Huge Medicaid CHIP surge boosts demand for doctors

These states have all seen their rosters for both Medicaid and the Children’s Health Insurance Program grow by more than half in the last year and a half, ever since Obamacare’s major insurance expansions rolled out.

The influx has been greatest in Kentucky, where 438,000 more residents have signed up in the last year and a half — an increase of nearly three-quarters in the government health insurance program run by states.

Vermont and Nevada’s Medicaid and CHIP programs have each grown by roughly two-thirds. In Oregon, nearly 360,000 people have signed up, representing an increase of more than half in that state’s safety-net insurance programs.

All four states have chosen to expand Medicaid to include adults earning up to 138 percent of the federal poverty level, an option provided under the Affordable Care Act. The new enrollees represent two types of people: those who are newly eligible for Medicaid and those who were eligible previously but just now signed up.

As many health advocates see it, the flood of new low-income patients whose care is now paid for is a huge success.

“It’s pretty astonishing,” said Chuck Duarte, Nevada’s former Medicaid director, who is now chief executive officer of the Community Health Alliance. “We’ve gone from having an uninsured rate of about 60 percent to 30 percent among our patients.”

Leslie Tallyn, chief clinical operations officer at Central City Concern in Portland, Ore., said her organization has also seen a large decrease in uninsured patients at its low-income clinics. Since 2013, the share has dropped from nearly half to less than a quarter, she said.

But the increase in insured patients also intensifies the need for more doctors who are willing to accept Medicaid payment rates, which in most states are well below what they’d be paid by Medicare and private insurance. Some policymakers have worried that after obtaining health coverage for the first time, some of the low-income will still be unable to get doctor’s visits.

More than half of Medicaid providers couldn’t offer appointments to enrollees in a recent survey conducted by the inspector general for the Department of Health and Human Services and released in December.

That’s a problem in Nevada, Duarte said. He said his group, which runs community health centers for the low-income, has added five more doctors to its staff of 16 and expanded the clinics’ hours in response to the upped demand.

“We have a huge number of patients who are trying to access primary care from us right now that we’re trying to accommodate,” he said. “I think everyone’s trying to accommodate and struggling with that.”

Tallyn said when Oregon first expanded Medicaid, her group and other providers “really struggled to keep up,” but now things are easier.

“Everyone had long waiting lists, but over the course of the last 14 months or so, we’ve seen an increased ability to meet that demand, in part because we’re now being reimbursed for services we used to provide for free,” she said.

But the problem varies by state and even county. States vary in how much they pay Medicaid doctors and how much funding they put towards graduate medical education to boost the supply of doctors. And rural counties typically have fewer providers than those with urban centers.

Some health advocates in Kentucky said access hasn’t appeared to be a problem, at least so far.

“In our area, we haven’t seen a huge issue with an insufficient number of providers,” said Sara Jo Best, public health director for the Lincoln Trail District Health Department, which serves several counties in western Kentucky.

She’s seeing the flip side of the Medicaid expansion, which is that the newly insured customers are no longer flocking to free government services to get most of their care. That is in turn freeing up her agency to focus on public health issues.

“It also allows us to focus on our true mission, which is population health versus individual healthcare services,” Best said.

The concerns about physician availability for Medicaid patients haven’t played out, at least yet, said Cory Meadows, director of advocacy for the Kentucky Medical Association.

“I think throughout the process [of Medicaid expansion], many wondered whether the workforce would be sufficient to handle those folks,” Meadows said. “As we sit here today, it’s not been a significant issue in Kentucky.”

The healthcare law temporarily gave Medicaid primary care doctors a pay bump, but that expired in January after the provision’s two years were up. The pay increase probably didn’t last long enough to significantly draw more into the program, said Atul Grover, public policy officer for the Association of American Medical Colleges.

“I think some of the physicians were saying, ‘this is a two-year thing, it’s going to be temporary,’ ” Grover said.