By Mike Klein
Health care policy is a complex beast with seemingly intractable political positions, lots of data to support or refute almost anyone’s perspective, tons of financial impact analysis – just last week the Congressional Budget Office released yet another health reform cost impact study — and at the end of the day, lots of ragged emotions that cloud and obscure the conversation.
Here is an idea that should not be overlooked: People will get sick and have accidents regardless of who is making policy and whatever that policy-of-the-moment happens to include or exclude. And when that happens, they need someone nearby who is able to help them.
In Georgia, we need help. “You’ve hit on a significant issue for the state,” said state Department of Community Health deputy commissioner Blake Fulenwider. “There is no doubt about that.”
Fulenwider, two other state officials, an Obama administration official and a national children’s advocate sat together last week for a Georgia Children’s Advocacy Networkdiscussion about what the recent U.S. Supreme Court federal health care law decisionmight mean for Georgia children. Might is a precarious word because of the November presidential election.
As the 90-minute session began to end, Fulenwider noted, “Today is an example that none of the things that we talk about have easy answers.” Debate will continue here for months about whether to expand Medicaid eligibility and how to create a health insurance exchange, if at all.
Here is a reality check: Georgia has a significant physician shortage and the state also anticipates a shortage of 38,000 nurses over the next decade. That is what a Georgia Health Sciences University report concluded last August when it was submitted to the University System Board of Regents. Urban medical facilities are overloaded and there are vast health care brownfields in rural areas.
An Association of American Medical Colleges report published in August 2011 said, “Without immediate statewide cooperation in expanding medical education and residency programs, the state may never again have an adequate supply of physicians. For too long Georgia has relied on out of state and international physicians to make up for the lack of Georgia trained doctors. Without changes in the state’s medical education system, Georgia will rank last in the United States in physicians per capita by 2020.”
No Silver Bullet for Medical Access
The University system report said the state is 1,450 graduate medical education positions below the national average and 315 below the average of southeast states. That forces students to leave Georgia for medical education which, in turn, decreases the possibility they will return to practice medicine back in Georgia. The state has 20.8 physicians per 100,000 persons; the national average is 35.7 physicians.
Governor Nathan Deal recognized the urgency of this shortage by creating 400 new physician residency slots in this year’s budget. Unfortunately, training hundreds of new physicians when you are short by many hundreds more means you are still short.
To further stress the already stressed system, about one-third of physicians and almost 40% of registered nurses statewide are eligible to retire now or within ten years. Many higher education programs are trying to address shortages but Georgia is clearly catching up, not getting ahead.
“Providing coverage does not mean providing access,” Fulenwider admitted. “We continue to be challenged with our budget environment and landscape that we’re in, in maintaining and being an attractive payer for our Medicaid providers. We’ve got to be sure that we’ve got boots on the ground to deliver service. I wish there was a silver bullet answer to that. There is not.”
Supreme Court Decision Impact
The U.S. Supreme Court decision threw a wrench into health care policy decisions. Whereas media was intently focused on what might happen with the individual mandate provision, the justices by a 5-4 vote blindsided nearly everyone by ruling states cannot be forced to expand Medicaid, and states cannot be penalized if they refuse to expand. The individual mandate was upheld as a legal tax. Health insurance exchanges were also upheld, although they will likely exist in many forms.
Here is part of the Georgia landscape. State decisions on Medicaid eligibility expansion and what to do about a health insurance exchange will not be announced until after voters decide whether Mitt Romney will replace Barack Obama. A state Medicaid redesign train that left the station early last year has been sent to a side rail but some elements will be implemented.
Georgia faces a November 16 deadline to tell the federal government how it plans to establish a health insurance exchange required by federal law unless a new Romney administration that would assume office in January issues exemptions and begins to dismantle the law.
“There will be an exchange in Georgia one way or another,” suggested JoAnn Corte Grossi, who works for the Obama administration as Mid-Atlantic States Director at the U.S. Department of Health and Human Services. That was her message to the Georgia CAN! panel last week.
Will the Obama administration be flexible with states that would prefer to receive Medicaid block grants? “We’ve obviously gotten lots of letters from lots of governors asking questions like that,” Grossi said. “Sorry to punt on this one but the honest answer is decisions are still being made.”
Some State-Based Decisions Already Made
Some state-based changes will happen regardless of November elections: Georgia foster care children – currently 26,409, according to the Department of Community Health – will move to care management organizations. Medical records will follow children regardless of where they live or how often their placement changes. This is similar to how the state manages health care for low-income Medicaid and PeachCare children. The change is anticipated in mid-2014 when the state executes new managed care contracts.
Georgia also decided Medicaid eligibility will continue to be done in conjunction with eligibility for food stamps, temporary assistance for needy families and child care subsidies. The state will launch a new consumer-focused web portal but that might take three years to develop.
Jonathan Duttweiler is Manager for Medicaid Eligibility at the Department of Human Services. He said 2,100 staff caseworkers currently average 571 Medicaid recipient clients. The average caseload would increase by 400 additional clients to almost 1,000 per caseworker if Medicaid expands starting in 2014. Duttweiler said the state has fewer caseworkers today than it had 15 years ago.
The state also requested and received a federal waiver from the health care law provision that insurers must spend 80 percent of each dollar earned on health care. The state position was that “smaller insurers wouldn’t be able to meet that 80 percent threshold,” said Jay Florence, legal counsel for the state office of insurance. The waiver required 70 percent spending levels last year, 75 percent this year and 80 percent starting next year.
The Georgia CAN! health care policy panel discussion was peppered with data. Indeed, at times it seemed almost no sentence was complete without a number included. One of those seated in the audience was Dr. Harry Heiman, director of health policy for the Satcher Health Leadership Institute at the Morehouse School of Medicine.
“I understand your lens,” Heiman told the panel. “My lens as a family physician is I am seeing children every day, adults every day that suffer health consequences for lack of access to quality care. Clearly, we need a balanced approach that understands your challenges and the challenges of the children and adults in our state.”