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Medicaid Expansion Presents Policy Challenges

Experts point to outreach and provider incentives as key factors in reaching enrollment goals.

In order to meet the state’s target of enrolling more than 100,000 new residents in an expansion of Medicaid, state officials, private healthcare providers and citizen advocates will have a great deal of work ahead of them this year.

That was the message offered by healthcare policy experts who participated in a panel discussion hosted yesterday In Trenton by NJ Spotlight.

Medicaid is the federal government’s primary health-insurance program for low-income residents. It is being expanded under the 2010 Affordable Care Act.

Among the chief challenges in implementing the expansion are the difficulty in reaching a population which includes many people who don’t know they are eligible for the program; the strain additional patients may create for healthcare providers, and maximizing the benefits of expansion while improving patient care.

“I think we have our work cut out for us, but it’s good work and it’s needed work,” said panelist Suzanne Ianni, president and CEO of the Hospital Alliance of New Jersey, a group that represents urban hospitals.

The newly eligible population largely consists of adults without children with incomes between roughly $2,500 and 138 percent of the federal poverty line, which currently amounts to $15,856 for a single adult.

Another panelist, Sen. Joseph F. Vitale (D-Middlesex), laid out several proposals for implementing the expansion, including a bill he’s writing that would enroll every eligible person in Medicaid whenever they visit a healthcare facility.

He said the state should establish benchmarks for reaching certain enrollment goals, as well as plans to meet those goals if it falls short on the benchmarks.

One challenge in enrolling patients is the state’s lack of infrastructure for reaching the newly eligible population, according to panelist Raymond J. Castro, senior policy for New Jersey Policy Perspective.

“A lot of other states have worked with community based organizations for years in their FamilyCare programs,” Castro said, referring to state-based Medicaid-funded care. He added that states that established state-run health benefit exchanges, unlike New Jersey, will have more money for outreach to these hard-to- reach populations. He noted that Maryland will have $25 million, while New Jersey may see as little as $3 million in funding through its federally operated exchange.

The funds will come through fees based on premiums paid by residents purchasing insurance through the exchange, an online marketplace through which residents will be able to buy insurance, learn about their eligibility for federal subsidies or apply to enroll in Medicaid.

A state study to determine who the eligible residents are and where they live is important. Outreach to different groups must vary, Castro said, adding that most people learn about Medicaid eligibility from their neighbors and relatives.

“Reaching out to these folks is really everyone’s responsibility,” he said. “Only by working together can we really improve the health of our state.”

Vitale expressed concern that the state has cut back its FamilyCare advertising in recent years, leading to a decline in public awareness of the program and enrollment in it. FamilyCare is the largest Medicaid-funded health-insurance program in the state.“Even today I think in some ways it’s the state’s best-kept secret,” he said.

Ianni predicted that it will be more difficult to enroll adults than it was to expand FamilyCare, which was largely accomplished by reaching children and their parents through schools.

“As we all know as parents you do a lot more for your kids than you do for yourselves,” Ianni said.

She added that while hospitals have programs to enroll patients in Medicaid, patients sometimes leave before hospital officials have a chance to inform them about their eligibility.

Vitale noted the importance of hospitals sharing information about insurance enrollment with the state. He expressed frustration that existing mandates for schools to share enrollment data aren’t being followed.

“What are they waiting for?” Vitale asked, referring to school districts that aren’t forwarding the information to state officials, who would send FamilyCare applications parents of children who aren’t enrolled.

She cautioned that while hospitals would like to see more patients enrolled in Medicaid, the state may not see a large drop in the amount of charity care – a program through which hospitals receive partial compensation for treating uninsured residents.

“We should manage our expectations,” Ianni said. “It’s a great thing -- Medicaid expansion -- but it’s not a cure-all.”

Medicaid must be made more transparent for the expansion to be effective, according to another panelist, Dr. Poonam Alaigh, former state health commissioner and a board member for the Common Sense Institute of New Jersey.

She recalled a doctor telling her about a patient who had racked up $220,000 worth of care and treatment in 20 visits to healthcare facilities, without any provider being aware of it. The doctor was able to find the data through information compiled by the federal Centers for Medicare & Medicaid Services.

“We need transparency, we need data at the point of care,” to allow doctors to better coordinate care and make it more cost-effective, she said.

John Koehn, CEO of managed-care insurer Amerigroup New Jersey, who also sat on the panel, noted that the state handled a similar expansion in the past four years, due to a recession that cost many residents their employer-provided insurance and an expansion of FamilyCare eligibility.

He added that while the state has more generous FamilyCare enrollment standards than other states, it hasn’t succeeded in enrolling as high a percentage of eligible residents.

According to other panelists, another barrier to the successful expansion of Medicaid is the lack of primary-care providers and specialists who treat Medicaid enrollees. Koehn disagreed, saying that the supply of providers shouldn't be a barrier to expansion.

Vitale said he recently visited a medical school class in which only two of 40 students planned to pursue primary care or family medicine. He’s proposed increasing the ability of advanced practice nurses to establish their own practices to help meet the growing need for primary-care services.

One important way to encourage doctors to accept patients with Medicaid is a two-year federal program to make Medicaid payments to doctors equal to those for Medicare, Koehn said. Castro added that the state should develop a strategy to assess where Medicaid-paid care is needed and use that information to encourage doctors to participate.

Alaigh said this two-year program will be most useful if it’s used as a starting point for shifting the basis for making Medicaid payments to doctors away from how much patients use healthcare services toward the health results of patients. She noted that doctors are concerned about the two-year expiration date for the higher payments.

While Christie has said he would reconsider the Medicaid expansion if federal actions reduce the benefits to the state, some panelists felt this is unlikely to happen. Castro said Medicaid funding is a priority for President Obama, while Koehn said that if a future Republican president wanted to cut Medicaid funding, he or she would meet resistance from many GOP governors.

Castro predicted that Pennsylvania Gov. Tom Corbett will be under increasing pressure to reverse his position against the expansion. Castro noted that Philadelphia hospitals will now receive Medicaid patients for New Jersey residents, but not for Pennsylvania residents, costing Pennsylvania taxpayers more money.

The roundtable was sponsored by Amerigroup, the Hospital Alliance of New Jersey, the Nicholson Foundation and Citizen Action. It drew a crowd of roughly 100 and was held at the Masonic Temple in Trenton.

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