Access to Care in The Medicaid Program Andrew B. Bindman, MD Professor of Medicine, Health Policy, Epidemiology & Biostatistics University of California San Francisco

Medicaid Expenditures by Service, 2006 Total = $304.0 billion Urban Institute based on CMS Form 64 prepared for Kaiser Commission on Medicaid and the Uninsured. Inpatient 14.1% Physician/ Lab/ X-ray 3.8% Outpatient /Clinic 6.8% Drugs 5.5% Other Acute 6.9% Payments to MCOs 18.0% Nursing Facilities 15.7% ICF/MR 4.3% Mental Health 1.0% Home Health and Personal Care 14.8% Payments to Medicare 3.3% DSH Payments 5.6% Acute Care 58.5% Long-Term Care 35.8%

CMS Office of the Actuary, National Health Statistics Group, National Health Expenditure Accounts, Total National Spending (billions) $2,098$697$702 $131$228 Medicaid as Share of National Health Care Spending 2007

Access Problems by Insurance Status Adults Children No Usual Source of Care Needed Care but Did Not Get It KCMU analysis of 2007 NHIS data Children

State Budget Challenges Could Impact Medicaid Beneficiaries’ Access Reductions in Provider Payments Reductions in Enrollment Managed Care

Physician Participation by Insurance Type Cunningham, Peter and May, Jessica. “Medicaid Patients Increasingly Concentrated Among MDs.” 2006 % Accepting All New Patients% Accepting No New Patients

Factors Contributing to Physicians Participating in Care of Medicaid Patients Participation is voluntary Some avoid Medicaid patients due to Patient characteristics and complexities Concerns about being sued Administrative hassles/payment delays Participation varies most strongly in association with state payment rates On average, Medicaid pays 70% of Medicare payments

Physicians’ Acceptance of Medicaid Patients and Fee Levels, 2001 US Low-Fee States High-Fee States All Physicians (%) Primary Care Physicians (%) Specialist Physicians (%) Zuckerman et al, Health Affairs, 2004

Medicaid Eligibility Any person who meets Medicaid eligibility criteria is entitled to benefit – no wait list Federal requirement of at least annual determination of eligibility Many states require or are considering more frequent determination of eligibility State determined frequency and ease of Medicaid eligibility process affects the number of beneficiaries with enrollment gaps

Children without Gaps in Medicaid Coverage in CA Before and After Eligibility Determination Increased from 6 to 12 Months Years of Enrollment Percentage Bindman, et al. Medical Care, 2008

Preventable Hospitalizations Increase with Interruptions in Medicaid Coverage Cumulative Probability Time (Months) Bindman et al, Annals of Internal Medicine, 2008

Medicaid Managed Care Delivery model used in most states Potential to improve access through requirement for a primary care provider Concern that access to high cost services (eg specialists) could be limited to save money Some states looking to expand mandatory Medicaid managed care for a larger proportion of their beneficiaries

Medicaid Managed Care Enrollees as a Percent of State Medicaid Enrollees, June 2007 AZ AR MS LA WA MN ND WY ID UT CO OR NV CA MT IA WI MI NE SD ME MO KS OH IN NY IL KY TN NC NH MA VT PA VA WV CT NJ DE MD RI HI DC AK SC NM OK GA TX IL FL AL % (13 states) % (14 states) 61-70% (17 states including DC) 71-80% (7 states) U.S. Average = 64.1% FPL SOURCE: Medicaid Managed Care Penetration Rates by State as of June 30, 2007, CMS, HHS CA