The Medicaid conundrum: Hundreds of thousands enrolled, but for how long? (Part 3)

For much of his adult life, Raymond McElfers never went to the doctor.

As a tree-trimmer, perks like health insurance just were never part of the job.

So in April, when the 30-year-old Latonia resident’s new Medicaid coverage kicked in, he went for a routine physical.

The father of four was told that a mass in his throat he had been ignoring was a cancerous tumor. By December, doctors had removed the original mass and another they later discovered.

“Without health insurance, I never would have been able to get surgery – let alone two surgeries,” said McElfers. “It’s been a life saver.”

Under the Affordable Care Act, Ohio and Kentucky are among the 27 states to extend Medicaid benefits to people like McElfers. Indiana announced last month it will soon embark on an expansion effort.

With So Many, Wait Times Grow

In Southwest Ohio and Northern Kentucky, more than 85,600 residents have enrolled into the new benefits in the last year.

The program’s expansion has been a boon for community health centers and safety net providers that for decades have offered deeply discounted care or forgone payments altogether from tens of thousands of people who couldn’t afford health insurance.

“Every day we’re enrolling someone new,” said Judith Warren, CEO ofHealth Care Access Now in Roselawn. “It’s providing so many a chance to get care who otherwise would have delayed it, or not managed their chronic disease appropriately and just get sicker.”

As the number of newly enrolled continue to swell, some say it can be difficult for some new Medicaid patients to connect with a doctor.

Some providers complain Medicaid still pays doctors too little for the care they provide, keeping many from accepting new patients.

Experts say it’s still too soon to know whether the new benefits are having any impact on local residents health.

“Medicaid is just a means to accessing care, and you wouldn’t expect this policy change alone to be responsible for changing the ultimate health and well being for those covered,” said Amy Rohling McGee, president of the Columbus-based think tank Health Policy Institute of Ohio, “It’s necessary, but it’s among multiple changes needed.”

Critics - argue that the move will prove too costly to taxpayers as millions of patients like McElfers begin to tap into their benefits.

The federal government has promised to pick up 100 percent of costs for expanding benefits to those who are newly eligible through 2016. That contribution phases down to 90 percent by 2020.

As the costs come in, even supporters have concerns that lawmakers may reconsider their support.

“There is a concern of how long you can ride this wave financially,” said Chris Goddard, CEO of HealthPoint. The nonprofit saw a more than 15 percent jump in Medicaid patients across its six Northern Kentucky offices last year.

“This is tremendous growth across the state,” he said.

You just hate to think that once you ramp up services, add capacity and offer these benefits – a few years later it could be all withdrawn. - Chris Goddard, CEO - HealthPoint

Expansion delivers boost, challenges for safety net providers

In Cincinnati, the number of uninsured people turning to the city’s health department has more than doubled.

About 50 percent of the department’s 35,000 patients seen across its seven health centers are now enrolled in Medicaid – a boost that’s brought in an estimated $2 million in revenue in 2014.

Despite adding a new office to try and meet demand for an estimated 3,000 new primary care appointments, new patients looking to connect with the doctor are waiting for weeks.

“We’ve had some capacity issues, and our biggest limitations have been finding providers,” said Dr. Lawrence Holditch, the department’s medical director.

Across the region, there’s a shortage of primary care doctors and not all of them accept new Medicaid patients because reimbursements for care are paid out at about a third of commercial insurance.

“It’s a real challenge to find doctors who will accept new patients,” said Warren, who runs a program aimed at helping high users of emergency room services.

“When we try to refer someone to a primary care doctor, it can take up to three to four weeks, or longer, to get an appointment, which defeats the whole purpose of trying to keep them out the ED,” says Warren.

Still, Holditch and Warren agree the current scenario is better than the alternative of having tens of thousands of patients with no way to pay for their care.

Longer term, expanded coverage should “enhance our community’s health,” Holdicth said.

Policymakers watching Indiana alternative

Just miles away in Indiana, about 350,000 residents are expected to qualify for new coverage under the state’s own version of Medicaid expansion dubbed Healthy Indiana Plan 2.0.

The state received approval two weeks ago from the federal government to move forward with the alternative program, after an eight-month wait.

Indiana’s plan will extend Medicaid to those who make less than 138 percent of the federal poverty limit, or $16,104 a year. Previously, Medicaid excluded coverage for adults under 65 who did not have dependent children.

Separating Indiana from other states, cost-sharing rules will require some of the newly enrolled to pay for a portion of their care. It also includes co-pays aimed at limited expensive emergency room visits ($8 for first visit, $25 for second.)

The expansion is welcome news to residents like Tracy Huismann of Bright.

Huismann, who lost coverage early in 2015, suffers post traumatic stress disorder.

The medicine she takes to manage it costs more than $200 a month.

“If I could just get this under control, I could have a job again and get my life back,” said Huismann, who’s already filled out an application with the help of enrollment assistors at Dearborn County Hospital.

Indiana’s move will be watched by lawmakers across the country who are calling for reforms to Medicaid that help curb the program’s cost.

In Ohio and Kentucky, Medicaid is the second largest expense in each state’s budget, just behind education. It rings in at $5.9 billion in Ohio and $3.2 billion in Kentucky.

Rohling-McGee said her think tank is “very interested in studying the relationship between employment and Medicaid, and how the coverage can help a person become or stay employed,” she said. “That can play a big role to some one moving on up the ladder and moving from Medicaid to private health insurance.”

Pushback from critics has leaders in Ohio and Kentucky working to make the case to keep their programs in place.

“The critics have shifted from ‘this is terrible’ to 'well, may be it’s OK, but are we going to be able to afford it?'” said Kentucky Gov. Steve Beshear. “Honestly, that’s a legitimate question.”

Beshear is awaiting the results of a consultant's report on the expansion’s impact on consumers, providers and the state’s budget.

“We don’t have all the results back yet, but just a few things we do know are encouraging,” said Beshear. “Just in one year there has been about 5,300 new jobs in health care created already ... Our hospitals in this state, they’ve gotten an infusion in money that they’ve never seen before. That bodes well for our economy.”

In Ohio, similar work has been under way in recent months as Gov. John Kasich works to get the legislature’s stamp of approval on his recent budget proposal.

Kasich sidestepped his party’s line in 2013 when he agreed to accept billions of federal dollars to expand Medicaid.

Now, he’s calling for cuts in other areas of Medicaid to curb the program’s cost.

Among his proposals:

• Eliminating Medicaid coverage for some pregnant women and certain disabled adults whose incomes are higher than $15,500 a year. Currently, these Ohioans are eligible if they earn up to $23,400 (or 200 percent of the poverty limit.) Those currently covered wouldn’t lose coverage, but the change would prevent new enrollees starting 2016. The savings is estimated at more than $7 million in 2016 and more than $15 million in 2017.
• Like Indiana’s plan, Kasich wants some low-income residents to pay for their coverage. Ohio is again petitioning the federal government to allow a $20 monthly premium to be assessed to those currently on Medicaid who earn more than $11,670 (or more 100 percent of the federal poverty level. If approved, the move would save Ohio more than $4 million over the next two years.

All told, the changes could save Ohio taxpayers $47 million over the next two years, Kasich’s administration says.

The proposals have some health care and low-income advocates concerned.

“Those all create barriers with people who have no disposable income,” Cathy Levine, executive director of Columbus-based Universal Health Care Action Network. “I’m hoping that smart health policy prevails at the end of the day.”

Photo Credit: Emily Maxwell/WCPO