The Supreme Court decision Tuesday to prohibit private healthcare providers from suing state Medicaid agencies over low reimbursement rates holds major implications for the access to care that will be available to many Medicaid beneficiaries.
“What's going to happen is you'll have all these people with the benefits [of Medicaid] who can't get care,” said Linda Rosenberg, president & CEO of the National Council for Behavioral Health.
In Armstrong v. Exceptional Child Center Inc., providers argued that suing over low rates is sometimes the only way to enforce federal payment requirements. The court disagreed, so legal recourse is now no longer an option.
“The main remedy providers now have is to stop providing services,” said William Dombi, executive director of the National Council on Medicaid Home Care, an advocacy group affiliated with The National Association for Home Care & Hospice. “It's the only way we have to get the point across.”
The decision could make it difficult for Medicaid beneficiaries to find or retain doctors. Safety net providers could end up shutting their doors because they won't be able to stay financially viable with the current level of payments, experts cautioned.
The ruling comes as the number of Medicaid beneficiaries continues to grow thanks largely to Affordable Care Act-related eligibility expansion. As of January, 2015, 70 million people were enrolled in Medicaid or CHIP, a net increase of nearly 11.2 million people since the summer of 2013. Twenty-eight states and the District of Columbia have expanded Medicaid eligibility to 138% of the federal poverty level.
“Medicaid's equal access promise to the patients it was designed to protect will likely go unfulfilled,” Dr. Robert Wah, president of American Medical Association, said in a statement.
The loss of going to court for a remedy will likely lead to primary-care doctors making some tough choices.
“Physicians will have a hard decision in terms of whether or not to take a Medicaid patient,” said Dr. Robert Wergin, president of the American Academy of Family Physicians. “If the reimbursement is too low, they will not take them.”
“The fear here is that children will not have access to preventive, wellness and specialty care,” Dr. Sandra Hassink, president of the American Academy of Pediatrics added. “If that happens, the usual default is emergency care.”
Both Hassink and Wergin said it's unlikely their members will drop patients as a result of the ruling, but it's possible that they may not take on new Medicaid beneficiaries.
Even emergency room physicians, mandated by The Emergency Medical Treatment and Active Labor Act (EMTALA) to see anyone crossing their thresholds, are concerned about the ruling.
“Once we stabilize them, we'll have nowhere to send them for follow up care,” said Dr. Michael Gerardi, president of the American College of Emergency Physicians. “Providers have rent and mortgages to pay and unless there are adequate rates, patient access to care will get severely limited.”
With the loss of legal recourse, providers plan to continue to advocate and lobby to reinstate an Affordable Care Act provision that temporarily increased Medicaid reimbursement for primary-care services to match Medicare rates, according to Wergin. Funding for the bump expired Dec. 31, 2014.
Last fall, the Kaiser Family Foundation reported that 22 states indicated that they would not be continuing the primary care rate increase, with another 14 indicating they had not yet made a decision and were still evaluating whether the enhanced rates had any impact on provider participation.
Another 15 states: Alaska, Alabama, Colorado, Connecticut, Delaware, Hawaii, Iowa, Maryland, Maine, Michigan, Mississippi, Nebraska, Nevada, New Mexico and South Carolina all indicated that they will continue the higher rates at least partially, if not fully.
Outreach to CMS during the Medicaid rate setting process, as well as to state lawmakers about the importance of adequate rates also will continue, Dombi and Hassink said.