Reform Update: Study looks at Oregon Medicaid enrollee trends to help prep other states for new beneficiaries

A new study tracking treatment trends for new Medicaid enrollees in Oregon aims to prepare other states for the demands of adding millions of beneficiaries to their rolls under the Patient Protection and Affordable Care Act.

A group of researchers interviewed 120 Oregon Medicaid beneficiaries three years after they gained access to the program. In 2008, the state used a lottery to expand its Medicaid program for low-income adults. Key findings included that 40% of those interviewed sought care infrequently because they were confused about coverage, faced access barriers, had bad interactions with providers or felt that care was unnecessary.

The findings come as some health policy experts and state and federal officials fret that new Medicaid beneficiaries will have trouble finding healthcare providers willing to participate in the program. The Oregon experience suggests they could face a different set of challenges.

“The access barriers were not the big problem,” said Sherry Glied, dean of Robert F. Wagner Graduate School of Public Service at New York University. “It was whether or not a personal relationship was developed.”

For the 60% who had multiple healthcare interactions, continuity and ease of relationships with physicians were critical to improved health. Few saw improvements to health quickly after gaining coverage. Most of those interviewed said substantial improvement to their health came after months or years of working closely and systematically with a provider.

The beneficiaries interviewed in the Oregon study “have something they can tell us,” said the study's lead author, Heidi Allen, an assistant professor in the School of Social Work at Columbia University. “As states expand their Medicaid programs, they want to see the experiences of care beneficiaries are getting once they have coverage.”

Allen was most surprised by the need for additional communication about the scope of coverage of Medicaid. A common story she and her fellow researchers heard was that upon receiving their Medicaid card, many immediately attempted to access dental services only to be told that the program paid only for emergency dental services. As a result, Allen said, many mistakenly thought that all Medicaid benefits were restricted to emergency services and only sought care in emergency departments.

Other policy experts were rattled by accounts of physicians who were dismissive to the newly covered patients or did not follow up as promised. Some of the beneficiaries interviewed cited those negative interactions as reasons they didn't bother to reapply for the program.

“First impressions really matter—even in healthcare,” said Kathy Gifford, a managing principal

Health Management Associates. “It is important that (new enrollees) have a positive experience when they try to take advantage of that coverage, or else they may be tempted to drop their coverage as occurred with some of the Oregon study subjects.”

Officials from state insurance exchanges say they've uncovered an unforeseen trend as the result of Medicaid expansion: Some of the newly eligible would rather buy private insurance through the exchange than join the public program.

Representatives from the California, D.C., Kentucky and Rhode Island exchanges discussed the phenomena during a media briefing hosted by the Robert Wood Johnson Foundation on Jan. 31.

The primary reason appears to be the stigma of Medicaid as the public dole. In Kentucky, for instance, the pushback has largely come from young college graduates, who may have come from middle-class families, but are unemployed and possibly unable to get on their family's plan, according to Audrey Haynes, secretary of Kentucky Cabinet for Health and Family Services.

The number of people who fall into this group is small, but it's an issue that should be addressed, the officials said.

“This is another piece of the law that needs to be fixed because people should be allowed to this,” said Christine Ferguson, director of the Rhode Island Health Benefits Exchange.

As the law is written, a person found eligible for Medicaid does not qualify for tax credits to buy insurance on the exchange.

Washington has seen fewer than 50 cases in which applicants have asked to enroll in exchange plans after they were deemed eligible for Medicaid, according to Mila Kofman, executive director of the District's Health Benefit Exchange Authority. In those instances, the state manually deleted the original applications and gave the residents forms to get insurance at full price.

“That is not something I expected to see,” Kofman said. “When folks qualified for our comprehensive public program, I expected them to enroll.”

A related concern is that applicants tentatively deemed eligible for Medicaid by mistake must wait weeks before they get a formal denial letter before they can re-apply for private insurance.

Follow Virgil Dickson on Twitter: @MHvdickson