Medicaid Enrollees Have Difficulty Getting Access to Care

Medicaid enrollment under the Affordable Care Act grew even in states that chose not to expand eligibility, making access to care a more pressing issue, according to a new report issued by HHS’ Office of the Inspector General. By the year 2018, Medicaid enrollment is expected to reach as many as 87 million people.

The report focused solely on managed care organizations, providing full-risk managed care for a comprehensive set of services and identified 33 states with 227 managed care organizations active January 1, 2012, to January 1, 2013.

Not only do standards for access to care vary state to state, but they are also rarely enforced, which has led to Medicaid patients waiting for months and traveling long distances to see a doctor, reported The New York Times.

The authors, led by Vincent Greiber, wrote that standards can range from requiring 1 primary care provider for every 100 enrollees to every 2,500 enrollees.

Over a 5-year period, most states did not identify any violations of their access standards, and those that did mostly relied on corrective action plans and 6 imposed sanctions, according to the investigators. They recommended that CMS strengthen its oversight to improve efforts, ensure standards are developed, assess compliance, and share effective practices.

According to the report, the 3 most common types of access standards limit the distance or amount of time enrollees should travel to see a provider, require appointments be provided within a certain timeframe, and require a minimum number of providers in relation to the number of enrollees.

“State standards vary widely and are often not specific to providers who are important to the Medicaid population, such as pediatricians, obstetricians, and high-demand specialists,” the authors wrote. “In addition, these standards often apply to all areas within a state and do not take into account differences between urban and rural areas.”

However, the states have substantial leeway in the standards they establish. As a result, 32 of the 22 plans have established standards regarding provider distance or time of travel; 31 have appointment availability standards; and just 20 established standards regarding provider-to-enrollee ratios. One state established just 1 of the 3 standards.

“Access to healthcare services for enrollees in Medicaid managed care is essential,” the authors concluded. “Without adequate access, enrollees would not receive the preventative care and treatment necessary to achieve positive health outcomes and improved quality of life.”