Critics Debate If New Health Law Will Help Uninsured

The new health bill signed by President Obama includes an incentive for doctors to serve the poorest patients by increasing their federal Medicaid payments. This could be quite a significant inducement, as an additional 16 million people are expected to join the Medicaid rolls in the next 10 years.

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Now the passage of the health-care law counted as a political earthquake, though we're still learning how it affects Americans. One part of this law seems straightforward. It involves the Medicaid health program for the poor, and the new law opens that program to millions of people who do not have insurance right now. What is not yet clear is whether getting people into Medicaid will actually get them in to see a doctor.

NPR's Julie Rovner reports on the effort to make the law work.

JULIE ROVNER: Back in February, at President Obama's bipartisan Blair House health meeting, Iowa Republican Senator Charles Grassley pointed out a dirty little secret about the health bill's plan to add millions of people to the Medicaid roles.

Representative CHARLES GRASSLEY (Republican, Iowa): Medicaid pays about, in my state, I think, about 60-something percent. Medicare pays 80 percent of costs. Doctors don't take Medicaid. So you're going to promise 14 to 18 million people in Medicaid that they're going to be covered? What if you don't have doctors to service them? Isn't that a little bit intellectually dishonest, to promise something that you can't deliver on?

ROVNER: Stephen Zuckerman, a health economist at the Urban Institute, says it's not just Iowa where Medicaid underpays. It's a problem in lots of states.

Dr. STEPHEN ZUCKERMAN (Health Economist, Urban Institute): There are fewer Medicaid enrollees that get access to mainstream physicians in large part because physicians can choose who they want to treat, and with Medicaid fees sort of at the bottom of the barrel, physicians are less likely to take patients with that coverage.

ROVNER: So the budget bill the president signed last week - which included fixes to the health bill - included something to address that Medicaid payment problem. It requires that primary care doctors who treat Medicaid patients be paid at least as much as they would be if they were treating Medicare patients. And the federal government, not the states, will pay the difference in rates. Zuckerman says he doesn't expect the difference to be dramatic, but he does expect it to be noticeable.

Dr. ZUCKERMAN: I think what you're going to see, as reimbursements are increased for primary care physicians, that there probably will be some primary care physicians that previously would not have considered taking Medicaid patients who will now say, all right, well, these patients are probably, you know, worth treating.

ROVNER: In many cases, however, it's more than just low rates that keep doctors from accepting Medicaid patients. Some doctors say Medicaid patients don't keep appointments, or they don't follow doctor's orders or take their medications like they should. And in some cases, says Zuckerman, it's not about the patients at all. It's about the bureaucracy.

Dr. ZUCKERMAN: The program is, you know, not the easiest to deal with. There are a lot of delays in payment. There's difficulties in getting certified in some states as a Medicaid provider who can actually bill the program. I mean, there are a lot of administrative hassles.

ROVNER: But both Zuckerman and Peter Cunningham, a researcher at the Center for Studying Health System Change, say boosting primary care payments may not be the most important fix for Medicaid. Finding primary care has never been the biggest problem for Medicaid patients, Cunningham says.

Dr. PETER CUNNINGHAM (Researcher, Center for Studying Health System Change): Because a lot of people on Medicaid get their care at community health centers or federally qualified health centers, and they are also going to be expanding.

ROVNER: Community Health Center funding is going up by $11 billion under the new law, effectively doubling that program's funding. Rather, says Cunningham...

Dr. CUNNINGHAM: Where there tends to be the biggest access problems for Medicaid is often with the specialty care, and their rates are not going to be increased, at least by the health reform.

ROVNER: That means for the foreseeable future, says Zuckerman...

Dr. ZUCKERMAN: You still may have a lot of Medicaid beneficiaries who are dependent on specialists that are working in public hospitals or other nonprofit hospitals that tend to have a greater commitment to dealing with the low-income populations.

ROVNER: Which will be fine in the urban areas, where there are lots of those kinds of facilities. But in smaller cities and rural areas, there may be lots of new Medicaid patients who can find primary care, but no one to care for them when they get really sick.

Julie Rovner, NPR News, Washington.

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