Hi everyone. My name is dr lacey humor and the topic of today's lecture is payers in the health care system. There are two broad categories for who is actually footing the bill of health care or who is financing health care on the left. You will see public financing which includes the Children's health insurance plan, or also known as Chip, the V A. Or veterans Health Affairs, Medicaid and Medicare. On the right there are private financing options which is insurance through the employer where the employer pays for a large portion of the premiums compared to the employee given as a fringe benefit. Finally, some people opt to buy health insurance completely self funded. So Medicare and Medicaid are often confused. So let's go through some key defining features of the programs. First on your left, Medicare is an entitlement program, meaning that people pay into Medicare through a paycheck tax for many years, but ultimately is a federal government finance sir and administrator. The funder of Medicare, which is the federal government. Medicare eligibility is for those 65 years and older and certain disabled groups, including end stage renal disease and Medicare financial status does not play a role in whether or not you receive coverage on the contrary on the right, you will see Medicaid which is a social welfare program that is only available for those who are low income. This is jointly funded by the state and federal government, depending on what state you live in. The eligibility differs and the benefits differ. Lastly, it is important to note that you can be on both Medicare and Medicaid also known as being duly eligible. So let's get into a bit more details on Medicaid. It is means tested which is related to income. It's financed by taxes, jointly by the state and with a matching proportion from the federal government. Each state has different income levels that will make you eligible to sign up for this program. Some states also have their own Medicaid brands into a different name because sometimes Medicaid has not a great reputation with its name. Again, you can be eligible dually for both Medicare and Medicaid. Since there is ST variation, some states have decided that Medicaid enrollees should be in private managed care plans with standardized benefits. This allows states to have a budget estimate for providing health care for this population because states, unlike the federal government, have to balance their budget every year. Medicaid often takes a large proportion of that budget as part of the patient protection and Affordable Care Act or the A C A. The federal government incentivize states to expand Medicaid eligibility to Childless adults before the Aca, Medicaid was mostly for adults with dependent Children. The federal government agreed to pay a higher proportion of the matching funds for this newly eligible group. As of February 2021, 39 states have expanded eligibility in this way. The majority of states who have not decided to expand are generally found in the South and a few in the midwest regions, let's move on to Medicare. Medicare again is the federal health insurance program for those 65 years and older, it has many different parts Part A which is hospital insurance, which accounts for 30% of health care spending within this program. Part B which is medical insurance, which accounts for about 20% of spending, Part C which is Medicare advantage. This accounts for about 1/4 of the health care spending And part D. Which is prescription drug coverage, which is about 10% of spending. Finally, there are some health insurance plans called Medigap which is supplemental insurance only for those people who are enrolled in Parts A And B. That you pay a monthly premium exchange for this plan, paying the copays and cost sharing on your behalf. Next I will go into details about each part of Medicare first, Medicare part A which is hospital insurance. This is financed by payroll taxes. If you look at your pay stub FICA F I C A is the abbreviation and you might see, You must pay into the system for 10 years in order to be eligible to receive Medicare. In addition to hospital inpatient services, part A covers some skilled nursing facility, Home health and Hospice. No, that Medicare does not pay for long term care and in fact Medicaid is the primary pair of long term care. However, Medicare will pay up to 100 days in a skilled nursing facility with a qualifying three night hospital stay in part A. There is also a deductible which restarts every benefit here And some services require cost sharing. For example, after 20 days in the skilled nursing facility on the 21st day to the 100th day, there is a co payment required. Next is Medicare Part B which provided provides health insurance for physician and outpatient services. It's voluntary. But most everyone enrols in part B It's financed partly by tax revenues like Part A. And partly by premiums. The premiums are income based and you can you pay more if your income is higher, Premiums generally range from 187- 4, 30 monthly. Part C of Medicare is sometimes known as Choice Plus or Medicare advantage. Medicare, Part C Combined services that Medicare, part A And B Cover in one managed care plan. Medicare advantage has been growing substantially over the past two decades and now enrolls about 40% of Medicare enrollees. Enrollees select plans run by private insurance companies but financed by the federal government. The federal government pays these plans on a per person or capitated basis. These plans must include all benefits that are provided in Medicare parts A and B. But often provide supplemental benefits such as dental vision and telehealth services. Lastly, Medicare Part D Which was added to Medicare in 2003 provides prescription drug benefits. It is not a required part of Medicare but if you enroll later after you are eligible, you will pay a penalty for not enrolling. These are all private plans, but financed by the federal government. Someone can have a standalone plan or have these benefits combined in their part C plans. In 2013, you will see that across the country there are many options for private prescription drug plans. So the takeaways from this lecture are that Medicare is not being tested And is federally financed health insurance for 65 years or older. In contrast, Medicaid eligibility is means tested but varies based on the state. And finally, even though Medicare and Medicaid are publicly financed, they can both be administered through private managed care health insurance plans. Thank you for your attention.
