- Oklahoma Medicaid Program
- Women With Disabilities
- The Patient Protection And Affordable Care Act
- Physicians’ Willingness To Serve Medicaid Patients
Beginning in 1966 Medicaid was a program funded by one billion dollars, and has now grown to a program with expenditures reaching hundreds of billions. Medicaid initially spent approximately $4 per the United States citizen in 1966 and though some States chose to implement the new Medicaid program right away others chose to wait until some data was available regarding the program’s success. By 1971 enrollment had reached 16 million with early projections being greatly underestimated with some forecasts projecting expenditures at half this amount. Per-enrollee growth exceeded economy-wide inflation by nearly 11% (Klemm, p107).
In 1971 and 1972, the Social Security Act was amended to create Supplemental Social Security Income, and virtually all recipients were also eligible for Medicaid. Optional modifications started to include intermediate care for mentally challenged individuals and psychiatric treatment for those under the age of 22. Enrollment had reached 20.7 million by 1976, with an average annual growth rate of 5% that remained stable for the following 10 years. As a result of this rapid expansion, the Reagan administration started to explore measures to reduce the deficit. In 1981, the Omnibus Budget Reconciliation Act started a three-year decrease in and also restricted certain welfare assistance eligibility. States started to experiment with Health Maintenance Organizations (HMOs) and community-based waiver programs, and the emphasis shifted to managing services and reducing healthcare costs.
Enrollment rates were constant, despite the fact that spending continued to grow. Congress agreed to adopt expansions in 1984, which continued to grow throughout the 1980s. Medicaid regulations and guidelines concerning women, infants and children began to become less focused on being closely linked to the AFDC program and were related to poverty guidelines and higher income-eligibility levels. In 1997 two important pieces of legislation were passed, the Personal Responsibility and Work Opportunity and Reconciliation Act replaced the original AFDC with a block grant known as Temporary Assistance for Needy Families. This allowed States the option of setting up their own managed care plans and more than half of Medicaid enrollees were in some type of managed care program.
In 2003, Medicaid expenditure was estimated to be about 275.5 billion dollars (Holahan and Ghosh, p 26), and it became a significant focus of the 2005 budget discussion. Between 2000 and 2003, spending rose by 10%, which is attributable to welfare reform. Growth was seen among the non-disabled and children, but when the economy started to deteriorate, the people lost jobs and money. Medicaid cuts were made, insurance rates were raised, and employer-sponsored coverage was reduced.
The Patient Protection and Affordable Care Act of 2011 was designed with the goal of providing health care to sixteen million people. Obamacare has established two fundamental pathways to universal health-care coverage (Reno, p 61). Although Obamacare has boosted financing for the public side of the existing health-care system, many people are concerned that private insurers would be forced to bear higher health-care expenses.
Oklahoma Medicaid Program
Medicaid provides acute health care and long term care services to over 600,000 low-income families and elderly individuals. The Oklahoma health care vision is ‘for Oklahoman’s to enjoy optimal health status through access to quality health care regardless of their ability to pay,’ (Connell, 2012). The Oklahoma Health Care Authority has administered and overseen the Oklahoma Medicaid program since 1995 and is responsible for rule making and policy development. The Oklahoma Medicaid State Plan includes coverage for the following services:
- Ambulance and ambulatory surgery center services
- Substance abuse and behavioral health services
- Case management services
- Radiation and chemotherapy services
- Renal dialysis services
- Certain dental services
- Durable medical equipment and supplies
- Family planning services
- Home health care services
- Laboratory X-ray services
- Inpatient health services
- Medical supplies and equipment
- Diabetic care and supplies
- Nursing midwife services
- Outpatient hospital care services
- Personal care services and preventative services
- Podiatry services
- Prescription services
- Prenatal care, delivery services
- Tuberculosis services
- Rural health care services
This list is not all inclusive and other services may be covered (Connell, 2012).
In order for an individual to be assured that the services or care they need are covered by the Medicaid plan three questions must be answered in the affirmative; is the service covered, is the service medically necessary, and is prior authorization required to receive services? The treatment, service, or intervention must be included in the State Medicaid plan; most services are defined in federal regulations.
Services that are considered covered by Medicaid must fit within the definition of a mandatory or optional service that is included in the State Medicaid plan. If the specific treatment is covered then it must then be established that the treatment is medically necessary. Medical necessity is not defined by the Federal Medicaid Policy though State law along with the attending physician will determine this factor. In Oklahoma there are some services which will require prior authorization. These services include dental services, blood products, durable medical supplies, and certain adaptive equipment. Services for children that require prior authorization include hearing aids, orthotic procedures and dental services.
The authorization service will determine if the service or treatment is necessary and also covered for the individual. If the therapy is experimental, the service will be examined further, and any rejection will be subject to all legal due process safeguards. Medicaid also provides a comprehensive screening, diagnosis, and treatment category of service which became a statutory requirement in 1989. Periodic screenings are required for vision, dental, and hearing services. When health care services are required to repair flaws, physical or mental disorders, they are called medically essential.
In accordance with federal law a schedule is determined for screenings and examinations from newborn to age twenty based on guidelines established by the American Academy of Pediatrics. Developmental assessments cover gross and fine motor skills, language and communication, cognitive skills, assessment of nutrition, immunizations, lab tests, health education, vision and hearing screening. Dental screenings are included and there is a requirement to report child abuse and neglect. Treatment is provided for emotional and psychological problems that are identified.
Nursing facilities and intermediate care facilities are also included for those with mental retardation though the preferred method of care for these individuals is home and community based services. A broad selection of services allows those with disabilities to retain their amount of freedom for a longer period of time. Oklahoma Medicaid provides five different home and community-based waiver programs. These programs consist of an Advantage waiver designed for the elderly, a homeward bound waiver for those involved in the homeward bound lawsuit, a community waiver for individuals at least age three, and -Home support waivers for children three through seventeen and also In-Home support waiver for adults.
Oklahoma Medicaid has been a stable, sustaining system of health care for over forty years in Oklahoma, and there is strong advocacy on the behalf of beneficiaries to ensure that eligible patients are able to receive high-quality health care.
The Children’s Health Insurance Program is a jointly funded program very similar to Medicaid that is administered by individual States. Each state has three different choices in how its CHIP program is designed. The program can be designated as a Medicaid expansion program, a separate child health insurance program, or a combination of the two (Medicaid). Oklahoma uses a combination of the two. In 2009 President Obama signed the Children’s Health Insurance Program Reauthorization Act which created new financial resources and options to improve children’s health care coverage (2010 CHIPRA).
This act also provides an array of incentives to States providing children’s insurance coverage. Children’s enrollment increased by over two million in the fiscal year 2010 and the combination of the CHIP program and Medicaid served over 42 million children. With the use of a CHIPRA outreach grant the Oklahoma Health Care Authority launched ‘Sooner Enroll,’ which uses outreach partners throughout the State to assist families with the enrollment process online. In order to keep families enrolled in the program the opportunity to reenroll by phone is now available and this fast and easy process takes only minutes while ensuring there is no lapse in health care coverage for children.
Women with Disabilities
Before the 1990’s research and information on women’s health care lagged behind all other areas. The lack of focus on this area led to the creation of the Women’s Health Initiative (Parrish and Ellison, 2007, p109). Though women’s health has received national attention through the health care system women with disabilities have largely been ignored. This has had the effect of rendering their particular health care needs invisible making it difficult if not impossible to meet the health care needs of this population. Women with disabilities are extremely over-represented among those considered to be at or below the poverty level.
Medicaid covers the majority of individuals who are disabled and is the most common source of insurance coverage for this population. In order to address the health care requirements of low-income women with disabilities, it is critical to understand their experiences. A 2007 study reports that this group has worse health care access in several important areas (Parrish and Ellison, 2007, p116), and more research needs to be focused on identifying what barriers are faced by this population. The National Institute of Health has begun encouraging women with disabilities to enter the health care field. The Institute has also begun being more focused on minority groups while supporting the training, development, and promotion of minorities in order to combat race-based disparities in health care.
Medicaid recipients are expected to act as if in a partnership with their health care providers. Women must be strong advocates for themselves; this study reports that women with disabilities are substantially more dissatisfied with the health care they receive. Thoughtful and comprehensive policy initiatives are extremely important if health care is to be improved for Medicaid recipients with disabilities.
The Patient Protection and Affordable Care Act
On March 23, 2010, the Patient Protection and Affordable Care Act (PPACA) was signed into law, with the main aim of increasing access to health care services via insurance changes. Immediate improvements in American health care and an increase in the number of people with insurance are the Act’s essential features, though there are many individual elements of the act that address specific issues. This legislation became necessary as a result of the Nation’s critical health care situation. Health care that is unaffordable, citizens with no insurance, an aging population with increased health care needs and a high percentage of American citizens living at or below poverty rates contributed to this necessity. This was primarily a democratic statute, passing the Senate without the Republican vote and getting through the House of Representatives with a high percentage of republicans voting against it.
An attempt to navigate the health care system without a strong continuum of care leads to misinformation, the use of unnecessary services and increased costs. These factors contribute to a trickle-down effect which can result in less services being covered by programs and more stringent eligibility rules. The ACA is designed to build a strong foundation for a health care delivery system that is able to integrate care across all settings and types of providers.
A research study involving comparing and contrasting different methods and modalities of treatment has been implemented; effectiveness and outcomes combined with appropriateness of treatments are to be reported on by an independent panel in an effort to reach this goal. Insurers would now be required to offer essentially the same coverage and benefits to each of their insured, despite preexisting conditions or individual factors. The ACA has other provisions included to make sure our health care facilities are properly staffed in today’s nursing shortage. School scholarships, loan and tuition forgiveness programs and grants all designed to attract, retain, and graduate new nursing staff are also included in the Statute.
States will each be receiving federal funding between 2014 and 2016 at 100%. Coverage will decrease after that in very small increments. States may choose to extend eligibility to individuals without children, although they will continue to get their normal FMAP until 2014. Those enrolled in the Medicaid Children’s Health Insurance program will now not see an eligibility increase until year 2019 and can be eligible at 133% the poverty level.This is the federal matching amount mentioned earlier. The ACA expanded Medicaid to all those non-Medicare eligible individuals under the age of 65 with incomes up to 133% the poverty level and he ACA will require Medicaid to maintain the current income eligibility limits for children in Medicaid and in the Children’s Health Insurance Plan until the year 2019 (Mcneal, 2010, p 38).
ACA section 1902 relates to a new eligibility group for Medicaid and is one expansion option written into the Act. This group includes very low income individuals who are not otherwise eligible to receive Medicaid. That means that they must not be pregnant, over 65, enrolled in Medicare part A or B, or any of those described in other groups, such as parents, those receiving SSI or children. This particular section is designed to fill in the gap and insure those who are usually not eligible for Medicaid. This would affect individuals or families who do have some income, enough to usually prohibit them from receiving Medicaid, though not enough income to afford health care premiums.
Seniors who have not yet reached 65 without full Medicare benefits will not be eligible. This group could also include men unable to find a job or those who are underemployed. Because they are often working with earnings too low to afford health care but too high to qualify for Medicaid, men have long been a group that has been overlooked. Without other existing factors such as being of Medicare age or disabled they frequently go without insurance. With income allowances higher more men are able to work and qualify for Medicaid.
Social Security Act Section 1115 Waiver gives States the ability to research improvements to their own Medicaid and CHIP programs. States may use this waiver to give individuals Medicaid who are not otherwise qualified. The waiver can also be used to cover non-Medicaid services. This program has made significant differences for those who have received Medicaid through this waiver or SCHIP, which is the Children’s Health Insurance through the use of the waiver.
The waiver program is very interesting in that it is very vague and seems to be very flexible as to who can receive this, provided it does not change the budget in any way. The fact that this waiver is budget neutral is what makes the waiver successful. It cannot change or increase the budget in any way, increasing the Federal government’s FMAP. An example of the waiver program was Oklahoma’s Learn Fare program (Harvey, Camasso, and Jagannathan, 2000). This was an initiative that set out to design a method on implementing a stay in school program for pregnant teenage girls. Partnered with the welfare program Oklahoma hopes to show the program as successful, thereby being implemented in other areas.
Medicaid expansion and the Act altogether have many arguments against it, notably most of the Republican Party. Saying that it is unreasonable and a cost that the Federal government cannot afford at this time is the primary reasons given by the Republicans in voting against it. Despite arguments against the Act it has remained and all provisions are expected to be in effect in the next two years.
The Medicaid Expansion Act under the Affordable Care Act is an excellent beginning in health care reform, though the Affordable Care Act has its number of positive and negative factors. Political opposition, especially from the republican sector means that this Act is likely to be delayed a great deal in being fully implemented due to constitutional challenges, both by individual States and Republican representatives and sectors (Gable, 2011). Elements included in the Act that are not Medicaid related such as the requirement of smaller employer’s to share in the cost of health care if they do not provide insurance are being battled against by activist groups and political representatives in each State. Arguments have also been made against the pre-existing condition clause in the affordable care act, pointing out that removing pre-existing clauses from insurance policies will simply cause many people to avoid buying private insurance until they have need of it, and this is an excellent argument as the Act at this time does not include any enforcement or provisions for cases such as this (Gruber, 2011).
States and multiple Representatives do not believe that Federal Government should have such authority when it comes to health care, though the Federal government has been looked to for years to make changes and provide Medicaid and Medicare insurance to individuals. Despite this being the case it seems only reasonable that the Federal government have such authority, which has ultimately been decided in every case thus far against this Act. Medicaid expansion has been the least argued element of the affordable care act, possibly because the federal government is assuming much of the cost of this.
Physicians Willingness to Serve Medicaid Patients
With the huge size of the Medicaid expansion and increased enrollment expectations of up to 25% Physicians are beginning to change the way they view Medicaid patients. Those becoming newly eligible for Medicaid due to the ACA will have very different health care needs in comparison with the traditional Medicaid patient. It is difficult to project how Physicians will react to the growth spurt in primary care. One study concluded that high share primary care Physicians were the most willing to serve new Medicaid patients (Sommers, 2011, p).
Factors that were reported that discouraged Medicaid participation were inadequate compensation, delayed reimbursement and high clinical demands. The study also reported that the most difficult provider to locate for a new Medicaid patient was a specialist. The requirements of prior authorization, prescription restrictions, and the psycho-social needs of the patient are all factors that must be considered when a Physician accepts new Medicaid patients.
Finally, the Medicaid program is a critical component of our country’s health-care system. Improvements to the program can only help it become more effective and assist more individuals. With Medicaid being a preferred choice in all fifty states, we have a strong belief in its capacity to fulfill the requirements of people who are unable to get health insurance for a variety of reasons. With the expanded eligibility requirements and the CHIP programs’ retained eligibility requirements Medicaid will be serving more individual that ever over the next several years and I see this increase continuing with the current economic situation as it is.
- 2010 CHIPRA Annual Report. (2010). Connecting Kids to Coverage: Continuing the Progress. Insure Kids Now. Retrieved May 3, 2012, from http://www.insurekidsnow.gov/professionals/reports/chipra/2010_annual.pdf
- Connell, M. O., & Southern Disability Law Center. (2012). Oklahoma Medicaid. Custom Web Express. Retrieved May 2, 2012, from http://www.customwebexpress.com/redlands/UserFiles/File/Oklahoma%20Medicaid.pdf
- Gable, L. (2011). The Patient Protection and Affordable Care Act, Public Health, and the Elusive Target of Human Rights. Journal Of Law, Medicine & Ethics, 39(3), 340-354. doi:10.1111/j.1748-720X.2011.00604.x
- Gruber, J. (2011). THE IMPACTS OF THE AFFORDABLE CARE ACT: HOW REASONABLE ARE THE PROJECTIONS?. National Tax Journal, 64(3), 893-908.
- Harvey, C., Camasso, M. J., & Jagannathan, R. (2000). Evaluating Welfare Reform Waivers Under Section 1115. Journal Of Economic Perspectives, 14(4), 165-188.
- Havens, L., & McCarty, J. (2011). Medicaid for Adults With Disabilities. ASHA Leader, 16(14), 3-23.
- Holahan, John, and Arunabh Ghosh. “Understanding The Recent Growth In Medicaid Spending, 2000-2003.” Health Affairs 24. (2005): 52-62. Academic Search Premier. Web. 27 Apr. 2012.
- Klemm, J. D. (2000). Medicaid Spending: A Brief History. Health Care Financing Review, 22(1), 105.
- McNeal, G. (2010). The healthcare reform bill and its impact on the nursing profession. The ABNF Journal: Official Journal Of The Association Of Black Nursing Faculty In Higher Education, Inc, 21(2), 38.
- Medicaid. Gov. (2012). Children’s Health Insurance Program (CHIP) | Medicaid.gov. Medicaid.gov. Retrieved May 3, 2012, from http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Childrens-Health-Insurance-Program-CHIP/Childrens-Health-Insurance-Program-CHIP.html
- Parish, S. L., & Ellison-Martin, M. (2007). Health-Care Access of Women Medicaid Recipients. Journal Of Disability Policy Studies, 18(2), 109-116.
- Reno, R. R. (2010). REFORMING THE HEALTH-CARE REFORM. First Things: A Monthly Journal Of Religion & Public Life, (204), 61-63.
- Sommers, A. (2011). Physician Willingness and Resources to Serve More Medicaid Patients: Perspectives from Primary Care Physicians. Medicare & Medicaid Research Review, 1(2), E1. doi:10.5600/mmrr.001.02.a01