Medicare and Medicaid have been around since 1965 when it was
first signed into law by then President Johnson. It originally only
included parts A and B which were hospital and medical insurance.
Since then, it has evolved to include more of our population. In 1972,
coverage expanded to include those with disabilities, end-stage renal
disease who required dialysis or a transplant, and those aged 65 or
older. Even part D has been added which helps cover prescription
drug costs. At first Medicaid was only available to those who were
receiving cash assistance through the government. Coverage for
Medicaid has also expanded over the years to include, pregnant
women, people with disabilities of any age, and those who need long-
term care assistance (Centers for Medicare & Medicaid Services
[CMS], 2021).
A large challenge Medicaid consumers face is that any change in
income affects coverage. If someone is only a couple dollars over,
their coverage can be suspended. If the extra income a person is
earning that puts them over the maximum monthly cap and does not
show to have medical bills that equals that excess income, consumers
may be eligible to pay monthly for their Medicaid coverage. If a
person earns an extra $5 each month, they can pay that $5 to have
coverage that month. So, let’s say a person excess income is only
equal to $10. This puts them over the free coverage, and they now
must pay monthly for their coverage. Which does not seem too
horrible, many of us do it. But lower socioeconomic families do not
have access to necessities that many of us are privy to (New York
State Department of Health [NYS DOH], 2010). One study showed
that 51 million households in the US did not have a monthly budget
that could include food, housing, transportation, etc. (Taylor, 2018).
So, this family now has the added expense of the insurance pay in.
But do they have transportation to get to the post office for stamps to
mail it? Do that have a checking account to write a check for this new
bill? Will this extra cost cause a family to continue to go without a
meal? There are many things to consider with this program but
keeping in mind that any added expense can be catastrophic for some
families is critical.
A challenge for those with Medicare, is the large out-of-pocket
expenses. A large portion of which comes from hospital stays, which
can cost people in the thousands of dollars. A great deal of Medicare
participants are low-income, this cost can put people over the edge.
Many things are left out of the traditional Medicare coverage as well
like dental care, vision, and hearing coverage. Adding in another extra
cost for enrollees to get the Advantage type Medicare coverage to
include these. The advantage coverage would also put a cap on the
out-of-pocket expenses one might face (Worstell, 2021).
HIPAA was signed into law in 1996. This law protects consumers
personal health information (PHI) from being disclosed with that
person’s consent. This protection limits the amount of unnecessary
sharing of health information, which also decreases the incidence of
identity theft (Centers for Disease Control and Prevention [CDC],
2018). HIPAA also helped shaped the prevention of discrimination
against those with pre-existing conditions. HIPAA limits on how far
back someone can look at healthcare treatment one has received,
called the “six-month look back limit (American Cancer Society [ACS],
2019).”
However, even with this law in place, if a clear violation has taken
place, consumers may not sue for a HIPAA violation, even if harm has
occurred due to federal law. Another disadvantage is the continuing
administrative burden it has placed on healthcare workers to
continuously remain compliant with HIPAA (Faille, 2018). While,
protecting a patients personal health information is clearly very
important, the more time any form of health care providers must
spend documenting, the less time we must spend actually caring for
our patients. Another is that providers do not need consent from the
patient for billing purposes. Unfortunately, this means patients could
unknowingly be billed for services that technically did not occur.
American Cancer Society (ACS). (2019). HIPAA (The Health Insurance
Portability and Accountability Act of 1996).
https://www.cancer.org/treatment/finding-and-paying-for-
treatment/health-insurance-laws/what-is
hipaa.html#:~:text=It%20limits%20what's%20considered%20a,befor
e%20enrolling%20in%20the%20plan.
Centers for Disease Control and Prevention (CDC). (2018). Health
Insurance Portability and Accountability Act of 1996 (HIPAA).
https://www.cdc.gov/phlp/publications/topic/hipaa.html
Centers for Medicare & Medicaid Services (CMS). (2021). Medicare
program – General information.
https://www.cms.gov/Medicare/Medicare-General-
Information/MedicareGenInfo
Faille, L. (2018). Pros and Cons of HIPAA. Vittana. 22 Pros and Cons
of HIPAA – Vittana.org
New York State Department of Health (NYS DOH). (2010,
November). Medicaid excess income (“Spenddown” or “Surplus
Income”) Program. Retrieved May 11, 2022.
Taylor, V. (2018). Almost half of families can’t afford necessities like
food, study finds, & here’s why. Romper.
https://www.romper.com/p/almost-half-of-families-cant-afford-basic-
necessities-like-rent-study-finds-heres-why-9136141
Worstell, C. (2021). The pros and cons of original Medicare, Medicare
Advantage, Medicare Supplement Insurance and Medicare Part D.
Medicare Advantage.
https://www.medicareadvantage.com/enrollment/advantages-and-
disadvantages-of-medicare
