Texas regulations permit insurance firms to sell a broad range of small company healthiness care schemes. The multiplicity of choices can end up rendering the exercise of establishing the appropriate worker health scheme taxing.
At the same time it can as well make it possible for employers to pick best schemes to appropriately suit them and their members of staff. It is therefore advisable to look around so as not to miss important details whenever out to select a health scheme for whatever kind of business or establishment.
The reference small employer in connection to insurance in Texas refers to an establishment with eligible workers ranging from two to fifty in number. The regulations offers such establishments extra safeguards, entailing a 15% once a year cap on rate augments connected to fitness aspects, an assurance that carriers cannot illogically put an end to coverage, and a proviso that permits small companies to team their procuring power to bargain cheaper insurance tariffs.
For workers of small establishments, the regulations offer a number of means to keep up benefits following departure from a job and restrict the waiting time ahead of a health scheme catering for pre-existent terms.
Away from these conditions, small-employer bearers may provide a broad array of schemes, with practically any arrangement of conditions and benefits.
Federal Health Reform
The national health care development regulation calls for insurance firms to offer considerable extra coverage(s) and makes stronger purchaser safeguards beginning with health insurance guidelines given or revamped after September 23, 2010.
Establishments with twenty five or lesser full-time workers that forfeit for at any rate 50% of bounties and remit mean yearly wages under $50,000 may be qualified for a tax acclaim of up to 35% of the bounties that the enterprise remits. These credits will go up later in 2014.
Small-Employer Coverage Eligibility
Texas establishments having two up to fifty members of staff may take small-worker coverage from an insurance firm or a health protection firm. Qualified workers are those who normally work leastways thirty hours in a week.
These are not provisional, or cyclic, and are not by the time of taking the coverage covered by any other group health scheme. Individual property owners, associates, and autonomous contractors are also entitled workers if the business decides to provide them with health care coverage. A venture(s)s proprietors count toward the worker entirety.
The amount of qualified workers, as opposed to the total workers, verifies whether an establishment is a small worker under Texas insurance regulation(s). For instance, if ones venture has sixty total workers, it could still make the grade if six of the employees are part-time and four hold coverage through some other scheme, such as a partners health scheme.
If the owner of a given business decides to provide a health scheme to his or her workers, he or she has to make it by the same token available to all of the qualified workers and their dependants.
Leastways 75% of a small employers qualified workers have to take part in the health scheme for the employer to acquire coverage. Carriers have to at all times round out when working out the amount of qualified staff members. For instance, a five-worker set would attain 75% involvement if three qualified workers take part. 75% of 5 are 3.75, and this figure is rounded out to 3.
In the instance of a venture with just two qualified workers, the regulation offers that there needs to be 100% involvement. A husband and spouse working at the same establishment are taken as two distinct workers. None of the two is qualified for coverage as a dependant of the other.
For those who offer a health scheme, national and state regulations permit workers to keep up benefits for a span of time following parting from the occupation. It is the insurance providers legal obligation to bring up to date workers of their liberties to uphold coverage.
Previous workers who choose to maintain their coverage have to pay the full charge of the scheme. The insurance provider is not required to throw in toward their bounties, regardless if the provider earlier paid a contribution.
Types of Schemes
Health insurance schemes are categorized as either government-consented schemes or end user preference schemes. A government-consented plan offers a given obligatory least aspects and coverage(s). An end user preference scheme is any scheme built up by a carrier that leaves out some government-consented benefits. One will normally have a lesser bounty for end user preference schemes.
Even though end user preference schemes are at times referred to as regular schemes, the coverage(s) offered are not evened out. Every carriers end user preference scheme may be diverse, and a carrier may provide a number of various end user preference schemes.
End user preference schemes cannot leave out a number of government-consented coverage(s). These include difficulties of pregnancy, least hospice stay following childbirth and restoration surgery.
Whenever presenting would-be insurance subscribers with an end user preference plan(s), providers have to incorporate on paper an expose that catalogs the government-consented scheme that are not offered.
In January 2021, the Department of Health and Human Services Office for Civil Rights announced that Excellus Health Plan, a health insurance provider, had agreed to pay $5.1 million. The money was paid as a penalty for a HIPAA violation case for a data breach that affected 9.3 million individuals (Cohen, 2021). The companys computer systems had been accessed by hackers for two years between 2013 and 2015. The malware had been installed into the companys computers and data for approximately 9.5 million customers accessed (Cohen, 2021). This data included names, contact information, dates of birth, social security numbers, health plan ID numbers, claims data, financial accounts, and clinical treatment information. Investigations revealed that the company was not in compliance with several HIPAA regulations and was, therefore, fined.
Mitigation or Prevention of Breach
Excellus Health Plan could have prevented the breach of the HIPAA privacy and security regulations by conducting regular risk analyses to identify weaknesses in their systems. These investigations into the electronically protected health information would have helped them invent means of strengthening their systems to combat malware. Additionally, the company could have ensured that its data is appropriately protected by ensuring that only authorized persons access it since the breach resulted from unauthorized access. The company could have established policies for regular reviews of the information system. These policies would have been a source of immense assessment of the electronic data and devices to ensure maintenance is within company needs and regulations. The company could seek the services of electronic system developers to ensure their electronic devices were installed with the latest malware detection and elimination tools.
Office for Civil Rights Enforcement Activities and Results
Similarities
In the majority of the cases, there is a third party entity that gains access to confidential information belonging to clients, therefore, violating their privacy. The access to data in most situations results from an insufficiency on the part of the party entrusted with the information, whether an insurer or a hospital (HIPAA Journal, 2021). The cases of HIPAA violations result in huge financial losses for the organizations entrusted with safeguarding such information.
Differences
A major difference arises in the nature of the institutions entrusted in safeguarding health information which includes hospitals and insurance agencies. There is a wide range of information that is divulged during the violation of the HIPAA rules, ranging from personal information to medical and financial information (HIPAA Journal, 2020). The nature of the HIPAA violations also varies, ranging from hacks of electronic devices using malware, diverging of information by staff, and data leak through unauthorized access.
Security Rule Violations and Privacy Rule Violations
Most of the security rule violations also involve privacy rules violations as there is the access of restricted information and divulgence of the same. Most cases present with the use of malicious malware to access protected data without the consent of the insurers and inappropriate use of that information (HIPAA Journal, 2019). The information is reportedly sold to the highest bidders who use this information for their own marketing needs, interfering with the lies of the patients.
Types of Cases and their Resolution
The cases were mostly due to negligence on the part of the organization entrusted with protecting the information. The most popular method of punishing the culprits involved fining them lsums of money for compensation (HIPAA Journal, 2019). This is appropriate, alongside proper modifications to their systems to ensure compliance with HIPAA rules. Additional monitoring is also crucial and is part of the resolution of most cases as it ensures such errors are avoided in the future.
The functioning of any healthcare institution is organized in accordance with specific rules that are introduced to guarantee its further rise and positive outcome when working with patients. The given paper is devoted to the investigation of the role some states play and the impact they have on the healthcare sector.
Besides, HIPAA Administrative Simplification Statute and Rules provides the necessary information related to the rules that should limit the functioning of both specialists and organization. For instance, the enforcement rule outlines the standards required for the enforcement of all Administrative Simplification Rules and guarantees the increased efficiency of the collaboration between different departments, collectives, teams, etc. ( The HIPAA Enforcement Rule, n.d.) The given rule could also be considered in terms of the health information system. It creates the basis for the further rise of the sector and the creation of long-term links between the integral elements of any care provider. In other words, a health information transaction becomes less complicated and contributes to the improved outcomes of the whole sphere. Additionally, the given rule also guarantees that the most essential requirements will be met, and crucial tasks will be performed. In this regard, enforcement, as one of eight major components of HIPAA, becomes a central concept for the given rule that should be appreciated and given great attention.
There is also a Security Rule that is also created to guarantee the protection of crucial information and provide specific safeguards that are needed to prevent the appearance of different complications. There could be administrative, technical, and physical safeguards introduced to protect PHI ( Summary of the HIPAA Security Rule, n.d.). All these elements of the security system are essential as they contribute to creating an efficient security system. For instance, technical safeguards audit controls the hard and software that are needed to store and protect PHI. Additionally, technical safeguards are also responsible for the transmission of security, which means that they trace any attempt of unauthorized access and guarantee that all information is protected. Hence, any health information professional should obviously possess in-depth knowledge of the given safeguard. There are several reasons for this statement. First, knowledge of the essential elements of this safeguard will contribute to the increased efficiency of a professional. Moreover, it will help to protect certain information better and guarantee that all problematic areas will be covered. Finally, good comprehending of these peculiarities might also ensure that a specialist will perform the major tasks on a high level.
Finally, there is also a specific Privacy Rule, which provides a set of national standards for the protection of certain health information (Rothstein, 2013). It means that any person who addresses any healthcare establishment has the right to privacy and might insist on the protection of the information that he/she shares with a health care specialist. Additionally, another main goal of the privacy rule is to assure that all information related to the functioning of a hospital or other establishment is adequately protected (Rothstein, 2013). This very rule covers all patients and workers functioning in the given sphere and presupposes specific penalties for those who act not in accordance with the basic principles outlined by the given statute.
Altogether, all the above-mentioned rules are introduced to guarantee the efficient functioning of the health care sector and other institutions that belong to it. Investigation of these postulates ensures increased efficiency and positive outcomes.
References
Rothstein, M. (2013). HIPAA Privacy Rule 2.0. The Journal of Law, Medicine & Ethics, 41(2), 525-528. Web.
The Dubai Health Authority is anchored on two major ideals. First, all residents of the city ought to have access to healthcare. Secondly, healthcare must be of high quality that can fulfil the needs of the targeted population. It is a requirement for all residents and nationals of Dubai to have mandatory healthcare coverage. In Abu Dhabi, the mandatory health insurance law was enacted in the year 2005. The requirement is extended to companies in Abu Dhabi and migrant workers in the company.
There are several relevant outcomes deduced from these laws in the United Arab Emirates. First, all residents of the two cities of the country are mandated to have insurance covers. Secondly, companies are obligated by the laws in the country to cover all workers with insurance covers. Thirdly, recognition of non-residents as part of targets of insurance covers has helped put all under favourable access to health care.
These elements of healthcare policies in the two cities point to a country focussed on enhancing quality healthcare in the country. However, there are still a number of shortcomings in the two healthcare insurance cover policies. As a way of providing effective mandatory health insurance policies in Abu Dhabi and Dubai, the administrations should focus on the overall cost, localities of coverage by the insurance policies on the insured and the network of services provided in the insurance covers.
Background
Abu Dhabi and Dubai now have mandatory insurance policies enacted in 2005 and 2014, respectively. These laws target nationals and residents of the two cities. The laws also obligate companies in the two cities to cover their employees, whether they are originally from the country or immigrants. According to Jabbour & Yamout (2012), effective healthcare insurance covers are supposed to maximally relieve health burdens of the insured. Insurance covers covering only parts of required healthcare requirements fail to capture the aspirations of the insured, and essentially, is a challenge to the county in attracting foreign investment. There are several shortcomings in Abu Dhabi and Dubai mandatory healthcare insurance policies.
Chapter two, Article 3 of the Law Number (23) of 2005 in the Emirate of Abu Dhabi exempts a number of categories from the health insurance cover. For example, a non-UAE wife who is married to a national in the country is exempted from this healthcare plan.
Also, there is no particular health provision in the law for tourists coming to the country. Chapter 2, Article 4 of the law state that the nationals are not mandatorily required to subscribe to the cities healthcare plan. Such kind of exemptions and non-requirements are general challenges that may harbour or have harboured effective implementation of an effective healthcare scheme. Jabbour & Yamout (2012) is of the view that an effective healthcare insurance scheme is one that is mandatory to all nationals of a country. To non-residents, it is supposed to be voluntary.
The shortcomings witnessed in the two laws governing healthcare access in the United Arab Emirates, and specifically in Abu Dhabi and Dubai compromise the quality of healthcare. Important in good access to healthcare and in instituting insurance healthcare schemes is the leverage of costs, widening the network of access and increasing the scope of access to healthcare. The following discussion looks at major options for an effective insurance scheme.
Option one: Leverage Cost of Insurance Healthcare Schemes
Cost is always a great concern for ineffective access to healthcare. In Dubai, contributions by individuals range between AED 500 to AED 700. While this is recognized as a minimal contribution, the coverage is very minimal. Members in the scheme are therefore expected to contribute more if they are to access wider services of the healthcare plan. Annually, the limit of the claims is AED 150,000.
This includes even coinsurance that is paid by each and every other member. It is possible that the cost may be more than this amount, especially when there are emergencies. This, therefore, does not fully remedy the health problems members may be suffering from. In Abu Dhabi, the annual limit is AED 250,000. While this is significantly high as compared to the limit in Dubai, it still does not offer a comprehensive medical cover as emergencies may push costs higher than the amount quoted. In this, therefore, it is important to leverage contributions. For example, increasing the amount contributed by members as a way of increasing the annual limit will significantly offer members the most needed health relief.
Option two: Increase Network of Services in the Insurance Healthcare Schemes
Based on the contribution, the number of services listed in the two schemes is limited. Essentially, emergencies are not covered by the schemes, while a number of drugs are not accessible through the schemes. For example, for child delivery, AED 500 will be deducted in Abu Dhabi, while in Dubai; there is a 10% co-insurance with AED 7,000 as the limit for normal delivery and AED 10,000 for C-section operation.
For maternity checkups, a member in Abu Dhabi will be required to pay AED 20 for consultation, while in Dubai; there is a limit of 8 visits in the 10% coinsurance plan. This kind of limitation in service provision in the two schemes significantly limits the quality of access to healthcare in the two cities. An effective health care plan is one with total coverage. The solution to this is to put the optimal cost in contribution.
Option Three: Increase the Localities of Access to the Insurance Healthcare Schemes
The two insurance healthcare schemes are listed in the two cities. In Dubai and Abu Dhabi, the schemes are limited to the two cities, with only the emergency treatment being spread to all emirates. This means that a member suffering from an ailment covered by the schemes apart from emergencies can only access the services in the two cities. This clearly highly limits access to quality healthcare. For example, if a member goes to work in another city, he or she would be required to go back to the city of membership to the insurance schemes so as to get the needed medication. This is not a limit to effective healthcare.
The administrations of the two cities need to give reviews to the insurance healthcare schemes to cover localities other than the two cities, but only for members of the schemes. It is also important to increase the network of access to people affiliated to members. For example, non-UAE wives married to nationals cannot access healthcare. This is discrimination as the non-nationals become part of the country on marriage. As a remedy, therefore, it is critical to the increasing locality of access in healthcare.
Recommendations
There are several negative outcomes noticeable in Abu Dhabi and Dubai Mandatory Insurance Healthcare schemes of 2005 and 2014, respectively. The shortcomings are related to the limitation of services, limitation of regions to access Medicare and limitation on annual claims. These shortcomings hamper good delivery of healthcare services in the United Arabs Emirates, and specifically, Abu Dhabi and Dubai.
It is therefore recommended that; one, the cost of a membership to the healthcare schemes be leveraged to increase the limit to annual claims. To, it is important to increase the network of services provided by the two insurance healthcare schemes. Three, it is important to increase localities and regions that the members can access healthcare services covered in the two schemes.
Reference
Jabbour, S. & Yamout, R. (2012). Public Health in the Arab World. Cambridge: Cambridge University Press.
According to the UN, children are one of the most vulnerable populations (Burns, Dunn, Brady, Starr, & Blosser, 2013). Despite the efforts of the U.S. government to ensure a thorough health care coverage for all children who are residents of the country, there remains a number of children who are uninsured and have no access to medical care, usually due to the parents low income and difficult living conditions (HRSA, 2015). This paper aims to examine the gaps in pediatric care coverage, as well as the reasons for these shortcomings.
Analysis
HRSAs (2015) analysis of health care use by pediatric population shows that the primary source of pediatric care is the doctors office: Among children with a usual source of care in 2012, 74.2 percent of children used a doctors office; 23.9 percent used a clinic; and 1.9 percent used the hospital and other places, including emergency rooms and hospital outpatient departments (p. 91). However, the preferred source of care varies considerably by family income, as well as race and ethnicity. For instance, HRSA (2015) states that children with household incomes of less than 200 percent of poverty were about twice as likely to use a clinic as a usual source of care than children with higher household incomes. Insurance coverage provided to children is either public or private, with private insurance usually being provided by the parents employer and public insurance supported by Medicaid or state-governed plans (HRSA, 2015). Childrens insurance coverage varies between populations: where the prevalent type of insurance for non-Hispanic white children is private (68.6), non-Hispanic black children are twice more likely to use public insurance (58.8) (HRSA, 2015). The percentage of uninsured children is high in Hispanic and native populations 11.8 and 11.9 respectively (HRSA, 2015). The overall percentage of uninsured children has been gradually decreasing over the past decade but remains relatively high at 6.6 (HRSA, 2015).
Therefore, the lack of universal insurance coverage is evident, meaning that the current health care sources of the U.S. are not sufficient to cover the entire pediatric population. The majority of child populations that are affected by these impairments are racial and ethnic minorities, such as Hispanic, Native American, and Black (HRSA, 2015). However, the family income also plays a vital role in health care access (HRSA, 2015). One of the main reasons for the difficulties in health care access is the refusal of some states to adopt the Affordable Care Act of 2010 and the Medicaid expansion. According to Blumental, Abrams, and Nuzum (2015), the Medicaid expansion has been effective in lowering the rate of uninsured persons and increasing access to health care, particularly in the low-income, Hispanic, and Black populations: Groups that have historically been at the greatest risk for lacking insurance young adults, Hispanics, blacks, and those with low incomes have made the greatest coverage gains (p. 2451). The overall number of uninsured persons declined from 16.4 million to 7.0 million over the 5-year period (Blumental et al., 2015). Nevertheless, there are 19 states that have not adopted the expansion act yet, which means that the health care access of vulnerable children in these states remains limited.
Conclusion
Overall, it is clear that the vast part of the pediatric population with limited access to healthcare is from low-income, Hispanic, and Black households (HRSA, 2015). The primary barrier that prevents their access to health care is limited public insurance. The ACA has managed to expand health insurance in some states; however, while there are still states that refuse to accept the expansion, the children living in these states will be subject to impaired health insurance and care.
References
Blumental, D., Abrams, M., & Nuzum, R. (2015). The Affordable Care Act at 5 years. The New England Journal of Medicine, 372(25), 2451-2458.
Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2013). Pediatric primary care (5th ed.). Philadelphia, PA: Saunders.
U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA). (2015). Child health USA 2014. Rockville, MD: U.S. Department of Health and Human Services. Web.
The implementation of Health Insurance Exchange in the framework of Obamacare program is likely to have a significant impact on three critical aspects: customers demand, pricing policy, and supply.
First, and foremost, it is necessary to focus on the changes that are likely to take place in the customers demand field. The implementation of the relevant law has transformed the basic principles of demand formation. Thus, people that used to choose whether to purchase a health insurance or not basing on their inner motives and estimations are now legally obliged to have an insurance coverage. Therefore, the major difference resides in the fact that the customers demand is now regulated by law. From the perspective of a free market , the relevant intervention is rather unfavorable. The artificial raising of customers demand minimizes the regulation power of clients in price setting due to the fact that the level of competitiveness in the insurance market will sag significantly (Glied and Ma 9). In the meantime, some specialists note, the increase in the demand is not as crucial for the market as it might seem. It is presumed that even though more people will now have a medical health insurance, the majority of them will not use the medical services more frequently than they used to do (Brezina et al. 194). In other words, people who purchase health insurance will not necessarily use them in practice. Therefore, the pressure on the supply sector might turn out to be less critical than one might expect.
The lack of balance between demand and supply is likely to have a negative impact on price setting. According to the basic principles of the law of the market, the decrease in supply leads to the inevitable cost rising. Thus, many analysts state that the implementation of the relevant law deprives American people of the right to control and regulate the costs of their medical service (Boyes and Melvin 89). Therefore, health insurance companies will receive a chance to impose higher costs for less medical care. Thus, the principal argument of the supporters of the Obamacare program that the new regulation provides equal terms for receiving the service seems to be irrelevant. In order to compensate for the reduced prices offered to particular social groups, health insurance companies will raise the costs of service for other people (Holahah and Garrett 2).
In addition, the implementation of the relevant law is likely to have negative outcomes from the standpoint of supply. Hence, according to the experts opinion, the health care market will face the problem of the supply shortage due to the sharp increase in customers demand. Most specialists agree on the point that the system overload is inevitable with the implementation of the new regulations (Mulligan 3). The American health care workforce has experienced the shortage of specialists for several decades. Now that the demand will rise significantly, there is no doubt that this shortage will become particularly critical. The decrease in supply is likely to result in a series of negative consequences such as additional difficulties in accessing providers, reduced time of service, increased cost, extended waiting time, and the general decline of the quality of the care delivery (Anderson par.2).
The relevant analysis shows the close interconnection between demand, cost, and supply. The principal negative impact of implementing Health Insurance Exchange , therefore, resides in disrupting the balance between these elements that is critical for a free market .
Boyes, William, and Michael Melvin. Microeconomics, Boston, Massachusetts: Cengage Learning, 2015. Print.
Brezina, Paul, Anish Shah, Evan Myers, Andy Huang, and Alan DeCherney. How Obamacare Will Impact Reproductive Health. Seminars in Reproductive Medicine Journal 31.1 (2013): 189-197. Print.
For health insurance to be effective, different aspects must be put into consideration. Universal coverage is a basic element of health insurance. Health insurance should cover majority of citizens in a particular country. In addition, health insurance should be continuous. Continuity allows early detection of a disease and uninterrupted treatment.
Moreover, health insurance should be affordable to low income families and individuals (Gunnar, 2006).Affordability includes incentives, inflation controls and cost to offer cost-effective services.
As a result, health insurance can be accessible to low-income individuals and families. Health insurance should promote health and well-being of those it covers. It should include mental health and preventive services. These elements can be summarized as: efficiency, effectiveness, patient-centered services, timeliness and equity (Quadagno, 2005).
There are several associated with the use of employment based coverage. Quadagno states (2005) that research has made it evident that it is always cheap for a worker to get a health insurance through his employer than doing it himself. It is because the employer can negotiate prices with issuers because he represents many workers.
This also becomes easy for the insurance company because it spends less per person as compared to insuring an individual. It is an advantage to the issuer in that the financial risks are spread over a group of people. In addition, the program ensures delivery of quality healthcare services. As a result, innovativeness is a key element in this program.
Employer based health insurance has drawbacks too. First, all citizens cannot have access to it because employers offer coverage to their employees only. In addition, if an employee decides to quit his job or resign he losses his coverage. In addition, the choices of healthcare plans are limited because the company intents to minimize the costs. Employer based insurance lacks universal coverage. As a result, the program lacks portability and benefits are not transferable (Quadagno, 2005).
There are basic elements which need to be incorporated in health insurance programs to ensure the poor and uninsured have access to insurance health. These elements should ensure services have the following characteristics: affordable, cost-shared, accessible, extended scope of benefits and financed.
The best way that has been known to provide health care to the poor and non insured is through provision of affordable premiums. Statistics show that nine out of ten of the uninsured families and individuals are classified as poor or low-income group (Gunnar, 2006).The premiums offered are expensive and this group of persons cannot afford to pay. Provision of affordable premiums can accommodate the poor and low-income persons (Quadagno, 2005).
Poor families and individuals are at high risk of being uninsured. In addition, this group of uninsured persons is in moderate or low income families. Cost sharing is essential in provision of health insurance to the poor and uninsured. The employers can contribute towards the payment of premiums for their employees. As a result, the poor can afford insurance premiums through cost sharing (Gunnar, 2006).
Stakeholders involved should review the existing health insurance programs to identify and address the gaps in accessibility of services. Insurance companies lack health insurance for children and the elderly (Gunnar, 2006). However, some insurance companies have revised eligibility of individuals to be covered to provide inclusive services.
Every citizen in a particular country should access health insurance. Services offered should be universal to ensure coverage of all citizens in a particular country. In addition, the scope of benefits should be reviewed to ensure all members of family are covered (Gunnar, 2006).
References
Gunnar, W. P. (2006). Fundamental Law That Shapes the United States Health Care System: Is Universal Health Care Realistic within the Established Paradigm, The Annals Health L., 15 (2), 151.
Quadagno, J. (2005). One nation, uninsured: Why the US has no national health insurance 5(3), 23-30.
The State Childrens Health Insurance Program (SCHIP) is an association of the federal government with the states whose aim is to give health insurance compensation to children from low-income families younger than 19 years old who are not fit for Medicaid (National Conference of State Legislatures [NCSL], 2007). Unlike Medicaid, SCHIP is designated not to individuals but states (NCSL, 2007). The states allocate the costs differently depending on the number of children in need and the health problems which they need to solve. One of the problems with SCHIP is that dental care is not compulsory under its regulations (Booth & Edelstein, 2006). Due to this crucial sphere of healthcare being optional, SCHIP makes the care system insecure, vulnerable, and irregular. It has been established that preventive dentistry is highly required among children whose families fit for SCHIP. Moreover, there is evidence of preventive dental care being rather cost-effective (Booth & Edelstein, 2006). Unfortunately, there is no settled standard in the allocation of costs for dentistry in every state. Such way of things leads to the decline of the number of healthcare services associated with dental care (Booth & Edelstein, 2006). Furthermore, the situation is aggravated because of the suggestion to implement cost sharing in SCHIP.
I think that the idea of cost sharing may impact the families eligible for SCHIP in a rather adverse way. The core idea of such programs as Medicare and SCHIP is to support the families who do not have enough resources to pay for the insurance. Consequently, they cannot afford to pay for healthcare services as a part of the program. Thus, cost sharing may lead to the restraint of these childrens chances to receive proper medical care (NCSL, 2007). Because of the implementation of cost sharing, the yearly allowances for the families eligible for SCHIP have been significantly reduced, leading to the impossibility of dental care for the children (NCSL, 2007). In my opinion, cost sharing should be considered very cautiously when it comes to those who are in Medicaid and SCHIP programs. Some families aided by these projects may afford copayments or premiums. However, most of the families cannot cover such expenditures and, as a result, are not able to obtain the necessary care. This situation is particularly common in the families with low income and serious or numerous health issues. The National Conference of State Legislatures (2007) remarks that the resilience allotted to the states in creating their SCHIP programs makes it possible to initiate some advantageous healthcare projects. However, I think that the problem of cost sharing outweighs the positive features of SCHIP. The government should take care of those who cannot afford insurance. Thus, before the implementation of cost sharing, a detailed plan should be developed which would make it possible to differentiate between the families who can participate in cost sharing and those who cannot do that. By doing so, the government will not deprive the children of the healthcare they need. Dental care demands a lot of expenses, and thorough consideration should be paid to its allotment. Children whose families cannot afford to pay for dental care should be eligible to receive it for free. Cost sharing may be a good idea, but it should only be applied to the families whose income allows them to cover a part of their healthcare expenses.
Vulnerability of a population is defined by access to health care and overall health outcomes (Grabovschi, Loignon, & Fortin, 2013).
Health policies aim to coordinate delivery of healthcare services, financing, and other practices while considering a broad range of health determinants.
The Childrens Health Insurance Program (CHIP) is an example of an effective policy that allows meeting the needs of a vulnerable population.
As stated by Grabovschi, Loignon, and Fortin (2013), the term health care disparities refers to differences in the quality of health care in terms of access, treatment options, prevention and health outcomes across groups that reflect social inequalities (p. 94). Population groups that are at risk of limited access to high-quality care are defined as vulnerable; it is clear that effective policies should be implemented to ensure better quality of life for vulnerable individuals. In light of these facts, in this presentation, I would like to discuss the role of the Childrens Health Insurance Program (CHIP), a component of U.S. health policy regulating different mechanisms for the financing, insurance, and rendering of individual-level medical services for children. During the policy review, I will talk about CHIPs impacts on nursing practice and changes that could be made in the policy to make it more applicable to nursing today.
Policy Description
Target population: uninsured children (aged 0-18) from lower-income families and not eligible for Medicaid.
CHIP and Medicaid complement each other to provide insurance to both lower- and middle-income children (He & White, 2013).
States have flexibility in designing their CHIP eligibility criteria.
Typical CHIP eligibility criteria:
Children between 0 and 18 years old,
Families having annual income up to US $44,000 per 4 members,
Income cutoffs between 200 and 300 percent of the federal poverty level (He & White, 2013).
The CHIP provides public healthcare coverage for uninsured children who are not eligible for other insurance options. The policy primarily focuses on lower-income families that do not have access to employer-sponsored insurance and who, at the same time, earn too much to enroll in Medicaid but cannot afford private insurance. As noted by He and White (2013), CHIP and Medicaid are layered programs, in the sense that CHIP eligibility begins where Medicaid eligibility ends and extends to higher income levels (p. E3).
KEY features
Provides expansive benefits, including dental care, hearing and eye exams, and so forth.
Unlike many private insurance programs, the CHIP provides a more expansive list of benefits for children, such as dental care (Paradise, 2014). Moreover, Paradise (2014) notes that of key importance for children with special health care needs, all CHIP programs cover physical, occupational, and speech and language therapies, often without limits (p. 1). Overall, the CHIP offers strong financial protection for lower-income families and their children and reduces out-of-pocket expenses to a minimum.
As stated by Bailey et al. (2016), CHIP was informed by evidence that uninsured children have significant unmet healthcare needs, and the program partially became responsible for the uninsured rate among children in the United States (US) dropping from 14% in 1997, when CHIP began, to 7% in 2012 (p. 947). The exhibit presented on this slide was created by He and White (2013) with the use of data provided by the U.S. Census Bureaus Current Population Survey Annual Social and Economic Supplement. The vertical line indicates the point in time when the CHIP was enacted and marks a decline in the share of uninsured children and an increase in the public health coverage rate in the same population group.
Vulnerable Population: Lower-Income Individuals
Lower-income people are exposed to a greater number of environmental hazards:
Limited access to healthy eating options,
Poor housing conditions,
Substance abuse,
Life in disadvantaged neighborhoods, and so forth.
Lower-income individuals interact less with healthcare practitioners due to a lack of insurance coverage and tend to suffer from chronic illnesses more frequently (Joszt, 2018).
As mentioned previously, vulnerable population groups are comprised of individuals with limited access to health care. Individuals belonging to these groups are also at risk of poor health outcomes due to various detrimental environmental influences. Such features are easy to find in lower-income families, who often cannot afford medical assistance and may fail to maintain a proper quality of life due to disadvantaged socio-economic conditions, affecting their food choices and stress levels, limiting their choices for accommodation to inadequate housing, and so forth. Statistics show that low-income people are more prone to develop chronic conditions and tend to have more comorbidities and severe symptoms than those with higher-income status (Joszt, 2018). Moreover, individuals from racial and ethnic minority groups are also disproportionally represented in the given vulnerable population (Joszt, 2018).
Vulnerable Population: Children
Children are not small adults.
Since childrens body systems are in the process of developing, they should avoid exposure to adverse environmental factors.
Medical care for children should be timely and age-appropriate.
Children are dependent on adults in medical decision-making (Joszt, 2018).
The vulnerability of children in terms of health care is primarily defined by their developmental needs. Joszt (2018) states that environmental hazards affect childrens health to a greater extent than that of adults because the bodies of the former are undergoing the process of growing. Thus, children are more likely to experience lifelong problems due to long-term exposure to adverse factors. Therefore, access to age-appropriate, high-quality medical care and supervision is essential for the pediatric population. Furthermore, due to their legal status, children are highly dependent on adults and cannot make independent informed decisions, which also indicates the necessity for proper health monitoring by practitioners.
General Policy impacts
The CHIP reduces the rate of racial and ethnic disparities in access to health care among children by covering
52% of Hispanic children,
56% of Black children,
26% of White children,
And 25% of Asian Children.
87% of eligible children were enrolled in the CHIP in 2011 (Paradise, 2014).
According to statistical data, participation in Medicaid and CHIP among eligible children averaged 87% nationwide in 2011 (Paradise, 2014, p. 4). Regardless of the fact that both participation and retention rates differ from state to state, it is clear that the number of eligible low-income children who stay enrolled in the CHIP remains significant. It is worth noting that the CHIP is playing a particularly important role in healthcare coverage for individuals of color who are at a higher risk of low-income status. As Paradise (2014) states, together with Medicaid, the CHIP covers 52% of Hispanics and 56% of Blacks compared to 26% of Whites.
Impacts on health
Increased rate of healthcare service utilization, especially primary care and dental care (Bailey et al., 2016).
Greater access to preventive care:
Long-term health benefits (illness prevention),
Lower hospitalization and mortality rates,
Better cost efficiency (Leininger & Levy, 2015).
Besides a significant increase in the number of insured children, the CHIP has resulted in an overall greater amount of healthcare service utilization in the population of interest. As stated by Bailey et al. (2016), children commence using pediatric primary and dental care services more within twelve months after gaining insurance due to easier access to medical care. Their study of pre- and post-coverage behaviors reveals that the rate of primary care visits and dental visits increased twofold within the period of one year (Bailey et al., 2016). Moreover, Leininger and Levy (2015) note that insurance increases the use of preventive services, which leads to long-term favorable impacts on health and cost efficiency even when these effects are not immediately noted.
Benefits beyond improved health
Improved social and emotional functioning,
Better long-term educational attainment,
Decreased school drop-out rate (by 5%),
Increased college enrollment and completion rates (Paradise, 2014).
Research evidence makes it clear that enrolled children show improvements in social, emotional, and academic functioning within two years of obtaining coverage (Paradise, 2014). As a result, they exhibit better performance at school and improve their long-term educational attainment. Noteworthily, the drop-out rate in newly insured high-school children has been shown to decrease by 5%, whereas college enrollment increased by up to 1.5% (Paradise, 2014). These data demonstrate that insurance-mediated health improvements affect individual functioning in various areas of life.
Policy Effects on Nursing Practice
CHIP is leading to a greater need for nurse specialists.
This fact emphasizes the importance of dealing with current workforce shortages in nursing as the U.S. pediatric population is expected to reach 84.6 million by 2025 (Betz, 2009).
Major factors contributing to staff shortages:
Lack of educators,
High turnover,
Inequitable distribution of the workforce (Haddad & Toney-Butler, 2019).
School nurses can play a vital role in assisting families with gaining access to health care.
They serve as liaisons between children and their primary healthcare providers.
The need exists to provide school nurses with necessary resources and include them as school leaders in order to perform this activity more efficiently (National Association for School Nurses, 2019).
Similar to the Medicare program launched in 1965 that resulted in an increased number of hospitalized older adults and a greater need for nurses in acute care settings (Cherry & Jacob, 2012), the CHIP has led to an increased need for nurses specializing in pediatrics. At the same time, the nursing profession continues to face shortages due to lack of potential educators, high turnover, and inequitable distribution of the workforce (Haddad & Toney-Butler, 2019, para. 1). Researchers predict that the demand for pediatric nurses will continue to rise. According to estimates provided by Betz (2009), there will be 81.6 million children aged 0-17 in 2020 and 84.6 million in 2025 in the United States, about 14% of them having special healthcare needs. It is clear that with greater CHIP-facilitated access to health care, not all of these individuals will be able to receive high-quality service if the workforce shortage is not eliminated.
The CHIP is also inducing an increased need for nurses in such community settings as schools. The National Association for School Nurses (2019) states that, as part of their efforts to promote healthy lifestyles in students, school nurses should be empowered to assist children and families to access health insurance. While it is valid to say that every nurse should be able to identify individuals who are potentially eligible for the CHIP and give them appropriate referrals to agencies, school nurses may play an essential role in helping families access health care because they can interact with students on a more regular basis compared to clinical nurses.
Historical Overview
1997 CHIP establishment with the purpose to expand public coverage and decrease the number of uninsured children,
Enacted by Title XXI of the Social Security Act and created by the Balanced Budget Act of 1997.
Key supporters and sponsors:
Senator Ted Kennedy;
Senator Orrin Hatch;
First Lady Hillary Clinton;
February 1999 47 states set up CHIP programs.
April 1999 1 million children were enrolled in the CHIP in different states.
First Lady Hillary Clinton played a major role in the promotion of the CHIP and improvement of public awareness.
The main objective of the outreach campaign was to increase the number of insured children to 5 million by 2000 (Annenberg Public Policy Center of the University of Pennsylvania, 2008).
The CHIP was part of the Balanced Budget Act of 1997 and came into force under the statutory authority of Title XXI of the Social Security Act (National Conference of State Legislatures [NCSL], 2017). It was created in response to President Bill Clintons comprehensive healthcare reform that he proposed in 1993 and that failed to get much support from the government and the public. The CHIP was sponsored by Senators Ted Kennedy and Orrin Hatch and was substantially supported by First Lady Hillary Clinton. According to He and White (2014), the main goal of the program was and is to lower the number of uninsured children by expanding public coverage to include the vulnerable population at issue (p. E4). In 1997, the CHIP became the biggest taxpayer-funded coverage expansion for children since 1965 when Medicaid was launched.
With Hillary Clintons efforts and active promotion of the CHIP, by February 1999, 47 states established CHIP programs, and by April of the same year, approximately 1 million eligible children obtained coverage (Annenberg Public Policy Center of the University of Pennsylvania [APPC], 2008). In addition, the Clinton administration funded an outreach campaign in order to increase the number of insured children to 5 million by 2000 (APPC, 2008).
While this ambitious goal was not achieved, as Exhibit 1 demonstrates, the enrollment rates were particularly impressive between 1999 and 2000 (Kenney & Chang, 2004). According to recent data, the CHIP currently covers about 9 million children and 300,000 pregnant women (Reusch, 2018; Rovner, 2018).
The Chip Renewal
February 2009 President Obama signed the Childrens Health Insurance Program Reauthorization Act, extending the CHIP until 2013.
The CHIP continued to be extended for two additional years each in 2013 and 2015.
December 2017 The Congress passed a temporary spending bill, providing US $2.85 billion to maintain the coverage (Rovner, 2018).
February 2018 The CHIP was extended for 10 years through 2027.
Key figures participating in the negotiation of the new budget bill:
Senator Orrin Hatch;
Senator Ron Wyden;
The historic CHIP extension would allow savings of up to US $6 billion (Reusch, 2018).
The CHIP is a renewable program, which means that the government must pass temporary spending bills to maintain coverage each time the funding period expires. Initially, the program was authorized for ten years, and as noted by the NCSL (2017), in February 2009, President Obama signed the Childrens Health Insurance Program Reauthorization Act of 2009, extending CHIP through 2013 (para. 1). Later, the CHIP was extended for two more years through the Affordable Care Act, and in 2015, the program was extended until September 30, 2017 (NCSL, 2017). Subsequently, the risk of loss of insurance coverage under the CHIP emerged as the government struggled to come up with a source of stable funding. After the last expiration date, a temporary spending bill passed in December provided the program with $2.85 billion, yet many states began to run short of funds as the sum was not enough to maintain coverage for 9 million children (Rovner, 2018). Recent threats to the CHIP have provoked heated public debate, even as the importance of the program has become increasingly apparent.
Luckily, the program was extended again in February 2018, this time for a period of ten years. Not only will this decision help keep children and pregnant women covered, but it will also result in significant cost savings. Reusch (2018) reports that investing in CHIP for 10 years will yield $6 billion in federal savings, according to analysis by the nonpartisan U.S. Congressional Budget Office (para. 5). This massive sum is projected to be used to support other child health and crisis relief programs as well as community health centers (Reusch, 2018).
Barriers to implementation
Coverage does not always guarantee access to high-quality health care.
Two of the main reasons:
Workforce shortage,
Practitioners unwillingness to work with children covered by Medicaid/CHIP due to low reimbursement rates.
Insurance fee levels are correlated with the overall health outcomes in children.
Analysis of the literature reveals some significant barriers to effective CHIP implementation. For example, Leininger and Levy (2015) state that coverage does not always guarantee access. The main obstacle, which is also directly related to nursing practice, is a lack of healthcare providers, especially specialists who are willing to render services to children covered by Medicaid/CHIP at the low governmental rate (Leininger & Levy, 2015). Research findings also suggest that low reimbursement rates associated with public coverage are correlated with poorer health outcomes in children with public insurance compared to those with private insurance (Leininger & Levy, 2015). Therefore, it is essential to research various organizational and administrative factors and come up with an appropriate solution that is cost-efficient and, at the same time, will generate enough benefits for both practitioners and patients.
Other necessary changes
Better outreach campaigns are needed to enroll more eligible individuals:
About 5 million eligible children currently remain uninsured ( Closing the health insurance gap, 2013).
Collaboration between different professionals and organizations is necessary to ensure better linkage of families to insurance agencies.
While the CHIPs impact on the overall coverage rate is undeniably good, a significant number of children remains uninsured. According to recent statistics, about 8 million U.S. children are currently uninsured, while approximately 5 million among them are eligible for various state and federal health coverage programs ( Closing the health insurance gap, 2013). Thus, it is necessary to establish lasting collaborative relationships between clinical and community organizations in order to increase enrollment rates and ensure that all eligible children are provided with coverage. For example, school counselors and nurses have beneficial effects on different aspects of childrens health, and school-based health centers specializing in preventive services usually have sufficient information resources to reach out to eligible individuals (Leininger & Levy, 2015). It is possible to recommend that nurses working in different settings should engage in networking in order to enhance outreach results within certain communities.
Nurse roles in CHIP Implementation
To assist families in gaining access to coverage, nurses should:
Gain awareness of the CHIP eligibility criteria in their state,
Implement principles of family-centered care:
Develop trustful and cooperative relationships with parents,
Facilitate information exchange,
Take into account multicultural differences of families (Festini, 2014).
In order to fulfill the CHIPs mission and purposes, nurses must become able to identify families who are potentially eligible for the program. Therefore, they should explore background information related to the policy, learn about eligibility criteria in their state, and obtain the contact information of state agencies for families use. In addition, they must develop strategies and communication approaches that may help in detecting eligible children, which may vary depending on the setting where the nurse is working. However, in any event, implementing the family-centered care model is particularly important in pediatric nursing. Since it promotes cooperation between parents, encourages the open exchange of information, and aims to consider multicultural peculiarities of families, it can assist in informed decision-making regarding coverage potential (Festini, 2014). Moreover, it is suggested that in order to bridge insurance gaps, nurses must arrange and volunteer at community events targeting uninsured individuals ( Closing the health insurance gap, 2013). Such practices facilitate building rapport with community members and help to raise their awareness.
In order to promote solutions that would eliminate barriers to CHIP implementation and ensure better access to health care in the vulnerable population, nurses should be advocates. Overall, to advocate for any policy change, a nurse may employ the nine policy development stages presented on the slide; notably, research is at the center of the learning cycle. Any policy change initiative can benefit from high-quality evidence. Therefore, extensive and thorough research of any issue, whether an exploration of better reimbursement options or support for longer-term CHIP funding, should be carried out.
Nurse Roles in Implementation of Changes
Conduct research on possible solutions to existing problems involving the vulnerable populations access to health care.
Use obtained research evidence to substantiate arguments in advocacy and lobbying campaigns.
Build professional credibility through continual self-improvement and education.
Develop networking skills and collaborate with interprofessional teams to foster desired changes at the organizational and community levels.
In addition, Yoder-Wise (2011) recommends that nurses develop their political and lobbying skills. In order to influence policy changes, a nurse should necessarily develop professional credibility, which is attainable with sufficient experience and as a result of continual self-assessment and education. It is equally important to have well-developed networking skills and be able to communicate effectively with diverse stakeholders and organizations. Overall, prior to trying to influence policies at the national level, it is helpful to start with promoting favorable changes at the organizational and community levels.
Conclusion
The CHIP has resulted in a significant decline in the rate of uninsured children since 1999.
Direct outcome: more frequent utilization of medical services.
Effects on nursing practice:
Greater need for pediatric nurses has emerged.
Organizational and administrative barriers to higher-quality care and access to medical services are more evident.
Major nurse roles:
Networking and volunteering for better family outreach,
Research and advocacy for organizational changes.
The conducted analysis revealed that CHIP establishment has helped reduce the rate of uninsured children from lower- and middle-income families to a significant extent since 1999. Currently, the program covers nearly 9 million U.S. children and is associated with more frequent utilization of medical services in general. However, the CHIP has not only impacted the vulnerable population of interest but has also affected the sphere of nursing practice by provoking a greater need for a competent workforce. As the number of insured children has increased, the obstacles to effective rendering of care has become more apparent. These include workforce shortages and organizational and administrative issues, such as service reimbursement, which prevent practitioners from working with children more effectively. Therefore, besides engaging in various family outreach practices, nurses must advocate for necessary organizational changes that would foster easier implementation of the CHIP and compliance with its mission.
References
Annenberg Public Policy Center of the University of Pennsylvania. (2008). Giving Hillary credit for SCHIP. Web.
Bailey, S. R., Marino, M., Hoopes, M., Heintzman, J., Gold, R., Angier, H., OMalley, J. P., & DeVoe, J. E. (2016). Healthcare utilization after a Childrens Health Insurance Program expansion in Oregon. Maternal and Child Health Journal, 20(5), 946-54.
Betz, C. L. (2009). The nursing shortage, pediatric and child family nursing. Journal of Pediatric Nursing, 21(2), 85-87.
Cherry, B., & Jacob, S. R. (2012). Contemporary nursing: Issues, trends, and management (5th ed.) St. Louis, MO: Mosby Elsevier.
Festini F. (2014). Family-centered care. Italian Journal of Pediatrics, 40(Suppl 1), A33.
Grabovschi, C., Loignon, C., & Fortin, M. (2013). Mapping the concept of vulnerability related to health care disparities: A scoping review. BMC Health Services Research, 13, 94.
Haddad, L. M., & Toney-Butler, T. J. (2019). Nursing shortage. Web.
He, F., & White, C. (2013). The effect of the childrens health insurance program on pediatricians work hours. Medicare & Medicaid Research Review, 3(1), E1-E33.
Kenney, G., & Chang, D. I. (2004). The State Childrens Health Insurance Program: Successes, shortcomings, and challenges. Health Affairs, 23(5), 51-62.
Leininger, L., & Levy, H. (2015). Child health and access to medical care. The Future of Children, 25(1), 65-90.
National Association for School Nurses. (2019). Patient protection and Affordable Care Act: The role of the school nurse. Web.
The Health Insurance Portability and Accountability Act (HIPAA) policy establishes national standards to protect individuals medical records and other identifiable health information (US Department of Health & Human Services, n.d., para. 1). In other words, this policy provides healthcare professionals with recommendations and guidelines on how they should behave to ensure that patients personal information is not revealed or stolen. It is challenging to overestimate the significance of this regulation to the entire medical sphere.
The given policy impacts multiple stakeholders, including organizations, healthcare professionals, and patients. Even though these people and entities are not directly involved in policymaking processes, they can influence this sphere. For example, individuals can join advocacy groups, while organizations are capable of lobbying their interests in the policymaking sphere. That is why these stakeholders have some power to impact the policymaking sphere, but they require much effort to ensure that a specific political decision is made.
Even though the HIPAA policy emerged in the late 20th century, some processes are still underway. According to the US Department of Health & Human Services (n.d.), this regulation has witnessed a few adjustments and modifications to improve coordinated care, reduce regulatory burdens, and regulate information disclosure. For example, it was extended in 2021 and modified in 2018 and 2021 (US Department of Health & Human Services, n.d.). These changes demonstrate that policymakers draw sufficient attention to ensure that the HIPAA policy addresses current issues and keeps abreast of changing technologies that are actively applied in the medical sphere.
In conclusion, the Health Insurance Portability and Accountability Act represents an important topic in the healthcare industry. That is why nurses should take specific measures to ensure that this policy is implemented. In particular, nurses should be aware of this regulations requirements, be professional, and have excellent communication skills. These strategies can significantly help these staff members implement this policy and ensure that patients needs are satisfied.
