Expanding Medicaid


Starting in 2014, the Affordable Care Act requires states to offer Medicaid coverage to individuals under age 65 who earn less than 133% of the poverty level (about $29,000 for a family of four). While a few states already cover these people, for most states this would be the first time that Medicaid coverage was available to nondisabled adults without children.

But it is unclear how many states will expand their Medicaid programs. In June, the Supreme Court found that Congress had overstepped its powers when it mandated the expansion. However, the high court said the expansion could move forward if states were given the opportunity to opt out and simply forfeit the associated federal matching funds.

Dr. David L. Bronson

The Congressional Budget Office estimates that 11 million people will gain Medicaid coverage; that’s compared with a projected 17 million before the Supreme Court decision.

Dr. David L. Bronson, president of the American College of Physicians, explained the possible impact of the Supreme Court’s ruling and the ACP’s views on the Medicaid expansion.

Question: Now that the Supreme Court has made the Medicaid expansion optional for states, what is the implementation likely to look like around the country?

Dr. Bronson: We feel the implementation will be challenging in some states. Many states will jump in right away and take advantage of the opportunity. Other states have indicated they don’t intend to participate. By comparison, Medicaid was originally passed in 1965, and it took until 1982 before Arizona actually joined the program. Hopefully it won’t take 17 years to get all the states participating. We’re hopeful that within a few years, all of the states will participate.

Question: If Medicaid expansion ends up being a patchwork, what will that mean for patient access?

Dr. Bronson: Access will depend on where you live. That will really be a very dysfunctional system.

Question: The ACA calls for covering low-income childless adults for the first time in many places. Is this a population that is currently falling through the cracks?

Dr. Bronson: Absolutely. This is a major gap in the current coverage system. This is a vitally important group to get covered. The practical difference is that if these people can be covered, they hopefully would be able to have their chronic medical problems managed, reducing the burden on the entire health care system. They would be a lot healthier because they would avoid complications of their chronic conditions. It would also help prevent both premature death and disability and all the health care expenses associated with sickness and disability. It’s really a big deal.

Question: Will the expansion of Medicaid guarantee access to care, or will low reimbursement for physicians cancel that out in some cases?

Dr. Bronson: It’s going to be a challenge. Some of those challenges are being addressed on the primary care side by increasing the Medicaid payment level to the Medicare level for at least 2 years. We are hopeful that will be extended beyond the initial period. If you don’t have primary care access, you can’t make the system work. Traditionally, many specialties have done reasonably well under Medicaid on the procedural side, though not on the evaluation and management side. So with specialists, access should be less of a problem. If primary care physicians and those that provide cognitive services are reimbursed at Medicare levels, I think that will help maintain access.

Question: What’s the impact of the ACA’s provision to temporarily boost Medicaid payments to Medicare levels through 2014? What happens if that provision is not extended?

Dr. Bronson: It makes a very large difference to the primary care practices. If you’re extremely efficient in your practice and you have a low cost structure, you might break even with Medicare, but you’ll never break even with Medicaid in primary care. Having that provision really helps primary care practices survive and serve that population. We are hopeful that over that 2-year period we will see improved access to patients and that will lead to an extension of the increased payments on a more permanent basis.

Question: What do physicians need to know about the Medicaid expansion in their states?

Dr. Bronson: Having health care coverage available to every American is a long-term policy goal of a lot of organizations, including the American College of Physicians. It’s simply the right thing to do. Physicians should know that the ACA is the only active, passed legislation that accomplishes it. Although it may not be ideal, waiting another 10 years to find a new solution only leaves us with 10 years of people with inadequate health care. We would encourage physicians to get behind the Medicaid expansion because it’s the right thing to do.


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