Table of Contents
Medicare and Medicaid
Very rarely is a person able to go through life without seeking some form of healthcare. Finding the healthcare is not the problem in most cases, however accessing it and paying for it is an on-going problem for Americans and immigrants in the United States of America. However, with the passage of the Patient Protection and Affordable Care Act (ACA) by then President Barack Obama in 2010, the hope for a healthier future was realized by more than thirty million Americans (Nickitas, Middaugh, & Feeg, 2020).
The goal of the ACA was to make affordable healthcare available to the millions of uninsured Americans by making gradual changes to current healthcare policies. Primarily by expanding and lowering eligibility for Medicare and Medicaid. The following paper will discuss how quality improvement organizations (QIO) and their role improving healthcare for those receiving Medicaid and Medicare benefits. It will also describe the qualifications enabling coverage and how those qualification should be modified to be more inclusive. Furthermore, this paper will elaborate on how the ACA has had both positive and negative effects on coverage benefits for its recipients. Lastly, this paper will describe the importance of the role the professional nurse holds in regards to advocating for cost-effective, quality healthcare easily accessible to vulnerable populations.
QIO Improvements for Beneficiaries
Quality Improvement Organizations are “a group of health quality experts, clinicians, and consumers organized to improve the quality of care delivered to people with Medicare”, Centers for Medicare and Medicaid Services website (2020). QIOs are required by law in order to improve the quality of healthcare received by Medicare and Medicaid beneficiaries. There are a number of ways QIOs accomplish these tasks: improve quality of healthcare received, decreasing costs of healthcare received, and protecting beneficiaries in a number of ways.
127 our experts are availableright now
There are a number of ways in which QIOs protect beneficiaries. One way is to improve safety with initiatives aimed at reducing hospital acquired infections (HAIs). Many if not most hospitals have created safety bundles aimed at preventing HAIs such as central-line associated bloodstream infections (CLABSI), surgical site infections (SSI), and catheter-associated urinary trac infections (CAUTI). CLABSI and CAUTI bundles each contains a check off list that must be met (in most circumstances) in order to proceed forward with implementation. Once a central line or a foley catheter has been placed, there are requirements that must be routinely met in order to prevent infection. If an infection still occurs despite the preventative measures, it is reportable to the state and the hospital must perform an investigation to identify possible breaks in protocol and how they will mitigate them.
There are many ways in which QIOs assist in decreasing healthcare costs, one of which is to help healthcare organizations participate in quality payment programs (QPP). A QPP program allows participating doctors and providers the ability to earn incentive payments from Medicare, Nickitas et al (2020, p. 244). The purpose is to entice more participants to provide lower cost, quality care with the benefit of receiving up to an five percent incentive Medicare payment, overall increasing value.
Qualifying for Medicare and Medicaid
One would think that anyone without a job or with a medical infirmity would automatically qualify for Medicare and/or Medicaid, but that is not the case, just living at the poverty line is not enough. There are a number of criteria individuals and families must meet in order to receive Medicare and Medicaid benefits. First, do they earn too much income? A family of three must earn less than thirty-four thousand dollars yearly, and a single adult must earn less than sixteen-thousand-six-hundred dollars yearly in order to qualify for Medicaid.
Recipients are required to maintain an address in the state from which they receive benefits, and be a United States Citizen, Medicaid website (n.d.). In addition, there are age requirements for Medicare: recipients must be sixty-five years old or older unless they are younger and suffer from a chronic disability or have end-stage renal disease. There are exceptions to both that are not addressed in this paper. Another qualifying factor is having worked for ten years or greater and paying into the system.
There are a number of simple changes to qualifications that, if enacted, would increase eligibility resulting in increased health coverage for millions more Americans and Immigrants.
Firstly, allow all immigrants who meet the requirements eligibility. Secondly, raise the “poverty line” and provide automatic eligibility for those who fall under it with no additional requirements. Of course, this will add an extra financial burden onto an already stressed system, however there is a solution. Streamline ‘big government’. This will be addressed later on in the paper. Thirdly, completely get rid of the coverage gap! Make it so everyone, individual and family has coverage.
Positive and Negative Impacts of the ACA
The impacts of ACA are still being felt ten years after its passage, even though it was not allowed to fully achieve its designers full vision due to the current political administration. Even though the current administration continues to try to hinder the ACA from reaching its intended potential, only eleven states are actively trying to add more requirements and increase the difficulty in which it requires to obtain Medicare and Medicaid coverage. And even with this continued interference from the Trump administration, there are a number of positive outcomes that have been realized because of its passage, as well as a couple of negative aspects. Most importantly, with the passage of the ACA upwards of thirty million Americans now have affordable healthcare and are facing the possibility of longer, healthier lives. According to Nickitas et al (2020), the effects are already being seen in a healthier population.
Another positive side effect of the ACA is the closure of the gap, commonly referred to as the “donut hole” in prescription drug coverage. Prior to its passage, patient’s prescription drugs were covered until they reached approximately three-thousand dollars. At which point they had to pay out of pocket up to upwards of five-thousand dollars before they were eligible for coverage again. After the passage of the ACA, they now only have to approximately five percent out of pocket.
