Face it, Medicaid could use a reboot

Ihave been working with Medicaid patients all my professional life, and years ago when it no longer made sense for me to file the cumbersome billing forms for minimal reimbursements, I began to see my Medicaid patients for free. In fact, 31% of doctors refuse to see new Medicaid patients these days, frequently not because they don’t want to but because they can’t afford to.

Medicaid is also becoming more expensive to provide, rising from 2.5% to 9.6% of government spending over the past two decades according to the Office of Management and Budget.

Don’t get me wrong — Medicaid does a lot of good for more than 70 million people in the U.S., people who are poor and disabled, children who would have no other way of obtaining basic care unless Medicaid paves the way. Medicaid helps people who have lost their jobs and have no other way to obtain health care. Now, in 32 states that have elected to expand Medicaid to people who have income up to 138% of the poverty line, it helps those who would otherwise find it very difficult to afford health care.

But does Medicaid fulfill such an irreplaceable need in our society, provided you can find a doctor or clinic that works with it, that it is beyond reproach or reform? Is it sacrilegious to suggest that Medicaid is wasteful or inefficient or requires substantial changes?

Consider that in most states Medicaid sets time intervals for replacing basic items such as eyeglasses (two years), or medical equipment and supplies (three years), which are not based strictly on need — what if your equipment breaks or is stolen? — and lead easily to overuse.

Emergency room usage under Obamacare’s Medicaid expansion has increased almost 9% in many states that expanded Medicaid, according to a study in the Annals of Emergency Medicine comparing 14 states which expanded Medicaid with 11 states that didn’t. The number of uninsured people going to ERs shrunk by 5% in the expansion states, which is certainly good for hospitals. But is all this ER use necessary?

The same type of concern of use versus overuse applies to the opioid epidemic, where the CDC reported in 2009 that Medicaid recipients were prescribed opioids at twice the rate of non-Medicaid patients and were at least three times more likely to die of a fatal overdose. According to Health Affairs, 15% of all Medicaid users received at least one opioid prescription in 2012 — opening a gateway to potential addiction.

Does Medicaid work despite all the inefficiencies, excesses and doctor unavailability? The answer is sometimes yes and sometimes no. Back in 2008, preObamacare, Oregon experimented with expanding Medicaid to over six thousand randomly chosen lower-income adults.

The results, published in the New England Journal of Medicine in 2013, shocked the health policy world, showing that “Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years but it did increase use of health care services.”

Meanwhile, a review by the Kaiser Family Foundation concluded that the Medicaid expansion has improved access to health care services if not necessarily outcome.

Medicaid cares for our country’s most vulnerable — our poor and our disabled. Extending it to the lower working class as Obamacare did expanded access to care while also indirectly making some serious problems — such as opioid abuse and ER overcrowding — worse.

What to do now? It is unreasonable to peel back the Medicaid expansion or limit funding to the states to such an extent that they are no longer able to provide Medicaid coverage to all who are eligible. A better approach to reform would be to utilize federal oversight and funding to cut back on overuse, pay doctors more to be involved, and create premium buy-ins where patients who can afford to can pay for extra services.

Proposed bridge-to-jobs programs would require that recipients work, look for work, train or study, and should be considered in all states for Medicaid recipients deemed capable.

Differences over what to do about Medicaid strike right to the heart of the health reform debate. Since its undeniable that Medicaid is both useful and wasteful, it also is a great place for compromise between Republicans and Democrats to begin.