Moneybox

Dreaming of a Medicaid Nightmare

The health insurance program for poor Americans was never as broken as the GOP said. If the Senate passes its repeal bill, it will be.

Senate Majority Leader Mitch McConnell listens during a meeting with President Donald Trump in the White House on Tuesday.

Olivier Douliery - Pool/Getty Images

Republicans like to argue that Medicaid is a rotten health insurance program because physicians simply won’t accept its patients. “More and more doctors just don’t take Medicaid,” House Speaker Paul Ryan told reporters in March. “I mean, what good is your coverage if you can’t get a doctor?” Secretary of Health and Human Services Tom Price also likes to trot out this talking point. “Why are those doctors not seeing Medicaid patients? Let me just suggest it’s because the Medicaid program itself has real problem in it,” he lectured a town hall attendee who’d survived cancer thanks to the program. And, of course, the doctors-won’t-take-Medicaid line is a mainstay of conservative op-eds.

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In reality, Medicaid patients don’t seem to have much more trouble, if they have any at all, getting care than similarly poor Americans who have private insurance. But the rhetoric is politically useful for Republicans since it lets them talk about reforming the program rather than simply cutting its budget.

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Now that Obamacare repeal seems to be gaining steam in the Senate, it seems worth pointing out the inconvenient fact that along with shrinking Medicaid’s rolls by millions, the legislation in the works would almost certainly make it harder for the remaining Medicaid patients to find a doctor. Republicans could finally turn the program into the sort of disaster they’ve always imagined it to be.

Today, a little more than one-third of physicians report that they either limit the number of Medicaid patients in their practice or don’t see any at all. This, of course, can make it tricky for the program’s enrollees to get a doctor’s appointment. But the problem is not necessarily much worse for the Medicaid population than it is for low-earners with private health plans. A recent report by the Medicaid and CHIP Payment and Access Commission, which compared Americans whose incomes amounted to less than 138 percent of the poverty line, showed that 8 percent of Medicaid beneficiaries said they had to put off needed care because they couldn’t schedule a doctor’s visit soon enough. Among those with private coverage, 5.2 percent reported the same sort of trouble. This shouldn’t be so surprising, since cheap insurance plans keep costs down by offering narrow doctors’ networks that limit options for care. Meanwhile, Medicaid patients were actually less likely to say they put off care because of cost.

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Still, the fact is that 1 in 3 doctors shy away from Medicaid. There’s a good, simple reason why: It doesn’t pay very well. On average, the program offers them just 72 percent of what they’d receive for their services from Medicare—which is already known for being stingy. This keeps costs down for states and Washington, which jointly fund Medicaid. But between the low reimbursements, onerous paperwork, and the fact that Medicaid patients can be difficult time-consuming medical cases, many M.D.s decide they’re not worth the effort—meaning that enrollees don’t necessarily have their pick of primary care doctor and may have to wait a while to see an orthopedist.

The Republican plan would almost certainly make those waits worse.

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We don’t know exactly what GOP lawmakers have in store for Medicaid, since Senate Republicans are writing their legislation in secret and aren’t planning to reveal its text until the last possible moment before a vote. But between the House repeal bill passed last month and the news reports filtering out of the Senate, the broad strokes are becoming clear enough.

First, Republicans want to end Obamacare’s Medicaid expansion, which made millions of able-bodied adults eligible for the program and provided federal funding to cover the vast majority of their medical costs. The House bill would roll back the expansion in 2020, while Senate moderates are reportedly angling for a slower, seven-year phase-out—but the end result will be the same. (Plus, some states will terminate their expansions automatically when federal contributions begin to decrease.)

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Second, the GOP wants to fundamentally revamp Medicaid’s funding structure in order to squeeze its growth. Today, there’s no limit on Medicaid’s budget. States and the federal government pay for the program together, with Washington covering a set percentage of each enrollee’s costs, no matter how much they rack up in medical bills. The House legislation would end that arrangement by capping the amount of money states receive each year per patient. The amount would be set based on today’s average spending and adjusted for inflation using the Consumer Price Index for Medical Services. Because the CPI-M only covers out-of-pocket medical costs, it will likely grow far slower than Medicaid’s budget would under current law, thereby choking off its future growth. The Senate moderates are reportedly more or less OK with that arrangement, though they are supposedly considering some tweaks to how the per-capita cap would be adjusted over time.

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According to the Congressional Budget Office, the combined changes in the House bill would torch $834 billion over a decade from Medicaid’s budget while reducing its enrollment by 17 percent. Unfortunately, the CBO’s forecast did not show how much of the carnage would be due to the end of the Medicaid expansion and how much would be due to the per-capita cap. But each would certainly damage the program in its own way.

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Ending the expansion would trim Medicaid’s rolls over time. Technically, states could still enroll adults who were made eligible through Obamacare, but it would be financially unfeasible for all but large, populous states like New York, California, and Massachusetts. The program would shrink.

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The per-capita cap, meanwhile, incentivizes states to make Medicaid stingier. Because it offers money for each new patient, it wouldn’t necessarily nudge states to chop down their Medicaid rolls across the board. But it would push them to reduce costs. The most obvious ways to do that would either be by reducing payments to doctors or by covering fewer services. States could decide to nix prescription drug coverage, dental coverage, or home health services for the elderly and chronically ill.

Now imagine all of this from a doctor’s perspective. Medicaid already pays little. Now it could pay even less, while covering fewer people, and its patients may not have coverage for essentials like the Lipitor you prescribed them. At some point, it becomes easier to simply wash your hands of the program.

Republicans will of course make noise about giving states “flexibility” to find savings and efficiencies, so Medicaid patients are better served. But Washington could give states more latitude without cutting the program’s budget. Instead, they’re raiding it to pay for a massive tax cut aimed at the wealthy. In doing so, they could make every bad word they’ve had to say about Medicaid finally come true.

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