Who Pays?

Abstract

This chapter talks about the different medical care programs available in the United States. Medicare and Medicaid were both created in 1965 and are administered by the U.S. Department of Health and Human Services. Medicare is a federally funded program, while Medicaid is funded by both the federal and state governments. Unlike Medicare, Medicaid is managed by individual states based on federal guidelines that stipulate the services that must be provided to specific groups of poor individuals. Medicare has historically been a driving force in U.S. health policy due to its conversion of typical fee-for-service medical reimbursements into a standardized prospective payment system. The differences in state regulations and mandates, as well as specific policy guidelines, mean that private insurance has significant variation. In regard to home health care, home visits are limited and home health agencies must get approval for the number of visits they make. These limitations have significant impacts on care recipients, and they structure the work processes for caregivers and nurses alike. The chapter also talks about the system's complexity and the disparities in coverage among various payer sources. The fragmented nature of payer sources greatly affects patients and caregivers, who often negotiate systems with limited knowledge. A large problem for people interviewed in this book was that they didn't know about waivers and other services that were available to them and didn't apply for them when they could have. Caregivers often found out about waivers from acquaintances, family members, or others. Currently, the multiple-payer system promotes confusion, additional stress, and uncertainty.