Medical professionals statewide say that not expanding Medicaid, as intended in the Affordable Care Act, might be a mistake.
However, they note that the current Medicaid system is flawed and they understand why Gov. Rick Perry — who recently announced he would not expand the program in the state — is leery of taking on more with the already expensive program.
Perry joined at least six other governors, all Republicans, in rejecting the expansion. Along with the health insurance exchanges, these two components are the major tenets of the health care law targeted at reducing the percentage of uninsured citizens.
Perry also said he would not set up the exchanges — an insurance network that will provide information about obtaining and selecting coverage for individuals and their families.
“The states must be given the freedom to implement and run programs that reinforce individual responsibility, control costs and focus on successful health care outcomes.”
Dr. Nancy Dickey, president of Texas A&M Health Science Center and vice chancellor for health affairs at the Texas A&M University System, once served on the governor’s Health Care Policy Council, which has since been replaced by another committee.
“Make no mistake. Those people do access health care,” she said. “They’re often late in a disease, late in an emergency room, which are expensive sources of care. Anybody who pays taxes is helping pay for the uninsured. Anybody who has insurance is paying a higher premium because the insured population is paying more in order to help cover those folks whose care does not get paid for.”
The Texas Hospital Association expressed its concern in a statement: “With a strained state budget, it’s hard to imagine addressing the uninsured problem in Texas without leveraging federal funds, which will now go to other states that choose to expand their Medicaid program. We, nonetheless, look forward to working with the governor and members of the Texas Legislature to find a way to ensure low income Texans have access to affordable insurance coverage and to reform the Medicaid program for those currently enrolled.”
Standard Medicaid eligibility guidelines apply to pregnant women, children, seniors and the disabled. The ACA had intended for all states to expand Medicaid to more poor people who are currently ineligible. People who earn up to 133 percent of the federal poverty level will qualify for Medicaid. That’s $18,088 per year for an individual or $37,160.20 for a family of four.
The remaining uninsured would shop in a competitive marketplace of health insurance exchanges set up by each state.
About 9 million people would be affected if states do not expand Medicaid. Nearly 2 million Texans will be left without coverage of any kind because Medicaid is not an option and they won’t qualify for government subsidies through the health insurance exchanges.
As governors began rejecting the expansion, U.S. Health and Human Services Secretary Kathleen Sebelius said low-income residents in states that don’t expand Medicaid will not face an individual mandate penalty.
The Congressional Budget Office has said the expansion would have states paying 2.8 percent more than it normally does on the program.
“We would be bringing in $9 for every dollar the states spend,” Dr. Dickey said. “You’ve got to spend the dollar to get the $9, and the $9 doesn’t come to be used for anything you want. You can’t use it on roads or education. You have to spend it on health care for a particular population.”
She added, “On the other hand, Texans are going to continue to pay taxes and the feds are not going to lower our taxes just because we aren’t going to collect our share of the federal Medicaid purse. So, we’ll pay our taxes if we choose not to do the Medicaid expansion. Those dollars that we send to Washington will go to New York, Massachusetts, California, those places that do expand.”
Dr. Kirk Calhoun, president of The University of Texas Health Science Center at Tyler, said he understands both sides of the argument.
“This is a tremendous problem certainly for (the uninsured), but for all of us because those uninsured patients ultimately drive up costs of health care and have worse health outcomes,” he said. “The Medicaid expansion probably would have affected close to $2 million individuals in allowing them to get into some kind of health care system. All that being said, I think Gov. Perry appropriately pointed out that there are two big concerns that have to be resolved before any state can make commitments.”
He said those issues include correcting fraud and abuse, setting up adequate provider networks and, most importantly, paying for it.
By 2015, the Medicaid payment scale is expected to increase, but the new rates would be reserved for primary care physicians and not specialists.
“There are some areas that the payment would increase, but it probably still would be a fraction of what a good insurance company would pay and even a smaller fraction of what doctors and hospitals charge,” Dr. Dickey said.
There aren’t enough doctors accepting Medicaid patients and the trend would continue without payment rates being addressed, Calhoun said. The Texas Medical Association last week released a study that showed only one in three physicians accept Medicaid patients today, an all-time low.
In addition to having a large uninsured population, the Agency for Health Care Research and Quality recently rated Texas at the bottom in the nation for health care quality.
Scrapping the entire health care law might not be practical, Dr. Dickey said. Using the legislation as a template makes it possible to fix what doesn’t work and build on what does.
Dr. Dickey pointed to Medicare, which became law in 1965. It looks nothing like it did when established, as it has been amended and modified numerous times.
“If we stop attempting to repeal it — which a lot of people still think we should repeal it — if we look at more of the template and say, ‘Do we agree with the goal of trying to get Americans insured and is this a reasonable platform even though we may need to change 150 things within the bill,’ then I would say to you we could start trying to modify the bill. If the bill stands and it’s not repealed, I do not anticipate that it will look the way it does today five years from now.”
Calhoun noted that states were not comfortable with Medicaid when it was first implemented, also in 1965.
“People should keep in mind that when Medicaid first came along, only six states signed up at first,” he said. “Forty-four states decided to wait a little bit, so it is not surprising that state leaders are wanting to be prudent in how they approach this.”
Aside from the costs, Texas — one of the fastest growing states — is also under pressure to produce more physicians.
“We are not keeping up with the demand of physician services,” Calhoun said. “We could need as many as 20,000 more physicians by the end of this decade.”
He said academic institutions have been looking at how to attract more physicians and better train them through innovative programs. One particular program being modeled at a Missouri school, he said, is aimed at students completing their training in a six-year curriculum instead of eight years.
“Certainly, those kinds of things are being considered all around the state,” he said.
Calhoun said officials at the health science center are also focused on how to better train doctors and nurses efficiently.
“When I talk about this issue, regardless of how the elected leadership decides to resolve them, I think it is important for us to in all these activities, to achieve five goals,” he said.
Those goals include: improving access to care; improving quality of care, patient safety and outcomes; improving the patient experience; controlling medical costs and delivering care at a lower cost; and having health insurance reform.
“Health care is a hot issue right now, but I think if we keep track of those five goals, work through our differences, we can arrive at the best solutions,” he said. “Medicaid expansion is probably going to be a part of that, but problems have to be resolved.”
Only time will tell how government leaders and each respective state will continue with planning.
“My assumption is, for the short term, we go on the way we currently are, which is those people use free clinics where they can find them, emergency rooms when they reach a crisis and hospitals, doctors and taxing districts largely pick up the costs,” Dr. Dickey said.
“As a physician, I’d have to say I don’t think that is the most thoughtful way to provide health care because we’re essentially saying we won’t make a mammogram available to you, but once you get metastatic cancer, we’ll pay for you. We won’t diagnose your high blood pressure, but once you have a stroke, then we’ll take care of you. It would be a smarter spending of money to take care of identifying disease early, catching the chronic disease and hopefully avoiding expensive crises.”
Calhoun underscored the importance of voting and believes that once the smoke clears, solutions will be formulated.
“I’m confident that the right things will be done for Texas,” he said. “The governor’s moving cautiously, and one cannot necessarily criticize him for that at this point, but with 25 percent uninsured and with potential loss of our other funding streams, the care for that population, we are going to have to figure out how Texas is going to respond to this problem.”