The United States adopts a unique healthcare system among the advanced industrialized nations. Instead of operating a universal and uniform healthcare coverage, the United States embraces a hybrid structure. In this regard, Medicare and Medicaid are examples of healthcare programs run by the federal government in collaboration with the states’ administrations to improve the health services and welfare of the American population. According to Moon (2018), President Lyndon B. Johnson approved the bill establishing Medicaid and Medicare programs in 1965. Presently, the Centers for Medicare and Medicaid Services (CMS) manages the two health policies, which influence millions of American lives. CMS’s primary goal is to offer a high-quality and efficient healthcare system that guarantees access to coverage, improved care, and superior health services. Fundamentally, Medicare represents an insurance program that serves mainly individuals aged 65 years and above, while Medicaid is an assistance health plan that helps low-income people of all ages.
Medicare is a federal health program that observes identical requirements and guidelines across the United States. CMS runs the insurance policy and ensures it pays the medical bills of its members. According to Moon (2018), the federal government finances Medicare through various means, including general revenues (43%), beneficiary premiums (15%), and payroll taxes (36%). Patients also meet part of the healthcare costs through deductibles for hospitals and other expenses. The primary population segment covered under the insurance policy is the older adults aged 65 years and above. The eligibility criteria state that seniors must have worked and paid into the healthcare system through payroll tax (Centers for Medicare & Medicaid Services [CMS], n.d.). Additionally, Medicare offers health coverage to individuals with recognized disabilities. The policy also includes persons of all ages characterized by End-Stage Renal Disease (ESRD), especially permanent kidney failure necessitating transplant or dialysis.
Medicare comprises various parts that assist cover specific healthcare services. The first section is Part A (hospital insurance), which caters the inpatient care across multiple healthcare facilities such as skilled nursing medical centers and critical access hospitals (Moon, 2018). It also covers hospice care and some expenses under home healthcare. Most individuals do not pay insurance premiums for Part A because they or their spouses contributed towards it through payroll taxes during their working years. Medical insurance represents Part B, covering outpatient care and physicians’ services, including some health services not included in Part A, such as those provided by occupational and physical therapists. It often pays for covered medical supplies and services when they become necessary. Part C (Medicare Advantage) includes plans provided by private insurance companies. Apart from services under original Medicare (Part A and B), it benefits its members by offering supplemental coverage. Part D represents the prescription drug coverage and requires members to join a plan ratified by Medicare. Generally, most people pay monthly insurance premiums for Parts B, C, and D programs.
On the other hand, Medicaid refers to a government-state-sponsored program that offers healthcare coverage for the low-income individuals. Federal funding is the primary source of Medicaid financing, although local and state governments also contribute to some of the program’s expenditures (CMS, n.d.). The local and state governments run the program based on federal guidelines; notwithstanding, it varies across the states. Although all states offer coverage for low-income families, pregnant women, individuals with disabilities, and the elderly, others expand Medicaid to include all adults below specified income levels. As a result, some Medicaid programs pay for their members’ care directly while others outsource services of private insurance companies to offer coverage (Smith & Moore, 2017). Eligible patients should receive covered medical services without paying anything. However, costs and eligibility also depend on states, and thus, patients sometimes are required to pay a small co-payment.
Medicaid is the primary payer for long-term services in the United States. States offer various mandatory benefits as required by federal law. These services include inpatient, outpatient, laboratory, nurse midwife, rural health clinic, X-ray, and family planning services, among other vital healthcare needs (CMS, n.d.). However, states are also free to provide additional optional benefits such as occupational therapy, dental, prescription drugs, and respiratory care services. Significantly, Medicaid covers various long-term care, mainly custodial services in nursing homes across all states. The assisted people must not have the ability to perform all or some of the day-to-day activities without assistance. For example, Illinois depends on Medicaid to cater to long-term care such as assisted living facilities and nursing homes (Smith & Moore, 2017). Strict rules often govern the eligibility due to the costs involved in providing health services in the long run. Therefore, states only approve beneficiaries who qualify financially and medically for long-term benefits under Medicaid.
Medicaid and Medicare are two essential programs that serve the healthcare needs of millions of Americans. For instance, Medicare pays health services for people aged 65 years and above, individuals with disabilities, and persons with ESRD. The Medicare program comprises four parts, which define a person’s eligibility for various healthcare services. Conversely, Medicaid covers the medical services for mainly low-income people. Significantly, there has been an expansion of Medicaid across states to include pregnant women, individuals with disabilities, and the elderly. In collaboration with the state governments, CMS runs and oversees the implementation of Medicaid and Medicare. The federal government acts as the primary financier of the two programs, although states support funding the Medicaid plans. Therefore, the partnerships and programs help achieve an inclusive, culturally competent, efficient, and people-driven healthcare system, which improve the wellness and welfare of the Americans.
Centers for Medicare & Medicaid Services. (n.d.). Medicare and Medicaid. Cms.gov.
Moon, M. (2018). Medicare now and in the future. Routledge.
Smith, D. G., & Moore, J. D. (2017). Medicaid politics and policy (2nd ed.). Routledge.