MEDICARE
MAIN ARTICLE:
MEDICARE (UNITED STATES)
In
the United States, Medicare is a federal social insurance program that provides
health insurance to people over the age of 65, individuals who become totally
and permanently disabled, end stage renal disease (ESRD) patients, and people
with ALS. Recent research has found that the health trends of previously
uninsured adults, especially those with chronic health problems, improves once
they enter the Medicare program.
Traditional Medicare requires considerable cost-sharing, but ninety percent of Medicare enrollees have some kind of supplemental insurance - either employer-sponsored or retiree coverage, Medicaid, or a private Medigap plan – that covers some or all of their cost-sharing. With supplemental insurance, Medicare ensures that its enrollees have predictable, affordable health care costs regardless of unforeseen illness or injury.
Traditional Medicare requires considerable cost-sharing, but ninety percent of Medicare enrollees have some kind of supplemental insurance - either employer-sponsored or retiree coverage, Medicaid, or a private Medigap plan – that covers some or all of their cost-sharing. With supplemental insurance, Medicare ensures that its enrollees have predictable, affordable health care costs regardless of unforeseen illness or injury.
As
the population covered by Medicare grows, its costs are projected to rise from
slightly over 3 percent of GDP to over 6 percent, contributing substantially to
the federal budget deficit. In 2011, Medicare was the primary payer for an
estimated 15.3 million inpatient stays, representing 47.2 percent ($182.7
billion) of total aggregate inpatient hospital costs in the United States.
The Affordable Care Act took some steps to reduce Medicare spending, and
various other proposals are circulating to reduce it further.
MEDICARE
ADVANTAGE
MAIN ARTICLE:
MEDICARE ADVANTAGE
Medicare
Advantage plans expand the health insurance options for people with Medicare.
Medicare Advantage was created under the Balanced Budget Act of 1997, with the
intent to better control the rapid growth in Medicare spending, as well as to
provide Medicare beneficiaries more choices. But on average, Medicare Advantage
plans cost 12% more than traditional Medicare. The ACA took steps to align
payments to Medicare Advantage plans with the cost of traditional Medicare.
There
is some evidence that Medicare Advantage plans select patients with low risk of
incurring major medical expenses to maximize profits at the expense of
traditional Medicare.
Medicare
Part D
Main
article: Medicare Part D
Medicare
Part D provides a private insurance option to allow Medicare beneficiaries to
purchase subsidized coverage for the costs of prescription drugs. It was
enacted as part of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA) and went into effect on January 1, 2006.[38]
MEDICAID
MAIN ARTICLE:
MEDICAID
Medicaid
was instituted for the very poor in 1965. Since enrollees must pass a means
test, Medicaid is a social welfare or social protection program rather than a
social insurance program. Despite its establishment, the percentage of US
residents who lack any form of health insurance has increased since 1994.[39]
It has been reported that the number of physicians accepting Medicaid has
decreased in recent years due to lower reimbursement rates.[40]
The
Affordable Care Act dramatically expanded Medicaid. The program will now cover
everyone with incomes under 133% of the federal poverty level who does not
qualify for Medicare, provided this expansion of coverage has been accepted by
the state where the person resides. Meanwhile, Medicaid benefits must be the
same as the essential benefit in the newly created state exchanges. The federal
government will fully fund the expansion of Medicaid initially, with some of
the financial responsibility gradually devolving back to the states by 2020.
In
2011, there were 7.6 million hospital stays billed to Medicaid, representing
15.6% (approximately $60.2 billion) of total aggregate inpatient hospital costs
in the United States.[13]
State
Children's Health Insurance Program (SCHIP)
Main
article: State Children's Health Insurance Program
The
State Children’s Health Insurance Program (SCHIP) is a joint state/federal
program to provide health insurance to children in families who earn too much
money to qualify for Medicaid, yet cannot afford to buy private insurance. The
statutory authority for SCHIP is under title XXI of the Social Security Act.
SCHIP programs are run by the individual states according to requirements set
by the federal Centers for Medicare and Medicaid Services, and may be
structured as independent programs separate from Medicaid (separate child
health programs), as expansions of their Medicaid programs (SCHIP Medicaid
expansion programs), or combine these approaches (SCHIP combination programs).
States receive enhanced federal funds for their SCHIP programs at a rate above the
regular Medicaid match.
Military
health benefits
Main
article: Military Health System
Health
benefits are provided to active duty service members, retired service members
and their dependents by the Department of Defense Military Health System (MHS).
The MHS consists of a direct care network of Military Treatment Facilities and
a purchased care network known as TRICARE. Additionally, veterans may also be
eligible for benefits through the Veterans Health Administration.
Indian
health service
The
Indian Health Service (IHS) provides medical assistance to eligible American
Indians at IHS facilities, and helps pay the cost of some services provided by
non-IHS health care providers.[31]
State
risk pools
In
1976, some states began providing guaranteed-issuance risk pools, which enable
individuals who are medically uninsurable through private health insurance to
purchase a state-sponsored health insurance plan, usually at higher cost.
Minnesota was the first to offer such a plan; 34 states (Alabama, Alaska, Arkansas,
California, Colorado, Connecticut, Florida, Illinois, Indiana, Iowa, Kansas,
Kentucky, Louisiana, Maryland, Minnesota, Mississippi, Missouri, Montana,
Nebraska, New Hampshire, New Mexico, North Carolina, North Dakota, Oklahoma,
Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, West
Virginia, Wisconsin, Wyoming) now offer them. Plans vary greatly from state to
state, both in their costs and benefits to consumers and in their methods of
funding and operations. They serve a very small portion of the uninsurable
market—about 182,000 people in the U.S. as of 2004,[41] and about 200,000 in
2008.[42]
These
risk pools allow people with pre-existing conditions such as cancer, diabetes,
heart disease or other chronic illnesses to be able to switch jobs or seek
self-employment without fear of being without health care benefits.[43]
However, the plans are expensive, with premiums that can be double the average
policy, and the pools currently cover only 1 in 25 of the so-called "uninsurable"
population.[12] Additionally, even plans which are not expensive can leave
those enrolled with little real health insurance beyond
"catastrophic" insurance; for example, one insurance plan through
Minnesota's high-risk pool, while costing only $215 per quarter, includes a
$10,000 deductible with no preventative or other health care covered unless and
until the enrollee has spent $10,000 of their own money during the year on
health care.[44] Very sick people can accumulate large medical bills during mandatory
waiting periods before their medical expenses are covered, and there are often
lifetime expenditure caps (maximums), after which the risk pool no longer pays
for any medical expenses.[45]
Efforts
to pass a national pool have been unsuccessful, but some federal tax money has
been awarded to states to innovate and improve their plans. With the Patient
Protection and Affordable Care Act, effective by 2014, it will be easier for
people with pre-existing conditions to afford regular insurance, since all insurers
will be fully prohibited from discriminating against or charging higher rates
for any individuals based on pre-existing medical conditions.[46][47]
Pre-existing
Condition Insurance Plan
Main
article: Pre-existing Condition Insurance Plan
The
Pre-existing Condition Insurance Plan, or PCIP, is a transitional program
created in the Patient Protection and Affordable Care Act (PPACA). Those
eligible for PCIP are citizens of the United States or those legally residing
in the U.S., who have been uninsured for the last 6 months and "have a
pre-existing condition or have been denied health coverage because of their
health condition." However, if one has health insurance or is enrolled in
a state high risk pool, they are not eligible for PCIP, even if that coverage
does not cover their medical condition. PCIP is run by the individual states or
through the U.S. Department of Health and Human Services, which has a contract
with the Government Employees Health Association, or GEHA, to administer
benefits. Both will be funded by the federal government and provide three plan
options. These options are the standard, extended, and the Health Savings
Account option. PCIP only covers the individual enrollee and does not include
family members or dependents. In 2014, the Affordable Care Act provision
banning discrimination based on pre-existing conditions will be implemented and
PCIP enrollees will be transitioned into new state-based health care
exchanges.[48][49][50]