Because the payment rates are so low, many doctors refuse to see Medicaid patients. Among those who do, the Medicaid patient is the last they want to see. This is one reason why newly enrolled Medicaid patients increase their visits to the emergency room by 40 percent.
Parkland Hospital in Dallas (the city’s safety-net hospital) tells the public online the average in-and-out time in their ER is almost six hours. And since Medicaid patients tend to be hourly employees, they lose a day’s pay.
Of the following potential reforms, the first three would give Medicaid enrollees access to the same kind of care middle-income patients receive, and save several hundred billion dollars in the process. Below are 12 reforms to supplement what I wrote in my Forbes column in March, “What Should Americans Do About Medicaid?”
‘Health Stamps’
Let people buy health care the way they buy food with food stamps.
If they go to a community health center or an ER, they pay Medicaid rates. But if they go to a MinuteClinic or a freestanding ER or any private practice doctor, they can add to the Medicaid rate with cash and pay the market price. This gives them access to the type of care that is now available only to other patients. This practice is currently illegal.
Roth HSA
Let enrollees have a Roth-style health savings account.
Medicaid-managed care insurers should be able to make deposits to HSAs, which can be designated for numerous purposes, including purchasing all primary care. Any money not spent can be withdrawn by the consumer for other purposes without taxes or penalties. This arrangement would be voluntary. It would be an opportunity, not a requirement.
Direct Primary Care
Let enrollees have access to direct primary care (DPC). This is 24/7 access along with a doctor’s phone number. Medicaid could supply the funds, or let enrollees make monthly payments from their Roth HSA. In all cases, they should be able to pay the market price so doctors will compete for their business. (DPC Cost in Wichita: $50 a month for a mother and $10 for a child.)
End Fraud
States must follow recommendations from the General Accounting Office (GAO) on eliminating fraud.
Over the past decade, CMS has made more than $1 trillion in improper payments: to the wrong person or entity, or for the wrong amount or the wrong reason. Many GAO recommendations have still not been implemented. One reform would be to conduct eligibility determinations more frequently.
Ban Insurer Taxes
California taxes insurers, gets a 60 percent match from the federal government for the tax, and then spends the money on medical expansion, including medical care for illegal aliens.
Ban Provider Taxes
This provider tax is when states charge providers a tax and then pay it back to them after the federal government reimburses the state for the spending. As The Wall Street Journal explains, this is mainly money laundering. If the practice were ended, ten-year savings would be more than $600 billion, the Congressional Budget Office predicts.
Equalize Reimbursement
In expansion states, the federal government is paying 90 percent of the cost of able-bodied adults, versus an average of 60 percent for everyone else. Children appear to be the victims of these distorted incentives. Especially disabled children.
Reps. Chip Roy (R-TX) and Scott Fitzgerald (R-WI) introduced the “Ending Medicaid Discrimination Against the Most Vulnerable Act” on May 9, which would end this imbalance (see page 4).
End LTC Subsidies for the Wealthy
California has abolished the asset test for Medicaid long-term care. As a result, federal taxpayers are subsidizing care for wealthy Californians. Many states allow these loopholes, and because it is so easy for anyone to get subsidized nursing care, few people save for it.
End Double Dipping
Medicaid has a poor record of tracking enrollees who move to another state. Medicaid spent $4.3 billion over three years paying insurers for the same patient more than once.
Work Requirements
If people value Medicaid coverage, they will work to keep it. People tend to put less value on goods and services that are free.
Fewer than half of Medicaid recipients work enough to comply with a work requirement today. When people work, they earn incomes that make them eligible for other insurance and reduce their need for Medicaid.
Liberalize Practice Rules
Congress should require states to liberalize their medical practice statutes as a condition for participation in Medicaid. If nurses could practice to the top of their training, they would provide more care at lower cost. The same is true for foreign-trained physicians.
Offer Block Grants
State governments should have the option of receiving 90 percent of their federal Medicaid dollars
in the form of a block grant, saving federal taxpayers the other 10 percent. With their share, the states could do some of the things discussed above.
For example, states could allow Roth HSAs outside the federal tax system. States could make deposits to these accounts and let enrollees pay market prices for their care.
John C. Goodman, Ph.D., ([email protected]) is co-publisher of Health Care News and president and founder of the Goodman Institute for Public Policy Research. A version of this article was published at goodmaninstitute.org. Reprinted with permission.
John C. Goodman is president of the Goodman Institute for Public Policy Research
