Funding looks iffy for state Medicaid expansion

Washington is among those enlightened states that embraced Medicaid expansion under the Affordable Care Act. The most recent Kaiser Family Foundation report found Washington with the nation’s sixth-largest increase in Medicaid enrollment from pre-ACA levels: 52 percent.

Both parties are to be commended for avoiding the partisan Medicaid expansion fight plaguing so many other states. Not only has expansion guaranteed the working poor potential access to health care, it also eases a charity care burden – still acute in non-expansion states like Florida and Texas – upon hospitals.

That’s the good news. The bad news consists of two questions. First, how accessible is this care now given Washington’s historically miserable Medicaid rates? Second, will it be decreasingly accessible in the future?

Bearing upon this second question is the combination of recurring budget crises in a state with an unstable revenue construct, a paramount duty to fund education at the expense of all else, and eventual state responsibility for some expansion cost now paid by the federal government.

The ACA designates certain health benefits as “essential,” and pediatric dental care is one of them. Yet for anyone 20 or younger, Medicaid pays as little as $19.79 for a problem-focused oral evaluation, or $21.73 for a routine one. A routine checkup for the littlest, least-cooperative patients – those 5 and older – pays $29.46. This is a bargain most dentists cannot afford.

And children have it better than adults, for whom it’s estimated Medicaid only covers 28 percent of dental visit costs – making emergency rooms often the place where untreated oral health complications are first addressed.

In some cases, Medicaid “coverage” is entirely illusory. Good luck finding an audiologist willing to take the financial loss required to provide a hearing aid to a child for as little as $751.19 – a payment that falls short of the hardware cost itself, quite apart from the expectation it also cover the pre-fitting evaluation, ear mold and at least three follow-up exams.

A psychiatrist must settle for $77.25 for an hour of psychiatric diagnosis coupled with medical services, while payment for a half hour of psychotherapy for a family is as little as $33.64.

All of medicine’s financial incentives steer physicians away from primary care, quite apart from Medicaid. Thus, the ACA temporarily lifted 2013-14 Medicaid payment rates for primary care visits to Medicare levels (the Obama administration stalled for months on implementation).

With the increase expired, doctors advocated for the Legislature to increase Medicaid rates, arguing they are 66 percent below Medicare levels. Regrettably, the request ran up against the budgetary buzzsaw; just to maintain current Medicaid funding, the Legislature raided marijuana revenue guaranteed to health clinics under Initiative 502.

Will resources ever match the rhetorical commitment to Medicaid expansion? There’s ample reason to worry.

The state’s Medicaid agency, the Health Care Authority, does a laudable job within resources allocated to it, but still rations even incontinence supplies from past frenzies of legislative cutting. Long-term care and disabilities programs are among longstanding state Medicaid obligations shortchanged by a lousy federal matching rate and absence of dedicated state funding.

If Medicaid expansion headlines are to equal real Medicaid access, it’s incumbent upon policymakers to convene providers in asking what’s next for the program as a whole.

This story was originally published August 1, 2015 at 5:54 AM with the headline "Funding looks iffy for state Medicaid expansion."