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Introduction

Obamacare is health insurance program offered by the federal government of the United States to cater for people with low income; people aged between 65 years and above; people aged below 65 years with disabilities; and people of any given age with permanent kidney failures (that necessitates kidney transplant or dialysis) or end stage renal disease (Medicare.gov 1). Obamacare offers a variety of specialty programs to the intended beneficiaries. These include hospital insurance that covers inpatient care, hospice, skilled nursing facilities, and home assistance. It provides medical insurance that covers the beneficiaries’ hospital outpatient care, doctors’ services, home and some preventive services that assist in maintenance of the beneficiaries’ health and treatment of certain illnesses. Obamacare plan caters for the government approved private insurance institutions that have a contract to provide its beneficiaries with various medical services (Medicare.gov 1). Hospice care is the only principal benefit that is not covered by Obamacare plans. However, the plan provides other extra converges ranging from hearing, dental, vision, and regular checkups, as well as other numerous health and wellness programs (Pipes 61). 

On the other hand, under Obamacare, health maintenance organizations (HMOs) provide managed care plans to their beneficiaries by collaborating with hospitals and doctors that they have contracts with (Huhn, 2006).  Some HMOs provide ‘point of services’ to their beneficiaries. This means that they allow their beneficiaries to use the services of hospitals and doctors that are not in the HMOs network or not in contract with the respective HMOs. According to the 2006 US Census Bureau, Obamacare was scheduled to take care of several HMOs, which account for 13.6 percent of the United States’ health coverage (Tate 9). The program is expected to cover approximately 47 million medical officers with approximately 39 million beneficiaries aged between 65 years and above and about 8 million younger but disabled populations (Tate 15).

Under Obamacare, the HMOs have not received any considerable change in scope over the recent past. However, these plans have experienced significant change with respect to the number of beneficiaries in the recent years and are projected to undergo further changes (McCaughey 32). Factors such as the need to reduce the cost associated with the medical care plan, for instance, have resulted into a considerable decline in the number of beneficiaries in these plans and increased enrollment in the program (Das 14). In fact, the numbers of beneficiaries are expected to increase further in future with continued change in policies.

Although these plans do not significantly vary by state, the number of beneficiaries varies with state depending on the person’s economic status. According to Tate (209), enrollment rates in Obamacare plan will vary widely from approximately 41 percent in Oregon, for instance, to less than 2 percent in Alaska (p. 44).  It is also argued that HMOs accounts for a greater part of the Obamacare plan, approximately 65 percent, followed by regional and local PPOs and other private for service plans (Tate 48).

History and Legislative Events of the Plans

Obamacare was enacted primarily to provide health coverage for the majority of the US citizens who, in one way or the other, could not meet the ever rising cost of medical care in the country, and it is expected to undergo a variety of changes (McCaughey 35). In the recent past, most of the changes in the plan have involved legislations to incorporate different schools of thought, some of which present opposing ideas. These include issues related to the affordability of the planned care system and the patient protection act as well as the education reconciliation acts that were signed in 2010 (Meadicare.gov 1). Some of the most current legislative events around Obamacare include the 2011 heath care legislation that placed a considerable freeze on the increase of care premiums. This new legislation further limits the HMOs and private insurance companies that provide Medicare plan from having higher cost sharing requirements such as copayments, coinsurance and deductibles (Medicare.gov 1). Obamacare programs that offer services not provided by the traditional Medicare are required to prioritize reductions on preventive care, out of pocket costs and wellness programs. In addition, enrollment dates and switching period between the Obamacare and original Medicare are likely to change in 2011 and subsequent years (Medicare.gov 1).

Costs of Administering the Programs

Obamacare is expected to be financed by citizens’ payroll taxes that were imposed by the federal insurance contribution and self employment contribution acts (Huhn 25). The tax is about 2.9 percent of the salaries, wages, and other compensations related to employment. The act has, however, changed over time: in 1993, the law specified a maximum compensation for which the tax could be imposed (Huhn 38). However, the compensation limit will be eliminated once the program kicks off.  The changes are predicted to continue: in 2013, the 2.9 percent insurance tax is predicted to continue applying for the first 200,000 dollars for individual income or 250,000 dollars for joint couples and is expected to rise further to about 3.8 percent on incomes above these amounts (Tate 59). 

The proposing argument indicates that the cost of medical care has changed over a period of time depending on the medical care program. For instance, Obamacare plans will cost the government about 10% more when compared to the traditional Medicare service that was basically a fee for service program (Tate 60). As a result of high costs incurred by the government on healthcare budgetary allocations, the plan has been targeted for cost reductions. For instance, the affordable care act of 2010 decreased the payment to the Obamacare plan bringing it closer to parity with or lower that the original Medicare program costs (Das 22). Under the planned Obamacare, the medical costs will reduce significantly, making it more affordable to the majority. It was prompted by the fact that proper Medicare in the country had greatly increased in the recent past due to a variety of economic changes, making it difficult for low income earners (Tate 62).

The cost of the medical care program to the beneficiaries or employers varies according to the type of plan. Generally, Obamacare is considered as fee-for-service program since its beneficiaries do not pay separately for other services (Tate 64). On the contrary, the beneficiaries of Obamacare plan are required to pay a fixed per month amount, regardless of the type and number of services that the plan delivers. Generally, payments are ‘risk adjusted’. This means that the monthly payments vary depending on the overall health status of beneficiaries (Huhn 67).

Obamacare plan allows its beneficiaries to participate in various enrollment payments or coverage costs to supplement the available funds for the program. To begin with, implementing the Obamacare  programs requires that many citizens are allowed to participate in ‘coordinated plan’ which allows beneficiaries to use various hospitals and doctors with a network as well as other providers incase they are able to pay extra costs (Tate 68). Obamacare plans provided by the HMOs have tighter restrictions while those provided by the preferred provider organizations (PPO) have looser restrictions on the beneficiaries’ hospital and doctor choices. Obamacare plan also has other options including private fee for service plans (are not required to be part of hospital and doctors network); and the special needs plans that is mainly focused on beneficiaries that are eligible for Medicaid or who may have particular disabling conditions, chronic diseases or those who require specialized institutionalized care (Tate 68). In addition, beneficiaries in Obamacare plans benefit from reduced copayments or no deductibles and other additional benefits ranging from vision, hearing care and discounted health club membership.

Evaluation of Heath Care Quality

The quality of care and various plans under Obamacare requires that the HMOs are evaluated on the basis of 36 standard performance measures. The standard measures are derived from majorly four sources: the consumer assessment of Obamacare providers and systems (CAHPS); effectiveness data and information set (HEDIS); health outcomes survey (HOS); and CMS administrative data which include audit results, members’ satisfaction, the appeal of the plans, and customer service among others (Tate 69).

The quality measures are then grouped into five domains: management of chronic conditions; staying healthy: tests, vaccines, and screenings; beneficiaries’ complains and appeals with respect to different plans; health plan responsiveness ratings; and the plan’s customer service (Tate 72). The averages for all measures are then calculated to determine the score. In certain cases, the quality measures may be adjusted for patient characteristics.  The score also takes into account whether the plan has demonstrated stable or high quality ratings across all other measures (Tate 73). Evaluation of the quality of services by beneficiaries was based on a few basic parameters. Most of beneficiaries and purchasers evaluated their satisfaction by the cost of the different plans, the ease of billing or payment of the plan and the coverage of the plan. In particular, most of my interviewees evaluated and described their satisfaction with respect to cost of the plans and level of medical care coverage (Pipes 97).

Issues Facing the Heath Care Program

One of the significant and current issues faced by the Obamacare plans revolves around the best ways to constrain the increasing rate of the health spending and to meet customer’s satisfaction. Other people especially the republicans have emphasized on the provision of Obamacare benefits through private options and preferred policies (Huhn 46). Some US citizens are also opposed to the increased taxation among the rich to provide enough funds to implement the program. On the other hand, democrats support equitable payment plans between the individual plans and the old Medicare program. In addition, Obamacare plans have been criticized as too costly and being imposed on the citizens. Various critics have recommended that plan’s payment should be closer to the traditional Medicare program in order to provide extra benefits to many deserving people (Pipes 104).

The advocates of Obamacare suggest the plan offers lower costs and less fragmented care compared to the traditional Medicare. They assert that Obamacare will lead to fewer unnecessary hospitalizations and readmissions than the traditional Medicare system.  Proponents of the plan have also emphasized on the significance of the plan to minority and low income beneficiaries, whom they argue cannot afford some Obamacare services such as the ‘medigap’ plans (Tate 75).

Success of Obamacare (Whether it will Work)

Despite the fact that Obamacare faces funding challenges and opposition, thus various reports have speculated that the medical care insurance funds are likely to run out of funds in 2017, necessitating a comprehensive medical insurance for the deserving cases (Tate 75). Furthermore, surveys have indicated that still there is no significant strategy that has been put in place by the government to keep the medical care programs solvent. In addition, the rations of tax payers to beneficiaries of these programs are shrinking, but the price of the Obamacare is likely to increase despite the program (Tate 76). Spending in Obamacare and other medical care plans is also projected to grow in the country, meaning that its objective implementation will definitely make it work for the majority of deserving cases in the US.

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