Ever-chang­ing Med­i­caid poli­cies

Gov­ern­ment, states show flex­i­bil­ity on ex­pan­sion

Modern Healthcare - - FRONT PAGE - Me­lanie Evans and Rich Daly

Since the U.S. Supreme Court struck down the manda­tory Med­i­caid pro­vi­sions of the health­care re­form law in June, the fed­eral gov­ern­ment ap­pears to be be­com­ing more pli­able when it comes to en­tic­ing re­luc­tant states to ex­pand their Med­i­caid pro­grams. And states, which gained lever­age with the high court’s rul­ing, are push­ing for more con­ces­sions.

For providers, the fact that the fed­eral gov­ern­ment and states are will­ing to dance with each other is good news as they are count­ing on more for­merly unin­sured pa­tients to be­come el­i­gi­ble for Med­i­caid. The health re­form law would ex­pand Med­i­caid el­i­gi­bil­ity in 2014 to le­gal res­i­dents with in­come up to 133% of the fed­eral poverty level, with a 5-per­cent­age-point lee­way to 138%. Un­der that sce­nario, about 16 mil­lion unin­sured could gain Med­i­caid ben­e­fits.

In Arkansas, Gov. Mike Beebe is in talks with the CMS over whether the state may scale back or undo ex­pan­sion in fu­ture years if the state should face bud­get pres­sure from, for ex­am­ple, an­other eco­nomic down­turn, Beebe spokesman Matt DeCam­ple said.

“Are those op­tions avail­able?” DeCam­ple asked.

Beebe per­haps got a hint at the an­swer last week, when Cindy Mann, di­rec­tor of the Cen­ter for Med­i­caid and State Op­er­a­tions at the CMS, said the agency will al­low states that ex­pand their Med­i­caid el­i­gi­bil­ity in or­der to re­ceive 100% fed­eral fund­ing for the newly el­i­gi­ble in 2014-2016 to cut their rolls in the fu­ture. “That’s en­cour­ag­ing,” DeCam­ple said. Still, he said, Mann’s com­ment doesn’t set­tle all of the gover­nor’s ques­tions. Beebe is sched­uled to talk with Mann next week, DeCam­ple said.

Demo­cratic and Repub­li­can gov­er­nors have ex­pressed con­cerns about the cost of the ex­pan­sion, which will be en­tirely fed­er­ally funded through 2016 and then will grad­u­ally in­crease state fi­nanc­ing to 10%. That has not stopped some states from pledg­ing to ex­pand Med­i­caid un­der the law. So far, 13 have said they will do so.

Mean­while, other states—in­clud­ing Cali- for­nia, Illi­nois and Ohio—have asked for flex­i­bil­ity to se­lec­tively ex­pand Med­i­caid ahead of sched­ule us­ing fed­eral waivers.

Un­der a pend­ing waiver for Illi­nois, about 250,000 unin­sured adults in Cook County with in­come up to 133% of the poverty thresh­old would gain in­sur­ance if they seek care from the county’s three-hospi­tal sys­tem. Of those, 100,000 al­ready re­ceive care at the Cook County Health and Hos­pi­tals Sys­tem, said Dr. Ram Raju, CEO for the county-owned sys­tem.

Why let chron­i­cally ill adults with lim­ited ac­cess to med­i­cal care po­ten­tially grow in­creas­ingly sick dur­ing the months be­fore ex­pan­sion, he asked. The fed­eral gov­ern­ment will even­tu­ally pick up the tab to care for chron­i­cally ill unin­sured adults, he said, and it could po­ten­tially save money by help­ing pa­tients ac­cess pri­mary care to avoid costly com­pli­ca­tions from un­treated ill­ness, he said.

“It makes a lot of sense to give ad­e­quate ac­cess to these pa­tients,” Raju said.

The pro­posal in Illi­nois would en­roll pa­tients into med­i­cal homes and seek to ex­pand ac­cess to pri­mary and pre­ven­tive care, a plan that will re­quire Cook County Health and Hos­pi­tals to hire and con­tract with pri­mary-care doc­tors, physi­cian as­sis­tants and nurse prac­ti­tion­ers, Raju said. The sys­tem will also hire care co­or­di­na­tors for pa­tients who have ex­pe­ri­enced highly frag­mented med­i­cal care.

Ohio of­fi­cials have sim­i­larly pro­posed ex­pan- sion of Med­i­caid in Cuya­hoga County, where about 21,000 unin­sured adults would gain cov­er­age un­der a pend­ing waiver pro­posal. Newly in­sured adults would be re­quired to seek care at the county-owned MetroHealth Med­i­cal Cen­ter, where an ex­ist­ing ef­fort to bet­ter co­or­di­nate care for the unin­sured has re­duced hospi­tal stays and emer­gency room vis­its, said John Cor­lett, vice pres­i­dent of gov­ern­ment re­la­tions and community af­fairs. But the 559-bed hospi­tal does not re­ceive re­im­burse­ment for care of the unin­sured, he said. MetroHealth wrote off $64 mil­lion last year on med­i­cal care for unin­sured pa­tients. Ex­panded Med­i­caid cov­er­age would re­duce those losses.

It’s un­clear whether waivers could be used by states to pur­sue a more lim­ited Med­i­caid ex­pan­sion up to 100% of the fed­eral poverty thresh­old, said Joan Alker, co-ex­ec­u­tive di­rec­tor at the Ge­orge­town Cen­ter for Chil­dren and Fam­i­lies.

That would in­crease costs for those with in­comes be­tween 100% and 133% of the poverty line to the fed­eral gov­ern­ment, which will pro­vide sub­si­dies for com­mer­cial in­sur­ance for in­di­vid­u­als with in­come be­tween 100% and 400% of the poverty thresh­old, Alker said. She cited a Con­gres­sional Bud­get Of­fice es­ti­mate that found an in­sur­ance sub­sidy costs the fed­eral gov­ern­ment $3,000 more per per­son than cov­er­age un­der Med­i­caid.

Other states have asked the CMS for more lat­i­tude but stopped short of ex­pand­ing Med­i­caid.

In New York, of­fi­cials asked the CMS for $10 bil­lion of pro­jected fed­eral sav­ings from the state’s ef­forts to re­form Med­i­caid, of which $1.5 bil­lion would be in­vested in the state’s pub­lic hos­pi­tals. That in­cludes the New York City Health and Hos­pi­tals Corp., the city’s 14-hospi­tal pub­lic sys­tem, which would use ex­tra funds to ex­pand ef­forts to pre­vent emer­gency-room vis­its and im­prove care co­or­di­na­tion.

One early ini­tia­tive at two hos­pi­tals placed care co­or­di­na­tors inside hos­pi­tals and emer­gency rooms and re­duced ad­mis­sions by 2,000 over two years, said LaRay Brown, se­nior vice pres­i­dent of cor­po­rate plan­ning, community health and in­ter­gov­ern­men­tal re­la­tions at the New York City pub­lic sys­tem.

Ef­forts have ex­panded the ini­tia­tive to other hos­pi­tals, but only dur­ing busi­ness hours of the work­week. HHC of­fi­cials would like to ex­pand hours to reach more pa­tients but can­not for one rea­son, she said: “Money.”

About 500,000 of the sys­tem’s 1.4 mil­lion pa­tients are unin­sured, she said. “We are peren­ni­ally chal­lenged in terms of our fi­nan­cial con­di­tion.”

HHC launched its ef­fort to place care co­or­di­na­tors in the emer­gency depart­ment at its Queens Hospi­tal Cen­ter.

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.