Tag Archives: medicaid expansion

The Insidious Non-Optional Medicaid Expansion That Further Clouds the Future for States

So much about Obamacare has been “by any means necessary”, from the legislative gymnastics to get the bill through Congress to the current mandatory expansion of Medicaid that is here now even though largely unnoticed.  Here now?  But wasn’t Medicaid expansion optional?  Some yes and some no as it turns out.  This almost unknown stealth expansion was required of the states and imposed on them despite the Supreme Court ruling because it is being funded 100% by the Federal Government, but only for two years 2013 and 2014, after which, funding abruptly ends.  Because a strong constituency is being created (or bought) that will demand this expansion be continued past 2014, and no one can predict the outcome of those likely demands, further possible complications and risks arise for those states that decide to embrace the optional Medicaid expansion.  Allow me to explain.

Because of current constraints to participation by medical professionals both by low reimbursement rates, 1800+ pages of cumbersome rules, and audits that go beyond financial fraud to interfere in actual treatment decisions, there are at present not enough willing doctors to adequately serve those now eligible for Medicaid benefits.  Realizing this, and attempting to avoid making the optional expansion to 133% of poverty and influx of new eligibles a disaster, “any means necessary” was once again deployed.

On November 6, 2012 (surprisingly not a Friday) CMS published a Final Rule to go forward.  146 primary care Medicaid services identified by the ACA would, by regulatory proclamation, be compensated at the higher Medicare rate, starting with 2013 but only for two years.  Since Medicaid reimbursement rates relative to Medicare reimbursements vary tremendously from state to state, the percentage increase covered by Federal funding varies accordingly.  At one extreme are two states that surprisingly pay higher Medicaid fees for the covered services than they do for Medicare.  These states will receive no additional Federal funding.  At the other extreme is Rhode Island, where Medicaid fees will increase 198%.  Five other states will receive boosts of over 100%.  Pennsylvania is number seven on the list and doctors will be compensated an additional 96% to equal the higher Medicare rates.  On average across the nation Medicaid fees for the ACA primary care services will rise 73% at an estimated cost of $11.9 billion, all in an attempt to keep willing physicians on board, expand their willingness, and attract newcomers.

The problem, of course is what happens after 2014.  It is unimaginable that doctors enjoying the higher reimbursements for two years will do anything but lobby stridently to extend the increases and indeed have them made permanent.  Realizing, otherwise, the carrot to participation would no longer exist, this outcome can be considered probable.  The mystery is who would then pay?  Would the increase be included in the ultimate 10% state funding under optional expansion to 133% of poverty or even some formula that would require states to pay more? Would the increases fall to each individual state or be averaged over all the states?  The point is that today no one knows.  While perhaps not being the main reason to avoid the optional Medicaid expansion, especially those states with the greatest percentage “temporary” increases need to consider the possibility of very serious consequences in the aftermath of this two year attempt by the Federal government to buy a loyal constituency for implementation and avoidance of massive failure.  It is also interesting that the current reimbursement increases were only applied for two years, as estimates for the cost of Obamacare have been made over a ten year period, allowing more, for now, to remain hidden from view.

The two main sources used for this post were a policy brief from the Henry J. Kaiser Family Foundation and an article in American Medical News published by the American Medical Association.  More details can be found at these two locations.  Also used was a recent article written by the President of the Texas Medical Association.

Note: This post was shared to WatchdogWire-Pennsylvania on Sep 24, 2013.

Every State Not Expanding Medicaid (and those that do) Needs to Do THIS — ASAP!

Pennsylvania is fortunate to have a governor who has made bold choices in opposition to Obamacare by both declining state insurance exchanges and the more difficult, but entirely correct, refusal to expand Medicaid, but it can’t stop there.  Governor Corbett and all non-expansion states need to explain why their decision was correct and promote alternative solutions asap, or lose the battle for public perception as Democrats are painting the Governor and the GOP as standing against the poor and caring only about the rich, despite it not being true.

Last week on PCN-TV, a Pennsylvania version of C-span,  State Senator Vincent Hughs was practicing his art of indignation by trashing the Governor on Medicaid expansion and demanding to see the figures on Governor Corbett’s fiscal concerns.  He also posted a response on his website.  Senator Hughes seems to have the idea that adding more free stuff from others better off can never go wrong, and because we would in the end retain 90% Federal funding, that Federal money somehow materializes from thin air, rather than from the pockets of people in the states, including Pennsylvanians.

For the benefit of Senator Hughes, and to his credit, we should look at numbers, and outcomes and realities as well, being sure to consider everything we know and leaving indignation, hubris, and emotion at the door.  If Senator Hughes would approach the debate in such fashion and the GOP would learn to articulate their message and promote detailed solutions and alternatives to Medicaid expansion we may find places where we can agree, and even discover ways to provide better care for the poor at less cost to the taxpayer.

Without too much detail, Medicaid is a mess.  Low reimbursement rates that don’t cover costs keep many physicians from participation entirely and must limit the number of eligible patients seen for those who do.  For others a different cost is too great, best summed up in this quote from an article written by the President of the Texas Medical Association, Dr. Michael E Speer :

“Texas physicians are also discouraged from accepting new Medicaid patients because of the program’s 1,802-page rulebook and exasperating, irreconcilable red tape. We need to return to treating the patient, not the administering bureaucrat.”

These constraints to participation create rationing by waiting time, length of visits, and lack of availability to care that result in the much higher cost of seeing non-emergency cases at hospital emergency rooms.  After all it’s better to wait 6 hours to see someone than 6 days or 6 weeks, and those facing such choices cannot be blamed for doing what they perceive is in their best interest.

All this has numbers attached too that Senator Hughes and those deriding the Governor’s decision should be equally interested in seeing as well.  Ask any doctor.  Medicaid patients often fare worse than patients without any insurance.  Expansion of eligibility will do nothing but increase the waiting times of those already attempting to find access from too few professionals who can afford to offer it.  Coverage clearly does not equate to care.  Also, expansion to 133% of poverty forces more people into Medicaid because only  those over 133% will be eligible for subsidies in exchanges.  Many additional people toward the upper end of the 133% will be be forced to drop private insurance they now have to join the ranks of the current overextended Medicaid mess.  Senator Hughes and others, is this what YOU want?

We must look to better ways to provide for our poor, not extend a system of failure.  Various alternatives to providing for the poor have been tried, some with much success and satisfaction.  Successful innovations have been tried in Indiana, Florida, and Rhode Island.  These involve empowering the poor with ownership via their own special accounts or insurance policies that have incentives to choose services wisely.

Perhaps the single best idea I’ve seen comes as a bill that has been introduced in the New Jersey Senate that uniquely looks at a partnership between state government and private charity.  Senate No. 2231, also known as the “Volunteer Medical Professional Health Care Act”, is a brilliant idea that should cross party and partisan lines with appeal to anyone who seriously wants to provide better access at lower cost along with less government involvement and control.

Very simply, New Jersey Senate No. 2231 would grant any physician (primary care or specialist) or any dentist who agrees to volunteer at least 4 hrs per week in a non-government free clinic, immunity from civil liability through the entirety of their medical or dental practice in the state.  These physicians would not need to purchase malpractice insurance and be freed from oppressive Medicaid regulations and scrutiny, creating an almost irresistible incentive for many more physicians to participate than are willing to commit to Medicaid.  Medicaid would never be involved or ever billed for any of this service.  The New Jersey chapter of the Association of American Physicians and Surgeons (AAPS), who inspired the legislation has estimated New Jersey could expect to save $2 billion of a $10.2 billion Medicaid budget or close to 20%, while offering more timely and much better care for those they see.   AAPS itself was inspired by the vision of two members, Drs. Alieta and John Eck, who responded to the needs of the poor and their concerns over the pitfalls of Medicaid by starting a free clinic in their hometown, Zarephath, NJ,  in September of 2003, thus will enjoy their 10th anniversary this year.

Governor Corbett in Pennsylvania and other Governors who courageously declined to expand Medicaid made the right choice and need to stick to it.  Opponents need to open their eyes to existing realities, and all need to come together to find better solutions such as S-2231 in New Jersey as well as others.  AAPS has informed me that similar legislation may soon be introduced in UT and AZ.  It is not enough to decline Medicaid expansion and then do nothing, while being falsely painted as uncaring by those with insufficient understanding.