WRITING ASSIGNMENT #2.
Name:
Institutional Affiliation:
Introduction
In the U.S, Health Care Finance involves three main plans that allow health-care service payments. Government insurances, personal or out-of-pocket funds, and private insurances are the three fundamental ways healthcare organizations get their fees for facilities they give. Medicaid and Medicare are the most extensive programs for state insurance. On the contrary, managed care covers involve collecting activities meant to offer health coverage to Americans. While at the same time working on the improvement processes of health qualities, it also involves minimizing the healthcare expenses. In the United States, it is also part of healthcare finance. Throughout the U.S, many families rely on managed care to get their desired service quality in various healthcare facilities.
PART ONE: The Salient Details of the System and the Pathway to Implement It
The healthcare system in the U.S is complex and vast. It consists of the government and different private payers and health providers. Statistics show that the U.S is rated lower on several necessary health measures even though it pays more health care per capita than any other developed state. Even though private insurance can achieve this, Medicare shall assist the country in solving all the challenges. The United States should have the benefits of high-quality health care services, which are reliably managed within a robust system of public health for the Americans to enjoy optimal health as a population and as individuals (Knickman and Kovner, 2015). The legislation of 1965, which created Medicaid and Medicare, declared that there would be no interference in clinical medicine. Medicaid and Medicare have had tremendous impacts on the practice of health care services despite the original intention. According to policymakers, health care funding should follow two distinct inquiry lines. The first different inquiry lines should be business-oriented that focus on financial systems within the organizations offering health care services. The second inquiry line focuses on health care delivery financing that focuses on Medicare and Medicaid. There has been a meteoric healthcare delivery system growth with the Medicaid and Medicare introduction in 1965. Funding the delivery of healthcare should be characterized by the mechanism of reimbursement and payer sources’ pluralistic system to the health-care services providers (Milstead, 2019). There should attempt to manage costs while maintaining access standards and care quality to promote continuous efforts of health-care reform.
The current healthcare systems in the U.S is selected for this assignment (Doyle, Graves, & Gruber, 2017). Based on the ability to pay, the government-run and single-payer systems would cover every American without barriers. The single-payer system is equitable, has the best access and qualities, lower administrative costs, and higher consumer satisfaction. Nevertheless, such systems can limit spending, resulting in limits on the freedom of people to choose, service shortage, and elective treatment delay. While providing users to purchase private supplementary coverages, pluralistic systems that involve the government and the private sector could ensure universal access to healthcare. For citizens who cannot afford to purchase coverages, it would have to include a warranty that all citizens have access to government subsidies and coverages. Pluralistic schemes are more likely to have higher organizational costs and generate inequities in coverage. In either case, the consumers should get major packages of gains, including protection from catastrophic healthcare costs, preventative care, and primary care that chronic illness management (Milstead, 2019). States need to be encouraged to design their plans until a national agreement is reaching on accomplishing universal health coverages.
The primary purpose and goal of PPACA (Obamacare) were to increase the number of American citizens covered by a health insurance policy, to decrease the overall cost of healthcare for all American citizens, to provide specific tax credits & subsidies for people and businesses and to streamline the delivery and quality of healthcare. PPACA comes with many benefits. For instance, many more Americans have access to healthcare, individuals with preexisting conditions cannot be denied healthcare coverage, more medical screenings are being covered, and overall health insurance has become more affordable for many Americans (Milstead, 2019). Some of the disadvantages that come with PPACA include companies cutting employees hours so that they can avoid paying for health insurance, taxes have increased, and the tax penalty that many Americans are faced with due to no health insurance is just a few disadvantages.
Terms of eligibility of Medicare and Private Insurance
Medicare is, in general, available for individuals aged sixty-five years. Above individuals with End-Stage Renal Disease such as permanent kidney failure, need a transplant or dialyzes and younger with disabilities (Knickman & Kovner, 2015). Medicare has two sections, Hospital Insurance (Part A) and Medicare Insurance (Part B). Those who are aged sixty-five and above and their spouses paid Medicare taxes and worked for at least ten years are eligible for Hospital Insurance (premium-free Part A). At age sixty-five or older, one qualifies for full Medicare benefits if they are permanent legal residents who stayed in the U.S for at least five year or citizens of the U.S. Provided an individual can pay for private insurance they are eligible to covered by the private insurance cover (Vuong et al. 2018). Regardless of the residency status in the U.S, to claim the rebate of private health insurance, one must be a beneficiary of private insurance incentives, eligible for Medicare and have an Adhering policy of health insurance American-registered health.
Services covered
Generally, private insurance cover is categorized into ambulance cover, hospital cover, and general treatment covers, commonly known as extras or ancillary coverings (Garrison et al. 2018). Combined with other policies, ambulance covers may be separately available and sometimes covered by the state governments. With hospital covers, a person has the right to select their medic and decide whether they will be treated at private or public hospitals which their doctors attend. Also known as an extra or ancillary cover, general treatment cover offers insurance certain treatment costs by ancillary health services providers. The extent of protection relies on policy types one selects and can involve services like healing aids (prostheses), contact lenses and glasses, eye therapy, speech therapy, occupational therapy, physiotherapy, podiatry, home nursing, chiropractic treatments, and dental treatments. The ambulance services and emergency costs are not covered by Medicare (Milstead, 2019). The private health insurance offers this alternative for ambulance cover that differs on what territory or state one lives in. Also known as original Medicare, Medicare Part A is the insurance program covering hospital services and stays. It also includes stays in hospice care, wheelchairs and walkers, and nursing facilities (Knickman & Kovner, 2015). A person is not able to go to a skilled nursing facility or hospital even if Medicare covers services of home healthcare.
Financing
Medicare and Medicaid are paid by the government (Milstead, 2019). Private health insurance covers may be bought from non-profit and profit organizations. In the U.S, even though there are many health insurance companies, a specific state appears to have a restricted number. As benefits for workers, most private health insurance is bought by companies. Typically, costs are shared by the employees and employers. The money amount employers spend on workers’ health insurance is not viewed as taxable income for the employees. In effect, the state is subsidizing this insurance to a certain level (Milstead, 2019). Also, individuals can buy private health insurance. Medicare assists users in paying for prescription medications, doctor and hospital visits, and other post-acute and acute care services. Medicare is primarily financed for beneficiary premiums (15%), general revenues (43%), and payroll taxes (36%) (Doyle, Graves, & Gruber, 2017). Primarily, Section A is funded via a 2.9% earnings tax paid by employees and employers at 1.45%.
Types of providers
The providers of Medicare include skilled nursing facilities (SNFs), physician rural health clinics, pharmacists, practice administrations, programs of opioid treatments, hospitals, hospices, home health agencies (HHAs), Federally Qualified Health Centers (FQHCs), Durable Medical Equipment (DME), critical access hospitals, clinical labs, anesthesiologists, ambulatory surgical centers (ASCs) and all fee-for-service providers (Garrison et al. 2018). The types of providers for private health insurance covers include high-deductible programs (HDHPs), Point-of-serve (POS) strategies, exclusive provider organizations, desired provider firms, and health maintenance firms that can be associated with accounts of health savings.
Quality of care
The private health cover is broad and is likely to cover all Americans’ healthcare needs. With administrative costs, Medicaid payments fluctuations are expected to wear off, and the United States may see more ascend in costs, the extrapolation of the negative leads and private health cover may solve such problems. Patients of the United States are more likely to obtain needed treatments and tests under the private health care cover (Milstead, 2019). The trips to the office of the medics or emergency rooms are expected to include a set of dealings that cover professional conduct more, so that improve the recovery of the patients under the private health insurance cover.
Part 2
Impact on Payments to hospitals and doctors
The best health system should have a robust basic care system, but the United States faces crises in its primary (Doyle, Graves, & Gruber, 2017). Like the “baby boomer” generation, the primary care doctors are facing retirements and requiring care for long-lasting disorders. Any national approaches to universal health coverages should also include programs of ensuring sufficient supplies of principal care physicians and medical homes where the primary care doctors coordinate teams of health experts to achieve the needs of the patients. There have been many effects regarding the state expansion of Medicaid based on several studies. The expansion has increased gains in overall coverage. There has been an improvement with access, financial securities, measures of health status/results, and a considerable amount of economic benefits for states and their providers. Based on further research, the Medicaid expansion did not lead to any significant increase in cost regarding state funds.
Concerning non-reimbursable care, one of the chief gains of the Medicaid expansion is to reduce the uncompensated care burdens that providers/hospitals have been faced with. With the development of Medicare, non-reimbursable care burdens decreased between 2013-2015 from 3.9% to 2.3% regarding operating costs, which totaled around $6.2 billion (Milstead, 2019). So, as you can see, the expansion provided some great benefits overall.
Affect payer-insurance companies, employers, and current insurance programs
Medicaid and Medicare require a new corporate structure (Knickman & Kovner, 2015). The Healthcare Financing Administration (HCFA) at the new administration needs to be substituted by a Federal Health Plan Management to administer Medicare. The Agency of a new Medicare administration needs to have different centers for exclusive populations/program developments, prescription drugs, health programs, provider payments, and beneficiary services. A new Congress needs to establish a committee of joint health, and the future Human and Health Services Department (HHSD) needs to have an assistant secretary for health care quality and prevention (Knickman & Kovner, 2015). Private health insurance organizations deal with any related clients matters and address the benefits of health insurance program delivery. The health plan operations refer to a set of outstanding support and administrative reinforcement services for providers and members of the health plan. The back office carries out activities like application processing, underwriting, actuarial, collection of premium payments, and health plan members’ support/service. The staff members of Back Office reinforce the health providers and customers of the health insurance organization within the internal employees and provider of the firm.
The policies will be canceled based on them not meeting the minimum ACA requirements concerning healthcare coverage (Knickman & Kovner, 2015). For example, before Obamacare, insurance companies were capable of denying individual coverage based on certain preexisting conditions. When ACA was signed into law, denying a personal coverage based on a preexisting condition was no longer allowed, yet many insurance policies still listed exclusions such as preexisting conditions within their system. Another reason why plans were being canceled was their failure to include “essential healthcare benefits” in their policies. An example of an essential healthcare benefit is mandatory coverage of all children and adults regarding vaccinations. Many insurance companies were not providing these critical benefits in their policies, so the plans were being canceled (Doyle, Graves, & Gruber, 2017). Insurance carriers were given time to modify their plans if done within a timely manner.
The way patients interact with the Health Care System
Universal health coverage facilitates free markets and competitive healthcare systems (Doyle Jr, Graves, & Gruber, 2017). All Americans have accessibility to healthcare. The question is about who needs to pay for health care. Socialized medicine such as low-cost and free government-run programs leads to every individual getting the same poor-quality healthcare because of the high costs. Health care needs to remain privatized. Within the open market healthcare systems, the uninsured individuals’ problem should be handled and solved (Vuong, Ho, Nguyen, & Vuong, 2018). The state should not control health care. With Universal health coverage, patients will have access to best-quality healthcare with minimal waits. Patients will be able to choose and keep their physicians in the provider network of ACA. Obamacare has narrowed the provider network by eliminating higher-cost providers so that they will be able to save money. So, if an individual has a doctor who is not within the Obamacare plan network, they will not be able to keep that provider if enrolled through the marketplace (Somashekhar, 2014).
Conclusion
For American citizens to enjoy best-health care services as a society and as a people, the U.S needs to have the gains of best-quality healthcare services. Robust healthcare systems should control these healthcare services. Healthcare financing in the U.S involves the applications of Medicare, Medicaid, and Managed care utilities. All of these payment plans efficiently aid the citizens in accessing healthcare services without struggling to pay for them. The healthcare insurer takes up the role to ensure that the services provided to the patients in various healthcare organizations are proportionate to the costs. As a result, they adhere to appropriate principles and standards in reimbursing the organizations that offer healthcare services. In managed care, patients and organizations share the expenses. Healthcare funds cover different people and allow Americans to meet high healthcare expenses. The funds enable the patients to pay for services via health insurance coverage.
References
Doyle, Jr, J. J., Graves, J. A., & Gruber, J. (2017). Uncovering waste in US healthcare: Evidence from ambulance referral patterns. Journal of health economics, 54, 25-39.
Garrison, L. P., Neumann, P. J., Willke, R. J., Basu, A., Danzon, P. M., Doshi, J. A., … & Ramsey, S. D. (2018). A health economics approach to US value assessment frameworks—summary and recommendations of the ISPOR Special Task Force report [7]. The value in Health, 21(2), 161-165.
Knickman, J. R., & Kovner, A. R. (Eds.). (2015). Health care delivery in the united states (11th ed.). New York, NY: Springer Publishing.
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Milstead, J. A. (2019). Health policy and politics: A nurse’s guide (6th ed.). Burlington, MA: Jones and Bartlett Publishers.
Reinhardt, U. E. (2010, Jan 20). State of the nation (a special report): Voices—A good start. The Wall Street Journal, p. R5.
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Vuong, Q. H., Ho, T. M., Nguyen, H. K., & Vuong, T. T. (2018). Healthcare consumers’ sensitivity to costs: A reflection on behavioral economics from an emerging market. Palgrave Communications, 4(1), 70.