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The Doctor Is In…. And He Wants to Expand Medicaid

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With a near 50/50 balance of power between Republicans and Democrats in the General Assembly, Governor-elect Ralph Northam will be in a much better position than his predecessor Terry McAuliffe to enact Democratic priorities. And what are those priorities? As he told NBC 4, Medicaid expansion tops the list.
Said Northam: “No family in Virginia should be one medical illness away from financial demise so, Medicaid expansion is very important and I will do everything I can to make that happen.”
We can all agree on the desirability of making health care affordable and accessible for all Virginians. It’s not so clear that expanding Medicaid is the best way to accomplish that goal. I have blogged in the past about the inadequacies of the Medicaid model, which has not demonstrated an ability to substantially improve medical outcomes. Among the more obvious problems: While Medicaid expansion provides coverage to the uninsured, it does not increase the supply of primary care physicians willing to take on Medicaid patients for whom they are paid 30% to 60% less than privately insured patients.
Despite below-market reimbursement rates, the cost of Medicaid expansion is considerably higher per patient than anticipated when the Affordable Care Act was enacted several years ago. The table below, taken from an article in the “Handbook on Healthcare Reform” published by the Thomas Jefferson Institute for Public Policy (TJI) last month, shows how Medicaid actuaries have consistently revised upward their cost projections since FY 2013.

The 2013 report projected that newly eligible adult Medicaid patients would cost $3,625 on average. By 2016, the figure had risen to $5,926 — a 63% jump. If Medicaid expansion was unaffordable four years ago, it’s even more unaffordable now. Despite their political setbacks, Republicans are highly unlikely to roll over on this issue.
It’s not as if states have no other options to improve affordability and access. The TJI report discusses several. They include eliminating mandated benefits so insurance companies can offer bare bones policies; removing barriers to healthcare technology innovation; rolling back onerous Maintenance of Certification requirements that encourage physicians to retire early; reforming the medical liability system that prompts physicians to practice defensive medicine; encouraging transparency in pricing so consumers can push back against expensive providers; abolishing the Certificate of Public Need process so physicians can provide high-quality, lower-cost outpatient surgery; promoting telemedicine; enabling Direct Primary Care that strips out third-party-payer middlemen and administrative costs; and repairing the broken Medicaid delivery model.
Most of the TJI essays were generic, not specific to the Old Dominion. As it happens, Virginia has taken limited steps toward implementing some of the ideas in the report, but much remains to be done.
The health care sector is a dense jungle of special interests, however. Hospitals, insurers, pharmaceutical companies, employers, physicians, and a welter of allied health professionals work doggedly to shape legislation to their benefit. Sadly, ordinary patients have no organized group representing their interests.
As a physician, Northam has a keener understanding of the issues confronting the health care sector than most lawmakers. He enjoys a unique opportunity to reshape Virginia’s health care sector in a way that lowers costs and improves outcomes for all Virginians. It would be a shame if he expends all his political capital to capture the dubious benefit of Medicaid expansion when so many alternatives lie fallow.
(This article first ran in Bacon’s Rebellion on January 4, 2018)

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