In Health Care Ruling, Vast Implications for ... - Health and Fitness

Mr. Mashburn, 39, is exactly the kind of person who stands to benefit from changes in Medicaid scheduled to occur under the new health care law ? a vast expansion of the program that is expected to add 250,000 people to the rolls here in Arkansas and 17 million across the country.

The expansion of Medicaid ? if it is upheld by the Supreme Court ? is among the most significant parts of the law, as it will provide coverage to people with the greatest financial needs.? Many health care advocates support the expansion, saying it will allow poor people to receive needed care, while many state officials, especially Republicans, worry that it will bring budget-breaking new costs.

The expansion may also strain the health care system, given the shortage in some places of primary care doctors, who will be vital to expanded coverage.

The Supreme Court, which is expected to rule on the health care law this month, devoted more than an hour of argument to the Medicaid provision.

Arkansas illustrates not only the potential benefits but also the major challenges facing states as they plan for a larger Medicaid program. The state does not have enough doctors and other health care workers to care for all the new beneficiaries, experts say, and state officials worry about the costs.

?The expansion of Medicaid is a sea change, and it?s occurring at the most difficult fiscal time in the history of the program,? said the Medicaid director in Arkansas, R. Andrew Allison, who is the president of the National Association of Medicaid Directors. ?States are preoccupied with the challenge of sustaining the Medicaid program we already have.?

Arkansas officials have discussed cutting Medicaid services in the coming year to help close a gap between Medicaid costs and expected state appropriations. The gap ? up to $400 million ? represents more than one-fourth of state spending on the program.

Medicaid is jointly financed by the federal government and the states, with Washington paying 50 percent of the costs in higher-income states and about 70 percent in lower-income states like Arkansas. States have historically had leeway to define eligibility and benefits within guidelines set by federal law.

Under the new law, the federal government will pay the full cost of covering those newly eligible for Medicaid for three years, from 2014 to 2016, and the federal share will then gradually decline to 90 percent in 2020 and later years. Administration officials say this is a good deal for states, but it may ultimately create new costs for states. Many state officials also worry that Congress will reduce the federal share and shift more costs to the states.

?There is uncertainty, very commonly conveyed to me by states, that the law as written now will somehow have to change to address the federal government?s fiscal crisis,? Mr. Allison said.

In challenging the constitutionality of the new health care law, 26 states have asserted that Congress cannot force them to make such a large expansion of Medicaid. The case raises profound questions about Congress?s ability to attach conditions to money that it distributes to states not only for health care but also for education, transportation and myriad other purposes. At some point, the states argue, financial inducement turns into coercion.

The expansion of Medicaid would have a large impact in relatively poor states like Arkansas, where current eligibility criteria for adults are strict and chronic conditions like diabetes and obesity are widespread. (Arkansas is less healthy than all but three other states, according to annual rankings by the United Health Foundation.)

Other states that expect large increases in Medicaid enrollment, like Louisiana and Texas, are among the plaintiffs in the federal lawsuit. In Arkansas, by contrast, state officials accept the expansion of Medicaid.

?Expansion of Medicaid will be a huge opportunity, a way to provide coverage for low-income citizens that we simply could not afford without federal financing,? said Dr. Joseph W. Thompson, the surgeon general of Arkansas.

Arkansas officials want to expand insurance coverage while also taking steps to keep costs under control. They would pay doctors a lump sum for each ?episode of care,? rather than a separate fee for each service.

The Census Bureau estimates that 500,000 people in Arkansas are uninsured. Half of them would be eligible for Medicaid under the new health care law.

Arkansas officials expect the Medicaid rolls to grow by more than 35 percent, to 925,000, from 675,000. Here, as in other states, most of the new Medicaid beneficiaries are expected to be adults.

Arkansas has taken significant steps to insure more children in recent years, under Gov. Mike Beebe, a Democrat, and his predecessor, Mike Huckabee, a Republican, who signed a bill creating an insurance program for children in 1997, five months before the federal program for children was established.

In the 15 years since then, the proportion of Arkansas children lacking coverage has been cut by more than half. But coverage of parents and other adults lags far behind. Some Arkansas adults have children covered by Medicaid or the Children?s Health Insurance Program but are themselves uninsured.

Heather D. Clubbs said that her children ? a 14-year-old daughter and two sons, ages 8 and 15 ? went regularly to doctors and dentists here for services covered by Medicaid. But Ms. Clubbs, who earns $9.71 an hour as a nurse?s aide at a nursing home, said she could not afford coverage for herself, which would take $200 a month out of her paycheck.

?I would go to the doctor more often if I had health insurance,? Ms. Clubbs said. ?I try not to go to the doctor at all.?

Current Medicaid eligibility rules are notoriously complicated, and to qualify a person must fit into one of several dozen categories. ?It?s a very common misconception that Medicaid covers all poor people, but that?s far from the truth,? Mr. Allison said.

In Arkansas, parents generally cannot qualify for Medicaid if their family income is more than 25 percent of the poverty level (in other words, more than $4,770 a year for a family of three), and childless adults generally cannot qualify unless they are disabled.

The new health care law will simplify eligibility, sweeping away many of those categories in favor of a single standard. People under 65 will generally qualify for Medicaid if their income is less than or equal to 133 percent of the federal poverty level (up to $25,390 for a family of three).

In addition to the costs, state officials here are not sure how they will cope with the expected surge in people eligible for Medicaid, given that doctors and nurses are scarce in some counties.

Dr. Steven F. Collier, the chief executive of a network of community health centers known as ARcare, said: ?The new health care law is a good thing. But if it is ruled constitutional, there will be some practical problems, and access to care is No. 1. If you give people health insurance and they do not have access to a doctor or health care, what difference will that make??

Darren Caldwell, chief executive of DeWitt Hospital in DeWitt, Ark., said: ?I worry that the Medicaid card will be like Confederate money. You won?t have anywhere to use it, and it won?t be worth anything.?

Sip B. Mouden, chief executive of Community Health Centers of Arkansas, whose members operate 75 clinics in the state, said: ?A lot of our community health centers are at capacity right now. An insurance card does not guarantee access to a regular source of primary and preventive care.?

Arkansas, like many states, plans to train more doctors, physician assistants and other health care workers. But the supply is expected to fall short of the demand, and Dr. Daniel W. Rahn, chancellor of the University of Arkansas for Medical Sciences, said the state had not identified ?a revenue source to build that additional capacity.?

Article source: http://www.nytimes.com/2012/06/16/us/in-health-care-ruling-vast-implications-for-medicaid.html?pagewanted=all

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