Health Care is Not Free
In an election year, it is important to discern facts from
fiction and this article addresses the subject of free or subsidized health
care in the United States. First, there is no free health care, someone is
paying for the care. For Medicaid eligible persons or families, the state and
federal government do provide health care without an insurance premium to those
who qualify. This does not mean there are no copayments for the Medicaid
participants, but these are generally modest. Access to health care providers
is not guaranteed, because many clinics and clinicians do not treat Medicaid
patients or have a limit on the number they will accept. This is because of the
low level of reimbursement from the government for providing care.
Medicaid-Eligibility
Medicaid, also known as Apple Health, Medi-Cal or whatever label
each state chooses, is a government run medical insurance program for low-income
residents. To be eligible for Medicaid, the individual or family must meet
certain criteria, for example, living within the United States for at least
five years, having legal residency status, meaning a work permit, student visa,
permanent resident status, or citizenship. Citizenship in the USA is based on
birthright, taking the oath of citizenship, or marriage. The funding for the Affordable
Care Act requires legal residency criteria, to control costs and to avoid
adverse selection from potential high-medical-needs immigrants. There are exceptions
to this, which are for immigrants who have refugee status for humanitarian reasons
(torture), Protected Juvenile Status, Temporary Protected Status and Victims of
Trafficking. Here is a complete list of the immigrant standards for
qualification for Medicaid or government health care subsidies, like tax
credits under the insurance exchange plans for the Affordable Care Act
(Obamacare): https://www.healthcare.gov/immigrants/immigration-status/
Finally, if someone is blind, disabled, pregnant, or caring
for a child on public support (foster child) you may be eligible for Medicaid,
if you meet the residency status requirements. In other words, people without
means who are immigrants do NOT have unlimited access for free or subsidized
health care. Wealthy people, including medical tourists with private insurance,
who can pay, will be able to have carte blanche access to the US healthcare
system.
State Medicaid Eligibility Varies
Most states have now expanded their Medicaid eligibility to
match the 2010 Patient Protection and Affordable Care Act standard of 133% of
the federal poverty level (FPL). In 2024, this is $15,060 for a single
individual and $31,200 for a family of four. So, the baseline for receiving
medical insurance through a state Medicaid program which has chosen the
Affordable Care Act standard and receives federal matching funds is: $20,030
for a single individual and $41,496 for a family of four. Some states, where
the cost of living is very high, have more generous subsidies, like California,
which offers pregnant women with incomes up to 208% of the FPL and children
under 18 are covered up to 261% of the FPL.
Federal government handy interactive chart to determine your state’s
Medicaid eligibility standards.
https://www.medicaid.gov/state-overviews/state-profiles/index.html
The federal Children’s Health Insurance Plan or CHIP has
been around since 1997 and was reauthorized by both Democrats and Republicans
in 2009.This is a positive thing because it is good public health investment to
make sure we are creating healthy children, which is after all our future work
force. Investing in the health and well-being of our citizens is a public good.
This is why we have parks and recreation, air and water quality standards,
sanitation systems, and standards for food safety.
Tax Credits Under Affordable Care Act
All the insurance exchange enrollments require persons
applying for medical insurance coverage to disclose their incomes, because the
Affordable Care Act provides federal tax credits for the purchase of the
insurance. The government is advancing an income tax credit, that you would be
expected to receive upon filing your annual tax return. If your income varies
from this declaration, the government will refund any unused tax credits or
require you to pay back some of the advance credits you received. It is the
onus of the insurance exchange participant to notify the agency of any material
change while enrolled. The tax credits are not free, but reflect earned income federal
taxes. If someone has no earned income and qualifies for some insurance
subsidy, this is determined through the process.
Tax Credits Under Employer Group Insurance Plans
The federal government provides significant tax incentives
for employers to provide health insurance, by allowing a tax deduction for the
entire expense which are paid by the company. Additionally, employees are often
given the opportunity to use pre-tax income to pay for their covered dependents
or elective benefits, through a Section 125 plan. These tax credits do not have
to be repaid, as long as the programs are administered correctly.
Medicare Eligibility
For persons reaching age 62, their eligible spouses, and
certain disabled people, the federal government provides Medicare, which has
components which are fully paid by the government, Part A for hospitalizations
and Part B, which is for outpatient care and requires an insurance payment
monthly. There is also a prescription drug program which requires an insurance
premium, unless the enrollee chooses a Medicaid Advantage Plan with an integrated
drug program. And there are Medicare
supplements, which cover the many deductibles and co-payments that Medicare
requires.
Obtaining age 62, 65, or 70 does not automatically mean that
person is enrolled in Medicare. The individual must apply for Social Security
Benefits first, and that process takes two months. During this time, the Social
Security Administration will verify residency status, address, and determine
the number of quarters the applicant paid the necessary payroll taxes to
qualify. Social Security is NOT FREE, the applicant must have earned wages and
paid payroll taxes for Social Security and Medicare for no less than ten years.
Some, myself included, think this is too liberal, because what other entity,
government or private provides a pension after only a decade? Social Security
is financed through a trust fund and current payroll taxes from employees and the self-employed whom are still
working.
In addition to the age qualification, Social Security is
eligible to persons who have end-stage renal failure (kidney) and are on
dialysis and for those who are blind. It is possible for other individuals with
disabilities to qualify for benefits, but this is not easy and is not guaranteed.
Conclusion
The United States does not offer FREE HEALTH CARE, rather it
provides various targeted programs for enrollment, based on eligibility. These
standards require individual tax contributions at all levels, based on the
Internal Revenue Service Code. Only billionaires and a few hedge funders seem
to manage tax exemptions. If you earn wages in the U.S.A. you will pay into the
Social Security and Medicare programs. Residents in the country may be eligible
for Medicaid or Insurance Exchange subsidies based on the duration of their
residency and their immigration status. Americans are raised with the ethos
that we work and earn that which we acquire and utilize. Though our tax code is
arcane, it does provide incentives for programs the nation is trying to
encourage and those it discourages. Universal healthcare is a myth, for even in
countries with national health systems (France, Germany), there are populations
whom are not covered under the safety net, primarily based on residency status. Where the US goes off the rails is in the affordability
of health care, ranked as the most expensive health care in the world. And of course,
there are more persons without medical insurance and access to care in the US than in
other nations with national healthcare systems. That said, this bellicose
nation does not appear ready to move away from its current system in the near
future.
And this is the healthpolicymaven signing off, encouraging
you not to sign blanket releases when you agree on a surgical procedure or a
hospitalization, do specify that for which you agree and decline. It is best to
do this with an Advanced Medical Directive or a POLST agreement. Make sure your
emergency contact is aware of this document and be prepared to present to healthcare
administrators.
Roberta Winter is an independent healthcare analyst and
journalist who receives no money from any sector of US healthcare. She is the
author of Unraveling US Healthcare-A Personal Guide, published by Rowman &
Littlefield in 2013. She has been a speaker at international and national healthcare events.
https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972
