The Affordable Care Act’s Medicaid bait and switch

As we enter year two of the Affordable Care Act, we have seen many issues arise during implementation.  Through both executive order and executive memorandum, President Obama has unilaterally changed the law more than 100 times in order to advance his political agenda.

When it became important to publicize enrollment and increased coverage of the uninsured, the president, and the ACA provided for an increased payment scale for patients with Medicaid.  With the rapid increase of Medicaid insured patients due to the implementation of the ACA, the administration utilized the increased payments as an incentive to attract more physicians to participate in Medicaid programs.

According to the New York Times, the ACA has resulted in the largest increase in Medicaid covered patients in history — now nearly 20 percent of all Americans are covered under this plan.  Attracting physicians to cover Medicare patients has been critical in order to meet the demand for access to care and  to adequately cover the newly insured.  Now, unless changes are made, Medicaid reimbursements will be cut once again leaving many physicians to wonder if they can continue to treat the increasing numbers of Americans covered through these programs.

Traditionally, Medicaid has reimbursed physicians at rates significantly lower than Medicare, making practices with large numbers of Medicaid patients financially nonviable.  As the ACA was rolled out, a provision provided for significantly better Medicaid payment rates to physicians in order to help provide larger networks of care for the newly insured.  Now, there looms an automatic payment rate cut of nearly 43 percent for Medicaid payments to primary care physicians. Many of these are the same physicians who agreed to expand Medicaid within their practices in order to meet demand.

According to Forbes, traditional Medicaid reimbursement averages just 61 percent of Medicare reimbursement rates (which is often significantly lower than private insurance rates).  In addition, many Medicaid patients require a disproportionate amount of time and resources from the office.  Doctors are caught between a rock and a hard place: between a moral obligation to treat these patients and a desire to avoid financial ruin.  These patients tend to be sicker, have multiple medical problems and have suffered from a long time lack of preventive care.

Finances are not the only piece of the Medicaid puzzle. Government regulation and paperwork and processing often delays payments to physicians and impacts their ability to run a financially sound business. Interestingly, a study from 2013 published in Health Affairs suggested that while physicians welcomed an increase in reimbursement rates as incentive to treat Medicaid patients that quicker payment times, reduced paperwork and simplified administrative processes would also need to be a part of any type of reform.

Many primary care physicians stepped up to answer the call for increasing coverage of Medicare patients when the ACA was initially rolled out.  Now, these same physicians are contemplating the need to drop these patients from their clinics with the pending change in reimbursement.

In addition to lower reimbursement rates, the Medicaid program requires an enormous amount of administrative work in order to file claims. And these claims are often paid very late; those running a small practice are forced with more work for less pay and often have to make difficult budgetary decisions in order to meet payroll for their staff each week.   While the administration touts the swelling numbers of Medicaid covered patients — nearly 68 million currently — I suspect access to quality care will soon become an issue.  Just as with every other manipulation of the ACA over the last two years, legacy and political agendas have taken precedent over what really should matter: providing quality medical care and prompt, easy access to care for the formerly uninsured.

In an effort to tout swelling numbers of covered Americans, the Obama administration has failed to anticipate the impact of short term financial incentives for primary care physicians to accept increasing numbers of Medicaid patients.  Even in states such as California, officials are bracing for a large number of physicians who have announced that they will likely drop out of Medicaid plans if the planned cuts are implemented as scheduled.

It is time for the Obama administration to stop playing political games with our health care.  If the mission of the ACA is to provide affordable quality health care for all Americans, then we need to ensure that there are quality, dedicated physicians available to provide that care.  The Medicaid bait and switch is just one example of our president’s shortsightedness and lack of connection to those dedicated physicians who work tirelessly to ensure that all patients have access to care (regardless of insurance type).

It is my hope that the new Congress will engage with the physician community and find real solutions to the U.S. health care crisis; and no longer allow the president to place his perceived legacy over the health care of those Americans who are in need.

Kevin R. Campbell is a cardiac electrophysiologist who blogs at his self-titled site, Dr. Kevin R. Campbell, MD.

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