With passage of federal health insurance reform last March, the clock began ticking for states to begin work implementing the complex bill. For state leaders, Medicaid expansion and the logistics behind setting up health insurance exchanges pose some of the bill’s biggest challenges, says Jack Meyer, professor at the University of Maryland and principal at Health Management Associates.
Enhancing the associated infrastructure of primary physicians, dentists and government administrators needed to handle Medicaid and insurance exchange requirements remains a daunting task for many states, Dr. Meyer told CivSource in an interview.
“Currently, some 68 million people pass through the Medicaid system. Some drop off and some come back on [over the course of a year] but by and large it serves patients pretty well,” Dr. Meyer argued. But he also acknowledged that Medicaid has remained solvent by “failing to update, if not reduce, the amount it pays to providers,” which is causing a shortage of participating doctors and access problems for patients.
“Rates for doctors are so low many don’t participate. So you’ve got a ticket to go wherever you want in the system, but there’s still an access problem,” Meyer said.
An estimated increase of 16 million new people in to the system, combine with a growing shortage of doctors, dentists, nurses and other health care professionals willing to see Medicaid patients will be a tremendous challenge for the states, Meyer said. And to make things more complicated, the 16 million newly eligible recipients are expected to be a high-need contingency – poor and near poor childless adults, 45 – 50 year-old who may have multiple chronic illnesses, mental health problems and related issues.
The federal government is trying to bolster program participation and the health care workforce through a two-year increase in payments and $11 billion to community health centers, Dr. Meyer indicated. There are also new provisions for loan forgiveness for doctors and nurses to serve in underserved areas.
Still, states do have over four decades of experience administering Medicaid. With the mandatory creation of health insurance exchanges, only Massachusetts and a few cities have experimented with formalized programs.
“The exchanges will be a new role for states,” Meyer said, indicating there will multiple components for states to handle. “States will have to arrange online shopping and other offline access points to handle enrollment. They will have to negotiate with a wide range of health plans in the commercial world to make sure they’re affordable and meet minimum requirements. States will have to work more closely with the IRS for tax data. And they will have to monitor quality assurance reporting and medical loss ratio,” which is the percent of total premium revenue versus the cost of care.
This new role will require more state staff and a different type of staff with a different type of skill set, Meyer argued. “And what are states doing right now? They are laying people off, running deficits, losing revenues and furloughing workers.”
“My concern is that while new responsibilities are looming, states are not augmenting their workforce, they are being forced to scale it back.”
One of the first waves of deadlines passed in July, involving the creation of “high-risk” pools. Almost half of the states (22) punted the obligation back to the Department of Health and Human Services to manage. But by 2014 all states must be operating their own health insurance exchanges, with federal tax subsidies going to middle-income earners to help pay premiums.
“We’ve got three-and-a-half years to prepare,” Meyer said.