A brief overview of Medicare and Medicaid is outlined together with the purpose for setting these programs up. The effect as a result of instating the above programs on those people who depended on the Supplementary Security Income (SSI) is covered.
An outline of the population covered by the Medicaid and Medicare programs. An outline of the government and medical response to the challenge facing the Medicaid and Medicare is highlighted. An examination of a number of issues and how they are related to Medicaid and Medicare is carried. Lastly an highlight of the lessons learnt is highlighted.
Historical Background
It was in 1965 that the congress passed the Medicare and the Medicaid by amending the social security act of 1935. Medicare targeted the payment of medical bills for the elderly and those people with disabilities, whereas Medicaid was established to pay the medical bills for the poor (David, 1976).
Medicaid is considered a fundamental source of funding especially in the case of behavioral health services; it is considered the largest payer for medical bills in the USA and the second in the substance abuse treatment. The expectation that the Medicaid bill be the largest and sole source of health funding makes the spending on it massive.
The states which have implemented the Medicaid program are thirty five but twenty two of them have included the general Medicaid population. People who suffered from disabilities arising from alcoholism or drug abuse were rendered ineligible to receiving Supplementary Security Income (SSI) in the near 1997; they received these benefits under the medical program called the Social Security Disability Insurance and Aid to Families with Dependent Children.
This policy change affected almost half of those who were considered eligible as per disability criterion. This policy adversely affected the health insurance of drug abuse and alcoholism since their medical aid eligibility was linked to their disability nature.
The loss of health care by those detached from the program was anticipated to have dire consequences on their health especially those who required psychiatric attention. This was because mental disability cases were much prevalent to those who suffered from the problem of substance abuse and hence there is a debate that these individuals should be admitted back due their disability status.
This however has proved difficult to them to undertake the reapplication process and to enroll back to the health program. The number of the population of those hospitalized, almost a quarter suffer from drug and substance abuse. The state of Oregon introduced a program they named Methadone which they considered as a cheap way of treating opiate addiction
Population Affected
The populations that are covered under the Medicaid are; pregnant women, children and teenagers, people who are physically disabled i.e. the aged, the blind and those that earn under the poverty rate. The emergence of alcohol and drug abuse as a problem and the intensification of people with mental health problems, have exposed the society to the likelihood of involvement of the population in substance abuse.
The inclusions of people with substance abuse problems have been administered through a separate program; this has however posed a serious challenge comprising of the health of those individuals with dual problems (Lambert, Gale, Bird & Hartley, 2001).
The population covered under the Supplementary Security Income (SSI) according to the state of Illinois was 11, 740, after six months and following the termination of the program, about 47% who were initially covered lost their cover under the new programs. Majority the beneficiaries of Medicare and Medicaid program are women.
These programs often target the minorities in the society. Also it is established that psychiatric problems are more likely to affect and also common to those who are under the Medicaid program. There is a high prevalence of drug abuse among those individuals who are uninsured.
Government Response
It is established in the research that that there is limited access to Alcohol, Drug and Mental (ADM) care and also lower rate of treatment for the demands of the uninsured as compared to those on Medicaid or privately insured individuals.
From the above information it is evident that there is need for the expansion of insurance coverage by the government, especially to those who are affected by alcohol, drug and mental problems. The recent developments by the federal government to expand insurance service to the children have been slow since it has been entrusted to states to undertake the implementation.
For this program to be successful, the issue of supply must be addressed so that public education awareness policy can be implemented which historically has been considered insufficient. Following the detection of fraudulence in the program, the federal government allocated $2million to the Substance Abuse and Mental Health Administration for a program dubbed National All Schedules Prescription Electronic Reporting for the development of drug monitoring.
Since Medicaid scheme varies from one state to another, the federal government has delegated the power of rolling out the programs to different states. In the state of Wisconsin where a high prevalence of alcohol drinking is reported and also where alcohol and drug abuse is the fourth killer and a leading cause of disability in men.
A massive Medicaid program has been rolled which include: Screening, Brief intervention, and Referral to Treatment (SBIRT) which has been identified as cheap to administer and was to be implemented by the Wisconsin Initiative to Promote Healthy Lifestyle (WIPHL).
In the state of Oregon, the state legislature initiated the massive plan to expand the Medicaid plan at the same time trying to reduce the spiraling costs. The bill which was dubbed the Oregon Health Plan, the bill included some provisions such as expanding the eligibility plan which indeed doubled by the inclusion of the chemical dependency program that incorporated substance abuse. The financing of the program was to be realized by among others raising the tax on the cigarettes.
Medical Response
Several doctors have suggested that the problem of alcohol and drug abuse can better be addressed through the referral system since this will enhance enrollment into the scheme. This program could be implemented through the selection of promotional advocates who could make a call to the treatment facilities and arrange for the transportation of the patients.
This was formulated to replace the already existent detoxification which was previously used. Following the identification of alcohol and drug abuse as a major health problem, the substance abuse improvement initiative was formulated. This allowed the people who were under the Medicaid program to choose their own medical provider if they were uncomfortable or out of contract with the managed care organization.
There were two main protocols used: the comprehensive substance abuse assessment which is undertaken through self-referral initiative which was launched recently, and the ambulatory detox; this is understood to mean the provision of detox services to the communities or outpatients health services (Lambert et al., 2001).
The change from fee for service to managed care has heavily revolutionized the Medicaid program. This is because it is considered better managed. This change led to increase in the treatment by the substance abuse patients. This shift to managed care was not without criticism, it was seen as creating a possibility of offering services to only severely impaired clients and also may lead to the decrease in services and the duration of treatment.
The interest in the outcomes of substance abuse treatment and the managed care services clearly cropped upon the implementation. A study in Colorado established that alcohol problems diminished slowly following the change from the free for service to the managed care service. This is as opposed to the Maryland study which showed no difference between the free for service to the managed care.
Environmental Issues
The abuse of drug abuse and alcohol has been one of the recent menaces that have cost The United States of America a lot of money in its efforts to address it. Alcohol and drug abuse has been linked to the numerous cases of unintended injuries, increased rate of violence and the rise in crime. This has led to the combined efforts of the government and private to address the problems associated with the abuse of alcohol and drug abuse (Wickizer, Krupski, Stark, Mancuso & Campell, 2006).
Public Health Issues
It was established from the research that the Medicaid program paid for certain prescriptions for drug abuse through purchasing of fraudulent controlled substances. This unscrupulous act was unearthed by the Government Accountability Office (GAO). This report raised several public health issues which demanded for an enhanced and advanced drug prescription monitoring system; this system is instrumental in the prevention of drug abuse and also will help curb diversion of drugs.
The GAO report failed to provide solution to the drug addiction treatment. This detection of fraudulence in the Medicaid led to the banning of 65 doctors and pharmacies and their subsequent exclusion from the federal health care like Medicaid since their actions led to some deaths of the patients (GAO, 2009).
It was also established that the beneficiaries of the Medicaid program used if to fraudulently obtain illegal and controlled substance which they could sell it for money or also using them to support their addiction, this posed a serious problem to the health of other individuals in the state.
In Kentucky, for example, the dispensing of substances spiraled by 13% and this was the evidence of how fraudulent subscription of controlled substances was a serious matter and how it continues to plague the well being of individuals and how disastrous it could be if left uncontrolled (GAO, 2009).
GAO (2009) identified various cases of what they called doctor shopping where there were some situations where patients sought the attention of up to six medical doctors. They did this with an intention of disguising on the addiction. There is also serious public health concern where some patients received prescriptions from doctors and pharmacies that had been banned (GAO, 2009).
Individuals who suffer from behavioral health have a higher tendency of developing other health conditions like physical illness and disability and the cost of medical care for such category is higher than that of people without any case of behavioral health conditions. This calls for better behavioral attention and treatment since it will be instrumental in the curbing and the reduction of health costs in the future.
There is also growing public health concern that people suffering from behavioral problems amount of the largest percentage of the total number of people under the Medicaid plan and also a significant percentage will be more likely to suffer from diseases like “hypertension, heart disease, diabetes and pulmonary disorders” (Friedman, 2011, p. 1).
Those who suffered from behavioral disorders at times ignored seeking medical attention until their situations were severe and this had the effect of pushing up the cost of medical attention since it will force them be admitted in the health centers..
Cultural Issues
It has been established that if the problem of substances abuse is not addressed, then there will be an increase in the level of dependency in terms of welfare and also elongates the duration with which a family relies on the welfare assistance. It has also been evidenced that alcohol and drug abuse problems is common to those who are in public assistance program like Medicaid.
The need to address this problem is necessitated by the fact that the children of drug abusers pose an intergenerational risk and this will make this problem perpetual. The provision of Medicaid is considered both cost and medically effective. Providing Medicaid services to those who are alcoholic and drug abusers will amount to the saving of lives, families, and money (Lewis, 2002).
Future Impact on Public Health Issue
Several people with substance abuse programs which include the alcoholic and the drug patients rely more on the government supported public health facilities and programs. The conversion of the Medicaid program from the fee for services program to managed care program opened the Pandora’s Box on the fate of those who were substance abuse patients, this was due to the assumption that the managed care program could provide a comprehensive services.
This conversion raised a lot of concern on the fate of treatment since there was a conception of thought that the patients would be undertreated. The variations on the outcome from patient’s treatment for those clients with financial arrangements like the case of for profit and not for profit status.
Consequently of great concern to the public health is the fact that little information is known on Medicaid issues like the eligibility criteria and what specific services is available for particular categories of recipients.
Since the problem of drug abuse and alcoholism are problems which are common in the society and are here to stay, public health officials have always wanted to analyze the relationship between the new managed care services and the quality of treatment.
Social/economic Factors
The increase in the Medicaid budget due to the spiraling number of substance abusers has pushed the budgets of several states high (Wickizer et al., 2006). It has been considered the greatest burden to tax payer in the United State of America, this is against the health policy of the United State of America that is aimed at reducing costs on psychiatric issues and substance abuse which when combined together is referred as behavioral health.
The current health system in America has continued to ignore the health needs and the plight of people with behavioral problems, but this ignorance comes at a greater cost which will one day exploit the savings (Friedman, 2011).
The fear with the introduction of the Medicaid is that it has led to the increase of medical costs since majority of the people enrolled are poor and therefore likely to cost the state since it accounts to 2% of the federal budget and also similar percentage n the state budget.
Media Coverage
Media in the United State of America has pointed to the funds that physicians are paid as the cause of the high cost of Medicaid. Other media reports have also cited the high cost of home nursing and kick backs to the states official who are charged with administering the program.
Also those who are under fraudulent health schemes or the recipients have come under attack by the media. They are being accused for taking leisure rides in ambulances and also taking of prosthetic shoes despite their normalcy. They have also been accused for having extensive dental work that involves gold on their teeth.
There has also been wide reporting on the fraudulent arrangements between the laboratories and the physicians which result from scrupulous billing or overbilling. According to the media reporters, this fraudulence amounts to a high costs to the program (David, 1976).
Lessons Learned
After the above analysis, substance abuse and also welfare should integrate health treatment as an activity, welfare workers should be trained, and development of referral system for cases of substance abuse. Also the federal laws that prohibit the provision of Medicaid to the drug and substance abuse should be repealed.
Substance abuse should be removed from the institutions of mental disease and its exclusion from the Medicaid program as it will facilitate greater capacity and effectiveness in the administration of the treatment. Medicaid coverage should be increased to include the coverage of alcohol and substance abuse to a uniform benefit structure.
There should be increased coordination between different agencies providing the Medicaid scheme to avoid fraudulent activities. Extensive public or civic education should be carried out to educate people on the effectiveness of substance abuse treatment (Lewis, 2002).
It is well accepted and acknowledged that Medicaid program has played a vital role in the health care system in United States of America. It has enabled numerous poor and unprivileged people to access mandatory health care. Despite the instrumental importance of the Medicaid, it is worth mentioning that the achievements of the program has not been widely appreciated since is has been clouded by the high costs and overwhelming consumption which is a major concern.
It has not met the expectations of the majority of America and still plagued by several problems. From the above discussion, the following should be addressed if the success of the project is to be realized; The reasons behind the rising costs should be addressed, also the gaps of the eligible parties should be defined, and there should also be a threshold on the on the benefits.
Limited degree of participation by the physicians and medical doctors should be condoned; these may include participation by the private health facilities and other health practitioners (Deck, Wiitala & Laws, 2006). The factors which account for the spiraling costs of the Medicaid should be addressed comprehensively. These factors include increased level of awareness.
This has led to the increase in the enrolment of those who are substance abuse patients because of the realization that they can better be treated when they are under the program. This goes hand in hand with the menace of unemployment which increases the coverage under the medical scheme since there is enlargement in the number of those who are unable to meet their medical expenses.
The substance abuse patients have also mismanaged the service provided under the program, since the program offers leeway for free accesses to the medical service, the recipients have used this advantage to abuse it. This abuse of the scheme may take the following dimensions: Demand of excessive hospitalization by the patients, excessive prescriptions by the physicians, repeated visits to the doctor, and also the unmanaged administration services.
The government should therefore take the responsibility of reviewing the services on periodical basis since this will guarantee the effectiveness of the services (David, 1976).
Conclusion
People who suffer from ADM have limited access to medical insurance coverage, which calls for the expansion of the program to this population since it will be instrumental to the improvement of ADM care. It has been observed also that access to a quality care is higher in the highly managed plans as juxtaposed to those that are less managed.
This calls for monitoring the access to and the quality of these plans. The government provided Medicaid is often characterized by unmet demands of the individuals. This can not meet the satisfaction of the ADM patients and others who are under the program.
The government should also enhance its supply to ensure that the objectives of the programs are met. States have developed innovative ways of limit their spending on the Medicaid without affecting the delivery of the services including the provision of services to those with on chemical dependency (Gever, 2007).
References
David, K. (1976). Achievements and problems of Medicaid. Web.
Deck, D., Wiitala, L. W., & Laws, E. K. (2006). Medicaid Coverage and Access to Publicly Funded Opiate Treatment. Journal of Behavioral Health Services & Research. 33(3) p. 324-334.
Friedman, M. (2011). Mental Health and Medicaid Cost: Why Ignoring Mental Health Is Expensive. Web.
GAO. (2009). GAO report blames Medicaid fraud for prescription drug abuse. Alcoholism & Drug Abuse Weekly. Web.
Gever, M. (2007). Lowering the cost of Medicaid by providing drug and control treatment. Web.
Lambert, D., Gale, J., Bird, D. & Hartley, D. (2001). Medicaid managed behavioral health in rural areas. Web.
Lewis, D. (2002). Physician leadership on national drug policy. Web.
Wickizer, T., Krupski, A., Stark, K., Mancuso, D. & Campell, K. (2006). The Effect of substance abuse on Medicaid expenditures among General Assistance Welfare Clients in Washington State. Web.