Medicare, Medicaid, and the Health Insurance Portability and
Accountability Act (HIPAA) have had significant impacts on the
healthcare industry. The mentioned services and federal law have
provided both benefits and challenges to the healthcare industry
regarding decision making. “A goal in the United States is to eliminate
health disparities by expanding access to health care for vulnerable or
at-risk populations.” (Stanhope & Lancaster, 2018, p. 357). Many
resources are available to service vulnerable populations’
individualized needs.
Medicare
Medicare provides health insurance to people aged 65 or older,
people under age 65 with certain disabilities, and people of all ages
with end-stage renal disease (Centers for Medicare & Medicaid
Services [CMS], 2021). The Medicare program is broken down to
three different parts including, Medicare part A, B, and D. Each option
provides different benefits selected to meet individualized needs.
Medicare part A helps cover inpatient care in hospitals, hospice care
and even some home health care (Centers for Medicare & Medicaid
Services [CMS], 2021). Medicare part B covers doctors services’,
outpatient care, and some of the services of physical and occupational
therapists. Lastly, Medicare part D covers prescription drug coverage
(CMS, 2021). While Medicare provides many benefits, the program
also faces some concerning challenges. “The federal government
discovered early that Medicare utilization and resulting costs had
been underprojected and that retroactive, cost-based reimbursement
to hospitals and charge-based reimbursement to physicians were
inflationary” (Nowicki, 2022, p. 132). While Medicare is intended to
provide benefits for those who qualify, the program has been
yearning for a balance in aiding the public, while also achieving
adequate revenue through reimbursement services.
Medicaid
Medicaid is the largest source of healthcare coverage in the United
States (CMS, 2021). The joint federal and state program provides aid
to “individuals who may be able to pay for normal living expenses but
cannot afford healthcare expenses” (Nowicki, 2022, p. 156).
Vulnerable populations include, but are not limited to children,
pregnant women, parents, seniors, persons with substance abuse, the
homeless, and individuals with disabilities (CMS, 2021). While
benefits vary state-to-state, mandatory benefits provided among all
states include “inpatient and outpatient services, physician services,
laboratory and radiology services, and home health services”
(Nowicki, 2022, p. 157). Though Medicaid benefits vulnerable
population, the program continues to face ongoing challenges. As
previously mentioned, Medicaid is a federated program, meaning
benefits vary state-to-state. Meaning location can greatly impact the
quality and extent of care received. Furthermore, Medicaid is not
accepted by all health care providers, ultimately limiting access to
care. “In a nationwide survey of primary care providers in 2015, only
45% indicated they were willing to accept new Medicaid patients
while 94% were willing to accept new privately insured patients”
(Hsiang et al., 2019, p. 1).
Health Insurance Portability and Accountability Act (HIPAA)
The Health Insurance Portability and Accountability Act (HIPPA) was
passed by congress in 1996. The law intends to protect patient health
information from being disclosed without the patient’s consent (CDC,
2018). HIPPA protects both patient privacy and confidentiality.
Furthermore, in my professional experience as a nurse, HIPPA has
protected patient safety. As technology advances, privacy concerns
arise. “With the implementation of digital heath tools such as patient
portals, health information exchanges, genomic registries, wearables,
and mobile health (mHealth) applications, a void in the protection of
health data emerged” (Theodos & Sittig, 2020, p. 3). Unfortunately,
many digital health tools are not covered under the current HIPPA
law, jeopardizing the protection and privacy of patients’ health
information (Theodos & Sittig, 2020).
References
Centers for Disease Control and Prevention. (2018). Health Insurance
Portability and accountability act of 1996 (HIPAA). Centers for Disease
Control and Prevention. Retrieved May 10, 2022, from
https://www.cdc.gov/phlp/publications/topic/hipaa.html
Centers for Medicare & Medicaid Services. (2021). Eligibility.
Retrieved May 11, 2022, from
https://www.medicaid.gov/medicaid/eligibility/index.html
Centers for Medicare & Medicaid Services . (2021). Medicare program -
general information. Retrieved May 11, 2022, from
https://www.cms.gov/Medicare/Medicare-General-
Information/MedicareGenInfo
Hsiang, W. R., Lukasiewicz, A., Gentry, M., Kim, C. Y., Leslie, M. P.,
Pelker, R., Forman, H. P., & Wiznia, D. H. (2019). Medicaid Patients
Have Greater Difficulty Scheduling Health Care Appointments
Compared With Private Insurance Patients: A Meta-Analysis. Inquiry :
a journal of medical care organization, provision and financing, 56,
46958019838118. https://doi.org/10.1177/0046958019838118
Michael Nowicki. (2022). Introduction to the Financial Management
of Healthcare Organizations, Eighth Edition: Vol. Eighth edition.
Gateway to Healthcare Management.
Stanhope, M., & Lancaster, J. (2018). Public health nursing:
Population-centered health care in thecommunity (8th ed.). Maryland
Heights, MO: Elsevier Mosby.
Theodos, K., & Sittig, S. (2020). Health Information Privacy Laws in the
Digital Age: HIPAA Doesn't Apply. Perspectives in health information
management, 18(Winter), 1l.
