New-Age American Health Care System (Part 3)

In Part 3 of a discussion from the Student National Medical Association (SNMA) Conference in Louisville, KY this past weekend, Bryant Cameron Webb and I discussed changes to Medicaid. 

The Underserved

One of the major elements impacting the care of the underserved will be the implementation of the Medicaid expansion in 2014. Originally, the under 138% of the federal poverty level. For a family of 4, that amounts to a mere $32,500 annually. However, the actions of the Supreme Court last year threatened this plan.

While , it also made the expansion of Medicaid optional for states. States can now either choose to keep their Medicaid programs as-is or could expand (with the first three years receiving 100% federal funding and ultimately costing the states only 10% of total costs in future years).

But Governors and legislators in various states – surprisingly those with the highest uninsured and worst levels of poverty – are threatening to opt out. So with the federal government refusing to allow for partial expansions, the all-or-none nature of the Medicaid expansion threatens to exclude about 5.4 million individuals in the 14 states firmly opposed to the idea.

In a previous analysis, we predicted that if , some of the governors currently (Nikki Haley of South Carolina) and formerly (Rick Scott of Florida) opposed would lose their next elections. Perhaps that is one reason why Rick Scott changed his mind and is now advocating that the state of Florida opt in to the Medicaid expansion for the first 3 years.

In other jurisdictions, politicians like Mike Beebe are exploring using private insurance via the Affordable Care Act’s insurance exchanges to cover Medicaid’s newly eligible beneficiaries. It is an idea that may ultimately garner support from the health reform law’s current opponents. Those currently opposed could declare the Arkansas strategy a private sector solution to health care reform as opposed to saying that “expanding Medicaid is no solution at all” as Rick Perry did in a recent USA Today op-ed.

It appears in the near term there will be several different paths for the underserved (specifically the poor uninsured). Some will expand Medicaid as planned and hopefully will find that getting an actual doctor’s visit is not too difficult. Others (income related subsidies do not kick in until a person makes at least 133% FPL). Thus some people will wind up ineligible for Medicaid but unable to receive federal assistance for purchasing health insurance. They too may be subject to the individual mandate tax. Lastly, a third group would include low-income people in states like Arkansas that attempt to expand Medicaid in non-traditional ways such as the currently proposed “private option.”

Depending on the state, it is crucial that health care providers understand how the Medicaid expansion (or lack thereof) might affect underserved patients in their communities. Physicians, medical students, and other clinicians must be aware of these situations if they desire to help their patients gain coverage.

by

Cedric Dark, MD, MPH