Jindal administration resists expansion of Medicaid despite success ...

After Charity Hospital?s doors were shuttered following Hurricane Katrina, the poor and uninsured who had depended on the public hospital for everything from emergency treatment to help with routine maladies were left without ready access to health care. But in that vacuum, something new, at least in the New Orleans area, took root.

Community health centers sprouted up to fill the need, with existing centers expanding into other neighborhoods and new clinics growing out of makeshift outfits that opened their doors in the chaotic days after the storm.

The clinics received a $100 million injection of federal money in 2007, but when that grant ran out, Gov. Bobby Jindal?s administration and the federal government agreed to continue providing help through a Medicaid waiver only applicable in Orleans, Jefferson, St. Bernard and Plaquemines parishes. This waiver allows adults who make too much money to qualify for Medicaid to receive primary care and mental health treatment through the nonprofit clinics, although any hospital stays aren?t covered.

The effort, championed by Dr. Karen DeSalvo, who is now New Orleans? health commissioner, has been heralded by a diverse collection of supporters, from Jindal?s health leaders to the Obama administration?s secretary of the U.S. Department of Health and Human Services. Instead of relying solely on the sometimes-cumbersome and centralized Charity system, the new system allowed people to regularly see doctors or physician assistants close to home, managing diseases like hypertension or diabetes before complications developed.

The clinics have been banking on the state expanding the Medicaid program in January 2014, when the current waiver expires. The expected expansion -? a key feature of Obama?s health overhaul -? would have continued the insurance benefits to the patients now on the wavier, as well as covering hundreds of thousands of additional people across the state.

But Jindal has said he won?t expand the Medicaid waiver, arguing that, while the costs are covered by the federal government in the program?s initial years, the state will eventually have to pick up part of the tab, to the tune of $3.7 billion over 10 years. Jindal also objects philosophically to expanding the program, saying it is too costly for taxpayers at a time when the federal govnerment should be cutting back.

Clinics, meanwhile, are starting to fret about their long-term financial stability: If the waiver isn?t extended or Medicaid isn?t expanded, they?ll lose part of their paying patient base.

The success of the primary care clinics in New Orleans also begs a question: If providing coverage -? albeit in a limited form -? has made sense for the uninsured in this region, why not expand it to the entire state?

?It (the waiver program) is a nice example of an effort to put people who were previously without primary care in a primary care network,? said Mark Keiser, executive director of Access Health Louisiana, a network of health centers in this region. The Medicaid expansion, he said, would give more low-income people ready access to primary care doctors at a time when the charity hospital system run by LSU -? the sole available venue for many uninsured people throughout Louisiana -? is cutting back on inpatient beds and clinic hours.

Bruce Greenstein, secretary of the Louisiana Department of Health and Hospitals, called the network of clinics ?a great, great model? in a recent interview. The clinics, he said, will be there to provide care for patients as the Interim LSU Public Hospital, which eventually replaced Charity after the storm, ratchets down services because of budget cuts.

But Greenstein said the inflexibility of the federal Medicaid program, created during the 1960s ?Great Society,? is one reason the Jindal administration rejects the expansion. As an example, he noted the federal government has always rejected implementing a co-pay to help offset the costs.

?If we had much more flexibility in our Medicaid program and could arrange it a certain way, it would make total sense,? he said.

Whether or not expanding Medicaid is even an option may depend on the outcome of next week?s election. While the Obama administration would obviously push forward with implementing the Affordable Care Act, Republican challenger Mitt Romney has vowed to repeal as much of the law as possible.

Romney says he will turn the Medicaid program into a block grant, which he emphasizes would give states greater flexibility in how they spend the money. Many experts, however, believe the changes will also mean a cut to the overall program, and how much states like Louisiana receive.

When the Louisiana Department of Health and Hospitals originally conceived of the Medicaid waiver, it was thought of as a ?bridge to national health care reform implementation,? according to a May 2010 white paper. That paper was written before the U.S. Supreme Court decision this summer upholding the health care law. While the decision upheld Obamacare, as the law is often called, it made the Medicaid expansion optional for states.

The local program that was approved in September 2010 is called the Greater New Orleans Community Health Connection. It allows adults in families with incomes up to 200 percent of the federal poverty limit ? or about $38,184 for a family of three ? to qualify.

In contrast, the Medicaid program for the rest of the state is much more restrictive: It has an annual income cap of $2,860 for a family of three, according to the Louisiana Budget Project. By comparison, a person working a full-time minimum wage job would make about five times that much. Adults who don?t have children and aren?t disabled simply aren?t eligible. Under the expansion, a family of three with incomes up to $25,390 would qualify for coverage.

While Louisiana has some of the toughest restrictions for covering adults with Medicaid, the state?s program provides generous benefits for children, resulting in a 97 percent child coverage rate in Louisiana.

Clinic leaders said they considered the local program, which covers about 53,000 people, as an intermediate step before Medicaid expansion. That?s why the waiver expires in 2014, when the expansion is set to begin.

Without something in place, clinics will be left with a much larger chunk of uninsured patients, and will thus have to scramble for ways to cover the cost of the care they provide.

Michael Griffin, president and CEO at the Daughters of Charity clinics, which have grown from one clinic before Katrina to four now, was stoic about the prospect of the waiver?s expiration. But he noted that the waiver had reduced the ?uninsured? portion of his patient load by half, from 70 percent to 35 percent.

?That is a considerable amount of resources that you would have to find money for,? he said.

Keiser, whose clinic network operates three centers in the region covered by the waiver, said without the Medicaid expansion, people who now have coverage through the waiver will again become uninsured. Eventually that will force clinics to cut back, he said.

?Those people become uninsured, low-income folks without access to primary care. The clinics will have no source of funding to provide those services,? he said. ?Consequently, the clinics will shrink.?

Bethany Bultman with the New Orleans Musicians? Clinic has had a less positive experience with the waiver than some other providers; she found that only 400 of her 2,400 patients qualified. After recent reimbursement cuts, the clinic undertook austerity measures, including cutting back some services and implementing a $10 co-pay.

Still, Bultman said she believed the Medicaid expansion was on the horizon. ?Our long-term strategy was that in 2014 that it would mean that we would by that point be a medical home and 80 percent of our care would be covered by the Affordable Care Act,? she said. ?Our patients would be covered.?

If Jindal continues on his current course, DeSalvo said New Orleans officials are looking at asking the federal government to allow the city to apply directly for a local Medicaid expansion. In an August interview, she also raised the possibility of simply asking for a renewal of the waiver.

Greenstein said there isn?t funding to extend the waiver, adding that it was intended to ?build sustainability? for the clinics. Under the waiver, they are getting paid more than typical Medicaid providers would for similar patients. That?s something that the clinics will have to improve upon, he said.?

See related story: Health care waiver covers fewer uninsured patients than earlier federal grant.

Source: http://www.nola.com/health/index.ssf/2012/11/jindal_administration_resists.html

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