I sense the Republicans repeal and replace of the Affordable Care Act is going to give states greater latitude in how they operate the Medicaid program in their states. Personally, even though I am a conservative, I think the expanded Medicaid program part of the ACA was a good idea but did not go far enough.
I would like to see Medicaid eligibility increased from 138% of the FPL (Federal Poverty Line) based on family size to 200%. This insures health care is available not only to those that are not working but the working poor and removes the fear of losing Medicaid coverage from the list of reasons why some people do not “go back to work”. Several studies show that “entitlements” which encourage work like the earned income credit actually boost economic growth and so if we are to achieve 3–4% annual GDP growth, then we need create more incentives for people not working to work. Unlike the ACA I would not “mandate” enrollment but simple expand eligibility.
There have been a number of successful Medicaid health care programs in various states. Underlying them is a “managed care” philosophy. As we struggle as a nation to contain health care costs while providing access to all Americans, we need to migrate all Medicaid beneficiaries into high quality outcome oriented managed care networks. I suggest we do so using two models one for high Medicaid population density areas and one for lower Medicaid population density areas.
In high density areas, I would contract with major inner city and rural hospitals to provide an integrated delivery model to Medicaid enrollees living within their “catchment area”. In effect, using a HMO model to manage care of this high risk population. Ideally, this model would by closer to the Kaiser staff model but in some markets could operate as a contract model HMO. To be viable it may be necessary to “carve out” certain high risk Medicaid patients and reimburse these health care systems differently. In addition, these entities would need to develop or outsource the ability to measure health outcomes of their “covered lives”.
For Medicaid beneficiaries living in rural, suburban, or urban markets where the concentration of beneficiaries is to small to make an integrated delivery model make sense, I would contract with “contract” HMOs to manage the delivery of care to those beneficiaries and the provider networks. The reimbursement of claims to providers would be on a sliding scale established by the state Medicaid programs. Providers with low Medicaid volumes would be paid a nominal amount to process the claim. Providers with normal or high Medicaid volume (i.e. consistent with the population of their region) would receive higher reimbursement.
Outcomes of patients would be monitored by the HMO at the provider level and providers with quality issues could be dropped from the program. In addition, providers with below a certain percentage of Medicaid patients would be subject to a “provider tax” to cross fund the Medicaid program.
In summary, we need a health care system that supports economic growth and that means providing the working poor affordable health care. Secondly, we need to do a better job managing the health care outcomes of the poor which is partially a function of the quality of the network delivering the care. We need to increase the health care dollars flowing to providers performing health care services to the poor in order to increase the willingness of providers to do so without increasing health care costs in the country overall. We need to begin discussing how to get health care costs under control and not just how to fund them using subsidies, taxes, and credits.