Reimbursement Models in Healthcare

The introduction of Medicare and Medicaid, popular insurance programs for social groups that need additional governmental support, is a part of the plan to reduce the number of uninsured citizens. Eligibility requirements are not the same for different states due to various concerns related to financial costs and effectiveness. With that in mind, the impact of eligibility expansions on healthcare providers and vulnerable populations remains an open question.

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The History of Medicare/Medicaid and Target Populations

The United States belongs to the number of countries that provide numerous insurance opportunities to their citizens, focusing on inequalities that exist in the sphere of social rights. Medicare and Medicaid are the well-known state programs aimed at the provision of health insurance to vulnerable social groups in the country. As for the history of Medicare, this program first appeared in the middle of the 1950s, when its primary goal was the provision of healthcare services to the families of soldiers in the U. S. (Blumenthal, Davis, & Guterman, 2015).

Almost ten years later, under the presidentship of Johnson, the tasks of the program were changed to shift attention to the healthcare needs of older adults with health issues or disability (Blumenthal et al., 2015). According to Blumental et al. (2015), the new focus of Medicare became an important political ploy, helping the president to win the support of voters. The key advantage of the project was the recognition of older adults’ specific problems.

A range of changes was implemented to Medicare since the creation of the project. As a result of some expansions, the number of U.S. citizens who had Medicare eligibility increased to include some categories of terminally ill patients and people with disabilities (Blumenthal et al., 2015). Nowadays, the populations that Medicare is intended to serve include citizens older than sixty-five (regardless of income levels), patients with end-stage kidney disease, and people with full disability from various age groups.

Medicaid is another program implemented in the United States to ensure that financially vulnerable populations have timely access to medical care. It was enabled in the middle of the 1960s to supplement Medicare and protect the rights of low-income citizens of all ages and individuals with disabilities (Berkowitz, 2017).

Speaking about the most important events related to the creation of Medicaid, it is pivotal to mention the implementation of EPSDT benefits for children in 1967 and the inclusion of expectant mothers and infants in the program in the 1980s (Berkowitz, 2017). Also, among the key changes indicative of the evolution of Medicaid, there are coverage improvements for women’s health at the end of the twentieth century and expansions following the adoption of the Affordable Care Act (ACA) (Berkowitz, 2017). Therefore, the served populations include low-income people of all ages or those with urgent medical needs, individuals with disabilities, and terminally ill patients.

Medicaid Expansions: The Situation in Florida and States’ Unwillingness to Participate

Nowadays, Medicaid eligibility requirements are dissimilar in different parts of the United States. After the adoption of the ACA, Medicaid expansions were implemented in more than thirty states to include more families with low incomes (Cohodes, Grossman, Kleiner, & Lovenheim, 2016). Speaking about Florida, it belongs to the number of states that oppose the introduction of these expansions (Cohodes et al., 2016).

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The reasons why Florida and other states avoid participating in Medicaid expansions are related to numerous factors and can reflect some territories’ particular financial concerns. The number of popular reasons includes the associated financial expenses, Medicaid patients’ health outcomes, and the lack of flexibility (Conover, 2017). Apart from that, the unwillingness to implement expansions can be related to the political situation in certain states.

In some of the states that avoid implementing Medicaid expansions, the key concerns are related to the practical effectiveness of this insurance program. For instance, some researchers report significant differences in the degree of its effectiveness for urban and rural populations, which can also be a reason why some states do not expand Medicaid. According to Benitez and Seiber (2018), the perceived reductions in barriers to healthcare services are not extremely significant in rural citizens if compared to people in urban areas. The changes in Medicaid eligibility do not solve the problem related to the lack of qualified healthcare specialists, which also acts as the reason to oppose the expansions.

Medicaid/Medicare in Hospice Care

In general, hospice nurses are expected to fulfill a range of responsibilities to alleviate the suffering of the terminally ill clients. Both programs discussed in the paper provide hospice care benefits to the eligible populations, and nursing services are among the key aspects of palliative care. When working with Medicaid and Medicare patients, hospice nurses are expected to act as the intermediaries between physicians and clients, helping the former to communicate with patients or their families. The role of a nurse in my area of specialization is to provide Medicaid/Medicare recipients with emotional support, coordinate care, and help other team members to conduct needs assessments. Taking into account the vulnerability of the social groups eligible for these types of insurance, hospice nurses should pay focused attention to the provision of spiritual support.

Conclusion

In the end, both reimbursement models discussed in the assignment are aimed at the reduction of inequality in healthcare. The effectiveness of Medicare and Medicaid and the impact of these care plans on the quality of medical care and patient outcomes are highly debated, which leads to some states’ unwillingness to introduce Medicaid expansions. Despite these issues with expansions, the reimbursement models are successfully used to cover a range of services, including palliative care.

References

Benitez, J. A., & Seiber, E. E. (2018). US health care reform and rural America: Results from the ACA’s Medicaid expansions. The Journal of Rural Health, 34(2), 213-222.

Berkowitz, B. (2017). Access to a healthy future. Nursing Outlook, 65(5), 492-493.

Blumenthal, D., Davis, K., & Guterman, S. (2015). Medicare at 50 – Origins and evolution. The New England Journal of Medicine, 372, 479-486.

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Cohodes, S. R., Grossman, D. S., Kleiner, S. A., & Lovenheim, M. F. (2016). The effect of child health insurance access on schooling: Evidence from public insurance expansions. Journal of Human Resources, 51(3), 727-759.

Conover, C. J. (2017). The case against Medicaid expansion in North Carolina. North Carolina Medical Journal, 78(1), 48-50.

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