Introduction
Currently, the issue of obtaining health insurance is increasingly complex since it demands specific eligibility. Medicare and Medicaid, the two most prominent federal health insurance programs, have set their standards for affordability and have offered their services for about half a century. Meanwhile, vulnerable groups are unlikely to acquire their services; this is problematic in terms of fighting against age, status, and racial disparities. Several governmental initiatives attempted to make services more available to all citizens; yet, certain negative consequences were also observed. Nonetheless, some organizations can improve policies and promote insurance accessibility for each layer of the population, providing high-quality services with lower payments.
Quality Improvement Organization (QIO)
Quality Improvement Organization (QIO), primarily known as Peer Review Organization, is a federal program aimed at improving the health of Medicare beneficiaries. As a part of a government plan, its goal is to reduce the cost of medical treatment and ensure the nation’s health. According to the law, the QIO program’s value is to perfect the efficiency, cost-effectiveness, and quality of services provided to insurance beneficiaries (Höög et al., 2016). Clinicians, quality experts, and clients are the key stakeholders who promote health awareness and suggest initiatives aimed at drug costs reduction. Specifically, these professionals distribute their ideas and projects to Medicare users.
Typically, QIO dispatches clinical health professionals to hospitals, nursing homes, and other healthcare facilities to aid them in implementing proven efficient practices and facilitate knowledge sharing. Physicians, nurses, as well as technical, communication, and technology experts, are among the healthcare workers involved in the process. QIOs analyze patient data and records to identify areas for improvement and help providers implement these improvements (Höög et al., 2016). In the community, QIO engages stakeholders and service providers through sustainable community-based collaboration consisting of local health leaders, patient advocacy representatives, and subject matter experts.
QIO also protects the rights of Medicare beneficiaries by reviewing beneficiary complaints and appeals for coverage and conducting audits to ensure that Medicare pays for reasonable and necessary care provided in the most appropriate settings.
These services are free of charge for suppliers and beneficiaries. Because QIO works with health care providers across the care continuum – hospitals, nursing homes, home health facilities, primary and specialty care providers – they are successful in reducing repeat referrals (Höög et al., 2016). It is especially relevant when caring responsibility shifts from one facility to another, such as when a patient moves from hospital to home care. QIO provides an independent review of patients’ medical records to identify areas where service providers can improve their practices (Höög et al., 2016). Using the information gathered during the audits, they can engage service providers to make systemic changes that are proven to enhance the efficiency of health care.
Qualifications for Medicare and Medicaid Benefits
Medicaid is a state and federal insurance program that helps reduce the cost of health services for individuals with limited income and offers such benefits as nursing homes. Concrete non-financial eligibility features must be met by those willing to acquire Medicaid. In general, Medicaid beneficiaries must obtain citizenship of the state where they want to receive program benefits (Halpern et al., 2016). They must either be residents of the United States or have a legal permanent residence permit. Some eligibility groups are constrained by such factors as age, pregnancy, or marital status (Halpern et al., 2016).
When an individual is confirmed to be eligible for health care, insurance coverage comes into effect either on the day of application or on the following month’s first day (Halpern et al., 2016). Insurance coverage usually expires at the end of the month, when the person no longer meets the qualification requirements.
Meanwhile, Medicare is a federal program aimed at improving people’s health nationwide; therefore, it has other requirements. Most people qualify for health care by getting older in the system when they turn 65 (Halpern et al., 2016). However, they can also be eligible for health care under 65 if they have a disability. Moreover, it is necessary that the resident beneficiary permanently resides in the United States for five years (Halpern et al., 2016). Citizens may automatically enroll in Medicare if they receive disability benefits from Social Security or if they have an end-stage renal condition and Lou Gehrig’s disease.
Yet, since solely specific categories of people fall under these qualifications, the vulnerable groups suffer from suitable health coverage unavailability. These weak layers include economically disadvantaged, low-income families, racial minorities, homeless people, and those with chronic and severe mental illnesses (Halpern et al., 2016). Primarily, being federal programs, Medicare and Medicaid can reduce the age of acceptance. Moreover, they may decrease monthly premiums so that people with minimum income could access the services. Otherwise, these insurance plans may create additional parts for enrollment.
The Effect of the ACA
The Affordable Care Act (ACA), also titled Obamacare, has caused a lot of controversy since its introduction in 2010. The law was intended to provide affordable health insurance for all Americans. The ACA was also designed to protect consumers from insurance companies’ tactics that could lead to increased patient costs or limited medical care. As a result of the interventions, some of Medicare and Medicaid’s elements were altered. However, these new additions have been widely discussed as to their usefulness.
The ACA has primarily reduced any elevations in Medicare payments to service providers and decreased Advantage payments over a six-year period. According to the source, “these reductions in Medicare spending, estimated by the Congressional Budget Office (CBO) to be $802 billion over ten years, are lowering costs for Medicare beneficiaries” (“Overturning the ACA,” 2020, para. 8). Under the ACA initiative, beneficiaries received a chance not to pay for the drug prescription entirely since the program could afford to pay it off. Besides, all Medicare beneficiaries could access preventive services without specific eligibility. The ACA established the Medicare and Medicaid Innovation Center (CMMI), which aimed to elaborate new means of provision and payment for health services that improve quality.
Meanwhile, it developed new alternatives for the growth rate reduction in Medicare spending. However, some researchers found that the negative impact of the ACA was the increased premium payment and deductibles that made many Americans bankrupt. Moreover, around four million citizens suffered from losing their employment-based health insurance. In addition, some people did not acquire any of the suggested insurance plans and were taxed (“Overturning the ACA,” 2020). Hence, even though Medicare was expected to reduce its costs, the premiums still remained high for the population.
Under the ACA influence, Medicaid received an expansion, which was associated with increased spending, services use, and their quality. The increase in coverage was seen across a broad range of population groups. These primarily included low-income adults, children and mothers, and early retirees who were likely already eligible for benefits. In addition, other studies demonstrated that Medicaid expansion had diminished racial inequities in health insurance.
Moreover, other research indicates that Medicaid expansion has reduced racial inequities in health coverage. There was also a decrease in the number of self-reported psychological disorders and days of poor mental health, as well as an increase in self-reported general health (“Overturning the ACA,” 2020). Medicaid expansion was attributed to improved hospital financial performance, which included uncompensated care reductions and revenue increases (“Overturning the ACA,” 2020). Yet, the increased wait time and bad debts in some non-profit medical organizations were among the expansion’s negative consequences.
In general, the Affordable Care Act has created a great demand for health insurance, and the number of the uninsured population has hit the lowest rate in its entire history. In particular, the majority of deprived families and people of color received access to healthcare services that they could never think of before. Additionally, the quality of medicine has significantly ameliorated due to an increased governmental interest in making the nation healthier.
Conclusion
In summary, it seems reasonable to mention that medical services remain increasingly expensive, especially in the United States; therefore, coverage programs help reduce health-associated costs. It is vital to implement new initiatives to reduce health disparities among the American population, as different societal segments (low-income families, people of color, and others) have distinct levels of access to medical services. Quality Improvement Organizations (QIOs) act as intermediaries between government coverage programs and health professionals to prioritize the country’s health care and reduce drug costs. Yet, solely the complex approach towards expanding the insurance eligibility criteria will help improve the nation’s well-being.
References
Halpern, N. A., Goldman, D. A., Tan, K. S., & Pastores, S. M. (2016). Trends in critical care beds and use among population groups and Medicare and Medicaid beneficiaries in the United States: 2000-2010. Critical Care Medicine, 44(8), 1490–1499. Web.
Höög, E., Lysholm, J., Garvare, R., Weinehall, L., & Nyström, M. E. (2016). Quality improvement in large healthcare organizations: Searching for system-wide and coherent monitoring and follow-up strategies. Journal of Health Organization and Management, 30(1), 133–153. Web.
Overturning the ACA would harm Medicare. (2020). National Committee to Preserve Social Security & Medicare. Web.