Health care, round two: Expansion of state’s Medicaid program

One down, one to go.

When the Silver State Health Insurance Exchange opened Tuesday, Nevada fired its first big salvo in the fight to cover its uninsured.

Now, even as the exchange works out website bugs and ramps up outreach to enroll consumers, state officials are keeping an eye on the second major coverage initiative: Expansion of the state’s Medicaid program.

Through Medicaid, which provides free health care to people at or below poverty level, state officials say they hope to enroll tens of thousands of Nevadans who other­wise couldn’t afford coverage. The idea is to slash the number of nonpaying patients and encourage preventive care, though there are concerns about whether boosting access to Medicaid can accomplish those goals.

“That’s a question every state right now is starting to ask themselves,” said Michael McMahon, administrator of the division of welfare and supportive services in the state Department of Health and Human Services. “We’re making sure people have some sort of funding to access health care, so we’ve eliminated a barrier to people reaching doctors earlier. But that’s obviously going to create some constraints on the system.”

Still, Nevada will experiment with expanding who qualifies for Medicaid. The program was traditionally for families who made 87 percent of the federal poverty wage, or $20,488 for a family of four. But in 2014, it will accept for the first time single, childless adults, and the income threshold will rise to 138 percent of the poverty level. That’s $15,856 for singles, and $31,809 for a household of four.

Families who make the new income cut can get Medicaid now, by applying through the division’s website at https://dwss.nv.gov/.

But childless singles can’t sign up until after Nov. 1, and their coverage won’t begin until Jan. 1.

McMahon said his agency is reaching out to community advocates and family resource centers to talk about increasing enrollment. The division has hired 96 family support specialists to sign up Medicaid members, and plans to hire another 96 through January. The division is budgeted to hire up to 410 specialists, administrative assistants and support staff, though McMahon said hiring will depend on consumer interest.

Steve Fisher, deputy administrator of the welfare division, said officials expect 68,000 Obamacare-related enrollees from Jan. 1 to June 30, most of them single, childless adults.

The division projects 34,300 Obamacare-based sign-ups from July 1 to June 30, 2015. By then, if you include both natural and Obamacare-related growth in Medicaid enrollment, the state program will have expanded to 477,900, up from 336,000 today. If enrollment meets forecasts, the program will cover 23.5 percent of Nevada’s 605,000 uninsured.

The state exchange is aiming to cover 118,000 additional people in its first year. It reported 77,000 unique visitors to its website in the first two days, but wasn’t reporting actual enrollments as of Thursday morning.

Expanding Medicaid wasn’t just about boosting the insured. When he signed off on the program in December, Gov. Brian Sandoval said the move would save money. The feds will cover 100 percent of expansion through 2016, and that will save $16 million in publicly funded mental health care that would have come from the state’s general fund, Sandoval said.

Plus, expanding Medicaid should ease the systemwide burden of un­compensated care, McMahon said. Hospitals today boost billing rates to cover uninsured patients who can’t pay. Produce more paying customers, and the costs should moderate for everyone, he said. And insured people are likelier to see a primary-care provider before they need costlier hospital care.

Of course, the newly covered can get care only if they can schedule a doctor’s appointment. A spring report from John Packham, a health policy researcher at the University of Nevada School of Medicine, found that Nevada ranks No. 46 for its share of primary-care doctors, and No. 50 for psychiatrists. It also placed No. 40 for obstetricians and gynecologists, and 51st for general surgeons.

And some doctors won’t accept new Medicaid patients because the program’s reimbursement rate runs lower than payments from private insurers.

The state will boost Medicaid payments for two years to match higher Medicare reimbursements, but both public programs pay less than private carriers.

Those access issues may be why public-health experts have a running debate on whether Medicaid even helps people stay healthy. The most recent study, published in April in the New England Journal of Medicine, found expanding Medicaid in Oregon led to more visits to the hospital and the doctor, but it didn’t make patients noticeably healthier based on blood pressure, blood sugar and other basic measures.

Nor does Medicaid seem to cut ER visits: A 2010 study from the University of California found that Medicaid patients were seven times more likely than the privately insured to use the ER to treat preventable illness.

The problem is so bad that some states, such as Washington, have curbed the number of ER visits Medicaid patients are allowed.

Despite potential burdens on the system, Packham said expanding Medicaid is worth a try.

“While I think our primary-care capacity will be strained for the next couple of years, it’s always a positive when people gain health insurance, because not having coverage is the ultimate access barrier,” he said. “Improving the ability of uninsured Nevadans to navigate the system and for providers to get paid for seeing patients is, over the long haul, the best thing for the system.”

Any potential fiscal costs won’t be an immediate burden on Nevada’s current budget, because the federal government is picking up the whole tab through 2016. The share drops from there, but never below 90 percent. And if state officials decide the program isn’t helping, they can pull the plug on it at any time, McMahon said.

Contact reporter Jennifer Robison at jrobison@reviewjournal.com. Follow @J_Robison1 on Twitter.

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