How Recent Law Changes To Medicare & Medicaid Will Affect You

In this episode, Dr. Mia provides a comprehensive overview of Medicare and Medicaid, explaining their differences, coverage options, and the implications of recent legislative changes. She emphasizes the importance of understanding these programs, especially for vulnerable populations, including the elderly and immigrants. The discussion also highlights the challenges faced by those needing long-term care and the critical role of advocacy in shaping healthcare policy.

Chapters

00:00 Understanding Medicare and Medicaid Basics
09:57 Medicare Coverage and Misconceptions
13:59 The Impact of Recent Legislation on Medicaid
18:31 Challenges for Immigrants and Healthcare Access
27:18 Advocacy and the Future of Healthcare Policy

Medicare, Medicaid, healthcare, insurance, legislation, advocacy, immigrants, dementia care, long-term care, eligibility

Transcript

0:02

Welcome back to Ask Dr. Mia. I am Dr. Mia and this episode is going to be an explanation episode of Medicare and Medicaid. Given the political climate that we live in and the recent news about changes in law, I am going to do my best to explain things in as plain language as possible. so that you walk away with the knowledge and the insight and hopefully feel empowered to do the next steps. So I am going to talk very briefly from the very beginning and just clarify some information about insurance and some terminology that people may know or may not. But I wanted to make sure that we are all starting the same place. So insurance is basically you purchase a plan that you pay on a monthly basis usually that's called premium. You pay a premium every month so that when something happens like a car accident or a health issue your insurance pays. There are some terminology about other insurance related payments. One is called a deductible. So that means that's the amount of money that you have to pay before out of pocket before insurance will kick in. So for someone who buys a, you know, just a disaster, rarely happen type of situation, insurance that needs insurance, you might, you might want to, um, You choose a plan that is cheaper to pay the premium or the monthly payment, but it may come with a high deductible, meaning you have to pay a lot of money out of pocket for a devastating injury or something before insurance will kick in. Health insurance in many ways don't work like life insurance or car insurance where there is a major accident or that you know, someone dies and then a large sum of money comes in. uh Health insurance in our country is uh really quite complicated. uh But in order to have access to health care, a lot of people really do need insurance. And it's something that you can choose to not pay into insurance. But uh like cart maintenance or going to the dentist. Sometimes if we wait until the last minute when there's a major crisis going on, then everything is more expensive. And coming back to Medicare versus Medicaid, there's a lot of confusion about what these programs are, who is eligible for them, as well as um how do you get some help for the persons living with dementia that you're caring for right now. So Medicare, I think of is really the insurance for the old. ah It's generally for 65 and older. And this is something that is regulated by the whole country on a federal level. And it is funded by uh what your tax payroll contributions have been over working over many years. And It is also coming from the government in terms of everyone's taxes, the revenue that comes into the government and for Medicare because it is an insurance, people also pay a premium even after they retire to get the Medicare insurance. I'm not going to go into the details between Medicare uh versus Medicare Advantage. but just to briefly say that traditional Medicare or fee for service Medicare is really something that you contract directly with the federal government versus Medicare Advantage are where you are buying a plan from a non-government entity like UnitedHealthcare, Aetna, Humana, Blue Cross Blue Shield. Those are the intermediaries between you and the government. Medicare Advantage programs oh are oftentimes doing a lot of marketing and talking about how you can get glasses and oh hearing aids and some of the things that traditional Medicare does not cover. However, Medicare Advantage plans also restrict who you can go see for your oh health insurance, for your health care, as well as what type of services are provided. Generally, traditional Medicare gives you the broadest access because everybody in the country pretty much takes Medicare if they're a healthcare professional, unless it's a concierge practice or some sort of pay out of pocket practice, which are also getting more common. So again, our taxes pay into Medicare, and this relates to some of the bills changes that I'm going to talk about later on. because if you have worked at least 10 years or so, generally people are eligible for Medicare, as long as you're a legal immigrant, uh asylum seekers, refugees, those are legal immigrants who oftentimes may have worked for a long time in the United States and are contributing to their Medicare as well as their social security. disability benefits down the line when they retire. Now Medicaid is really insurance for the poor and the disabled. Medicaid or aid, aiding the poor. uh It is generally regulated by each state, but it is jointly funded by both the state and the federal government. So the state will pay some money into the Medicaid pot And the federal government usually also has a match of whatever the state pays into. This becomes really complicated. And some of you may have heard about Medicaid expansion. If you're in North Carolina, that was just expanded not that long ago. And so uh some of the expansion basically allows more people to access Medicaid. Generally, at the most strict level of eligibility for Medicaid is that you have to be at 100 % of the federal poverty limit, which is only about a little over $1,000 in terms of income. If you're one person, it's a little bit more. If you're a family with multiple people, again, I don't have all that memorized. But you have to be really, really poor. to be eligible for Medicaid. A Medicaid expansion basically raises that income level to a higher amount, like say 137 % of the federal poverty level so that you could be potentially working at a low paying job and still qualify for Medicaid. because you might not earn enough to pay for your food and your housing and healthcare. um When the bill that was recently introduced, there's a lot of talk about basically cutting back how much the federal government is going to contribute to Medicaid. And that has to do with the match. If you think about having two different pockets of money coming in into a Medicaid pot, say within the state of North Carolina, you have the state money and the federal money. And if there's less federal money coming in, then the overall pot is still gonna be fewer. So people can actually also be dually eligible for Medicare and Medicaid. So you can be poor, but not old. You can be old, but not poor. You can be disabled and old and poor, or you can be disabled and young and likely poor, because if you're disabled, you're not generating an income. So the dually eligible are a population of people who have both eligibility for Medicare and Medicaid. And that is important to understand because any cuts to Medicaid will also affect people on Medicare because of these dually eligible. And then some Medicaid expansion states, the Medicaid expansion, the increase in benefits actually help some people pay that monthly premium to buy their Medicare coverage. So I think that is as simple as I can. hopefully explain about Medicare and Medicaid. uh One other thing that you may hear about is Medicare part A, B, C, and D. What does that mean? Medicare part A is for your hospital-based services. Medicare part B is for your outpatient or clinic-based services. Most non-hospital services are automatically categorized as part B. I'm going to skip C for a second. Part D is for drug coverage. And part C is really Medicare Advantage. So the C basically usually wraps around, uh gives you inpatient coverage, outpatient coverage, and may or may not include drug coverage, all lumped into one Medicare Advantage program. And sometimes that's more convenient. for people to remember to just pay one thing rather than having to pay three different components of your Medicare Part A, B and D coverage separately. Now there are some common misconceptions when it comes to dementia care about what Medicare and Medicaid pay for. So one of the biggest misconception that I hear is oh people thinking that Medicare will pay for someone to remain at home, but bringing in help into the home. So unfortunately, Medicare, so insurance for the old, does not cover that. Medicare in general does not cover anything that does not require a skilled person to do. Now, I would say taking care of a loved one with dementia is very skillful. But I think Medicare means skill in the term of a license. So Medicare will pay for a home health nurse. They will pay for physical therapy, speech therapy, occupational therapy, rehab. They of course pay for hospice, probably not palliative care. That's under another branch. But Medicare will not pay for someone to come to the home. uh for four hours at a time, three times a week to help your loved one with dementia. Get out of bed, make them some breakfast, give them their medicines, take them to the grocery store. Medicare will not cover that. Medicaid, or insurance for the poor, is the primary insurance in this country, in the United States, depending on where you're listening from, uh in this country that pays for what is called long-term care services. So if you need something beyond just a couple months, like after a surgery or hospitalization, usually those Medicare covered services can only cover for a short period of time and then they have to go off and stop. So anything that you need for long-term care services are generally paid only under Medicaid, unless you have separate, privately bought uh life insurance or long-term life insurance or uh those things that are not regulated by the government. And so it becomes really tricky and I find that the majority of patients I see and the families I talk to are basically too rich to qualify for Medicaid, but too poor to pay for out-of-pocket care to bring someone into the house. At the time of this recording, which is in August of 2025, the average payment for an hour of a home aid to come in to the home is probably anywhere between 25 to 30 dollars an hour. And of course, this will vary depending on where you live. The more higher cost of living areas will have a higher rate. And if you're in a more rural area with potentially a lower cost of living, it may be a little bit lower than the rate that I just quoted. But if you think about, say, $30 an hour, even if you were only to need it four hours a day and say three times a week, is $120 times three or $360 per week times four. So $1,440 for a month, which is a substantial amount of money for retirees to have to pay out of pocket when they have a limited income. Okay, so let's now talk about what is this bill and what kind of things are being changed. So, I find the name of the bill, One Big Beautiful Bill Act or OBAA, a little bit of a misnomer and I prefer not to call it the big beautiful bill because it really, unfortunately, is not very beautiful. It is big, but it's not very beautiful. uh Billionaire boosting bill, maybe another way to use the same acronym, but uh I probably would just call it HR1, which is house resolution one uh bill uh to share with you all in terms of uh what it entails. One other thing about Medicaid I wanted to mention is that Medicaid covers a much broader list of services than Medicare. So uh Medicaid will cover for Nursing home care, they'll cover that home or community-based services like a home aide coming into the home to help someone with dementia. Medicaid will also cover non-emergent medical transportation. So, you know, going to the doctor's office may be challenging for people with disability and oftentimes Medicaid will cover for that. And then it can also uh cover some financial assistance. for those who are duly eligible for Medicaid and Medicare to help the poor afford the premiums for insurance of the old, which is Medicare. um So this is the HR1 bill is really the largest cut to Medicaid in history. The Congressional Budget Office really estimate close to one trillion. I can't even fully understand that number, but one trillion. and it is likely going to kick 15 million people off of insurance, whether it's Medicaid or Medicare, because like I said, those two are related. um It is also going to make people have a harder time uh applying and getting Medicaid, and it also eliminates uh eligibility. for a lot of the tax credit that many immigrants are currently now able to get. So, you know, with Obama, there was the Affordable Care Act, so people could actually get subsidies or reduce price to purchase insurance on the marketplace. And those are usually tax credits. And a lot of immigrants, even if you don't have a green card, may be eligible for that. ah So the more people who can buy into the insurance usually the better and that lowers the cost for everyone because you have healthy people buying insurance in addition to unhealthy people. And this bill, even though it was passed now, a lot of the changes are not coming in until later on. So I will go through in more detail as to what the time, what the proposed timeline may mean. uh So starting this July, they're going to change some of the eligibility and the enrollment rules for Medicaid uh and that uh they officially limit the type of immigrants who are eligible for Medicare and Medicaid to people who have a green card, people who are Cuban and Haitian, and people who are what's called COFA migrants and these are two very small countries in the Pacific, basically islands. So all of the other groups, if you don't have a green card, if you're not from Cuba or Asia or these two islands in the middle of the Pacific, you're not eligible for Medicare and Medicaid. uh It is, uh I think, particularly unfair because remember Medicare was the revenue for Medicare is partly from people's working. So people have paid at least over 10 years of work history to get Medicare. So now even people who have paid into it from working are not eligible for Medicare. They are also allowing states to implement work requirements. Typically, uh Most states do not require work requirements because it is really burdensome to prove that you are working for a certain number of hours out of a month. uh In fact, this is really just a way to limit how many people can actually get Medicaid. I think it was uh one of the states had maybe Arizona had recently implemented work requirements and a lot of the money was actually going to the state to go through the paperwork of checking who had or who didn't have the approved work requirement. And it didn't actually make the program better. It just limited the number of people who can actually become eligible. So on a broad spectrum, in January of 2026, those tax credits that allow for people to buy insurance cheaper on the Affordable Care Act marketplace will end. They're also going to um limit uh people who are, um they're also going to limit a lot of the lawfully present immigrants from being eligible for Medicaid. uh Starting in 2027, that's when adults between the age of 19 and 64 must show that they meet the Medicaid work requirements. And this is one that is tricky because if you're disabled uh and that allows you to become eligible for Medicaid, then you really can't work. And if you don't have health insurance to see a doctor, to sign a letter that says you can't work due to a medical disability, then it becomes a catch-22. You know, can't access the people to write the document to say you can't work because of a disability. To get the insurance that will get you access to the doctor, it makes no sense. But it also limits, in 2027 is also when they will limit the retroactive Medicaid coverage period. So what typically happens right now, because it takes a long time to get Medicaid, you have to have all the income paperwork and documents and all of that. Say someone needs their loved one to move into a nursing home for memory care or for uh a long-term nursing home that helps with dressing and changing and transfer and whatnot. The facility can take someone who have their Medicaid application in progress. with the understanding and the law that if approved right now, Medicaid will cover the three months preceding to when the coverage is officially approved. So you basically have a timeline of three months to be able to wait for the bureaucracy of processing your application while still getting the health care services. Now the rule, the bill, the H.R.1 bill, is limiting that retroactive coverage from three months to one month. So you only have a very short amount of time to get that ready. I think what this is going to translate into is that a lot of nursing homes, especially in more rural areas or nursing homes that take a lot of Medicaid patients may actually go out of business because they won't have the guarantee that the work before someone is Medicaid approved will be covered and that will just become a financial loss. And also in 2027 is when Medicare coverage, so insurance for the old, will only be allowed for people who have a green card from Cuba, Asia, or COFA migrants. So all of the other people who are immigrants who have paid into their Medicare pot of money will be terminated in January of 2027. uh Then it becomes more complicated and talks about uh other rules that changes co-pays as well as reducing the amount of uh home equity. What that means is that typically a lot of people A lot of older adults may be what's called house rich but cash poor, meaning that they have paid into their house that they're living in over many years. they really, their only asset is the house that they're living in. They don't necessarily have a whole lot of dispensable income sitting in their bank that can be used to pay for healthcare or pay for care. uh the Medicaid uh home equity basically has a limit of a million dollars uh in terms of what is considered allowable in terms of assets under Medicaid. And I think with changing that rule of how much your house. and your asset is eligible for and still be allowing you to get Medicaid is really going to harm people who have bought their house, you know, decades ago and now their home equity have increased in value. Those people are no longer going to be able to be eligible for Medicaid unless they sell their house and spend down that cash money until they have basically no assets whatsoever. and become destitute and poor and qualify for Medicaid. So all of those things are kind of what is in the bill. The one other issue I wanted to mention for those who are dually eligible is that even though only say 15 to 17 % of the people who out of everyone who is getting Medicaid or also getting Medicare and same thing from the other pot. 17 % of people who are eligible and get Medicare also get Medicaid. So somewhere in that range, less than 20 % of people are duly eligible. A third of Medicaid spending is actually for those 20 % because those people have the dual problem of being poor and being old. and oftentimes with disability. And so it's very expensive ah to take care of those people in society because oftentimes they just have more needs because they have little other resources. And so basically any cut to Medicaid is also a cut to Medicare. All right, so on that note, uh I think the issue about immigration is very complex and I'm certainly not an immigration expert. I do have personal experience in being an immigrant going from having a green card to a naturalized citizen. And I know from my personal experience how time consuming and expensive it is to go from even a a green car holder to uh a naturalized citizen. And I certainly don't have experience going from someone who may have come here as a child, like a DACA recipient, worked for many years, uh or people who came on certain immigration status that were protected that are now at risk for not being able to get healthcare. A lot of the people who work in healthcare are actually immigrants. So those home care workers, like I mentioned earlier, unfortunately, they don't, you even though you might pay $25 an hour, they don't get $25 an hour. This is a very hard work that people are usually paid the minimum wage and the rest of that money actually goes to the agency. So one in four direct healthcare workers. are immigrants and if those people lose coverage for Medicaid, they're also going to be in trouble in terms of taking care of other people who might have dementia, who might be citizens. So this is something that affects not just immigrants, but affects all of us. ah And I think what's difficult about this bill and the proposed changes is that Because not everything happens immediately right now in the summer of 2025, we're really not going to see the changes and people being uninsured until several years by now. And unfortunately, we just don't have a great memory as a country to remember even what happened six months ago, much less something that happened three years ago. as to who put these rules in place and who made these decisions back then. oh One thing that I would say, besides listening to this podcast, which if you have been listening, have already gotten to this point, is that uh now is really the time to share your experience, share your story with your Congress people. uh And if you don't know who represents you, In Congress, there's the five call app, uh as well as the, I'll also share in the show notes, the directory for congressional representatives that you can call and let them know how this will personally impact you, whether it's you personally or someone that you are caring for. uh One final thing that is limited in this law, which really makes no sense to me, but there has been recent proposal to have a minimum nursing home staffing role where, know, for nursing aides, the people who are quote unquote, not skilled, I hate that terminology, but not skilled, so they don't necessarily have a license like a nurse or a therapist, but are the people who really make a big difference in the quality of life of people living in memory care or assisted living. These are the people who are getting people out of bed and changing them and bathing them and dressing them and moving them and or provide them with activities. uh There really should be a minimum nursing home staffing rule because we know you can't take care of 20 people who all need their diapers changed at the same time. It's the same with childcare. should be rules as to what is safe because otherwise people will be harmed and the people who aren't stuck in those situations oftentimes can't leave because they can't just move into another nursing home that has better staffing. uh So all of this is tremendously important I think for you who are listening and the reason why I wanted to talk about this on this podcast because I really think We are at a crucial moment in history where we have to make our voices heard, even if it feels like it's a drop in the sand and maybe no one is listening. But I do think that with everyone pitching in and joining in the voice to oppose Medicaid cuts, again, not all of these things have really been enacted yet. So there is still time to change the rules. or change the law that has been approved. This is the time to really call your representatives and tell them how much this will harm you. And thank you so much for listening and I will talk to you next time.