PHILADELPHIA -- Although the Affordable Care Act will dramatically expand Medicaid eligibility in 2014, the fiscal catastrophe currently enveloping state governments is forcing draconian cutbacks in the actual care that program provides.
The stark reality that the ACA's future promise of a new level of health services for the poor could be reduced to little more than an illusion in some areas of care worries Michael Chernew. The Harvard Medical School health economist, who is a consultant to the U.S. Congress on health policy, discussed the subject in an appearance at the University of Pennsylvania's Leonard Davis Institute of Health Economics (LDI)
'Hollowed out' "I have concerns that the (federal Medicaid) subsidies will increase coverage but, because of a number of details of how this is paid for, you'll see certain programs cut back on aspects of that coverage. So, people will have coverage, but the coverage itself might be hollowed out in various ways," said Chernew in an interview after a formal presentation at LDI.
He pointed to Arizona and New York as harbingers of what is likely to come elsewhere across the country as provisions of the Affordable Care Act are implemented and states suffering historic budget deficits are faced with covering as many as 30 million more Medicaid patients.
For instance, in October, Arizona's Medicaid program ended coverage for pancreas, liver, heart, lung and bone-marrow transplants. The Arizona Republic reported that 96 residents with Medicaid coverage and life-threatening conditions requiring transplants are currently affected by those cuts.
Draconian budget cuts Meanwhile, the state budget proposed by New York Governor Andrew Cuomo slashes
Photo: Associated Press
Skyrocketing deficits are forcing many states to reassess their Medicaid budgets. Here, Dr. Sara Weisenberger treats a Medicaid patient in Jackson, Miss.
New York's proposed state budget targets Medicaid for big cuts.
"So," said Chernew, "just because someone has insurance coverage doesn't mean that they get access to health care. And the extent to which the health care system responds to changes in the health insurance sector will determine how much 'health' we get for that coverage. But given the shortages of different types of doctors and other things, that all remains to be seen."
Chernew, a professor of Health Care Policy at Harvard, is a member of both the Medicare Payment Advisory Commission (MedPAC) which advises Congress and the Congressional Budget Office's Panel of Health Advisors. He appeared at LDI to present his evaluation of the first year of operation of a Massachusetts Blue Cross-Blue Shield alternative health care insurance program.
Shrill political hyperbole Much of his ongoing research is aimed at identifying and analyzing market mechanisms that may provide higher quantities of quality health care for less money. One of his frustrations is the shrill political hyperbole surrounding virtually any public discussion of the issue.
"The rhetoric is often an obstacle to real progress," he said. "It prevents us from addressing problems we really have to address, such as the notion that we don't have enough resources to provide all health care to all people all the time."
"You don't need to be an economist to understand that the amount you spend on health care is the product of price times quantity," he said. "Any time we try and have a debate about controlling quantity, people yell 'rationing.' But if the opposite of rationing is that everybody gets everything, then we're going to need some form of rationing."
His presentation featured a series of Congressional Budget Office charts detailing the explosive growth trajectory of health care costs and the unsustainability of the country's related debt.
'Differential access to care' "I think there are some fundamental questions we as a nation haven't faced particularly clearly," Chernew said. 'One of them is 'To what extent are we willing to tolerate differential access to care across different groups of people?' In the current system, there is differential access to care based on income, for example; I think that's problematic, although it's not clear that we can provide a system that gives everybody the same access to care. So, a little more discussion of care and a little less discussion of coverage would have suited my tastes well. A little more focus on what care we want this coverage to provide access to as opposed to just saying, 'Oh, you have insurance so we can check off the box that you're good,' would have been helpful."
