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Doctors, hospitals divided over Medicaid expansion

Associations representing hospital executives and physicians appear to be on opposite sides on whether to greatly enlarge the state’s Medicaid rolls.

The Mississippi State Medical Association has declared that Mississippi’s uninsured deserve medical care but cautioned “a Medicaid expansion may perpetuate a broken system.”

The official MSMA statement is clear in expressing what it says are the anxieties of the state’s physicians that Medicaid expansion would jeopardize and an-already troubled health care delivery system in which Medicaid now covers 644,000 low-income, needy or disabled Mississippians.

The MSMA’s worry is nearly opposite that of the Mississippi Hospital Association. The association made up largely of hospital and health care executives says disastrous consequences could befall the state’s hospitals once the federal government shifts money from paying hospitals to cover treatment of the uninsured to expanding Medicaid in the states that participate in the expansion.

Medical check up (clipping path included)In a statement issued last June just after the U.S. Supreme Court ruled that states can opt in or out of Medicaid expansion under the Affordable Care Act, the Mississippi Hospital Association predicted that rejecting the expansion would spell “devastating” consequences for uninsured Mississippians and hospitals alike.

“Failure to expand Medicaid eligibility will leave just under 200,000 Mississippians with no health care coverage at all,” the MHA said in detailing its position.

“These Mississippians will be left ‘in the gap’ — not eligible for Medicaid and not eligible to purchase health insurance through the health insurance exchange. The result could be devastating. Hospitals cannot be expected to treat such a large volume of people with no expectation or prospect of payment for those services. The result could very well mean the closure of many of our community hospitals.”

By contrast, the Mississippi State Medical Association official statement predicts huge harm could come from Medicaid expansion:

“Mississippi physicians believe all uninsured patients in Mississippi deserve medical coverage; however, physicians have concerns that a Medicaid expansion may perpetuate a broken system. Physicians fear that an expansion of Medicaid may not be financially sustainable and will impose on the state unintended consequences that will weaken provider capacity which is inadequate now and will worsen. We are concerned that the State is not prepared to handle those immediate and future consequences.”

Meanwhile, the expansion issue has been in a partisan stalemate for weeks. Democrats in the Mississippi Legislature have refused to extend Medicaid past July 1 without an expansion. Republicans, led by Bryant, say the tens of millions of dollars the state would have to come up with to cover its share of the expansion would be a quick ticket to bankruptcy.

The likelihood of a special session next week on Medicaid grew this week with a new legal opinion from Attorney General Jim Hood. The AG insists that the governor can’t authorize Medicaid payments beyond July 1 without legislative approval.

The non-binding opinion from Hood, a Democrat, contradicts Republican Bryant. The governor has said for weeks that he thinks he can run the program himself, even if lawmakers don’t vote to keep it alive beyond June 30, the end of the current budget year.

Hood wrote last week that without legislative action to keep Medicaid in business beyond July 1, “the Division of Medicaid and the position of its executive director will no longer exist.”

With a legislative showdown having begun with a Special Session in the Mississippi Legislature over re-authorizing Medicaid beyond its July 1 expiration, Democrats are seeking to force a vote on adding the working poor to Medicaid rolls.

While the Mississippi State Medical Association is clear in expressing the harm that could come from greatly enlarging the state’s Medicaid rolls, the association’s president is a bit less emphatic in his public objections to growing Medicaid.

Dr, Steven L. Demetropoulos, MSMA’s 2012-2013 president, emphasized in the April JOURNAL MSMA that emergency rooms around the state serve as a primary health care source for many of the working poor who would be covered under the Medicaid expansion. Keeping low-income workers off the Medicaid rolls and forcing them to rely on emergency rooms and federally funded free clinics around the state will put tremendous financial stress on the state’s entire health care system, wrote Demetropoulos, an ER physician at Pascagoula’s Singing Rivers Hospital.

A significant portion of the stress would come from the loss of federal disproportionate share, or DSH, payments the hospitals receive to cover at least some of the cost of treating uninsured people, Demetropoulos said.

Just this year, the state’s hospitals received around $155 million in federal DSH payments. The Mississippi Hospital Association projects reimbursement cuts could total $5 billion over the next 10 years, based on current provisions of the Affordable Care Act.

“It is vital for those hospitals to maintain their bottom lines,” Demetropoulos said in a press statement Thursday, referring to the importance of the reimbursement money.

“If a hospital is not duly paid for the care they give, this could mean reduction of access to care, testing, and any other services the hospital provides.”

The federal government has agreed to wait until after 2015 to initiate a phased lowering of the amount disbursed nationally in DSH payments. The original plan specified a lowering of payments nationwide by $5 billion in 2015 before lowering the total DSH care payments by $20 billion in 2020. Presumably, the U.S. Department of Health and Human Services will return to that schedule after the 2015 reprieve.

Addressing the state’s mandated share of Medicaid expansion – which he estimated would be $159 million by 2025, Demetropoulos wrote in the JOURNAL article: “Some people would say this is an impossible number for the state to reach inasmuch as we already are having difficulty funding our current Medicaid budget, which was $30 million over budget this year alone.

“Others would say, ‘If I come up with $1 and you would give me $9, then I would take that match any time.”

Demetropoulos noted that economics projections say Medicaid expansion would create about 8,000 new jobs. “Some people have gone so far as to say that if the state were trying to recruit a business into the area and it would have to come up with $159 million each year but the business would generate $1.2 billion, (the state) would be clamoring to take on that extra money.”

In an “on the one-hand-and-on-the-other-hand” approach used throughout his article, Demetropoulos said others argue that providing the working poor with free medical care would diminish their sense of responsibility. Further, he said, others argue:“If they do not have to pay anything for these services then they don’t really value them.”

Another worry raised, he said, is the lack of sufficient primary care physicians to handle a massive influx of new people into Medicaid.

Alternatives that others has suggested, he said, include covering the working poor through some type of health insurance exchange or providing plans offering high deductibles or tax credits.



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