As the longtime head of the Kaiser Commission on Medicaid and the Uninsured, Diane Rowland had been involved with research and debates surrounding health policy for 20 years. That is, until the Government Accountability Office tapped her to chair the newly formed MACPAC: the Medicaid and CHIP [Children's Health Insurance Program] Payment and Access Commission. Created as part of the CHIP Reauthorization Act last year, MACPAC existed only on paper until the Affordable Care Act brought it to life to investigate how well these programs provide affordable, quality care.
I sat down with Rowland to discuss her plans for the new commission and her thoughts on the future of Medicaid in a post-health reform (and post-election) world in this abridged and edited transcript.
How is MACPAC going to interact with the states, all of which have their own access and reimbursement advisory committees?
Some have said that MACPAC is to Medicaid and CHIP what MedPAC [Medicare Payment Advisory Commission] is to Medicare. Of course Medicare is a federal program, and the federal government determines the payment levels and oversees the overall program. MACPAC is going to have to look at how 50 different states, plus the District of Columbia, run their programs, pay their providers and also deal with long-term care facilities, nursing homes, home health agencies, assisted living facilities... We're going to have to really have the states as our partners.
We've started that process by doing what we call state consultations, where we look at the various stakeholders, meet with them, try and assess what their issues are [and] what their perspective is. At the end of the day, we're going to need to be able to have data and information -- and ultimately analysis -- on how the states are running the Medicaid program and how the variations exist across all of the states. It's going to be a far more interactive relationship with the states. There will have to be, maybe, indicator states that we follow more closely, do more case studies on and do more state consultations with -- just to be sure we're seeing the program on the ground as well as at the federal level.
What might be a specific issue that you could imagine MACPAC focusing on?
Let's take maternity and obstetrical care. Medicaid pays for a very large number of America's births: over a third in some states, up to a half in some states. We'll want to look at how those services are reimbursed. How has the state integrated prenatal care with delivery? What kinds of barriers there might be to access to obstetrical care? We hear concerns in some places that there are no obstetricians in several counties who will see a pregnant Medicaid woman. So, we might want to go into a state, look at how well the services are being provided in urban vs. rural areas, so that we see what the extent of participation problems are in rural areas as opposed to urban.
This kind of analysis is obviously very data intensive. How heterogeneous is data quality across the states?
Well, one of our first analyses is to try and figure out what data is currently available to assess how Medicaid and CHIP are working. And, of course, there are also timeliness issues: We've been charged in the statute with developing an early warning system [for provider shortages]. So, how do you get real-time data on these programs as opposed to information that's two to three years old? One of our first steps will be to examine what information you need to evaluate how well the program is working. There is an ongoing review in the Department of Health and Human Services of the Medicaid program data. We want to look at both programs' data as well as the need for some survey data.
You mentioned the statutory requirement of providing an early provider shortage warning. How concerned are you that the movement towards something more closely approaching universal health insurance will exacerbate provider access issues that already seem severe in some places?
There have always been reports of areas in the country where you can't find specialist jobs. Specialty care has been a particular problem in the Medicaid program. Primary care has often been provided through mostly community health centers and in shortage areas. Medicaid patients tend to live in areas that have been identified as medically underserved, so that they have inadequate resources to begin with. One of the chief goals of the program will be to try and develop a set of metrics that can be used to assess areas where there is a particular problem, where we may need to look at better use of community health centers, or better placement of national service corps doctors to help alleviate some of the shortages.
Let's talk about the broader impact of the Affordable Care Act on Medicaid. We hear from some states like Indiana, Louisiana or Alabama that Medicaid expansion requirements are but a sad old state with hundreds of millions or billions of dollars in new expenses which they can't afford. We hear from other sources like the folks at the Center on Budget and Policy Priorities that those concerns are vastly overstated. What's your opinion?
Well, clearly, the expansion of Medicaid is being substantially financed by the federal government. If you just look at the numbers, the states are getting a pretty good deal in terms of a lot of coverage for their population at a very low cost to the state. The states that are getting the most out of health reform are really the states that have the largest uninsured populations, like in Alabama or Louisiana, where they have covered adults at very low-income eligibility levels in the past.
However, in this economic climate, any cost to the state is viewed as overwhelming. What I think is more on people's minds is: Can the states absorb and expand to take on over 16 million new individuals by 2019? I think one of the interesting statistics that we've developed at Kaiser is: During the economic recession, states have added six million new eligibles to their Medicaid programs in just two years because of the downturn in the economy. So, I think if they can add six million in two years, the [large] expansion should not be as daunting task as it seems when you look at the raw numbers.
One of the things that strikes me, from my recent conversation with Maine's Trish Riley [also a member of MACPAC], was how she saw the Affordable Care Act as a step towards the standardization of Medicaid. Do you agree with that?
The biggest change that health reform has brought to the Medicaid program is it has finally severed the link to its welfare-based history. For all of Medicaid's years, it has precluded coverage of childless adults and has focused on the old welfare categories: children, parents with dependent children, the aged, blind and disabled. And now, with health reform, coverage becomes an income related criteria without any categories. Breaking the categorical requirements, is the biggest step forward. If you are truly poor and need help with your health care, you are going to get that care. So I think the eligibility side of Medicaid becomes much more standardized. The determination of income is also going to be done now under a common definition; states will no longer have varying ways of counting assets and of determining offsets to income for eligibility purposes. We are moving toward a much more standardized eligibility system, and having people know that they're eligible, regardless of which state they're in. That's one change.
So, I'd say the eligibility step has been smoothed and standardized nationwide, and we're going to begin to see more movement toward more common coverage policy down the road.
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