Struggles in Medicare Programs and Health Insurance

Stethoscope and chalkboard with text HEALTH INSURANCE on wooden table

Medicare programs and health insurance plans have been around for decades, but many people still face difficulties when it comes to navigating them. From high premiums to confusing eligibility rules, there is so much complexity around healthcare coverage that even experienced administrators may struggle with it. Recent reports show that out-of-pocket costs continued to climb for the millions of Americans relying on Medicare for their medical needs.

Overview of Medicare Programs

Medicare is the federal health insurance program that provides coverage to people over the age of 65 and certain disabled individuals. The program is administered by the Centers for Medicare and Medicaid Services (CMS), a division of the U.S. Department of Health and Human Services (HHS).

Providing adequate coverage for individuals in Medicare programs has been difficult. This is particularly true when it comes to access to healthcare providers, the cost of care, and gaps in services provided by the various Medicare programs. For instance, access to providers can be poor in some areas due to a lack of reimbursement for certain procedures or services. Additionally, there are often disparities between different types of Medicare plans, such as patient co-pays for certain treatments. Finally, gaps may exist due to the lack of a national database for comparative information on healthcare quality, utilization rates, and costs across different Medicare plans.

What are the Medicare Program and the Health Insurance Program?

The Medicare Program and Health Insurance Programs provide health coverage to eligible individuals aged 65 and older, adults with disabilities, and those with End-Stage Renal Disease. Under the Medicare program, those who qualify have access to a comprehensive package of basic medical services, including:

  1. Outpatient Care
  2. Inpatient Care
  3. Home Health Care
  4. Hospice Care
  5. Prescription Drugs
  6. Medical Equipment and Supplies
  7. Mental Health Services

Medicare also offers a variety of supplemental plans for those who want additional coverage for certain services not covered under the standard Medicare program, such as vision, dental, and long-term care. Moreover, there are various cost-sharing options, such as deductibles, copayments, coinsurance, and other out-of-pocket costs, available for Medicare enrollees.

State Health Insurance Assistance Program

The State Health Insurance Assistance Program (SHIP) provides resources to help consumers navigate the Medicare system. They offer advice on finding programs to help pay for medical expenses and offer free and unbiased advice about Medicare, Medicare Advantage plans, and Part D drug plans.

Unfortunately, not all states offer this service as part of their Medicare program. In addition, the SHIP counselors are often overburdened with requests, leaving few resources available to those who need help. This lack of resources could be particularly problematic for those living in rural areas, who may not have access to proficient internet connections or one-on-one counseling sessions.

Universal Assistance Health Insurance

The Medicare system needs to improve to provide universal and comprehensive access to quality care. Current program limitations mean many people are without access to health insurance or other forms of financial assistance. This can lead to individuals suffering from inadequate coverage, higher out-of-pocket costs, and delayed care.

Universal assistance health insurance would provide comprehensive coverage regardless of age, income, preexisting conditions, or employment status. It would also create a system where individuals could be offered quality healthcare at a low cost, with no deductibles or copayments. This would reduce the burden on families and individuals who struggle with accessing quality healthcare and make them more confident when making decisions about their health. Universal health insurance could also help reduce costs associated with long-term treatments or chronic diseases by helping individuals get on the right treatment path sooner rather than later. Furthermore, it could help increase preventive care visits, which could help reduce the overall healthcare burden of the nation by reducing unnecessary hospitalizations and readmissions due to preventable illnesses.

The Criticisms and Struggles of Medicare Programs

The United States government’s Medicare program has faced its fair share of criticism and struggles over the years. From high costs to limited coverage, the Medicare system has been unable to meet all of the needs of elderly and disabled citizens in the country.

  • High Costs: One of the main critiques is that Medicare is too expensive and doesn’t cover enough. Since its creation in 1965, Medicare spending has steadily increased, with taxpayers spending an estimated $732 billion in 2019 alone. With skyrocketing costs, some have argued that there are not enough incentives for individuals to get insured through Medicare.
  • Limited Coverage: Many seniors have reported feeling frustrated with the limited options that Medicare provides when it comes to coverage for medical care, prescription drugs, and hospital visits. Furthermore, many seniors are subjected to out-of-pocket premiums for services such as vision or dental care—services that other insurance companies often cover up-front.

Medicare needs to address current issues to improve access to affordable health insurance for seniors.

The Impact of Medical Necessity on Benefits Coverage

Medicare is not just for senior citizens. It also covers some of the medical costs for other populations, including those with disabilities, those who’ve been diagnosed with end-stage renal disease, and veterans with a service-related disability. However, individuals in all these categories can struggle to receive the coverage they need due to the concept of medical necessity.

  • Medical necessity requires that treatments be determined to be both reasonable and necessary under the Medicare program for them to be covered. In other words, treatments must serve a beneficial purpose for patients and prove to be cost-effective. 
  • Many seniors and others on Medicare find that medical necessity rules lead to denials of coverage for needed treatments or medications. 
  • It’s estimated that approximately 28% of Medicare claims are denied due to medical necessity issues each year. With low reimbursement rates from insurance companies and high patient demand, it can become difficult for healthcare providers like hospitals and doctors’ offices to remain profitable while providing the care patients request. 

This can lead to a denial of treatment due to a lack of availability or affordability, leaving those on Medicare without the benefits they need or deserve.

Problems with the Medicare Program: Co-Pays, Deductibles, and Premiums

The Medicare system is designed to provide health insurance to people over the age of 65 or with certain disabilities. Unfortunately, there are several major issues with the system.

  • Co-Pays: Medicare co-pays can be a considerable burden for those on a limited or fixed income. Co-pays range from $20 to $100 per visit, depending on the type of service. This can add up quickly if an individual is receiving regular treatments or services from multiple doctors.
  • Deductibles: The deductibles that come with Medicare can be quite costly as well. These are recurring payments that a person has to make at the start of each year to receive medical coverage and can range anywhere from $150 to over $2,000 depending on the type of plan and coverage needed.
  • Premiums: Medicare premiums need to be paid every month for an individual to keep their coverage active and must be paid even if an individual remains healthy throughout the year. Depending on their income level, individuals may face higher premiums than others who earn less income but have similar plans.

Accessibility Barriers to Quality Care

Medicare provides quality healthcare to all age groups, regardless of their ability to receive it. Unfortunately, there are numerous barriers to accessing these benefits.

  • Disparities in Access: Whether due to geographic location or language, individuals are often unable to take full advantage of the health insurance program due to disparities in access.  In certain rural areas, for example, there is a shortage of healthcare providers who accept Medicare.
  • Costly Coverage Gaps: Another issue faced by many Medicare recipients is coverage gaps caused by costly premiums and co-pays. These gaps can leave individuals with large financial burdens when seeking medical treatment, leading many to forgo necessary care.
  • Language Barriers: Language barriers often separate non-English speaking patients from their healthcare providers. This can lead to miscommunications, putting the patient’s health at risk.

Medicare provides complex and wide-ranging health insurance programs. Despite its efforts to provide quality care for America’s oldest citizens and those with disabilities, there remain numerous obstacles that must be overcome for people to receive necessary services without the financial burden or additional stressors on their health.

Finding Relief Through Medicare Program Changes

The Medicare Program is constantly evolving, and new changes can help people who are struggling with the current Medicare system. These changes are put in place to make sure that everyone receives the care they need and that insurance companies are held accountable for their policies. Some of the recent changes to the Medicare Program include:

  • Allowing individuals to change their plans more frequently
  • Strengthening consumer protections by introducing new coverage criteria
  • Ensuring consumer access to vital healthcare services
  • Expanding Medicaid coverage in some states
  • Lowering drug costs through expanded generic drug options
  • Enabling greater access to telemedicine services as well as remote patient monitoring technology.

These changes have allowed people to find relief from their Medicare struggles and receive the necessary coverage they need.

Misconceptions about the Problems of Medicare Programs and Health Insurance

When it comes to issues facing Medicare programs and health insurance, certain misconceptions can further exacerbate the problem. Many people falsely believe that Medicare will cover all of their needs, or that health insurance premiums should not be continuously rising. Some of the most commonly held beliefs include:

  • Medicare and Medicaid are the same programs: While both are government-run health insurance programs, Medicaid is designed for low-income individuals, while Medicare is available to those aged 65 or over.
  • Doctor Visits Are Free Under Medicare: Medicare typically covers up to 80% of your costs with no copayment necessary. However, there is no “free” coverage.
  • Medical Treatments and Medications are Covered by Medicare and Health Insurance: This may not always be the case; many treatments and medications may come out of pocket or have limited coverage depending on your plan and provider.
  • Premium Costs Won’t Increase: Premium costs for both Medicare and private health insurance plans will rise due to inflation or other factors such as age bracket changes or changes in services offered under certain plans.

It’s important to stay informed about what is covered under a given plan so that individuals can make the best decisions for their needs without making any false assumptions about what is available to them through these programs.

The struggles of getting healthcare coverage and proper medical treatment for those enrolled in the Medicare Program are often real and difficult. Despite the many obstacles, those enrolled in the program should be aware of their rights and options to ensure they receive the medical treatments, services, and coverage they need. With the right information, support, and resources, individuals can access the specialized care and treatments they would otherwise be denied.