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Student Note

 

Thesis:

This annotated bibliography will explore the primary federally and state-funded healthcare programs, Medicare and Medicaid, from a number of perspectives. First, this annotation will develop a broad understanding of the programs, including: the purpose of the programs, the intended beneficiaries of the program, how these programs are funded, and how costs of the program are allocated. Also, and perhaps of most immediate interest, this annotation attempts to create a comprehensive understanding of how the Affordable Care Act will affect Medicare and Medicaid and on what grounds the proposed healthcare program is potentially violating the Constitution.

Specific attention will be paid to the Medicaid program and its role in providing increased access to affordable health services to underserved and underprivileged minority groups in America. Blacks represent a disproportionate portion of enrollment in Medicaid which brings about a number of unintended results, including Blacks having less access to facilities and providers of comparable quality to whites. Additionally, because states have some latitude in determining what services and resources are available through Medicaid, Blacks are adversely affected because many diseases and infirmities that fall more heavily on Blacks may not be covered as comprehensively as those that do not. Also, availability of, and access to, quality health care facilities is another hurdle that tends to fall disproportionately on Blacks and people of color. This annotation will explore what the Affordable Care Act will do, via federally funded programs, to reduce the number of uninsured Blacks and reduce the health disparities between Blacks and the rest of the population.

The following resources are included in this bibliography:

Statutes – Federal:

  • Civil Rights Act of 1964, Title VI – Nondiscrimination in Federally Assisted Programs §601, 42 United States Code Annotated §2000d (1964).
  • Civil Rights Act of 1964, Title VI – Nondiscrimination in Federally Assisted Programs §602, 42 United States Code Annotated §2000d-1 (1964).

Regulations:

  • Nondiscrimination in Federally Assisted Programs – Implementation of Title VI of the Civil Rights Act of 1964, 28 Code of Federal Regulations §42.104 (Westlaw current through March 11, 2012).

Cases:

  • Alexander v. Sandoval, 532 United States Supreme Court 275 (2001).
  • Bryan v. Koch, 627 United States Court of Appeals, Second Circuit 612 (1980).
  • NAACP v. The Medical Center, 657 United States Court of Appeals, Third Circuit 1322 (1981).

Law Review Articles:

  • Maxwell Mehlman & Karen Visocan, Medicare and Medicaid: Are They Just Health Care Systems?, 29 Houston Law Review 835 (1992).
  • Walter L. Stiehm, Poverty Law: Access to Healthcare and Barriers to the Poor, 4 Quinnipiac Health Law Journal 279 (2001).
  • Carol Ewald Bowen, Medicare and Medicaid: An Overview of Existing Programs and Compliance Issues, 2009 Westlaw 534744 (2009).
  • Melanie K. Gross, Invisible Shackles and the Compromise to the Medical Civil Rights Movement, 47 Howard Law Journal 943 (2004).
  • Gwendolyn Roberts Majette, Access to Health Care: What a Difference Shades of Color Make, 12 Annals of Health Law 121 (2003).
  • M. Gregg Bloche, Race and Discretion in American Medicine, 1 Yale Journal of Health Policy, Law, and Ethics 95 (2001).
  • Michael Campbell, Did I Do That? An Argument for Requiring Pennsylvania to Evaluate the Racial Impact of Medicaid Policy Decisions Prior to Implementation, 82 Temple Law Review 1163 (2010).
  • Thad Kousser, The Politics of Discretionary Spending, 1980-1993, 27 Journal of Health Politics, Policy & Law 639 (2002).
  • Ruqaiijah Yearby, African Americans Can’t Win, Break Even, or Get Out of the System: The Persistence of “Unequal Treatment” in Nursing Home Care, 82 Temple Law Review 1177 (2010).
  • Laura Hermer, The States’ Challenge to the Affordable Care Act’s Medicaid Expansion, 33 Whittier Law Review 1 (2011).
  • Matthew McKennan, Medicaid Access After Health Reform: The Shifting Legal Basis for Equal Access, 7 Seton Hall Circuit Review 477 (2011).
  • Sara Rosenbaum & Benjamin D. Sommers, Rethinking Medicaid in the New Normal, 5 St. Louis University Journal of Health Law & Policy 127 (2011).
  • Renee M. Landers & Patrick A. Leeman, Medicaid Expansion Under the 2010 Health Care Reform Legislation: The Continuing Evolution of Medicaid’s Central Role in American Health Care, 7 National Academy of Elder Law Attorneys Journal 143 (2011).

Websites:

 


Annotations

Statutes:

Civil Rights Act of 1964, Title VI – Nondiscrimination in Federally Assisted Programs §601, 42 United States Code Annotated §2000d (1964). Pages: 1.

Section 601 is in place as a broad prohibition against discrimination of persons, on the bases of race, color, or national origin, by programs that receive federal funds. This section serves two basic functions: first, it prohibits intentional discrimination by programs receiving federal funds and second, it allows for private individuals to sue for enforcement of this section.

Civil Rights Act of 1964, Title VI – Nondiscrimination in Federally Assisted Programs §602, 42 United States Code Annotated §2000d-1 (1964). Pages: 1.

Section 602 provides the authority to government departments and agencies to promulgate rules and regulations effectuating section 601 of Title VI. In addition to listing the procedural requirements associated with promulgating rules, section 602 also indicates that discrimination can result in penalties as severe as discontinuation of receiving federal funds. Finally, regulations promulgated pursuant to this section may prohibit activities that have a disparate impact on persons because of their color, race, or national origin. While only intentional discrimination is prohibited by section 601, section 602 extends to activities, rules, or regulations that are not intentionally discriminatory but have a discriminatory impact on the basis of the aforementioned protected classes.

Regulations:

Nondiscrimination in Federally Assisted Programs – Implementation of Title VI of the Civil Rights Act of 1964, 28 Code of Federal Regulations §42.104 (Westlaw current through March 11, 2012). Pages: 3.

The regulation is promulgated by the Department of Justice to enforce the Civil Rights Act of 1964 against federal departments and agencies that receive federal funds. Generally, this regulation prohibits federal programs, including Medicare and Medicaid, from being arranged or functioning in such a way as to subject persons to discrimination on the basis of color, race, or national origin. Also, programs are prohibited from selecting the location of facilities with the purpose of impairing the benefits, or access to services, of persons on the basis of color, race, or national origin. More broadly, this regulation is in place to ensure that the goals of nondiscrimination of the Civil Rights Act of 1964 effectuated by government agencies.


Cases:

Alexander v. Sandoval, 532 United States Supreme Court. 275 (2001). Pages: 29

In Alexander, the Alabama Department of Public Safety put a rule in place that required the driver’s license test be administered only in English. Sandoval brought suit under the Civil Rights Act of 1964 claiming that this rule has a disparate impact on those not born in the United States (i.e. national origin). This case solidifies a couple of propositions in relation to the Civil Rights Act of 1964: first, a person has a private right of action of intentional discrimination under section 601 and second, a person does not have a private right of action for disparate impact under section 602. The rationale for this conclusion is that private actions under section 602 are barred because there are enumerated penalties, such as termination of federal funds, for programs operating in a way that has a disparate impact on persons because of race, color, or national origin. The court concluded that because a private right of action was not expressly mentioned, the likely intent of Congress was for this remedy to be intentionally excluded.

Bryan v. Koch, 627 United States Court of Appeals, Second Circuit 612 (1980). Pages: 19.

The plaintiffs in this case challenged the closing of a municipal hospital that served a predominantly minority population, consisting of low-income Blacks and Hispanics. The closing of the facility was challenged under Title VI of the Civil Rights Act of 1964 as having a disparate impact on the basis of race. The closing of the hospital initially arose during lean financial times in the late 1970s when then-mayor of New York City Ed Koch assembled a Health Policy Task Force which conducted a thorough analysis of the 17 facilities in the municipal hospital system.

The closing of the hospital quite easily failed the intent requirement under Title VI, however the court also reviewed the decision under an “effects” test which will allow for a claim of racial discrimination to stand if it has a disparate impact on a minority group that is not justified by a legitimate governmental purpose. The concern of the low-income minority plaintiffs was that there would not be adequate facilities to take the uninsured and Medicaid patients in the community who primarily used the hospital slated for closing. Under a disparate impact theory, the court found that the decision to close the hospital did have a disparate impact on low-income minorities. After reviewing the findings of the Task Force, the court concluded that the closure was justified by the need for efficient operation of the municipal hospital system. This case shows the difficulty in proving discrimination, intentional and disparate impact, under Title VI and the rather easy “justifiability hurdle” placed on the State in disparate impact claims.

NAACP v. The Medical Center, 657 United States Court of Appeals, Third Circuit 1322 (1981). Pages: 31.

A group of advocacy organizations brought a claim of Title VI discrimination against the Wilmington Medical Center, consisting of a group of three non-profit healthcare facilities. The plaintiffs challenged the medical center’s decision to reorganize, moving many of the Medical Center’s services to suburbs away from the inner-city location. The court spent minimal time discussing the plaintiffs’ claim of intentional discrimination, finding no evidence of the requisite intent in the Medical Center’s decision to relocate.

The court discussed at length the framework for arguing a claim of disparate impact under Title VI. The plaintiff bears the initial burden of making a prima facie case, proving that the defendant’s action, although facially neutral, has a disparate impact on a protected class. However, even if a prima facie case is proved, the defendant may escape liability by demonstrating that less discriminatory means would not accomplish the defendant’s business purposes.

This case makes clear that most Title VI plaintiffs claiming disparate treatment or impact by a healthcare facility will likely find themselves between a rock and a hard place. Absent extreme carelessness by the defendant, proof of intentional discrimination by the defendant will not be readily available. On the other hand, a defendant can justify its business decisions that fall more harshly on minorities by showing that there was no other way to accomplish its goals or continuing to serve that population is expense prohibitive.


Law Review Articles:

Maxwell Mehlman & Karen Visocan, Medicare and Medicaid: Are They Just Health Care Systems?, 29 Houston Law Review 835 (1992). Total pages: 27.

This article explores whether, and how, the Medicare and Medicaid programs abide by and promote concepts of justice. The article focuses on three primary concepts of justice: equality, redistributive justice, and equity.

Equality. The article intimates that there may be some inefficiencies in Medicaid system because eligibility is determined, among other things, by financial standing and not on medical need. Additionally, the authors state that the Medicaid program is incomplete. Medicaid is jointly funded by states and the federal government. States have some latitude in deciding what services and how much of those services will be covered by Medicaid funds, which effectively bars some who otherwise meet the eligibility requirements of the Medicaid program.

Redistributive Justice. The authors point out that while the goal of the Medicaid program is to pool resources from those who have available resources and distribute it to those with little to no resources, the system is being gamed by those in the former category. In the case of long-term care, some who would be ineligible for Medicaid coverage are able to get creative with their assets and wealth to become eligible for Medicaid coverage of long-term care costs.

Equity. Finally, the authors bring to light the fact that Medicaid program may be sufficiently complex so as to bar those who would otherwise be eligible. This could be the result of socioeconomic factors and educational disparities between those who are eligible for Medicaid and those who are not.

Walter L. Stiehm, Poverty Law: Access to Healthcare and Barriers to the Poor, 4 Quinnipiac Health Law Journal 279 (2001). Pages: 26.

This article identifies and explores a number of direct and indirect economic and non-economic barriers to access to healthcare services imposed on the low-income population. Well-documented factors such as race, ethnicity, culture, language, and education were explored. The article also discusses a number of other factors that are less well-known such as: ability to take time off of work, availability of child care services, and coverage of select services by Medicaid.

The article discusses the economic pitfall that much of the “working poor” population falls into by working low-income jobs that do not offer employer-funded healthcare programs but that same population makes too much money to be eligible for the Medicaid safety net. Also, education level is an important factor in barriers to access to healthcare services. These two factors are significant to the Black population because Blacks tend to be less educated and have lower income than whites, contributing to an imbalance in access to adequate healthcare services.

Also, the article discusses the lack of availability of physicians in low-income urban areas. Low reimbursement from the Medicaid program causes many physicians to not serve such populations, of which Blacks are a significant portion of enrollees.

Carol Ewald Bowen, Medicare and Medicaid: An Overview of Existing Programs and Compliance Issues, 2009 Westlaw 534744 (2009). Pages: 12.

This article provides a summary of the Medicare and Medicaid programs but primarily focuses on common compliance issues that arise in relation to practitioners and healthcare facilities. One of the more interesting points raised in the article is that the most common type of fraud under these programs are related to billing and coding (i.e. billing for services not actually provided, ect). As has been found in other readings, there seems to be diminishing incentives for providers to take patients enrolled in the federal programs, which could lead to attempts by providers to “up-charge” patients enrolled in these programs.

Melanie K. Gross, Invisible Shackles and the Compromise to the Medical Civil Rights Movement, 47 Howard Law Journal 943 (2004). Pages: 40

This primary focus of this article is an analysis of the Alexander v. Sandoval case and the implications that case has had, and continues to have, on the ability to combat racial discrimination in healthcare. This article also identified some of the prominent results of racial discrimination in healthcare. Specifically, the author purports that the issue of “access” today is less about Blacks getting in the door of healthcare facilities and more about what happens once they get in the door. The author points to racial disparities in disease areas such as: maternal and child care, cardiovascular care, cancer screening and diagnosis, and HIV/AIDS. Also, access to adequate healthcare providers and facilities contribute to the resultant racial disparities in health outcomes. The article also points out that Blacks tend to rely heavily on public clinics and ambulatory care centers that are being closed in favor of for-profit facilities outside of communities where reliance on Medicaid is heaviest.

Gwendolyn Roberts Majette, Access to Health Care: What a Difference Shades of Color Make, 12 Annals of Health Law 121 (2003). Pages: 18.

This article explores the racial basis of disparities in access to adequate health care. The author identifies four components that help define access: Affordability, availability, usability, and acceptability. The author contends that health disparities based on race are inevitable because the health care system is based on, and run by, a white male paradigm which fails to identify with those who fall significantly outside of that classification. The author points out, among other things, two facts that contribute to the discrimination experienced by minorities in access to health care: Availability of insurance and availability of health care providers and facilities. First, minorities are disproportionately represented in marginal low-paying positions that skimp on the provision of health care benefits to employees. The inference can be made that these “working poor” may have an income that is too high to be eligible for Medicaid and not significant enough to warrant an employer-sponsored health benefit plan. This represents a huge gap in coverage for many minorities.

Second, the author addresses some significant cases representing failed attempts by minorities to use Title VI to keep health care facilities in minority communities. The barriers to bring a winning claim of disparate impact against a health care provider are almost insurmountable, seeming to frustrate the purpose of Title VI to prohibit federally funded entities from acting in ways that tend to discriminate a population based on a protected class.

M. Gregg Bloche, Race and Discretion in American Medicine, 1 Yale Journal of Health Policy, Law, and Ethics 95 (2001). Pages: 27.

This article explores the racial and socioeconomic disparities in America’s health care system. The author proffers that American politics has a fascination with overt discrimination based on quality and access experienced by people of color while ignoring the disparate impact a discriminatory health care system has on those of a lower socioeconomic status, even though there is an identifiable link between race, socioeconomic status, and access to health care resources. The author believes that the issue should be framed in the context of the “race-related economic disadvantage arising from pervasive racial bias.”

Concerning Medicaid, the author believes that the reimbursement rates that physician’s receive for performing services to Medicaid enrollees serves as one barrier that creates an inherent disadvantage to those of lower socioeconomic status. Additionally, because private physicians are not compelled to accept Medicaid rates (private physicians, even those that accept Medicare patients, are generally not considered entities that receive federal funds according to Title VI) many enrollees are confined to public hospitals and clinics that are limited by tight financial constraints.

 

Michael Campbell, Did I Do That? An Argument for Requiring Pennsylvania to Evaluate the Racial Impact of Medicaid Policy Decisions Prior to Implementation, 82 Temple Law Review 1163 (2010). Pages: 15.

This article explores Medicaid policy decisions and the subsequent effects, both positive and negative, that such policy decisions have on minority communities in Pennsylvania. While the article focuses on state policies promulgated Pennsylvania, there are relevant solutions that apply to Medicaid as a federal policy on a broader level.

Throughout the country, Medicaid is a dominant force in residents’ payment for long-term nursing home care. However, Medicaid payments to non-government facilities are limited to Medicare reimbursement rates. Thus, there is little financial incentive for nursing homes to take residents enrolled in Medicaid. The interaction between the financial constraints and strategic financial maneuvering by nursing home administrators creates an interesting phenomenon which adversely impacts people of color. First, private nursing homes know that Medicaid reimburse rates are limited by federal regulations. Thus, the nursing homes move out of the urban areas (if they were even there in the first place) to the more affluent areas where Blacks are disproportionately underrepresented and nursing home residents pay for their services with private funds. Eventually, if the residents live long enough, those private funds will run out, requiring the residents to enroll in Medicaid to continue receiving services. Federal law prohibits nursing homes from discharging residents because they become enrolled in Medicaid. Thus, the private pay beds are converted to Medicaid beds, but the people in those Medicaid beds are not those originally intended to be beneficiaries of Medicaid, rather it’s the formely-affluent white resident who ran out of money, leaving historically-poor Blacks to find other, likely substandard, means of long-term care.

Thad Kousser, The Politics of Discretionary Spending, 1980-1993, 27 Journal of Health Politics, Policy & Law 639 (2002). Pages: 26.

Through detailed analysis the author attempts to demonstrate the influence that state politics have on funds allocated to the Medicaid program. The author makes clear that by “political power” the author means which party controls (greater than 50%) the state legislature, not the political party of the governor. Additionally, the author indicates that his focus is only on discretionary spending of the Medicaid program over which the states have considerable latitude.

One of the interesting findings that supported the author’s initial research was that studies have shown that the larger a state’s nonwhite population is, the less money the state’s leaders allocate to welfare program that tend to disproportionately benefit minorities. This seems somewhat backwards because, as statistics have shown, minorities are heavily depended on state welfare programs, including Medicaid. The proffered explanation for this phenomenon is that race is a more politicized issue in those states and state leaders, in an effort to not polarize white voters, curtail spending on such social benefit programs.

Ruqaiijah Yearby, African Americans Can’t Win, Break Even, or Get Out of the System: The Persistence of “Unequal Treatment” in Nursing Home Care, 82 Temple Law Review 1177 (2010). Pages: 29.

This article focuses primarily on the disproportionate representation of African Americans in low quality long-term nursing homes as compared to whites. As a basic foundation for the author’s argument, three levels of racial bias are identified: Structural, institutional, and interpersonal. The author’s argument of structural racial bias is of particular relevance in regard to the impact of structural barriers on African Americans’ ability to receive equal treatment via the federally funded health programs.

A national study of nursing homes conducted in 2004 concluded that the nursing home system consists of two tiers: high and low. The low tier nursing homes generally have Medicaid as the primary source of payment, poor quality of care, fewer nurses than high-tier counterparts, and a number of other unfavorable characteristics. Alarmingly, albeit not surprisingly, nine per cent of whites reside in these low tier facilities compared to 40 per cent of African Americans.

African Americans are disproportionately represented in the Medicaid program. The Medicaid program only provides limited resources to nursing home facilities that tend to serve a majority of Medicaid enrollees, sometimes paying less than the cost of services rendered. Consequently, because Blacks are over-represented in Medicaid and nursing home facilities that cater to a predominantly African American populations tend to be of lower quality, African Americans are adversely impacted in quality of care and resources allocated to long-term care facilities.

Laura Hermer, The States’ Challenge to the Affordable Care Act’s Medicaid Expansion, 33 Whittier Law Review 1 (2011). Pages: 10.

The author outlines the challenges that have been raised by a number of states to the Affordable Care Act [“ACA”]. These challenges arise as a result of fundamental tension between state and federal interests and authority [“Your money, my rules”]. Most famously, cases have arisen in Florida challenging the ACA’s eligibility expansion of the Medicaid program to include childless adults who are under 65. Additionally, the Constitutional challenges to the ACA focus on the ACA’s attempt to implement a near-universal program system of health care coverage. A controversial way the ACA seeks to accomplish this goal is by imposing a penalty, effective in 2014, on individuals who do not have some source of health care coverage. States claim that this is effectively Congress over-stepping its boundaries and regulating what should be considered a matter of state concern.

The author proposes that Medicaid be federalized. Under the current structure, Medicaid is funded by state and federal funds. States are required to provide a minimum level of coverage to a federally-mandated population but retain some latitude in who is covered and what services are covered. The author suggests changing the system to be wholly-run by the Federal Government and funded by a payroll tax, similar to the Medicare program. The increase in funding through this structure would allocate a portion of funds to increase provider reimbursement to at least match Medicare levels.

Matthew McKennan, Medicaid Access After Health Reform: The Shifting Legal Basis for Equal Access, 7 Seton Hall Circuit Review 477 (2011). Pages: 30.

The author focuses on the changes to the Medicaid that have been, and will continue to be, implemented as a result of the passing of President Obama’s Patient Protection and Affordable Care Act in 2010. The author identifies many of the well-known deficiencies of the Medicaid program, including low reimbursement rates that serve as strong disincentives to provide care, and subsequently access, to the low income population enrolled in the Medicaid program.

The crux of the author’s work is the fact that there need to be changes to the legal framework for holding the state and federal governments responsible for running a Medicaid program that doesn’t create a chasm between the care and services received by those enrolled in Medicaid and those covered by private insurance. The author suggests a private right of action to enforce the Medicaid Act, most specifically, §30(A) which requires that Medicaid rates be maintained at a level above that which becomes cost-prohibitive for providers treating Medicaid enrollees. The author proposes that this would hold states accountable for ensuring that the low income population’s access isn’t hampered by private physicians electing to not participate in the Medicaid program because of low reimbursement rates.

Sara Rosenbaum & Benjamin D. Sommers, Rethinking Medicaid in the New Normal, 5 St. Louis University Journal of Health Law & Policy 127 (2011). Pages: 20.

This article focuses on a discussion of the concerns related to the proposed expansion of Medicaid eligibility as a result of the Patient Protection and Affordable Care Act (“ACA”). The concern of particular relevance and importance is whether the proposed expansions will simultaneously expand access, rather than simply increase eligibility to a program that only nominally provides access to the intended populations. Low rates of provider reimbursement, leading to provider non-participation, serves as a significant barrier to access to many of Medicaid’s intended low-income beneficiaries.

As a remedy to the history of categorical exclusion, the authors address some of the proposed changes to Medicaid that are expected to increase access to the low-income individuals, including: Financial support from the Federal Government to support new enrollees and simplification of the Medicaid enrollment process coupled with streamlined eligibility determination. Ultimately, the authors conclude that the continuation of Medicaid is vital to the support of low-income individuals and that the ACA makes respectable efforts to increase access while eliminating barriers that have been a staple of the program.

Renee M. Landers & Patrick A. Leeman, Medicaid Expansion Under the 2010 Health Care Reform Legislation: The Continuing Evolution of Medicaid’s Central Role in American Health Care, 7 National Academy of Elder Law Attorneys Journal 143 (2011). Pages: 24.

This article provides a solid summary of the changes to the Medicaid program via the eligibility expansion provisions implemented under the Patient Protection and Affordable Care Act (“ACA”). The article also provides information on how these expansion provisions are supported financially as a result of covering “new” populations with a basic level of health care services. The article also addresses the opposition to the changes to the Medicaid program via the ACA. Of most recent interest, the ACA has been challenged by the states on the ground that the “penalty” is not a constitutional exercise of the Federal Government’s authority under the Commerce Clause.


Websites:

The Henry J. Kaiser Family Foundation, Medicaid’s Role for Black Americans, http://www.kff.org/medicaid/upload/8188.pdf (accessed Feb. 11, 2012). Pages: 2.

This article provides census data and analysis related to the insurance coverage of Black Americans. The articles points out that, in 2009*, almost one in three Blacks were covered by Medicaid. Additionally, more than one in five Blacks was completely uninsured. Approximately 75% of poor and near-poor Blacks were covered by Medicaid. What about the other 25%? Finally, there are substantial revisions to the Medicaid program, via the APA, that will make an additional four million Blacks eligible for Medicaid.

*All data is taken from 2009

 

The Henry J. Kaiser Family Foundation, A Guide to the Supreme Court’s Review of the 2010 Health Care Reform Law, http://www.kff.org/healthreform/upload/8270-2.pdf (accessed Feb. 20, 2012). Pages: 10.

This article addresses the main issues to be addressed in oral arguments to the Supreme Court in late March 2012. The primary issues of Constitutional concern are: The individual mandate of insurance coverage and the expansion of Medicaid coverage.

Medicaid generally covers pregnant women and children under the age of six at or below 133% of the federal poverty level (FPL), children ages six through 18 with family incomes at or below 100% of the FPL, and adults who qualify for social security based on low income and disability status (population is generally 65 or older). The expansion to Medicaid eligibility seems to extend to most low income people (not just women and children) who are at or below 133% of the FPL. This expansion is anticipated to provide eligibility for an additional 16 million Americans. It seems that one of the concerns from the perspective of the states is the cost associated with coverage of this additional population as Medicaid funding is supplied jointly by states and the federal government. The government will initially foot the bill of the expanded coverage, but the government’s contributions will decrease in subsequent years, pushing the cost to the states.

The Henry J. Kaiser Family Foundation, Explaining Health Care Reform: Questions about Medicaid’s Role, http://www.kff.org/healthreform/upload/7920-02.pdf (accessed Jan. 23, 2012). Pages: 4.

This article addresses a number of the widely-discussed revisions to the Medicaid program that are scheduled to take place under the Affordable Care Act, including: the expansion in Mediciad eligibility, the individual mandate for insurance coverage, subsidies provided to help low-income persons obtain health insurance.

U.S. Department of Health and Human Services, Medical Loss Ratio: Getting Your Money’s Worth on Health Insurance, http://www.healthcare.gov/news/factsheets/2010/11/medical-loss-ratio.html (accessed Feb. 11, 2012). Pages: 4.

Insurance companies have been portrayed as villains in the healthcare industry because of the profits that continue to grow even as the country has struggled through the recent recession. This article addresses a number of the changes in the Affordable Care Act that will increase the transparency and accountability of insurance companies.

In addition to requiring insurance companies to report how premium dollars are spent, insurance companies are required to spend at least 80% of premium dollars received on medical care and quality improvements. These requirements will serve one the Affordable Care Act’s many goals – To arm consumers with information about their health care options thus causing consumers to take a more active role in the health care status.

One problem experienced by low income people of color is limited access to quality health services. The Affordable Care Act contains provisions to increase financial investment in community health centers, one of the more common location where low-income individuals go to receive care. Subsequently, this is expected to improve the number of visits by low-income individuals, as well as the care received at these locations.

The Henry J. Kaiser Family Foundation, The Digital Divide and Access to Health Information Online, http://www.kff.org/kaiserpolls/upload/8176.pdf (April 2011). Pages: 2.

The Affordable Care Act contains provisions that require the health information related to the federal programs and insurance alternatives be posted on the internet. This article provided demographic data that showed that almost four of 10 Blacks that earn less than $40K per year do not have a computer in the home. Additionally, of the same population, only four of 10 have used the internet to access health information. This leads to the conclusion that efforts should be made to increase awareness of the availability of health resources online, specifically targeting low income individuals who will likely be impacted by the expansion of the Affordable Care Act.

Lisa Potetz, Juliette Cubanski and Tricia Neuman, Medicare Spending and Financing, http://www.kff.org/medicare/upload/7731-03.pdf (accessed Feb. 7, 2012). Pages: 20.

This article provides a very broad overview of the Medicare program and many of the financial components of the program. The Medicare program is administered and funded entirely by the federal government. The program is pervasive, with Medicare spending accounting for 20% of all dollars spent on health services in 2008. Additionally, Medicare spending represented 15% of the United States’ federal budget in 2010 and is expected to account for more than 17% of the federal budget by 2020. One of the most prominent financial burdens on the Medicare program is the aging population in the United States. Between the years of 1995 and 2009 Medicare enrollment grew by an average of 623,000 enrollees each year. Between the years 2010 and 2030, Medicare enrollment is expected to grow by an average of 1.6 million enrollees each year, putting additional strain on resources.

The Henry J. Kaiser Family Foundation, Health Reform and Communities of Color: Implications for Racial and Ethnic Health Disparities, http://www.kff.org/medicare/upload/8016-02.pdf (accessed Feb. 11, 2012). Pages: 14.

People of color comprise 50% of the total uninsured population in the United States. This article explores the efforts made in the Affordable Care Act to address the cultural and racial disparities in healthcare coverage and access to healthcare resources.

This article quite adeptly points out that the Affordable Care Act’s provisions related to Medicaid’s eligibility expansion do not necessarily equate to an identical increase in enrollment. States will retain considerable latitude in enrollment procedures which currently work to exclude at least some eligible persons that would enroll in Medicaid with more simple procedures.

Another problem that disproportionately affects low income persons enrolled in Medicaid is limited availability of quality physicians providing care to Medicaid enrollees. This problem is generally related to reimbursement rates under Medicaid. The Affordable Care Act imposes a temporary increase in rates to fall more closely in line with Medicare reimbursement rates to incentivize physicians to provide services to enrollees.

The Henry J. Kaiser Family Foundation, Explaining Health Care Reform: How Will the Affordable Care Act Affect Small Businesses and Their Employees?, http://www.kff.org/medicare/upload/8275.pdf (accessed Feb. 11, 2012). Pages: 3.

Small businesses (businesses with no more than 50 employees) have notoriously failed to provide employees with adequate employer-sponsored health benefits. In 2011 more than 40% of small businesses offered no health benefits to employees compared to three per cent of businesses with more than 100 employees that did not provide health benefits to employees. The Affordable Care Act attempts to increase the availability of employer-sponsored health benefits to employees in small businesses. Insurance plans purchased by small businesses will be required to provide a minimum level of coverage to employees.

To increase the availability of employer-sponsored health benefits plans of small businesses, the Affordable Care Act imposes penalties on small businesses that do not provide employees with access to affordable insurance plans. Additionally, some small businesses with fewer than 25 employees will be eligible for tax credits for providing employer-sponsored plans (with some limitations).

 

Marsha Lillie-Blanton, Julia Paradise, Megan Thomas, Paul Jacobs and Bianca DiJulio, Racial/Ethnic Disparities in Access to Care Among Children: How Does Medicaid Do in Closing the Gaps?, http://www.kff.org/minorityhealth/upload/8031.pdf (accessed Feb. 14, 2012). Pages: 15.

This article examines the health disparities among children enrolled in the Medicaid program as compared to children who are either uninsured or covered by private insurance. The four indicators of access used in the analysis include: usual source of care, failure to have at least one ambulatory medical visit in the past year, persons reporting problems getting to necessary care, and persons reporting problems seeing a specialist. One of the more notable findings in this report is that while insurance increases access to care for children of color, barriers to access to care tend to disproportionately affect children of color.

The Henry J. Kaiser Family Foundation, Medicaid and the Uninsured: Key Questions About Medicaid and Its Role in State/Federal Budgets and Health Reform, http://www.kff.org/medicaid/upload/8139.pdf (accessed Mar. 18, 2012). Pages: 6.

The Affordable Care Act makes significant changes to the Medicaid program and this article serves as an overview of some of the changes incorporated in the statute. The article begins by providing a baseline review of Medicaid and its intended purpose, which is to provide a base level of healthcare coverage for low income and high need Americans. A problem that becomes evident, perhaps unwittingly, from the information in this article is the relationship between populations enrolled in Medicaid and the proportion of the total dollars spent on the respective populations. For example, dual eligibles (those who are eligible for Medicare and Medicaid) account for approximately 15% of Medicaid spending, but take up approximately 40% of all Medicaid spending. Additionally, elderly and disabled enrollees account for 25% of total Medicaid enrollment but consume about 66% of Medicaid dollars. This implores the observation that Medicaid dollars may be diverted from the intended beneficiaries and given to another population. The Affordable Care Act takes strides to remedy this disparity by expanding the eligibility of Medicaid by eliminating the requirement of having a dependent and increasing the income eligibility thresholds.

The Henry J. Kaiser Family Foundation, Income-relating Medicare Part B and Part D Premiums Under Current Law and Recent Proposals: What are the Implications for Beneficiaries?, http://www.kff.org/medicare/upload/8276.pdf (accessed Feb. 20, 2012). Pages: 11.

This article provides an overview of Medicare Parts B & D, respectively, outlining the efforts of policymakers to subsidize the increasing cost of the Medicare program. Some proposals seek to increase enrollment premiums across the board, while other proposals implement income-related increases in premiums. It is estimated that, with implementation of the income-related proposals to Medicare Parts B &D, more than 20 million beneficiaries will be subject to the income-related premiums, compared to approximately 7 million beneficiaries under current law.

Office of the Legislative Counsel, Compilation of Patient Protection and Affordable Care Act, http://housedocs.house.gov/energycommerce/ppacacon.pdf (accessed 4/13/12). Pages: 24.

One of the key provisions of the Patient Protection and Affordable Care Act (“ACA”) is the law’s eligibility expansion provision. Eligibility expands to include persons under the age of 65, who are not pregnant, and whose income does not exceed 133% of the federal poverty line. This expansion serves as a significant departure from Medicaid’s initial eligibility ties to the welfare program. The significant cost of covering newly eligible persons will, initially, be borne solely by the federal government through increased federal contribution for this new population of beneficiaries.

Through the law, the government takes a more purpose-focused approach by providing financial incentives for states to implement preventive programs and meeting health outcomes targets. This seems to show the government’s desire to provide more than a healthcare program in name only, but focusing on creating a healthier population.

The ACA also contains provisions that specifically relate to improving the access to health services and the health status of minorities. The federal government will appropriate funds for the improvement of minority health through increased access and education until the year 2016.

The ACA also addresses provider enrollment by increasing the reimbursement rate for Medicaid to at least match the Medicare rate. This will specifically address the issue of primary care physicians electing to not provide care to Medicaid populations because of low reimbursement rates. It must be noted that these increased rates are only in effect for 2013 and 2014.