Holes in the Safety Net, Even With Health Reform

It’s been a pretty good couple of weeks for the state of health care in the US. With the passage of health care reform, we hope to see an end to the nonsensical decisions that have allowed medical insurance companies to deny coverage to too many Americans in need. What hasn’t changed, though, is that even those that do have coverage are facing significant barriers to getting the services they require. Those insured under the federally- and state-funded Medicaid program are still particularly hard hit.

It never fails to amaze the way a series of smaller actions always seems to add up to a much bigger picture of systemic discrimination against marginalized populations -- in this case, low-income Americans. In Washington State, pharmacy chain Walgreens has just announced they will no longer be accepting Medicaid prescription coverage as of mid-April. Doctors and dentists are also dropping their Medicaid patients (and refusing new ones) at an alarming rate, claiming (rightfully) that they can’t afford to maintain their practices if they are losing money due to a drastic reduction in reimbursements from the program. The lesson learned here, though, isn’t somehow that government can never do anything right.  Medicaid is a pretty good program for people who wouldn’t otherwise get insured through their jobs.  It’s just underfunded.

Health reform is supposed to translate into more federal money helping the states.  In the meantime,  though, low state reimbursement rates have left many unable to get the care they need. For example, in recent years, New York paid doctors $30 as reimbursement for a checkup, and New Jersey paid $25. When those of us with insurance go to the doctor, they definitely charge a lot more!  These amounts can't possibly cover their costs.  The New York Times tells the story of two Michigan parents unable to find a pediatrician for their two-year-old son:

"I called four or five doctors and asked if they accepted our Medicaid plan," said Ms. Curtis, a 21-year-old waitress. "It would always be, ‘No, I’m sorry.’ It kind of makes us feel like second-class citizens."

How is this possible, you wonder? The Medicaid Act was written to include a number of protections meant to ensure quality care for those enrolled in the program.  One such protection is called the Equal Access provision, which is supposed to ensure that people in the Medicaid program have access to care that is equivalent to their privately insured counterparts.  Payments (or reimbursements to providers) are supposed to be at a rate "consistent with the efficiency, economy, and quality of care."  There's also a provision to make sure that there is enough access that patients get needed care with "reasonable promptness," and a provision intended to ensure that access to OB/GYN services for Medicaid participants is comparable to the general population.  The problem is that it’s not always possible to enforce these laws.

We all understand that states are faced with tough budget choices these days, and that the federal government only reimburses states for part of the cost of the program -- but access to medical care has to be meaningful.  Thankfully, many communities have safety net providers such as federally qualified health centers and public hospitals, but not all, and those that exist have a hard time meeting the demand.  Unfortunately, these safety net providers also have a hard time making ends meet when Medicaid reimbursement rates fall are so low that they can’t begin to pay for their costs.

Health care advocates have long struggled to hold states accountable and to make sure that Medicaid programs are run in a way that ensures access to care.  But ever since a Supreme Court ruling in a seemingly-unrelated case known Gonzaga v. Doe, they have had to spend their time just trying to hold onto their ability to get into court.  In Gonzaga, the Supreme Court raised the bar for when a federal law can be enforced in court.  Even when Congress passes a law and the President signs it, it turns out that this doesn’t mean that we can enforce the law.

In the years since Gonzaga, courts across the country have had to decide whether or not they are responsible for enforcing these assurances in Medicaid law. Courts have held that some of the provisions are enforceable while others are not. This broadside attack on the enforceability of the Medicaid Act has diverted attention from real and pressing social problems such as a pronounced lack of access to medical care for low-income and/or rural Americans.  It has also meant that participants in the Medicaid program have had a harder time using one of the most powerful tools to enforce their rights -- the court system.

In the meantime, people like Carol Vliet, who is battling with cancer in Flint, Michigan, are still waiting and searching for care.

(Photo by leoncillo sabino.)