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Since 1978 North Carolina’s Medicaid program has been managed by the Division of Medical Assistance, which is within the NC Department of Health and Human Services (DHHS). As the state’s Medicaid program stands today, most Medicaid enrollees are categorically needy – in other words, aged, blind, disabled or very low-income families (including pregnant women). As Medicaid enrollment has grown from under 500,000 enrollees in 1978 to over 1.5 million enrollees in 2015 so have the expenditures. Even though Medicaid spending growth between 2007 and 2012 was less than growth in private health insurance premiums, many states are reforming Medicaid to enhance budget predictability, increase quality of care, and promote long-term cost savings as enrollment increases. NC is no different as both the House and Senate have recently released their plans for Medicaid reform.

The House Medicaid reform bill was discussed in a previous post, but here is a quick recap. The House reform bill aims to build upon the system NC already uses by establishing provider led entities (PLEs). As the transition takes place, the PLEs can rely on the expertise and knowledge of Community Care of North Carolina. This model is similar to an Accountable Care Organization (ACO) approach in that networks of providers such as hospitals and doctors take responsibility for not only coordinating patient care, but for the finances. This model moves away from the current fee-for-service payment model, which rewards quantity of medical visits and/or procedures over quality of care and ultimately increases costs to providers taking a capitation payment. Capitation payment allows for providers to take on financial responsibility as they receive one risk-adjusted payment per patient. Providers in an ACO work to refer patients to other providers within the network. It is important to note that patients can select a provider outside of an ACO at no additional cost. Finally, five million dollars has been provided to reform Medicaid over a five year period in the House bill.

The Senate budget provides 10 million dollars to reform Medicaid by 2017. Like the House Medicaid reform bill, the Senate also includes the transition from a fee-for-service model to a capitation payment model. One major difference is that instead of using one type of organization to provide care and take financial responsibility, the Senate’s version of Medicaid reform uses a hybrid model. NC would contract with outside Managed Care Organizations (MCOs) who would then work with regional PLEs to provide care to Medicaid enrollees. Another significant difference between the two reform bills is that the Senate’s version of reform would remove oversight of Medicaid from DHHS to a new Health Benefits Authority, an eight member board focused on Medicaid and NC Health Choice. What is interesting is that members of the board would be appointed by the Governor, President Pro Tempore of the Senate, Speaker of the House of Representatives, and Secretary of Health and Human Services .

No matter how NC lawmakers ultimately decide to reform Medicaid, there is one action that both versions fail to do – expand Medicaid to 500,000 North Carolinians in the coverage gap. The same waiver that policymakers will submit to CMS to reform Medicaid can also be used to expand Medicaid as many other states have done.

Commentary

Yesterday, the highly anticipated Medicaid Modernization Act or Medicaid reform bill  was described as transformative, innovative and the dawning of a new day by members of the House Health Committee. During the morning meeting, Representatives Dollar and Lambeth explained that the aims of Medicaid reform are to produce long-term cost savings, budget predictability, as well as increased patient satisfaction and quality of care through building upon North Carolina’s current medical home model. House bill 372 will implement an accountable care organization (ACO) model by establishing provider led entities (PLEs) with a full-risk capitation payment method (providers will receive a risk adjusted payment per patient). This is a move away from the “traditional” fee-for-service payment model. Further, transitioning to ACOs and a capitation payment method is supported by CMS for Medicare  as it promotes coordinated care and de-incentivizes providers from ordering numerous medicals tests and procedures that increase Medicaid costs. What is more, early results from Oregon, Colorado and Minnesota are showing cost savings for Medicaid ACOs. The Medicaid reform bill is positive in that it will build upon North Carolina’s current system and rely on the expertise and knowledge of Community Care of North Carolina. However, this bill has received some early criticism for being too similar to previous Medicaid reform bills, including carve outs for local management entities/ managed care organizations which handle dual eligible patients, and lacking clarity concerning how patients that do not select a PLE will be auto-assigned.

Despite the above mentioned factors that may draw skepticism from the Senate, we cannot say that the reform bill is a major movement forward as it does not include Medicaid expansion. The reform bill outlines that the new PLE model with full-risk capitation will cut spending growth by a minimum of two percentage points as compared to non-Medicaid expansion states. When referencing the success of states with ACO Medicaid models during the committee meeting – Colorado, Minnesota, New Jersey, Oregon, Massachusetts, and Vermont – representatives failed to say that these are states that also expanded Medicaid. In other words, North Carolina can expand and reform at the same time too. As the committee brought up issues of the economic feasibility of Medicaid reform, our policy makers are ignoring that Medicaid expansion will bring nearly $2 billion in federal funding per year to our state. More importantly, by expanding coverage, our legislators will move the conversation from business to people. There are 500,000 North Carolinians that lack access to affordable health care and 1,000 unnecessary deaths annually by refusing to extend health coverage to people in the coverage gap. Expanding Medicaid is transformative and innovative as it allows for reform while improving health care access and quality for all.

Commentary

IMG_0831Last year Mayor Adam O’Neal from the tiny, scenic town of Belhaven, NC, made national headlines as he walked nearly 300 miles from Beaufort County to Washington, DC, to protest the closing of his rural hospital and to urge states to accept Medicaid expansion.

On Monday, June 1, O’Neal left Belhaven to replicate last year’s feat. And this year he is taking along advocates from around the country. As marchers filed out of town yesterday to start the arduous journey they wore shirts advertising their home states. A team of advocates travelled from Texas, some came from West Virginia and Alabama, a rural hospital CEO from Kentucky joined the walk, as did a woman from Seattle, Washington.

The message of the marchers is clear: we must save rural health care.

A key part of that agenda includes expanding Medicaid, as an Episcopal priest from Belhaven reminded the audience during a prayer before the send off. Rev. William Barber from the NC NAACP noted that Jesus made health care a central part of his ministry.

You can follow the march at this website. You can also tweet with the hashtag #savethe283. That refers to a national estimate that 283 rural hospitals are at risk of closing this year.

You can also join the final rally as marchers reach Washington, DC, and gather at the Capitol on June 15 at 10am.

And, finally, you can ask legislators and the Governor in North Carolina to accept new federal Medicaid funds to expand insurance coverage to 500,000 more people in our state.

Commentary

In 2013 the North Carolina General Assembly rejected new federal funds to expand health insurance coverage in the state, but that hasn’t stopped local governments from urging the Governor and legislators to change course.

Counties such as Mecklenburg and Durham have passed Medicaid expansion resolutions as have cities like Greensboro and Winston-Salem. Even Sen. Phil Berger’s hometown of Eden officially went on record endorsing expansion. The Rockingham County towns of Reidsville and Madison have since joined Eden.

This month three more counties — Nash, Edgecombe, and Chatham — joined the chorus.

As retired cardiologist Jim Foster pointed out to the Chatham Commissioners there are tremendous economic benefits to accepting more federal Medicaid dollars. From news coverage of the resolution:

“Anytime money flows into the economy, it ripples through and multiplies,” Foster said.

He pointed to a George Washington University study that broke down the costs and revenues from expanding Medicaid.

The study broke figures down for the state and for its 100 counties.

In Chatham, for example, the study stated that not expanding Medicaid cost 136 jobs and $6 million in gross product.e study Dr. Foster mentions can be found here.

Approval of the Nash County resolution was unanimous and Commissioners added a call for simultaneous reforms to Medicaid. This makes sense. In fact, nearly every expansion state is also reforming the program at the same time.

There is no reason North Carolina’s leaders can’t learn to walk and chew gum like most other states in the country.

Commentary

News item from the Charlotte Observer:

“The Fort Mill, S.C., Republican who went public Tuesday with his plea for help paying for sight-saving surgery had raised almost $12,000 by Wednesday evening – most of it from self-described liberals and Affordable Care Act supporters saying they hope he’s learned a lesson.

That’s enough to ensure he can get the treatment he needs, said Dr. Andrew Antoszyk, an eye surgeon with Charlotte Eye, Ear, Nose and Throat Associates. After reading Luis Lang’s story in the Observer on Wednesday, Antoszyk said he’d work with Lang and with Novant Health to give him the care at reduced cost.

Lang, a self-employed handyman, declined to get health insurance until he needed expensive surgery for diabetes-related eye problems. His story went viral, spurring blogs and comments, national media commentary, thousands of social media shares and vigorous discussions across the country.

His GoFundMe.com page has been shared on social media more than 1,700 times since Tuesday morning, with more than 600 people making small donations, often with political commentary.

‘No one should be without medical (care) even if they have not made their own best choices in life,’ wrote Steve Kadel, who gave $10. ‘The party of personal responsibility (has) left you hanging on your own consequences. Progressives like me think that’s just cruel. Be well.’”

Whether Lang or other Affordable Care Act naysayers will learn a lesson is unclear at this point — Lang himself, offers rather muddled comments on the subject later in the Observer article — but a few things are clear from all this:

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