Medicare, Medicaid, and HIPAA all share a common benefit. They
make health insurance accessible to individuals who may otherwise
not have been able to obtain or maintain insurance. Individuals who
are 65 or older, disabled, or have end-stage renal disease qualify for
Medicare. These individuals are typically retired or unable to work
due to illnesses and treatments. Therefore, without employer covered
benefits, they would either have no insurance or would have to
purchase a plan with a premium too high to pay. According to
eHealth (Poretta 2022), "in 2020 the average cost for individual
healthcare premium was $452 monthly and $1152 monthly for a
family". The Department of Health and Human Services states that
"most low income individuals, families, children, pregnant women,
those with disabilities, and elderly people quality for Medicaid" (HHS
2021). HIPAA which stands for Health Insurance Portability and
Accountability Act, ensures that "individuals who lose their job,
dependents up to age 26 and individuals who have to change plans
and have preexisting conditions are still able to have continuous
coverage" (Edemekong, et al. 2022).
While Medicare and Medicaid allowed more access to healthcare, in
the beginning, there was abuse of the plans and quite a bit of
unnecessary testing and procedures performed. In response to that
came federal programs to monitor against fraud and abuse. First came
Experimental Medical Care Review Organizations (EMCROs), which
opened the door to many other monitoring programs. These
eventually led to the quality care initiatives that are responsible for
the improved quality of care and patient outcomes we see today. An
additional benefit of HIPAA is the protection of patient's health
information. The HIPAA act allows a patient to authorize and restrict
(in most instances) access to their protected health information.
HIPAA is also utilized to allow healthcare providers to disclose patient
information to other providers to allow continuity of care. c
One challenge concerning Medicare is the financial sustainability.
Medicare is funded through federal funds. According to the American
Academy of Actuaries (2020), "Medicare’s Hospital insurance (HI)
trust fund is projected to be depleted in 2026." Another Medicare
challenge is the enrollment process for patients. "Beneficiaries have
seven months from their 65th birthday to select their plan. If a
decision isn't made in a timely manner penalties will accrue. More
importantly, there isn't a source of personalized information to help
patients navigate their plans" (Waddill 2020).
Medicaid is challenging to both providers and patients. Providers are
opting out of accepting Medicaid plans because they are finding that
the pay out is less and there are issues with the claims. "About 19
percent of the initial claims submitted to Medicaid are not paid in full
compared to Medicare's 8 percent and private insurers' 5 percent"
(Scott 2021). Patients that qualify for Medicaid, typically face
socioeconomic disadvantages that make it difficult for them to get
medical care. Some issues are "unstable housing, financial insecurity,
the absence of paid family leave, and transportation problems"
(Mahajan 2021).
The last couple of years have been challenging for HIPAA due to the
public health crisis and the need for telehealth. It proved difficult to
institute privacy laws in the face of telehealth. With patients using
unsecured networks on their end and doctors relying on platforms
such as Zoom in some circumstances, HIPAA rules were relaxed to
ensure that patients would still get the necessary care and the
physicians would not be punished for "breaking HIPAA privacy rules
by using video conferencing solutions that aren’t fully compliant"
(Charles 2021). The biggest challenge for healthcare regarding HIPAA
has been security. An organization can increase their cybersecurity
and train their staff to recognize phishing scams. However, protecting
patient information from employees proves to be the most
challenging. There are many healthcare organizations that have had
breach incidents resulting from employees accessing patient
information out of curiosity and not for the purpose of their job.
According to Laura Dyrda (2020), "The temptation to gain information
about individuals at hospitals is huge when hospitals treat high-profile
individuals or cases."
References
American Academy of Actuaries. (2020). Medicare’s Long-Term
Sustainability Challenge | American Academy of Actuaries. Actuary.Org.
Retrieved May 11, 2022, from https://www.actuary.org/node/13472
Charles, F. (2021, March 31). HIPAA challenges of 2021: 6 ways the
healthcare sector is responding. Charles IT. Retrieved May 12, 2022,
from https://blog.charlesit.com/hipaa-challenges-of-2021-6-ways-
the-healthcare-sector-is-responding
Dewalt, D. A., Oberlander, J., Carey, T. S., & Roper, W. L. (2005).
Significance of Medicare and Medicaid programs for the practice of
medicine. National Library of Medicine. Retrieved May 11, 2022, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4194929/
Dyrda, L. (2020, June 15). 10 common reasons for HIPAA violations.
Beckers Health IT. Retrieved May 12, 2022, from
https://www.beckershospitalreview.com/cybersecurity/10-common-
reasons-for-hipaa-violations.html
Mahajan, A. (2021, December 16). Value in Medicaid, part 2: Challenges
concerning health-related social needs. Health Affairs. Retrieved May
12, 2022, from
https://www.healthaffairs.org/do/10.1377/forefront.20211214.703
281/full/
Scott, D. (2021, June 7). Medicaid is a hassle for doctors. That’s hurting
patients. Vox. Retrieved May 12, 2022, from
https://www.vox.com/2021/6/7/22522479/medicaid-health-
insurance-doctors-billing-research
Waddill, K. (2020, October 8). 5 Challenges, 5 Policy Solutions for the
Medicare Enrollment Process. HealthPayerIntelligence. Retrieved May
12, 2022, from https://www.healthpayerintelligence.com/news/5-
challenges-5-policy-solutions-for-the-medicare-enrollment-process
