What Good Is Health Insurance If You Can’t See a Doctor?

I’ve already said my piece (for now) about why everyone needs comprehensive, affordable health insurance. But that’s not the end of the story for the more than 68.5 million low-income people now enrolled in Medicaid. They’ve got to find doctors who will treat them.

This may become even more difficult than it’s been in the past — and for the same reason it’s been difficult. Medicaid doesn’t pay enough. Or at least, that’s what doctors say.

As The New York Times has reported, Congress didn’t renew a now-expired provision in the Affordable Care Act that requires state Medicaid programs to pay qualifying physicians at the same rate Medicare does when they provide primary care.

Like the now-optional Medicaid expansion provision, the Medicaid parity provision has been wholly paid for by the federal government. In other words, federal funds have made up the difference between what state Medicaid programs were paying and what they had to pay because of the ACA.

The two provisions are closely related because having more low-income people enrolled in Medicaid could otherwise make it more difficult for them to get preventive and various other outpatient services when they need them — or indeed, at all.

Before the parity provision because effective, in 2013, only two states reimbursed for the covered services at the Medicare rate or higher. The shortfall in all but 11 of the rest was at least 25%, but so much higher in many that the study I’m linking to estimated the nationwide average fee boost at 73%.

As of last October, only 15 states had said they’d use their own funds to preserve, at least partially, the so-called fee bump. Twenty-two and the District of Columbia said they definitely wouldn’t, in response to a Kaiser Family Foundation survey. Only one of them — North Dakota — had previously paid more than the fee bump required.

The Center for Health Care Strategies reports, based on we don’t know what, that six states and the District “have taken it upon themselves to extend the [parity] policy on their own.” If accurate, a far larger number of Medicaid beneficiaries could wind up with health insurance that means little or nothing if they need primary care. And who doesn’t?

We don’t for sure what will happen if Congress continues to sit on its hands. We do, however, have some indications.

A survey conducted in 2011 found that nearly a third of doctors didn’t intend to accept any new Medicaid patients. Higher percents would accept new patients with private insurance or Medicare. So it wasn’t that they were all fully booked.

A deeper dive discovered that higher percents of doctors would accept new Medicaid patients in states that paid higher reimbursement rates — and conversely. Which looks like bad news for Medicaid enrollees who don’t already have — or need to change — primary care providers in a lot of states that will revert to their prior rates.

A 10-state audit conducted during the months immediately before and after the fee bump officially kicked in found that only about 58% of Medicaid patients could get an appointment with a primary care physician, though 84.7% of privately-insured patients could.

On the other hand, an Urban Institute analysis of other survey results found that only a small fraction of working-age adults who’d had Medicaid for at least a year couldn’t get an appointment — or get one soon enough.

So, as Martha Heberlein at The Children’s Health Blog observes, the access problems seem pretty well limited to new enrollees — some of them probably folks who’d gained coverage because their states expanded Medicaid.

Some doctors have said they began accepting Medicaid patients — or accepting more — because of the fee bump. A recent Urban Institute report tells us that we don’t yet have good data on whether many have done any such thing.

By the time we do, the horse may be out of the barn. And as the law stands now, it’s unclear whether either primary care physicians or Medicaid beneficiaries who can’t get needed treatment because states won’t pay enough can even get a hearing in a federal court. The U.S. Department of Justice has argued that the former can’t.

Meanwhile, a ruling that will almost surely provoke an appeal held Florida accountable for failing to ensure that children in Medicaid receive the medical and dental care they’re entitled to. Low reimbursement rates are “by far the most important factor,” the court said.

I personally find it hard to believe that rate cuts averaging nearly 43% — and over 50% in four states, including populous California and New York — will have no effect on whether Medicaid beneficiaries can get primary care when they need it.

And they’ll have suffered harms that can’t be undone — even if, as seems doubtful, the Supreme Court ultimately results in their favor.





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