Medicaid Expansion Not the Final Solution…But A Start?

I got an e-mail message from Iowa State Representative (Democrat), Mary Mascher, the other day.Iowa rep mary mascher She is a hard-working legislator working on a number of issues for Iowans, including health care expansion. At her recent public hearing held in the House Chambers, She reported that doctors and patients had a lot of stories to share about how difficult it is to get health care.

Most of the speakers (87%) supported Medicaid expansion under the Affordable Care Act (ACA), noting that Governor Branstad’s plan covers fewer Iowans and and costs more than simply expanding Medicaid. University of Iowa leadership, including The Iowa Consortium for Mental Health, (see link Iowa Consortium for Mental Health – Iowa Mental Health Resources) are working diligently to resolve the debate because the health care plan we currently have, called IowaCare, may or may not expire later this year. The Iowa Medical Society also supports expansion: Iowa Medical Society Supports Medicaid Expansion

The Iowa Medical Society supports efforts to expand and improve Medicaid in Iowa. Bill to watch: SF 296 – Expands Medicaid eligibility as allowed under the ACA, transitions Medicaid beneficiaries to a medical home-based model of care, and establishes a legislative commission to evaluate integrated care models. Passed Senate; IMS is monitoring.

see link

As a psychiatric consultant, I see many patients who have IowaCare which, for reasons that are not very clear to me, does not allow patients who have this form of insurance to get their outpatient psychiatric care at the University of Iowa Hospitals and Clinics. Nearly every day when I am on service, I have to tell patients this, and many of them do not understand it either. IowaCare requires them to get all of their medical care at our hospital–but does not cover mental health care here.  It does provide access to outpatient psychiatric care at their local mental health centers, usually at the patient’s medical home, often located in the county in which they live. The Iowa Consortium for Mental Health is working with other stakeholders to change the current county-based mental health care access system to one that is region-based, hopefully allowing for easier access.

Certainly from my perspective, it would make sense to strongly consider Medicaid expansion in Iowa, despite the possibility that there may not be enough doctors to cover the growing patient population that would entail. The April 19, 2013 issue of Psychiatric News published a story entitled “More Graduates Choose Psychiatry in 2013 Match” (PsychiatryOnline | Psychiatric News | News Article More Grads Choose Psychiatry 2013 Match). However, about 500 U.S. seniors still did not match, many of them carrying more than $100,000 in debt. This points to the need for increased federal support of residency positions. There was the usual reminder of the projected shortage of more than 90,000 doctors by 2020 and the need to avoid the coming shortage by increasing the overall supply of physicians in the country by lifting the cap on residency training positions originally imposed in 1997 by the Balanced Budget Act. In my opinion, the state also needs to drop the pilot implementation projects for Maintenance of Licensure (MOL) as well in order to remove barriers to physician recruitment, including this disincentive for physicians to practice in Iowa.

Moreover, those states who choose not to expand Medicaid rolls could see a substantial reduction in the Disproportionate Share Hospital (DSH) payments that general hospitals have been receiving for care of the ininsured, (see article PsychiatryOnline | Psychiatric News | News Article States’ Decision on Expanding Medicaid Will Impact Inpatient Psychiatric Care). Many of the uninsured are struggling to cope with mental illness. The bottom line in the story is that losing a big chunk of DSH money could “…dramatically affect state mental health budgets, and states that rely heavily on DSH payments should weigh this consideration when deciding whether to expand Medicaid rolls”.

Ironically, I just read an item in AMA MorningRounds indicating a recent study found that Medicaid expansion may not improve the health of the poor. The study was published in the New England Journal of Medicine (The Oregon Experiment — Effects of Medicaid on Clinical Outcomes — NEJM) and got a lot of national coverage [1]. It examined the implications of Medicaid expansion on 2 identical populations in Oregon, finding that the population who obtained access to the program, while being more financially secure and spending more on care, were not demonstrably healthier.

However, the expanded access to Medicaid did lead to a reduction in the incidence of depression, and the importance of this needs greater emphasis. It seems the impression that their overall health was not improved was based on a simple set of health measures including cholesterol and blood pressure levels. Criticism of the study’s scope included its very short time window, which was only 2 years. I hope that this will lead to more health care policy makers realizing that just increasing access to Medicaid will not fix our broken health care delivery system or our fragmented health care payer system.

Maybe they should look at some of the information available on the Academy of Psychosomatic Medicine website, Health Reform: Toolkit for Promoting PM. There is a PowerPoint slide set entitled “Integrated Behavioral Health and Primary Care: Competencies and Skills of Psychosomatic Medicine Psychiatrists” which is particularly relevant to this issue. It makes a convincing case for collaborative care reducing total health care costs and improving physical health. Two excellent examples of the integrated care model are described: the IMPACT Model and the DIAMOND Project. These are described in even greater detail in the links on my website under the menu heading “Integrated Care”.

I’m just roll-up-your-sleeves doctor in the trenches, but whether you say Medicaid is a broken system or not (and it makes some grown legislators cry)–we need to start somewhere.

1. Baicker, K., et al. (2013). “The Oregon Experiment — Effects of Medicaid on Clinical Outcomes.” New England Journal of Medicine 368(18): 1713-1722.

%d bloggers like this: