Progress, challenges as Medicaid rolls swell in state
One of the most successful initiatives in the Affordable Care Act has been the effort to sign up patients to be covered by Medicaid under an expanded program. Now comes the hard part: facing up to challenges brought on by having so many more people in the program.
Special to The Seattle Times
Apple Health by the numbers
In Washington state, Medicaid is known as Apple Health. Here’s a rundown of the program.
Medicaid budget: $10 billion
Medicaid recipients: 1.5 million
Newly eligible adults under the Affordable Care Act expansion: 285,275
Previously eligible but had not enrolled: 137,930
Ratio of children to adults: Roughly 50-50
• Adults under age 65 earning up to 138 percent of the federal poverty level
• Low-income children and seniors
• Pregnant women
• People with certain disabilities, including blindness
• Foster children
• People in long-term-care and assisted-living facilities
Washington state has blown past its targets for signing up new Medicaid participants under the Affordable Care Act (ACA).
The program’s ranks have grown roughly 25 percent in the past six months, helping fulfill one of the act’s key goals to provide health care to nearly all Americans.
By the end of March, more than 285,000 adults who are newly eligible to participate in Medicaid had signed up for coverage. That’s twice the number officials had hoped to reach by then, and a target they hadn’t expected to hit for three more years.
But with enrollment success comes the challenge of serving more people in a $10 billion program that’s already stretched thin in places.
Some of the new enrollees haven’t seen a doctor in years and need help navigating the health-care morass. Medicaid patients already struggle to get care in parts of the state and for certain medical specialties.
And while the hope is that more efficient, better care for all will drive down medical costs, they could still rise as more people are being helped.
Medicaid advocates acknowledge the hard work ahead but are committed to it.
“It’s the right thing to do,” said MaryAnne Lindeblad, Medicaid director at the state Health Care Authority, which oversees Washington Apple Health, the local name for the Medicaid program.
“Health care should be a right, not a privilege,” she said. “From that perspective, all folks ought to have access to a basic package of health-care services. It shouldn’t be based on income or need.”
Washington is one of 26 states where lawmakers voted to expand Medicaid coverage beginning Jan. 1 of this year. As part of the Affordable Care Act, federal funding will support that expansion.
Before then, Medicaid was available to low-income children and elderly people, pregnant women, people with certain disabilities, foster kids and as a temporary aid to the neediest families.
Poor, childless adults younger than 65 essentially were out of luck and had to rely on charity care.
Now people earning up to 138 percent of the federal poverty level can get free health and dental care. That covers individuals earning up to nearly $16,000 a year or a family of four making $32,500. Low-income people with higher wages must buy private insurance, though they would receive subsidies to reduce the cost.
For Heather Hawley, health care has been a luxury beyond her financial means.
The 28-year-old SeaTac resident has worked in call centers, but the jobs rarely have included benefits, or the pay has been too low to afford insurance premiums. She has asked about government-funded health care, but nothing was available.
“You have to have a lot of kids,” she said. “And I’m not going to have kids just to get health benefits through the state.”
Hawley was laid off more than a year ago when her job answering calls for a bank’s reverse-mortgage program ended. She lives with her mom to save money.
“It’s tough times right now,” Hawley said. “There are so many people looking for the same job.”
Hawley has a promising lead with a department-store call center, but the benefits wouldn’t kick in for three months.
So she was thrilled to qualify now for Medicaid. She doesn’t have chronic health issues but wanted a backup plan beyond the emergency room, the default option for many uninsured people.
Two years ago, Hawley rushed to the ER when a bout of food poisoning resulted in her needing IV fluids. In December she was sick with bronchitis. It was a Saturday when her coughing got bad, Hawley said, and the ER “was the only place I could think of going.”
She was billed for the ER visits but doesn’t recall the amount and believes the bills have been sent to collection agencies.
The state and health-care providers hope to save money through Medicaid expansion by giving people like Hawley more cost-effective alternatives.
With better medical access, Medicaid supporters reason, people will seek more preventive medicine, such as vaccinations, and treat minor illnesses before they become severe. They’ll manage chronic conditions like high blood pressure and diabetes, forestalling emergency trips.
That should reduce the amount of free charity care hospitals provide, costs often passed on to insured patients through higher prices.
While reducing ER visits may be one goal, a recent study from Oregon found that people newly enrolled in Medicaid actually used the ER more than other adults, potentially undermining one argument for savings. Some experts suggested the ER visits increased because the patients struggled to find doctors willing to take Medicaid insurance.
But a Washington state project that sought to reduce ER use by Medicaid recipients cut nearly $34 million in costs last year. And Washington leaders predicted expanding Medicaid would save the state $300 million in the first 18 months, mostly because of an influx of federal funding to cover health costs previously paid by the state.
That federal funding is a result of an ACA provision in which the feds pay 100 percent of the costs of newly eligible enrollees in states that expand Medicaid. Up to now, most Medicaid costs in Washington were split 50-50 with the federal government.
The 100 percent lasts three years, then ratchets down to 90 percent by 2020.
Meanwhile, the intensive enrollment outreach also recruited Medicaid-qualified people who hadn’t joined — an effect state officials had expected.
Some 138,000 of Washington’s new enrollees fall into this category, and their care will be matched at a lower rate — likely 50 percent — adding to the state’s financial burden. Last year, medical assistance for Medicaid enrollees cost on average $321 per person, per month.
Even with the higher match, 24 states have chosen not to expand Medicaid.
Savings to states
Studies show the expansion will save states money, in part by shifting costs to the federal budget, said Alan Weil, executive director of the nonpartisan National Academy for State Health Policy.
Academics and policymakers are interested in a more challenging question: Will Medicaid save money by reducing health costs?
But even before that answer emerges, Weil said, “we have a lot of evidence that people who have health insurance fair better, they’re healthier and live longer, and they’re more productive.”
Elizabeth Winders, manager of Medicaid programs at HealthPoint, a nonprofit with King County clinics, recalled one woman who hobbled on crutches into its Tukwila clinic. The woman had an accident, but wasn’t insured because her employer’s plan was too expensive. She had gone to the ER but couldn’t get needed follow-up care from a specialist. Her injury persisted and she lost her job.
When she enrolled in Medicaid, the woman told Winders: “ ‘This is going to change my life. I’m going to recover and get a new job. It’s hard to go to an interview on crutches and be someone they want to hire.’ ”
But even with Medicaid, the woman might have had trouble seeing a specialist.
Medicaid insurance generally pays doctors at a lower rate than Medicare and private insurance. To recruit and maintain Medicaid physicians, the ACA temporarily boosts the rate for primary-care doctors and services up to the level of Medicare.
Medicaid payments were so low that it required a 70 to 90 percent increase to reach Medicare rates, said Lindeblad, of the state Health Care Authority. The difference is being paid out of the federal budget.
The boost didn’t include specialists such as dermatologists and orthopedists.
22 cents on the dollar
The low reimbursements mean the specialists are earning 18 to 22 cents for every dollar they charge, said Sallie Neillie, executive director of Project Access Northwest, which helps uninsured and Medicaid patients find doctors. That’s compounded by uninsured and Medicaid patients being more likely to miss their appointments, she said.
State officials say they believe the Medicaid patients for the most part are finding care, and Molina Healthcare, a large Medicaid insurance provider, says it is increasing its network of primary-care doctors.
The state has crafted a multifaceted Health Care Innovation Plan designed to make health care more efficient and cost effective for those privately insured and those on government programs. A recent audit found that with better oversight of insurers covering Medicaid patients, the state could save by reducing overpayments.
Programs like Project Access Northwest offer a model for improving efficiency. The group assigns case managers to ensure patients get needed lab work, helps them get to appointments, and makes sure they do prescribed follow-up treatment.
Efforts to increase access include a greater use of nurse practitioners, giving scholarships for doctors who will practice in underserved areas, and opening more clinics targeted to low-income patients.
Because the greater goal isn’t simply an insurance card in every wallet. “People don’t want health insurance and health care,” said Sallie Thieme Sanford, a law and health services professor at the University of Washington. “They want to be healthy.”
Lisa Stiffler, a freelance writer in Seattle, can be reached at firstname.lastname@example.org. This story was produced through a partnership with Kaiser Health News, an editorially independent part of the Kaiser Family Foundation.