Medicaid Essay ⋆ Essays on Controversial Topics ⋆ EssayEmpire

Medicaid is a joint federal and state health insurance program for low-income eligible children, adults, the elderly, and people with disabilities. This federal entitlement program was established in 1965 as Title XIX of the Social Security Act. The nation’s largest publicly financed health care program of its kind, it funds nearly half of nursing home care and a significant percentage of prescription coverage in the United States. Federal regulations provide broad coverage guidelines, but the states determine specific services. The program’s broad range of medical services include inpatient and outpatient care; rehabilitation services for people with mental and physical disabilities; primary care to women, families, elders, and children; prescription benefits; and long-term care for the aged. Title XIX is administered federally by the Centers for Medicare and Medicaid Services (CMS) but operated by individual state systems.

Each state establishes distinct eligibility standards, defines what type and length of medical care will be available, and also sets its own reimbursements rates to providers. As such, Medicaid eligibility does not cross state lines; anyone who moves from one state to another must seek eligibility anew. The insurance application process is a lengthy one, requiring documentation of citizenship, living situation, and financial assets.

More than 55 million individuals receive care under the Medicaid program, and at least 40 percent of Medicaid expenses are for long-term care in nursing homes. The governmental cost of caring for elders in long-term care is a major social issue because of the rapidly increasing numbers of the population who are aging and concerns about who will pay for their care.

Basis of Eligibility

Financial need determines Medicaid coverage, and each state conducts a means-tested evaluation of the resources of an individual or family, including property and bank assets. Certain categories of individuals are eligible for medical care if they fit into broad groups following the poverty levels set by Health and Human Services (HHS) or fall into the category of Disabled, Aged and Blind (DAB). In some states, individuals who receive Supplemental Security Income (SSI) are automatically eligible. A number of low-income eligible Medicare recipients supplement their health care, including prescriptions with Medicaid benefits, through state-administered programs.

One cannot simply transfer assets to a family member to become Medicaid eligible, since all states require a “look-back period” to determine eligibility to receive Medicaid benefits. This look-back period varies from 3 to 5 years to determine whether property or financial assets were gifted simply to gain Title XIX eligibility. If so determined, these assets are deemed available and the applicant will not qualify for Medicaid benefits. Also, most states have established estate recovery laws to recoup funds from the estates of Medicaid beneficiaries.

Additional Services

Many states offer optional personal services to help seniors and people with disabilities remain at home. Financially eligible seniors and people with disabilities may qualify for personal care programs that offer in-home assistance with daily living activities such as bathing, dressing, and food preparation. The primary purpose is to allow people to live in their own homes or apartments at less expense than nursing home placement paid by Medicaid and to allow more freedom, independence, and choice for people with disabilities.

Since 1997, the states have offered health care programs for children in families with incomes above the poverty level. Children can receive health care services even though the adults in the household may not be eligible, as legislated in the State Children’s Health Insurance Program (SCHIP). Even with SCHIP benefits in place, access to services may require additional fees, and if low-income families cannot afford even these minimal costs, their children who are otherwise eligible for SCHIP will still not be able to obtain necessary medical care.

Medically needy individuals may also qualify for benefits even though their income is above the eligibility level set by the state. For example, individuals with acute illnesses, high medical bills, or high-cost chronic medical needs may access Medicaid services for care.

Problems With Medicaid

Major problems with Title XIX include access to minimally adequate care or any care at all. Since the reimbursement rate for Medicaid providers does not meet the actual costs of care, many medical practitioners limit the numbers of Medicaid recipients they accept as patients or do not participate in the program at all. For example, access to dental care and pediatric dental care is quite problematic, given the few providers of this basic medical necessity. Also, because doctors and clinics that accept Medicaid reimbursement are limited, the wait for appointments is often long.

Fraud is another concern, leading states to set up fraud units to investigate false or duplicate charges by providers that could easily be lost in a large bureaucratic system. Fraud committed by patients ineligible for benefits is another problem.

Current Legislative Issues

With the passage of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (commonly known as the Welfare Reform Bill), more restrictions exist on who is eligible for Medicaid services. Also, recent trends indicate that the federal government is shifting the costs of Medicaid care back to the states. Ten years ago, Congress acted to ensure health care access for low-income and near-poor children by passing SCHIP. But SCHIP programs are dependent upon congressional reauthorization, and the federal government renewed the program until 2009, after unsuccessful conservative attempts to tighten financial guidelines to reduce eligibility standards so as to disqualify many children from the SCHIP medical safety net.

The next steps for Medicaid legislation include a nationally standardized Medicaid program to set minimum standards of care for those deemed eligible. Since federal law permits wide flexibility in providing Medicaid services to low-income people, a minimum standard could ensure a medical safety net on a national level. Other advocates propose universal access to health care for all, which implies a major funding increase in the future.

Bibliography:

Centers for Medicare & Medicaid Services. (https://www.cms.gov/).
Kaiser Program on Medicaid and the Uninsured. 2017. (http://kff.org/about-kaiser-commission-on-medicaid-and-the-uninsured/).

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