The last and perhaps most controversial piece of health reform's universal coverage has many miles to go in terms of financial sustainability. But there are signs of progress.
More than three million low-income Americans who would be eligible for Medicaid coverage are still living uninsured, across the 20 states that have not expanded eligibility for the program to people earning up to 133 percent of the federal poverty level. In states like Florida, Georgia and Texas, both low-income residents and hospital systems are struggling amid this gap.
Patients who are uninsured but need medical treatment have to navigate charity care and patient assistance options, and some many have forgone getting a test -- until they need it. One middle-age Kentucky man, highlighted by the New England Journal of Medicine, spent a year with abdominal pain, saw a primary care physician, and, being uninsured and ineligible for Medicaid at the time, decide to bare with it.
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Then the pain and bowel obstruction mounted, and he went to a university hospital. After an exam, lab tests and a CT scan -- costing his life savings, $10,000 -- he went home with a diagnosis of metastatic colon cancer. "If we'd found it sooner, it would have made a difference. But now I'm just a dead man walking."
Such is the predicament Americans can find themselves in without access to basic health coverage and preventive care; a colonoscopy a year earlier could have caught the disease when it was more treatment. An estimated 45,000 American adults die each year because they have no health insurance, according a 2009 study in the American Journal of Public Health.
That problem is one reason why John Kasich, the former Ohio governor and current Republican presidential candidate, said he bucked the trend of conservative state leaders and expanded Medicaid eligibility under the Affordable Care Act.
Instead of having the "working poor" use "emergency rooms where it costs more, where they're sicker and we end up paying, we brought a program in here to make sure that people could get on their feet," Kasich said in the recent GOP debate.
Medicaid, Kasich argued, is also important in treating the opioid and drug addiction epidemics and mental health problems linked with crime.
"Ten thousand (mentally ill) sit in our prisons," he said. "It costs $22,500 a year to keep them in prison. I would rather get them their medication so they can lead a decent life. Secondly, we are rehabbing the drug-addicted. Eighty percent of the people in our prisons have addiction problems. We now treat them in prisons, release them in the community, and the recidivism rate is 10 percent. And everybody across this country knows the tsunami of drugs is threatening their very families. So we are treating them and getting them on their feet."
About 20 percent of Medicaid beneficiaries have behavioral health diagnoses, and some 3 million children who qualify for Medicaid based on disability have behavioral health diagnosis, according to the Medicaid and CHIP Payment and Access Commission.
Medicaid beneficiaries who are eligible for reasons other than disability have unmet needs for behavioral health screening, treatment and referrals, MACPAC argues in its annual report to Congress. "Early intervention and treatment could help delay or prevent loss of function and allow beneficiaries to manage problems before they become disabling," the Commission said.
Primary care and integration
Perhaps the greatest challenge for Medicaid and its 51 varieties across the states and Washington D.C. is how to harness the potential of primary healthcare for preventing high-cost behavioral and acute care.
Many physicians, especially family practitioners, have long complained of Medicaid's low reimbursement rates. As of 2012, about one-third of PCPs were not accepting Medicaid beneficiaries as new patients.
But at least 15 states are continuing the ACA's Medicaid "pay bump," which for 2013 and 2014 paid primary care docs the same rates as Medicare.
Some states are also redesigning their Medicaid programs around robust primary care, blending the models of the patient-centered medical home, accountable care organizations and outsourced managed care.
So far a success is Colorado's Medicaid accountable care program, in which regional collaborative care organizations coordinate care for patients across primary care, speciality services, hospitals and community and social supports.
The program covers about half of the state's beneficiaries, and in its first full year saw a 15 percent reduction in hospital admissions and a 25 percent reduction in high-cost imaging. That led to $44 million in savings, with most going to providers as incentive bonuses and $6 million returning to state coffers.
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Elsewhere, in states relying heavily on Medicaid managed care, hospital systems are sponsoring their own Medicaid health plans, and using their physician practices as an integrated network of sorts. As Karla Lord, the director of business operations for Gundersen Health System's health plan said, a provider-sponsored Medicaid plan can help bring "easier collaboration and fewer barriers, because the provider and health plan are owned by the same parent company."
As former Ohio governor Kasich suggested, extending Medicaid coverage to the working poor can be an investment for the future It may requires decades for the investment ends up paying off in terms of population health benefits, but it also may not be as big an investment as the expenditures on long-term care.
Around one-third of Medicaid's $475 billion total spending is devoted to long-term care for the elderly and the disabled; the program is the largest payer of long-term care and the payer of last resort.
Many seniors who need long-term care "spend down" their savings (not including housing) to be able to qualify for Medicaid coverage of long-term services and supports, including to reside in a nursing home.
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"It's actually very common, far more common than people understand," said Bruce Chernof, MD, the president and CEO of the SCAN Foundation, a nonprofit health plan in California, in an interview with the PBS News Hour.
"Unfortunately, the Medicaid program was built in a different time and place," Chernoff said. "And while many states are working to re-balance their services and make more services available in the home and the community, for many folks, the only option may be in a nursing home."