Medicare is one of the biggest providers of healthcare funding in the United States, and covers around half the health costs of almost 60 million people (Mason, Leavitt, & Chaffee, 2013). Despite this, the original 1965 Medicare legislation contains anti-discrimination text that means that often, the nuances of health conditions are not covered (Mason et al., 2013). This singular approach means that individuals with diabetes cannot get eye tests covered, due to the fact that eye tests are not covered under Medicare.
Despite this, regular eye tests are recommended for individuals with diabetes and is part of living with this chronic condition, meaning that Medicare is not providing the essential services that it needs due to a lack of nuance in the wording (Mason et al., 2013). Diabetics currently have to pay 20% of the cost of these eye exams and in a hospital setting are liable for a copayment (Mason et al., 2013). The purpose of this paper is to explore a policy change designed to improve the specificity of Medicare for those with long-term health conditions.
The House of Representatives have recently passed a bill that helps Medicare to provide more clinically nuanced benefit systems in the Medicare Advantage Program (Mason et al., 2013). This is due to the fact that anti-discrimination laws written into the original Medicare protocol do not allow for nuance in coverage (Mason et al., 2013). Despite this, there is still room for improvement in terms of improving the nuance of Medicare to ensure that people are getting the services that they need. Diabetics, for example, now have some elements of a yearly eye test for glaucoma covered, but still have to pay a copayment in some scenarios (medicare.org, 2016). Physicians may also recommend that a diabetic patient gets eye tests more regularly than yearly, or other eye-related testing, which is not covered by Medicare despite the fact that diabetes is a chronic condition (mediare.org, 2016). The proposed change is to allow for more nuance in the development of Medicare protocol in terms of long-term conditions.
Chapter 4 of the Medicare provision bill currently contains a passage that aims to prevent discrimination. The current wording of this passage aims to prevent discrimination, but the proposed change would allow for discrimination on the basis of providing more nuanced healthcare. The current wording for the bill is:
“An MAO may not deny, limit, or condition enrollment to individuals eligible to enroll in an MA plan offered by the organization on the basis of any factor that is related to health status, including, but not limited to the following: claims experience; receipt of health care; medical history and medical condition including physical and mental illness, genetic information; evidence of insurability, including conditions arising out of acts of domestic violence; or disability” (cms.gov, 2016).
The proposed change would include an additional clause that would allow for discrimination based on the better provision of health services to those that fulfill the above criteria. The change would be worded as follows:
“Discrimination based on the above factors with the aim of specifically providing better services to those that fall into these categories is accepted. The provision of eye tests to those with long-term conditions that require additional monitoring is allowed, as is promotion of health services that can benefit marginalized populations.”
The first step of implementation is to research countries that have full healthcare coverage, like the United Kingdom. Understanding how the National Health Service bills are worded can help to understand what type of information needs to be provided in order to make Medicare work more efficiently in the United States. The second step is lobbying for change. Nurses need to be involved in the political process and understand who needs to be approached in order to get this additional passage added to the Medicare bill. It will be useful to know who is most likely to support better coverage for the marginalized under Medicare and use this individual as a public advocate for the proposed change.
This can also involve researching the different levels of care in different states to assess how the change would work on a national/federal level. It can also be useful to understand which parts of the bill will be affected through the change. The final stage is preparing hospital staff for the change after it has been passed. This involves training on Medicare provision and how the change is going to affect incoming payments from Medicare patient. Billing departments need to be notified in order for the bill to work successfully in real-life scenarios.
The two main advocates for this change are likely to be federal legislators, who need to understand the proposed change and make economic concessions for how the bill will affect national finances and provision of Medicare (Mason et al., 2013). These individuals need to lobby for the change in the Senate to ensure that it is passed in an appropriate manner. The second main advocate is national state nursing organizations, who are likely to support the change in that it will provide better services that are appropriate for those who have certain life-long conditions and need extra care to be covered by Medicare. These organizations will be influential in making changes occur. I have not voted for the individual in office that will be responsible for making the change, but lobbying is still an option. It will be interesting to see how national nursing organizations approach the change.
