Role of Health Plans in Medicaid Expansion

Joseph Alvarnas, MD: What has been the role of health plans in the expansion of Medicaid?

John Fox, MD: I’m a clinician; I’m not an administrator. But I think we’ve been very welcoming of patients into the plan. We’re advertising, certainly, to attract patients to the plan. But I would say, from an economic vantage point, that it’s been a mixed bag. There are a number of things, as we were talking about earlier, that need to be fixed—that aren’t going to be fixed now—to ensure that health plans can remain on the market. I think that’s the biggest challenge right now: those fixes that will allow health plans to remain economically viable on the exchange marketplace.

The other thing that you brought up is access. Have we improved access? I’m not sure. We haven’t changed the number of physicians in the country. We haven’t changed the number of ER physicians. I think there was an expectation that, with the passage of the ACA, patients who were previously going to the emergency room for their care would now go to a primary care physician. Well, we didn’t increase the number of primary care physicians either. We certainly improved payment access, but I don’t know if we’ve improved clinician access under the ACA.

Joseph Alvarnas, MD: The DSH funds went away ostensibly because people were going to have access to primary care physicians. I also haven’t seen a wholesale expansion of nurse practitioners to provide that role or change in the scope of practice with legislative perspectives. So, I think the access issue is a genuine concern. From a political point of view—Elizabeth, we’ll start with you, but I encourage the others as well to help—we heard John raise the question that maybe one of the grievances is that issue. Is healthcare a right or is it a privilege? We’ve had other functional issues raised as to whether or not the law has actually been effective. If you were to characterize the grievances that led to the formulation of the Republican healthcare plan and then subsequently led to its rejection, what would those key issues be?

Elizabeth Carpenter: I think it’s a couple of things. You start, fundamentally, with the fact that the Republican Party has not aligned on what replacing the Affordable Care Act looks like. And so, on one side, you have a group of individuals in the Freedom Caucus saying, “This is Obamacare light. This doesn’t go far enough. We want to roll back a lot of those patient protections”—that we articulated earlier in this segment—“things like guaranteed issue; things like making sure that health plans cover the 10 essential health benefits; those types of reforms.”

And now, on the other hand, you have 20 Republican senators that represent states that expanded Medicaid. And so, some of the Medicaid provisions in the law were very troublesome. Members who have grown to accept and embrace much of the market weren’t comfortable with where the Freedom Caucus was taking the bill. Unfortunately for House Speaker Ryan and Republican leadership, the party is pulling the policies in the bill in opposite direction. And the question is if they can come together and find a policy that reflects both sides’ ideology.

Robert Carlson, MD: I’d like to make this a little bit more real. Recently, I had reason to send some letters to Congress and the Senate about the Affordable Care Act and the American Health Care Act and access was a major focus of that. We need to be sure that patients with preexisting conditions can continue to get affordable healthcare. We need to eliminate lifetime limits, so that people can get lifetime healthcare, and we need to be sure that the high-risk pools aren’t there so that patients can actually afford the healthcare. Healthcare that they can’t afford doesn’t help. One of the responses that I got from a staffer in one of the congressmen’s office was, “No patient with cancer has ever died because they didn’t have health insurance.” I’m sorry. I’m a practicing clinician. I have seen patients die because they couldn’t afford their healthcare, usually because they had no health insurance.

Joseph Alvarnas, MD: Me, too.

Robert Carlson, MD: Patients die if they don’t have health insurance, and that’s really what this boils down to. Are we—as a society, as a medical system, and as a culture—going to configure healthcare so that we recognize that we just are writing off some lives? Or are we going to recognize that healthcare is a right and that we, as a society, have a responsibility to figure out how to responsively deliver affordable healthcare to individuals? It boils down to that. I personally don’t care what it’s called, as long as I don’t have to watch people die because they don’t have a big bank account.