By skyforbes 
In general while I thought the ACA was seriously flawed from the beginning, I supported the expansion of Medicaid to include working families earning below 138% of the Federal Poverty Line (FPL). While as a nation we continue to debate whether health care is an “ancillary” right of all Americans, I think by and large most Americans support basic health care being available to all Americans regardless of their financial capacity to pay for it.
If a premium were attached to it index to their income, I would go so far as to support expanding Medicaid even further and making it available to families earning 200% of the FPL that do not get health care coverage from their employer. Some would argue that this expanded “entitlement” is anti-American. But I am not sure what that means. I do know that our country is best off when everyone who can work does and the last thing I would want to see is people opting not to work because they need Medicaid and therefore cannot “afford” to go to work.
Most Americans probably do not know the Medicaid reimburses providers at rates far below other health care payers including Medicare. In many instances Medicaid reimbursement barely covers the nominal cost of providing care. In a reasonably affluent communities a family experiencing hardship should be able to find the providers they need that will accept them as Medicaid patients, since the their other patients with good insurance are essentially footing the cost of the physician’s practice. And so expanding Medicaid seems like a good solution for the poor living in communities where the majority of people have either Medicare and private health insurance.
But for Medicaid and expanded Medicaid to work, we need to develop a solution for providing regular health care to those living in communities where the majority of people have Medicaid. In those communities the reimbursement rates from Medicaid make operating a “good medical” practice almost impossible and hence the emergence of what are referred to as “Medicaid mills”, where physicians see hundreds of patients per day or alternatively Medicaid patients jamming emergency rooms.
To address this problem, I think the best solution would be for the government to “cost reimburse” up to a stated limit per patient encounter hospitals with offering primary care physician services to their community. Because most hospitals are sited on mass transportation routes they are accessible to the poor and working poor. In essence, inner city hospitals need to be integrated delivery systems to the patient population they serve and not just hospitals. Overseeing these “integrated delivery systems” by the Medicaid program administrator with health care utilization management teams that focus on producing optimal outcomes with the health care resources available and shut down the Medicaid mills that generate health care claims but no health care results.
This approach should minimize the cost of providing good health care to the poor, since communities with low Medicaid populations will receive only limited health care funding and communities with high Medicaid populations will get the bulk of Medicaid spending. Secondarily, the improved quality of the primary care function of the health care system should reduce higher dollar claims downstream. Having run large physicians groups in the past as well as having been the CFO of a Medicaid program administrator, I believe this approach will improve health care outcomes for that segment of the poor that are having the worst outcomes today.
So as the debate rages on how to reform the health care system, I hope they keep the expanded Medicaid program in place, but I also hope states figure out how to better manage the care being delivered to the poor in their states. I write this as a Republican that believes the health care system will require both the government and private sector including private health insurance companies to work together to get our health care costs down. If you browse my name, you can find other articles I have written on health care. I am concerned that our politicians in Washington push for ideological solutions to health care instead of pragmatic ones. I think that kind of thinking doomed the ACA and could do the same with the Republican proposals being considered today. So I am trying to push for pragmatic solutions hoping that when all else fails, our government will start considering them.