impact health and wellness.

Examples of poor social determinants of health (SDOH) that render the population vulnerable include poverty, low income, housing issues, low-level education attainment, limited access to healthy foods, unemployment, deficiencies in transport infrastructure, and proximity to environmental issues like pollution. Notably, these factors are the leading causes of disproportionate effects and prevalence of diseases. As a result, healthcare professionals and policymakers should enact policies and implement programs that seek to address the underlying causes of health inequalities and disparities.

As a nurse leader, advocating for cost-effective care is a profound strategy for improving care affordability and accessibility among vulnerable populations. According to Williams et al. (2018), advocating for social policies enables healthcare professionals to assist patients, families, and communities to navigate healthcare challenges.

In this sense, nurses should gain expert knowledge on the social determinants of health to advocate for favorable policies and speak on behalf of disadvantaged and vulnerable populations. My Role as an advocate for vulnerable populations includes educating them about the importance of insurance coverage, collaborating with quality improvement organizations (QIOs) in delivering quality and convenient care, assessing community health needs and sharing information with policymakers, supporting policies for addressing childhood/adulthood poverty, and using my expert experience and knowledge of social determinants of health to influence policies.

Conclusion

The enactment of Medicare and Medicaid Services in 1965 remains a landmark strategy that improved care accessibility, affordability, and utilization among vulnerable individuals like the elderly, people with disabilities, and low-income individuals.

In this sense, these policies prompted the need to form quality improvement organizations (QIOs) to oversee the delivery of quality and convenient care. In 2010, the US Congress enacted the Affordable Care Act (ACA) which aimed to facilitate Medicaid expansion at the state level.

Although ACA has significantly reduced the coverage gap, some sections of the US population remain uninsured and underinsured. As a nurse leader, I have a professional and ethical duty to advocate for these vulnerable populations by influencing policies, supporting interventions for addressing unfavorable social determinants of health, and educating them about the importance of insurance coverage.

References

Centers for Medicare & Medicaid Services. (2020). Quality improvement organizations. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityImprovementOrgs

Elmaleh-Sachs, A., & Schneider, E. C. (2020). Strange bedfellows: Coordinating Medicare and Medicaid to achieve cost-effective care for patients with the greatest health needs. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-020-05914-y

Ercia, A. (2021). The impact of the Affordable Care Act on patient coverage and access to care: Perspectives from FQHC administrators in Arizona, California, and Texas. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-06961-9

Garfield, R., Orgera, K., & Damico, A. (2021, January 21). The coverage gap: Uninsured poor adults in states that do not expand Medicaid. The Henry J. Kaiser Family Foundation. https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/

Quigley, D. D., Dick, A., & Stone, P. W. (2019). Quality innovation networks share varied resources for nursing homes on mostly user‐friendly websites. Journal of the American Geriatrics Society, 67(11), 2376–2381. https://doi.org/10.1111/jgs.16201

Rudowitz, R., Garfield, R., & Levitt, L. (2021, April 22). Filling the Coverage Gap: Policy Options and Considerations. https://www.kff.org/medicaid/issue-brief/filling-the-coverage-gap-policy-options-and-considerations/

Shi, L., & Singh, D. A. (2019). Essentials of the U.S. health care system (5th ed.). Burlington, Ma Jones & Bartlett Learning.

MOD8 Policy Assignment HCA 320 Medicare and Medicaid

Signature Assignment: Medicare and Medicaid  HCA 320

Consider how people qualify to receive Medicare and/or Medicaid and write a paper that addresses the bullets below. There should be four (4) sections in your paper; one for each bullet below. Separate each section in your paper with a clear brief heading that allows your professor to know which bullet you are addressing in that section of your paper. Start your paper with an introduction and include a “Conclusion” section that summarizes all topics. This paper should consist of at least 1750 words and no more than 2000.

This week reflect upon the Medicare and Medicaid programs to address the following:

  • Describe the Quality Improvement Organization (QIO) and explain how the QIO improves policies and healthcare for Medicare beneficiaries.
  • Briefly define the qualifications for Medicare and Medicaid benefits. How can qualifications be modified to serve more people who are considered a vulnerable population?
  • Discuss the impact (including at least two positive and two negative aspects) that the ACA has had on benefits and coverage for Medicare and Medicaid recipients.
  • Describe your role(s) as a healthcare leader as it applies to the practice of advocating for cost effective care for vulnerable populations.

M8 Assignment UMBO – 2, 3, 4
M8 Assignment PLG – BSHCA – 2, 4, 5 RN-BSN – 1, 2, 5
M8 Assignment CLO – 1, 2, 3, 4, 5, 6, 7, 8

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Instructions & SpecificationsSubmissionsRubric

Start by reading and following these instructions:

  1. Study the required chapter(s) of the textbook and any additional recommended resources. Some answers may require you to do additional research on the Internet or in other reference sources. Choose your sources carefully.
  2. Consider the discussion and the any insights you gained from it.
  3. Review the assignment rubric and the specifications below to ensure that your response aligns with all assignment expectations.
  4. Create your assignment submission and be sure to cite your sources, use APA style as required, and check your spelling.

The following specifications are required for this assignment:

Length: 1750-2000 words; answers must thoroughly address the questions in a clear, concise manner

Structure: Include a title page and reference page in APA format. These do not count towards the minimal word amount for this assignment.  Your essay must include an introduction and a conclusion.

References: Use the appropriate APA style in-text citations and references for all resources utilized to answer the questions. A minimum of two (2) scholarly sources are required for this assignment.

Format: Save your assignment as a Microsoft Word document (.doc or .docx).

Filename: Name your saved file according to your first initial, last name, and the module number (for example, “RHall Module 1.docx”)