Exam 2 Short Answers Flashcards
(28 cards)
What are the basic characteristics/features of the insurance system in the US? Does the ACA change these basic characteristics/features?
Private insurance market: system of private health insurance companies to provide coverage to individuals and families, these companies offer various plans with different levels of coverage and premiums
Employer-sponsored insurance: many Americans receive health insurance through their employers, this is a significant source of coverage for individuals and families
Government programs: US government operates several health insurance programs, including Medicare and Medicaid that offer coverage to specific populations who may not have access to private insurance
Individual mandate
Pre-ACA: no requirement for individuals to have health insurance, however, those who did not have coverage may face penalties when filing taxes
Post-ACA: one of the most significant changes brought by the ACA was the individual mandate, which required most Americans to have coverage or pay a penalty. This was intended to increase the number of people covered and spread risk across a broader population
Other ACA changes: ((expanded coverage, implemented consumer protections, created new avenues for obtaining insurance))
- Creation of health insurance exchanges: markets where individuals and small businesses can shop for and purchase insurance plans, exchanges offer a range of plans often with subsidies to help lower income individuals afford coverage
- ACA prohibits insurance companies from denying coverage to individuals with pre-existing conditions or charging them higher premiums, the goal of this was to ensure that individuals with health issues could still obtain coverage
- Medicaid expansions: ACA allowed states to expand their Medicaid programs to cover more low-income individuals and families, however, not all states chose to expand Medicaid
- Essential health benefits: ACA required all health insurance plans to cover essential health benefits like preventative care, maternity care, prescription drugs
Which premium assessment method does ACA rely on in the marketplaces? Community Rating or Experience Rating? Why?
Community rating
Insurance companies can’t vary premiums based on factors such as an individual’s health status, medical history, or gender. Instead, premiums are based on factors like age, geographic area, family size, tobacco use
This ensures that individuals with pre-existing conditions or higher healthcare needs can’t be charged significantly higher premiums, making insurance more accessible and affordable for a broader range of people
Community rating promotes fairness and accessibility in the insurance market, preventing discrimination to align with the ACA goals of expanding coverage and providing protections for consumers in the healthcare system
(Before the ACA) Which groups had difficulty obtaining health insurance in the US? In other words, as Bodenheimer and Grumbach (B&G) discuss, who were the uninsured before the 2010 ACA reforms? Were these groups able to get insurance coverage after the ACA?
Unemployed individuals: people not covered by employer-sponsored plan often struggled to afford coverage on their own, especially if that had pre-existing conditions or limited financial resources
Low-income individuals and families: couldn’t afford health insurance premiums even if they were available, and also, Medicaid eligibility criteria varied by state which left some low-income individuals without access to coverage
- ACA expansion allowed states to cover move low-income individuals and families and provided affordable coverage to millions of previously uninsured individuals
People with pre-existing conditions: diabetes, cancer, health disease etc. patients often faced difficulty in individual insurance market because insurers could deny coverage or charge prohibitively high premiums based on an individuals health status
- Guaranteed issue: ACA prohibited insurance companies from denying coverage or charging higher premiums based on preexisting conditions
Young adults: people who aged out of their parents insurance plans or entered the workforce without access to employer-sponsored coverage
- ACA allowed young adults to stay on their parents health insurance plans until the age of 26, providing coverage option for those transitioning into adulthood
Minority groups: certain minority groups including racial and ethnic minorities faced disparities in access to coverage and services due to various socio-economic factors and systemic inequalities
ACA aimed to reduce number of uninsured individuals by addressing the barriers to coverage faced by vulnerable populations
What are the differences and similarities between HMOs and PPOs?
Both types of managed care plans, meaning various mechanisms are used to manage and control healthcare costs, utilization, and quality
- HMOs offer lower costs and more comprehensive coverage for in network care but have stricter restrictions on provider choice and out of network coverage. PPOs have higher costs and require more out of pocket expenses for out of network care, but offer more flexibility in provider choice
Both cover essential healthcare services like doctors offices, preventative care, hospital stays, and prescription drugs
Provider networks
- HMOs have more restricted network of healthcare providers, usually need to have a PCP within the network and all medicare care goes through them, referrals to see providers required
- PPOs have larger network of healthcare providers, no PCP necessary, can see any doctor inside or outside of network, but will pay less if staying in network
Costs
- HMOs have lower premiums and lower out of pocket costs, but have to pay a lot if you go out of network
- PPOs have higher premiums and out of pocket costs, but more flexibility in choosing healthcare providers, including out of network options
Referrals and prior authorization
- HMOs require referrals from PCP to see specialists, prior authorization needed for certain procedures or treatments
- PPOs don’t need referrals to see specialists, and prior authorization requirements are less strict
Coverage for out of network care
- HMOs don’t cover out of network care unless in emergency, will have to pay full cost yourself
- PPOs provide coverage for out of network care, but you’ll pay more in coinsurance or deductibles compared to in network care
Flexibility
- HMOs less flexible in terms of choosing healthcare providers and require you to coordinate care through PCP
- PPOs more flexible in choosing providers and accessing care without referrals
Which groups oppose managed care plans and why? What happened as a result of this backlash/opposition? What happened to managed care?
Patients: dissatisfaction due to restrictions on choice of healthcare providers, perceived delays in accessing care, and concerns about the quality of care received within network constraints
Healthcare providers: criticize reimbursement practices, which often involve negotiating discounted rates for services and implementing utilization management techniques that can interfere with clinical decisions
Legislative and regulatory changes: aimed at addressing managed care issued including mandates for coverage of certain services, requirements for external appeals processes, and greater oversight of plan operations
Consumer protections: enhanced disclosure of plan terms and coverage limitations, as well as mechanisms for addressing grievances and appealing coverage denials
What kinds of insurance marketplaces/exchanges are there and why? Who can go to these marketplaces and buy insurance? What kinds of plans are offered in the insurance marketplaces/exchanges? Do they cover all medically necessary services at 100% actuarial value? How do the premiums get calculated? Who gets the subsidies?
What kinds of marketplaces/exchanges?
- State based exchanges: operated by individual states and offer health insurance plans to state residents, states have flexibility to tailor their exchanges to their specific healthcare needs and demographics
- Federal marketplace (healthcare.gov): for states who choose not to establish their own exchanges, the federal government operates the marketplace through healthcare.gov, residents of these states can still access and purchase health insurance plans through the federal exchange
- State-federal partnership exchanges: some states choose to partner with the federal government to operate their exchanges, these partnerships allow states to retain some control over aspects of the exchange while leveraging the federal platform for enrollment and administration
Who can go?
- Only people who do not have access to employer-sponsored health insurance and who do not qualify for public programs like medicare and medicaid
- Small businesses can use the marketplace to offer health insurance options to their employees
What kinds of plans?
- The plans have to adhere to certain standards set by the ACA, which include coverage of essential health benefits like hospitalization, prescription drugs, preventative care, and maternity care
- Bronze, silver, gold, platinum
Do they cover all services at full value?
No, they don’t have to. Plans are categorized into the metal tiers based on their actuarial value
How do premiums get calculated?
- Various factors, including the level of coverage (the metal tier), age, location, and tobacco use of enrollee. - Generally, older individuals and those living in higher-cost regions will pay higher premiums
Who gets subsidies?
- Lower income individuals and families
- Premium tax credits: income between 100 and 400% of FPL to lower cost of monthly premium payments
- Cost-sharing reductions: incomes between 100-250% of FPL to reduce out of pocket expenses like deductibles, copayments, and coinsurance
What is the insurance rationale for creating an “individual mandate” and “guaranteed issue” as part of the ACA?
Bans many crueler practices that private health insurance companies used over the years
Individual mandate required most Americans to have health insurance coverage or pay a penalty, rationale was to encourage healthier individuals to participate in the insurance market.
- Without the mandate, there was a risk that only sicker individuals would purchase insurance, leading to adverse selection and higher premiums
- By requiring everyone, including healthy individuals, to have coverage, the individual mandate aimed to spread the risk pool more broadly. Helps to stabilize premiums by ensuring that the costs of caring for those with high healthcare needs are shared among a larger group of people
Guaranteed issue: before ACA, insurance companies could deny coverage to individuals with pre-existing conditions or charge them higher premiums. This practice left many people with chronic illnesses or medical histories unable to obtain affordable coverage
- Guaranteed issue prohibits denying coverage or charging higher premiums, which increased insurance access, promotes principle of healthcare equity and helps to ensure people with preexisting conditions have access to the care that they need
According to Reading 8, by Schwab, R., Swindle, R. and Giovannelli, titled “State-Based Marketplace Outreach Strategies for Boosting Health Plan Enrollment of the Uninsured”, what kinds of outreach strategies were used in the state-based marketplaces (SBMs) to promote health insurance take-up among the uninsured? Which ones were more effective?
Targeted advertising/enrollment campaigns: employed advertising campaigns across various media channels to raise awareness about the availability of health insurance coverage through the marketplace and to educate the uninsured about their coverage options and enrollment process
Community outreach and events: enrollment fairs and info sessions to engage directly with uninsured people, provided opportunities for in person assistance with enrollment, as well as education and outreach about the benefits of health insurance coverage
Navigator and assistance programs: provide personalized assistance to people seeking coverage, these programs trained and deployed navigators and assisters to help uninsured individuals understand their coverage options, complete the enrollment process, and navigate any challenges they encounter
Successful:
Strategies that involved direct, personalized assistance and community-based outreach events were often cited as more effective in reaching and enrolling uninsured individuals
What does a “successful” or “resilient” insurance marketplace look like? According to Reading 7 by McDonough, Massachusetts has been successful in covering more of its residents than any other state. How did Massachusetts manage to do this? What kinds of lessons can be learned from Massachusetts?
High enrollment: high percentage of its population enrolled in health insurance coverage, indicates that the marketplace is effectively reaching and engaging with its target population
Accessible coverage: ensures coverage options are accessible to all residents, including those with pre-existing conditions or lower incomes. This involves implementing policies such as guaranteed issue and premium subsidies
Financial stability: financially stable with balanced risk pool and sustainable premiums, requires a mix of healthy and less healthy enrollees to spread the cost of healthcare across the population and prevent adverse selection
Quality coverage: meets healthcare needs of its enrollees, includes access to a broad network of healthcare providers, comprehensive benefits, and effective care coordination
Massachusetts:
- Individual mandate
- Subsidies to help low income families, expanded medicaid (masshealth) to cover even more low income residents
- Massachusetts health connector: an exchange where individuals and small businesses can compare and purchase health insurance plans, connector facilitated enrollment in coverage and provided a centralized platform for accessing subsidies and other assistance
- Collaboration and bipartisanship: policymakers, providers, insurers, consumer advocates worked together to develop and implement comprehensive reforms that garnered broad support
Lessons learned from MA
- Implementing an individual mandate can encourage broad participation in the insurance market and help stabilize premiums
- Providing subsidies and expanding Medicaid eligibility can make coverage more affordable and accessible to low income individuals and families
- Establishing a state based exchange or marketplace can streamline enrollment and facilitate access to coverage options and financial assistance
- Collaboration and bipartisanship are crucial for enacting and sustaining meaningful healthcare reforms
Which factors explain the record high marketplace enrollment in 2023? Do Biden administration policies help or hurt enrollment?
- Expanded subsidies: Biden admin implemented changes to ACA premium tax credits, making them more generous and available to a wider range of people, this could have made coverage affordable for many more people, leading to increased enrollment
- Enhanced outreach and enrollment efforts: raising awareness about coverage options and encourage enrollment
- Economic factors: changes in the economy, such as job losses or changes in employment status due to covid may have led more people to seek coverage through the marketplace
- Stabilization of the insurance market: stable premiums and insider participation increasing consumer confidence
- Policy continuity: Biden admin’s commitment to preserving and strengthening the ACA may have provided sense of stability and confidence
Biden
Helped: expanding premium credits and outreach make it more affordable and accessible, and the support for ACA increases confidence
What happened in the three separate Supreme Court cases [The National Federation of Independent Business v. Sebelius (2012) and King v. Burwell (2015) and Texas v. United States? How was the ACA implementation impacted as a result?
The National Federation of Independent Business v. Sebelius
- Supreme Court upheld majority of the ACA, including the individual mandate
- The court ruled that the federal government couldn’t penalize states that chose not to expand medicaid, leading to a situation where medicaid expansion became optional for states
King v. Burwell
- Supreme court upheld ACA provision of subsidies provided to individuals purchasing health insurance through the federal exchange
- Case centered on whether the language of the ACA limited subsidies to state-run exchanges
Court’s decision ensured that individuals in states that didn’t set up their own exchanges could still access subsidies
Texas v. United States
- Several states challenged the constitutionality of the ACA after Congress reduced the penalty for not having health insurance to zero dollars
- Argument was that without a financial penalty, the individual mandate could no longer be considered a tax and thus was unconstitutional;
- Additionally, plaintiffs argued that since the individual mandate was inseparable from the rest of the ACA, the entire law should be invalidated
The Supreme Court ruled in a 2021 that plaintiffs did not have standing to challenge the individual mandate as it stood, but left the door open for states to challenge other provisions of the ACA, ruling does not directly impact ACA’s implementation, but it kept the law intact for the time being, but it still faces challenges
Texas v. United States
Texas v. United States
- Several states challenged the constitutionality of the ACA after Congress reduced the penalty for not having health insurance to zero dollars
- Argument was that without a financial penalty, the individual mandate could no longer be considered a tax and thus was unconstitutional;
- Additionally, plaintiffs argued that since the individual mandate was inseparable from the rest of the ACA, the entire law should be invalidated
The National Federation of Independent Business v. Sebelius
The National Federation of Independent Business v. Sebelius
- Supreme Court upheld majority of the ACA, including the individual mandate
- The court ruled that the federal government couldn’t penalize states that chose not to expand medicaid, leading to a situation where medicaid expansion became optional for states
King v. Burwell
King v. Burwell
- Supreme court upheld ACA provision of subsidies provided to individuals purchasing health insurance through the federal exchange
- Case centered on whether the language of the ACA limited subsidies to state-run exchanges
Court’s decision ensured that individuals in states that didn’t set up their own exchanges could still access subsidies
Who can enroll in Medicare and how? What is covered under Part A, Part B, Part C and Part D and Medigap?
Eligibility
- Individuals 65 and older qualify if they or their spouse have worked and paid medicare taxes for at least 10 years
- People under 65 who have certain disabilities or end-stage renal disease or ALS
Enrollment
- Initial enrollment period: starts 3 months before 65th bday month, ends 3 months after
- General enrollment period: runs from Jan 1 to March 31 each year, coverage beginning in July
- Special enrollment periods: certain situations like losing employer coverage or moving to a new area
Part A hospital insurance
Part B medical insurance
Part C Medicare advantage
Part D prescription drugs
According to Reading 11 by Health Affairs, why is enrolling in a Medicare plan difficult and what could help?
Complexity of options
- Medicare offers various plans with different coverage options, premiums, deductibles, and copayments. Navigating through these options can be overwhelming, especially for individuals who are not familiar with health insurance terminology
Information overload
- Medicare enrollment involves understanding numerous details about each plan, including coverage networks, prescription drug formularies, provider networks, and cost-sharing arrangements. The abundance of info can confuse and frustrate people trying to make informed decisions about their healthcare coverage
Limited resources for assistance
- While resources like the medicare website, informational materials, and customer service lines exist, they may not adequately address individuals’ specific questions or provide personalized guidance. Additionally, some individuals may lack access to reliable internet or may face language barriers, further complicating the enrollment process
Timing constraints
- Medicare enrollment is time sensitive, with specific deadlines and enrollment periods, missing deadlines can result in penalties or delays in coverage, adding pressure to individuals already struggling to understand their options
What could help?
- Simplified information
Providing clear, concise, easily understandable information about medicare plans and enrollment options can help individuals make informed decisions
- Personalized assistance
Offering personalized assistance through trained counselors or navigators who can guide individuals through the enrollment process, answer questions, and provide tailored recommendations based on their healthcare needs
- Improved access to resources
Ensuring access to resources such as multilingual informational materials, in-person assistance centers, and user-friendly online tools can help individuals overcome barriers to enrollment
- Extended enrollment periods
Extending enrollment periods or implementing special enrollment periods for certain circumstances can provide individuals with more time and flexibility to explore their options and make decisions
Are older Americans who benefit from Medicare happy? Do they receive free health care services? Why do they need Medigap or Supplemental policies?
Overall satisfaction levels with medicare tend to be relatively high, but individual experiences and perspectives differ and many people have concerns or frustrations with certain aspects of the program
Medicare is not entirely free
- While part A (hospital insurance) is often premium free for those who have paid medicare taxes during their working years, part B (medical insurance) and part D (prescription drug coverage) typically require monthly premiums
- Beneficiaries may face deductibles, copayments, and coinsurance for various services depending on the specific medicare plan they have
Why might someone have medigap or supplemental policies?
Coverage gaps
- Part A and Part B don’t cover all healthcare expenses, leaving beneficiaries responsible for out of pocket costs such as deductibles, coinsurance, and copayments. Can fill these coverage gaps by paying for some or all of these expenses
Predictable costs
- Medigap policies can provide greater predictability in healthcare costs by offering standardized coverage options that help control out of pocket expenses
Choice of providers
- Original medicare doesn’t typically restrict beneficiaries to specific healthcare providers or networks, allowing them to see any doctor or specialist who accepts medicare. Medigap plans offer similar flexibility, allowing beneficiaries to maintain their choice of providers without worrying about network restrictions
Peace of mind
- Having additional coverage through a medigap or supplemental policy can provide beneficiaries with peace of mind, knowing they have extra protection against unexpected medical expenses
What kinds of changes are introduced to Part D with the ACA? According to Blumental and colleagues (The U.S. Can Lower Drug Prices Without Sacrificing Innovation) could we encourage innovation while reducing the expenditure on drugs? How do we do this?
Closing the donut hole
- ACA aims to gradually close the coverage gap in medicare part D that is called the donut hole. The coverage gap occurs when beneficiaries reach a certain spending threshold, at which point they are responsible for a higher percentage of their drug costs until catastrophic coverage kicks in. ACA implemented provisions to reduce out of pocket costs during this coverage gap, and ultimately closed it completely by 2020
Discounts on brand name drugs
- ACA required pharmaceutical manufacturers to provide discounts on brand name drugs purchased by beneficiaries who reached the coverage gap, these discounts gradually increased over time
Improving access to generic drugs
- ACA incentivised the use of generic drugs by providing additional subsidies to part D plans that offered them at lower cost sharing to beneficiaries
Yes, they say that we can both encourage innovation while reducing expenditure on drugs
Value based pricing
- Pricing models that tie the cost of drugs to their demonstrated value in terms of health outcomes can incentivize innovation in areas where it is most needed while ensuring that the prices reflect the value provided
Promoting competition
- Encouraging competition among drug manufacturers, including through measures such as speeding up the approval process for generic drugs and biosimilars, can help lower drug prices while still fostering innovation
Negotiating prices
- Allowing medicare to negotiate drug prices directly with pharmaceutical companies, as it is done in other countries, could result in lower prices for beneficiaries without necessarily stifling innovation
Rewarding innovation
- Implementing policies that reward innovation in areas of unmet medical need or for breakthrough therapies that significantly improve patient outcomes can encourage pharmaceutical companies to focus their research efforts where they are most needed
What is Medicaid? Who administers/runs the Medicaid program? How is it funded?
- A joint federal and state program in the United States that provides health coverage to low-income individuals and families, including pregnant women, children, elderly adults, and people with disabilities
- The largest source of health coverage for low income Americans
- Program is administered by both the federal government and individual state governments. Federal government sets guidelines and regulations for the program, but each state has flexibility in determining eligibility criteria, covered services, and how the program is managed within its borders which leads to some variation in Medicaid programs from state to state
- Funding comes from both the federal government and the individual states, the federal government matches a percentage of each state’s medicaid expenditures, with the federal share ranging from 50-83% depending on the states per capita income, states contribute the remaining portion of the funding. The federal government guarantees that states receive at least a certain percentage of their medicaid expenses reimbursed, regardless of fluctuations in economic conditions or medicaid enrollment
What (which services) does Medicaid cover? What are the mandatory benefits that must be covered in all states?
- Wide range of services for eligible individuals, the specific services may vary somewhat by state
- State benefits may include prescription drugs, dental care, vision care, mental health care
Mandatory benefits
- Inpatient and outpatient hospital services: necessary hospital stays including surgeries, treatments, and other services provided in a hospital setting
- Physician services: visits to doctors, including primary care physicians, specialists, and other healthcare providers
- Lab and X-ray: diagnostic tests and procedures like blood tests, imaging scans, other lab services
- Early and periodic screening, diagnostic, and treatment services for individuals under 21
- Nursing facility services: long-term care in nursing homes and other skilled nursing facilities
- Home health services
Family planning services and supplies
- Transportation to medical services
Who constitutes the largest group of beneficiaries in the Medicaid program? Which group accounts for the highest percentage of expenditure/cost? Is this why Medicaid is associated with negative stigmas?
Largest group in medicare: children
- Millions of low income children and adolescents receive coverage through the program
Highest percentage of expenditure/cost: the elderly and the disabled
- More complex healthcare needs and may require long term care services like nursing homes or home health care, which can be costly
Stigma
- It’s perceived that medicare primarily serves able-bodied adults who are incorrectly seen as not working or not contributing to society, this misconception ignores the significant number of children, elderly people, and people with disabilities who rely on medicaid for essential healthcare services
- Stigmas associated with poverty, negative stereotypes and biases against welfare programs
- Concerns about the cost of medicaid and its impact on government budgets, critics may argue that medicaid is expensive and unsustainable, particularly if they believe that a large portion of the budget is spent on able-bodied adults rather than on vulnerable populations with genuine need
What were the problems with Medicaid before the ACA? What kinds of changes has the ACA introduced in Medicaid?
- To receive medicaid before the ACA, you had to be poor AND old, blind, disabled, pregnant, or the parent of a disabled child
- States had different and low eligibility thresholds, most states did not cover adults without children
- Many states had restrictive income thresholds that left millions of low-income adults without access to medicaid coverage
- Coverage gaps: people who didn’t fall into traditional eligibility categories left without affordable health insurance coverage
- Uneven coverage for preventative services
Screenings, immunizations, wellness visits, etc. varied among states, which left many individuals without access to essential preventative care services
What did ACA do?
- Expands Medicaid eligibility to include individuals younger than 65 and families with incomes up to 133% of FPL, simplifies CHIP enrollment process
- Established new methodology for determining income eligibility for Medicaid, new method determines eligibility for Medicaid, CHIP, and premium tax credits and cost sharing reductions available through the health insurance marketplace
- Made it easier for people to apply and enroll in the appropriate program
Streamlined eligibility
- Enhanced benefits, essential health benefits: preventative services, prescription drugs, maternity care, mental health care
Why did some states decide not to participate in Medicaid expansion? What are the concerns/problems in those states in the aftermath of the ACA? Why are more states expanding Medicaid more recently?
Supreme court effectively allowed states to opt out of the Medicaid expansion
Political opposition
- In some states political opposition to the ACA and Medicaid expansion led policymakers to reject expansion. Opposition was often rooted in ideological or partisan differences regarding the role of government in health care and concerns about the long term costs of expansion
Budgetary concerns
- Some states are concerned about long term financial implications of medicaid expansions, particularly regarding the potential costs to state budgets. While federal government initially covered 100% of the costs of expansion, states were required to gradually assume a portion of the costs over time
State sovereignty
- States value their autonomy and control over healthcare policy and may have been hesitant to expand medicaid due to concerns about federal intrusion into state affairs
Philosophical opposition to welfare programs
- In states with strong emphasis on personal responsibility and limited government intervention, there was resistance to expanding a government funded healthcare program like medicaid, even if it meant leaving many low-income individuals without access to health coverage
What concerns did they face?
Coverage gap
- Low income adults eating too much to qualify for traditional medicaid but didn’t qualify for subsidies to purchase private health insurance through the ACA’s health insurance marketplace
Health disparities
- Disparities in access to health care persistent in non-expansion states, as low income individuals lacked access to affordable health coverage and preventative care services, leading to poorer health outcomes compared to expansion states
Financial consequences
- Non-expansion states missed out on federal funding available for medicaid expansion, which could have injected billions of dollars into their economies and supported jobs in the healthcare sector
Why are states expanding now?
Public pressure
- Advocacy efforts by healthcare providers, community organizations, and constituents have increased public awareness and support for medicaid expansion in many states, public pressure has influenced policy makers to reconsider their opposition to expansion
Evidence of benefits
- Positive impact of medicaid expansion of health outcomes, access to care, and financial stability for long income individuals and families
Financial incentives
- American Rescue Plan Act of 2021 provided additional financial incentives for states to expand medicaid by offering temporary increases in federal funding for expansion
Covid
- Covid pandemic highlighted the importance of access to health coverage and exacerbated existing health disparities, the pandemic underscored the need for medicaid expansion to ensure that low income individuals have access to necessary health care services during public health emergencies
Overall, political, ideological, and financial considerations have historically influences states decisions on medicaid expansion, increasing public support, evidence of benefits, financial incentives, and the impact of the Covid pandemic have contributed to a growing number of states choosing to expand medicaid in recent years
According to your readings, what is the reason for introducing work requirements in Medicaid? What are the advantages and disadvantages of work requirements?
Promoting personal responsibility
- Proponents argue that work requirements encourage able-bodied individuals to take responsibility for their own well-being and reduce dependence on government assistance programs
Workforce participation
- Some policymakers believe that work requirements can incentivize medicare beneficiaries to enter or re-enter the workforce, thereby increasing the workforce participation rates and reducing unemployment
Cost savings
- Supporters of work requirements content that encouraging individuals to work can lead to cost savings for the government by reducing the number of people enrolled in medicaid and other public assistance programs
Advantages
- Promotes self-sufficiency and economic independence
- Improved health outcomes: employment is associated with improved health outcomes including better mental health, reduced risk of chronic diseases, and increased access to employer sponsored health insurance coverage
- Reduces government spending
Disadvantages
Barriers to access
- Work requirements can create barriers to accessing healthcare for low income individuals who may face challenges in meeting work requirements due to factors such as disabilities, caregiving responsibilities, lack of transportation, or limited job opportunities
Health impact
- For individuals who lose medicaid due to noncompliance with work requirements, there may be adverse health consequences, including delayed or forgone medical care, exacerbation of health conditions, and increased risk of mortality
Administrative burden
- Implementing and enforcing work requirements can impose administrative burdens on states and healthcare providers, including costs associated with verifying compliance, tracking exemptions, and managing appeals and processes
Legal challenges
- Legal challenges on grounds such as violation of medicaids purpose of providing medical assistance to low-income individuals, arbitrary exemptions, and disproportionate impact on vulnerable populations
Overall: work requirements aim to promote employment and self-sufficiency among beneficiaries, they also pose challenges and potential risks, particularly for vulnerable populations who may face barriers to meeting work requirements and accessing health care. Balancing these considerations is crucial in evaluating the effectiveness and appropriateness of implementing work requirements
