Health Care Law and Regulations assignment 4
Emir7
Chp4.HA6101.pptxChapter 4
Medical Insurance and Access to Care
Processes For Thinking About the U.S. Health Care System
“In view of the Constitution, in the eye of the law, there is in this country no superior, dominant, ruling class of citizens. There is no caste here.”
— Justice John Marshall Harlan
Lecture Overview
Principles and Applications
The Three W’s of Medicaid Insurance: Who? What? Why?
Children’s Health Insurance Program
Why Is Government Insurance Economically Necessary?
Unaffordability of Advanced Medicine
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Medicaid insurance and access to medically necessary care. In Health care management and the law: Principles and applications (pp. 65-86). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Principles and Applications
As millions of Americans gain health insurance as a result of the Affordable Care Act:
(1)Affordability of coverage remains a persistent problem for some
(2)Many technological innovations and health care initiations are focused on affluent communities and are accessible mainly to people with private health insurance.
(3)Health care in the United States costs more every year:
For every one in four adults who may be without health insurance for part or all of any given year, access to quality health care is simply not affordable
The Three W’s of Government Health Insurance: Who? What? Why?
Federal Share of Medicaid Spending
Medicaid is the government health insurance program for Americans with limited means and the severely disabled.
For states that expand Medicaid insurance through the Affordable Care Act, the federal government pays 100 to 90% of the costs
Regular match rate 60%
States that do not adopt the expansion will forgo substantial federal revenues:
Low income adults may fall into a coverage gap
Federal contribution varies based on state per capita householdincome relative to the national income average
The Three W’s of Government Health Insurance: Who? What? Why?
Who is Categorically Eligible for Medical Insurance?
Medicaid insurance is the principle safety net for:
Blind or severely disabled children and adults
Low income working families with children
Medicaid eligible with limited resources, who need assistance with filling gaps in their Medicare coverage
Uninsured pregnant women
Medicaid insurance does not provide coverage for everyone unless the state expanded traditional coverage
The Three W’s of Government Health Insurance: Who? What? Why?
Who is Categorically Eligible for Medical Insurance?
Disabled Medicare Beneficiaries:
1 out of 4 of the Medicaid insured are seriously disabled and receiving Medicare benefits
This population group accounts for more than 70% of the nation’s Medicaid insurance spending
Severely Disabled Children and Adults:
Medicaid insurance provides health insurance coverage for people with physical and mental disabilities and chronic illnesses.
Uninsured Pregnant Women:
Medicaid insurance provides access to prenatal care and neonatal intensive care for eligible women and their babies
The Three W’s of Government Health Insurance: Who? What? Why?
What Medicaid Insurance is Required?
There is no national consensus of the 3 W’s of Medicaid insurance:
Who is deserving of financial assistance?
What health care costs should be covered?
Why should the government be involved in the first place?
The demand for broader state accountability is a constant theme for Medicaid insurance as the 3 W’s are debated
The Three W’s of Government Health Insurance: Who? What? Why?
Coverage Issues
Controversies that remain unresolved include:
Rules for when someone may be eligible for Medicaid insurance coverage (3 month rule)
Entitlements for non citizens, if they are entitled at all, for taxpayer Medicaid insurance
Identification of what constitutes a life threatening medical event
Delivery system inequities between the uninsured/underinsured compared to those with comprehensive health insurance coverage plus the ability to pay out of pocket costs before any non life threateningtreatment is ever received
The Three W’s of Government Health Insurance: Who? What? Why?
Coverage Issues
Three Month Rule
Coverage may start 3 months prior to application for Medicaid insurance, if the individual would have been eligible during the retroactive period but:
was unaware of this opportunity, or
because the nature of their illness prevented them from seeking coverage
States seldom develop outreach programs to advise their residents of the benefits of Medicaid insurances
Coverage Issues
Lawful Permanent Residents
Most states have charity programs to provide medical assistance to residents who do not qualify for Medicaid but face extraordinary circumstances
MA Case legal residents 5 year rule
Coverage Issues
Definition Of Medically Needy:
Low income is only one test for Medicaid eligibility; assets and resources are also tested against established thresholds
The middle class is often covered when their private insurance is exhausted from medical situations:
Expenses from a catastrophic injury or illness that exceed private insurance
The medical treatments they elect are excluded from their coverage
Coverage Issues
Emergency Medical Services:
Emergency services must be life threatening to be covered by Medicaid insurance
Coverage Issues
Coverage Issues
Delivery System Inequities:
States increase Medicaid enrolments to qualify for more federal assistance rather than being given incentives to increase efficiency and higher quality
There are significant differences between states on measures of health care access, quality, costs, and outcomes
Coverage Issues
Coverage Incentives:
Accessibility
Accurate and comparable payment rates
Health outcomes, or whether coverage is actually improving health
Quality of health care
Should coverage be revoked if it turns out an individual experience was not life threatening?
Should there be a limit on the total amount of coverage Medicaid insurance will provide?
What should be considered life threatening?
Coverage Issues
State Waivers:
In states that chose to expand Medicaid insurance under the Affordable Care Act, all low income adults are now eligible for Medicaid health insurance that is subsidized by the federal government
A handful of states have received special permission, known as waivers, from federal regulators to take steps to improve their Medicaid insurance plans:
Indiana, Louisiana, North Carolina, Pennsylvania
Coverage Issues
Economics of the Medicaid Insured
With health insurance premiums rising more rapidly than the federal poverty level, the protection offered to the sickest and poorest Americans by Medicaid insurance has not kept pace with rising health insurance costs
Medicaid: Who? What? Why?
Access to Medically Necessary Care
While Medicaid insurance is an improvement over being uninsured, it often relegates Medicaid insured consumers to inferior health care:
Disparity in health care
Major reform of the U.S. health care system will require significant inter-governmental mandates for decades to come
Equal Access for El Paso, Inc. v. Hawkins
Equal access provision unenforceable
Paediatric Specialty Care, Inc. v. Arkansas Department of Human Services
Found an enforceable right
The Three W’s of Government Health Insurance: Who? What? Why?
Economic Inequities
Medicare/Medicaid Insured
Access problems faced by those who qualify for both Medicare and Medicaid insurance, generally referred to as being dual insured:
4 out of 10 physicians restrict access
30% of U.S. physicians refuse to accept new patients with Medicare/Medicaid insurance
Access for patients with Medicare/Medicaid insurance is most limited in urban areas
Most of the individuals who are dual insured face restrictions on access to the latest medical technologies
The Three W’s of Government Health Insurance: Who? What? Why?
Economic Inequities
Treatment of Serious Heart Conditions
The treatment of heart disease discloses clinical disparities that can only be attributable to the influence of insurance status:
80% of the hospitalizations for heart failure are patients with Medicare/Medicaid
Patients who are Medicaid insured face significantly more angina, poorer quality of life, and higher risks of hospitalizations after myocardial infarctions
Patients with Medicaid coverage are almost 50% more likely to die after coronary artery bypass surgery
The Three W’s of Government Health Insurance: Who? What? Why?
Economic Inequities
Diagnoses of Cancer
The probability of being diagnosed with late stage cancer is greater for the uninsured and Medicaid insured than it is for people with private coverage and health care
The Three W’s of Government Health Insurance: Who? What? Why?
Economic Inequities
Treatment of HIV/AIDS
The uninsured/underinsured with inadequate prescription plans complain about being denied access to the antiretroviral drugs that can prevent their immune systems from being weakened to the point of acquiring AIDS
Lack of early access is the difference between life and death from AIDS
Treatment is withheld for many uninsured Americans of limited means until it is too late for preventive care
Children’s Health Insurance Program
Created in 1997 to address the growing challenge of uninsured children:
Directed by the Centers for Medicare and Medicaid Services
Administered by the states, with broad federal guidelines, each state determines:
Administrative and operating procedures
Benefit packages
Design of its program
Eligibility groups
Payment levels for coverage
Should states be able to place limitations upon enrollment in Medicaid insurance, such as maintenance of a healthy weight, not smoking, or not abusing drugs?
Children’s Health Insurance Program (CHIP):Who is Targeted for CHIP?
CHIP is designed to provide health insurance to uninsured, low income children who:
Reside in a family with household income below 200% of the federal poverty level
Whose family has a household income 50% higher than the state’s Medicaid insurance eligibility threshold
Certain children cannot be covered under CHIP, including children who are:
Eligible for Medicaid coverage
Insured through an employer, an association, or an individual plan
Members of a family eligible for government sponsored health insurance based on employment with a public agency
Residing in an institution for those with mental illnesses
Waivers to use funds to cover adults with children exist
Children’s Health Insurance Program: Expansion of Medicaid Insurance to Higher Income Households
If a state elects to expand its Medicaid insurance using CHIP, the Medicaid insurance eligibility rules apply, including the inability to:
Enact lifetime caps
Enforce residency requirements
Establish time limits for eligibility
For states that opt for a separate child health program, certain other federal restrictions affecting Medicaid insurance eligibility are optional:
Choose to offer children one year of continuous eligibility
Enforce enrollment caps for eligible children
Have waiting lists for coverage of uninsured children
All states must establish a dual system of government insurance eligibility for children
Children’s Health Insurance Program
Limitation of Government Insurance Coverage
The federal government used to restrict the availability of CHIP to children who were not U.S. citizens
Since 2009, all children residing in the United States who meet need based requirements for participation are now eligible for coverage
Need Based Cost Sharing
States are permitted to impose different cost-sharing on CHIP
Some of the poorest insured families in America have unenforceable rights when their children are denied medical coverage
Children’s Health Insurance Program:
Middle Income Families
Families must be advised of their maximum annual cost sharing limit for each child; the state plan must describe the:
Consequences of not paying cost sharing charges
Disenrollment protections for families who cannot pay their cost sharing obligations
Methods used to determine cost sharing amounts
Should participation in CHIP be limited to children who are U.S. citizens?
Children’s Health Insurance Program
Low Income Families
Where children reside in households at or below 150% of the federal poverty line, states may not impose more than:
Nominal cost sharing fees
One cost sharing charge for all services delivered during a single office visit
One type of cost sharing for a medical service
What Health Insurance is Required for Uninsured Children?
States are required to offer medical services to eligible individuals and families that meet specified financial criteria
States cannot restrict Medicaid insurance coverage to focus on improving the health of their children
Why is Government Insurance Economically Necessary?
In a democratic society there is an economic need for the federal government to:
Seek expected utility maximization
Enhance state capacities for health insurance coverage
Help generate economic activity in the states
Maximize economic impacts on the U.S. health care system
Support a safety net
U.S. Health Care System and Safety Net
The guarantee of federal financing for Medicaid insurance enables states to respond to:
Aging population
Chaotic economic downturns
Emergencies and disasters
Increases in health care costs
Children’s Health Insurance Program
Generation of Economic Activity:
Additional tax revenues are derived from the health care jobs and household incomes generated
Economic impact of Medicaid funds is impacted because of the federal matching dollars
Health care jobs generate household income within the health care sector and throughout other sectors of the local economy due to the multiplier effect
Medicaid insurance funding to health providers supports health care jobs and household incomes
State spending on behalf of Medicaid insured consumers for health care pulls federal tax dollars into local economies
Children’s Health Insurance Program
Economic Impact on the Health Care System
Government payments to health providers, on behalf of the Medicaid insured, directly impact health providers by:
Creating household income
Promoting consumer purchases associated with the provision of health care
Supporting health care jobs
State Capacity for Health Insurance Coverage
The magnitude of economic impact from Medicaid insured consumers is dependent on:
Economic conditions of the state economy
Federal funding to the states for Medicaid insurance
Level of state funds available for Medicaid spending on health care
Unaffordability of Advanced Medicine
The United States has long prided itself in medical innovations, as the global leader in medical research and health care technology
One in four Americans cannot afford the costs required to meet their medically needed care
Prohibitive costs keep advanced medicine completely out of reach for many members of society, including the:
Low wage earners
Medicaid insured
Underinsured of limited means
Uninsured
This lack of access has been termed a health care crisis
