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Dr. Reid Blackwelder, president-elect of the American Academy of Family Physicians
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Reform Update: Providers likely to feel pressure as Medicaid gets new enrollees


By Rich Daly
Posted: June 25, 2013 - 4:30 pm ET
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New Medicaid enrollees may be healthier than the program's current beneficiaries, but that is unlikely to relieve much of the pressure on providers as millions of newly covered patients seek care next year.

Researchers—including some from the Centers for Disease Control and Prevention—looked at national health data collected through detailed surveys of uninsured adults and concluded that new enrollees are less likely than current beneficiaries to have chronic diseases—30% compared with 39%.

However, among the newly covered enrollees who do suffer from chronic conditions, their conditions are more likely to be undiagnosed and untreated.

The Patient Protection and Affordable Care Act offered federal funding to help states expand Medicaid eligibility to all residents with incomes of up to 138% of the federal poverty level. Thirty states are at least leaning toward participating, according to the Advisory Board Co., but some of those have yet to fully approve it.

The law yielded an estimated 1 million new Medicaid beneficiaries this year in seven states that expanded eligibility early, and another 8 million are expected to enroll next year, according to May projections by the Congressional Budget Office.

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Physician groups have raised concerns that the expansion will overwhelm their ability to meet the new demand for care. That appears to be supported by some research. In a 2012 study based on CDC survey data, National Center for Health Statistics economist Sandra Decker concluded that only two out of three primary-care physicians would accept new Medicaid patients. That February study, published in the journal Health Affairs, concluded that up to 7,000 more primary-care physicians would be needed nationwide to meet the demands of the projected 29 million people who will gain coverage in 2014 through the federal healthcare law.

The new research—also led by Decker and published online this week by JAMA—indicates an increased load is coming to available physicians. The CDC researchers anticipate that at the time they enroll, the newly covered Americans will have an “intensive need for medical care” due to their untreated health conditions. About 35% didn't seek care within the last year, and 46% lacked a regular healthcare provider.

The researchers found other evidence suggesting the new Medicaid beneficiaries are likely to flood primary-care providers even though they're generally healthier than current enrollees. Among the uninsured population, 11% used hospital emergency departments for “routine care,” compared with 5% of Medicaid beneficiaries. “For the uninsured, it likely is tied to their being less likely to have a usual source of care that's in the community, a place they can go for their primary care, and there's likely a connection there,” said Genevieve Kenney, a senior fellow at the Urban Institute and one of the study's authors.

The somewhat encouraging findings regarding the health status of the new patients did little to allay primary-care physicians' concerns about the surge.

“I for one am not breathing a sigh of relief, saying 'We don't need to worry anymore about a workforce shortage,'” Dr. Molly Cooke, president of the American College of Physicians, said about the new research. “We still do.”

One way that policymakers have hoped to mitigate the expected onslaught of both new Medicaid enrollees and another 7 million gaining private insurance exchange coverage is by enticing more physicians to accept Medicaid patients by boosting primary-care pay rates. Medicaid programs pay 59%, on average, of what Medicare pays for primary-care services, according to a December Kaiser Family Foundation report.

“Before parity, you could not make ends meet, pay your overhead and keep your office doors open by accepting new Medicaid patients because the payment was inadequate,” Dr. Reid Blackwelder, president-elect of the American Academy of Family Physicians, said in an interview. “So very few practices were expanding their Medicaid rolls, and these were patients who would then have no source of care.”

The increase, authorized by the Patient Protection and Affordable Care Act, aims to boost Medicaid primary-care pay rates to Medicare levels for 2013 and 2014.

But the federal government and states have lagged in implementing that pay boost, which will be retroactive to Jan. 1. As of June 20, the CMS has approved 49 state plan amendments to implement the boost, according to an agency spokeswoman. California's is still pending.

“These are patients that require significant resources often and the boost just has not yet happened” for many physicians, Blackwelder said.

The delayed pay boost has similarly put off states' collection of required data tracking physician participation and primary care utilization in 2013 and 2014 and whether it increased from 2009. Such data may eventually be used to push for making the federal primary-care pay boost permanent or expanding it to include other medical care where there are access problems.

Miss. governor calls special session

Mississippi Gov. Phil Bryant planned to call lawmakers back for a special session Thursday to reauthorize the state's Medicaid program before it expires July 1, the Associated Press reported.

Democrats in the state had blocked the reauthorization during the regular legislative session to protest the opposition of Bryant and other Republicans to approve an expansion of Medicaid as authorized by the 2010 federal healthcare overhaul.

Health coverage for more than 1 in 5 Mississippi residents is at stake if the Medicaid program authorization lapses. Bryant has indicated he may continue operating the program under administrative authority but it remains unclear whether that is legal.

Mich. governor pushes for expansion

Michigan Gov. Rick Snyder has launched a statewide promotional effort to get his fellow Republicans controlling the state Senate to back a Medicaid expansion there.

His first stop Tuesday afternoon is at a hospital in Grand Rapids.

The Senate adjourned last week without voting on Medicaid expansion legislation and doesn't plan to meet again for voting for two months.

The Senate's Republican leader is unwilling to call a vote on Medicaid expansion until at least half of majority Republicans support it or at least support proceeding with an up-or-down vote. Snyder says there should be a vote as early as next week.

Follow Rich Daly on Twitter: @MHrdaly


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