Medicaid reform meeting provides platform for calls to expand

by Jordan Green

State health officials who came to Winston-Salem for a “listening session” about Medicaid privatization got an earful instead about the state’s refusal to expand the program last week.

Patients and healthcare workers urged the state health officials to expand Medicaid during a so-called “listening session” attended by a capacity crowd last week at the Forsyth County Department of Public Health for the purpose of getting public feedback on plans to privatize the system.

The new plan, which was signed into law by Gov. Pat McCrory in September 2015, transforms the state’s health insurance program for low-income citizens from one based on fee-for-services to a pre-paid system that is value based. Implementation of the program requires federal approval of a so-called 1115 waiver, estimated to take place by early 2018. After that, it would likely take the state another year and a half to fully implement the new system. One of the goals of the system is to build more predictability into the cost of Medicaid — the second largest expenditure by the state after education.

The Republican-controlled General Assembly and Gov. McCrory undertook privatization of Medicaid while refusing to expand the program to cover people who currently earn too much to qualify yet don’t earn enough to receive a subsidy under the Affordable Care Act. North Carolina is one of 29 states that have chosen to not expand Medicaid, which is reimbursed 100 percent by the federal government this year, with the federal government’s cost burden dropping to 95 percent next year and 90 percent starting in 2020.

The city councils in Winston-Salem and Greensboro have both passed resolutions calling on the General Assembly to expand Medicaid. The governor has expressed willingness to consider expansion, while the more conservative leadership in the General Assembly has maintained staunch opposition to the proposal.

Dr. Peter Lichstein, an internal-medicine physician at Baptist Hospital in Winston-Salem said that not a day goes by when doesn’t encounter “patients who do not have insurance and do not get what they need.”

“They don’t get the screening services, hypertension care, and particularly for chronic disorders, the management they require,” said Lichstein, who said he was speaking on behalf of 3,000 internal medicine physicians as governor of the state chapter of the American College of Physicians. “The whole patchwork of free clinics and charity services doesn’t and will never be able to make up the difference. The concerns that we have about the 1115 is that it seems to delay expansion.”

Dr. David Colonna, an anesthesiologist in Winston-Salem, said he worries that if the private insurers contracted by the state under the new system are “not doing well economically they’re going to drive down the reimbursement for physicians.” He added that the arrangement could adversely affect small medical practices “in rural parts of the state, and they can’t keep the lights on if they can’t get paid.”

While the Medicaid reform plan is only a proposal until it receives federal approval, Vivian Smith, the lead physical therapist at Winston-Salem/Forsyth County Schools, indicated that cost-containment efforts might already be resulting in reduced services. Smith said the proposed budget for the state Medicaid program eliminates reimbursements for a number of services provided in public schools, including audiology, speech language pathology, occupational therapy and physical therapy. Those reimbursements are used to purchase equipment and supplies for exceptional students such as wheelchairs, standers and iPads, she said.

Matthew Potter, a Pfafftown man who lives with cerebral palsy, lambasted the state.

“We often hear that Rome wasn’t built in a day,” he said. “I’m here to submit to you that if the state legislature of North Carolina had started building Rome thousands of years ago, that city never would have been built. There would be buildings that they would start to construct, and then on a whim they would tear those down and try to build new ones and say to the citizenry of Rome: ‘No guys, it’s really going to be better this time. We promise.’ So all I will say is this: The state of North Carolina and the legislature in particular has a lot of work to do before I trust them with anything with regards to sustainability and looking out for the good of the citizens.”

Potter, who serves on the board of directors of CenterPoint Human Services, currently receives Medicaid through the Community Alternatives Program for Disabled Adults program. He also qualifies for the more robust Innovations program, but has been on a waiting list — the so-called “registry of unmet needs” — for five years. Potter said enrollment in the Innovations program would give him confidence about weathering unforeseen contingencies and covering major costs such as replacement of his motorized wheelchair, which is more than 10 years old.

“With the services I get currently, we’re really trying to figure out how to do it,” he said. “For someone like me, a wheelchair is a need, not a luxury.”

Potter and his mother, Sarah, both favor Medicaid expansion. Sarah questioned the state’s goal of sustainability while people like her son have unmet needs.

“I keep hearing the words ‘sustainable’ and ‘predictable,’ but I don’t think we can do that until we meet the needs of the registry of unmet needs,” she said. “The fact that we call it that is appalling to me. Here in Forsyth County we have as many people on that registry of unmet needs as we do people that we’re serving.”

Not everyone agrees that expansion is the best way to go. Mary Short, whose adult daughter lives with tuberous sclerosis complex, cited the fact that an estimated 10,000 to 13,000 people across the state remain on the waiting list as a reason to “be very, very careful about the idea of expansion.”

Kendra Gerlach, the communications director at the state Department of Health and Human Services, assured the speakers that “what’s been said here today, we’ve heard every word of it.”

She added, “It’s been captured and it will be used. And it’s important to shape the outcome. It’s important for the decisions being made going forward. So I hope you hear us when we say that because we genuinely mean it.”

A June 2015 White House report estimated that Medicaid expansion in North Carolina could reduce the number of annual deaths in the state by 380, while a study published by the Health Affairs Blog in January 2014 estimated the number could be as high as 1,145. The White House report also projected that Medicaid expansion would reduce the number of people in North Carolina with catastrophic out-of-pocket costs in a typical year by 14,000, and would provide preventative care including cholesterol-level screening to an additional 45,600 people and mammograms to an additional 11,500 women.

More recently, in late March, the US Department of Health & Human Services estimated that 144,000 uninsured people in North Carolina with mental illness or substance abuse disorders could qualify for Medicaid under expansion. The report cited a study estimating “that low-income adults with serious mental illness are 30 percent more likely to receive treatment if they have Medicaid coverage.” The report added, “This is especially important to states as they work to address opioid use disorder and serious mental illness.”

Will Cox, a Winston-Salem healthcare worker, told the state health officials last week: “In our state we’re looking at 1,100 people a year that may die because of the lack of healthcare coverage. Let’s see who wants to stand up and say that’s justified. It’s not even an accounting measure that says it costs too much: We refuse the federal dollars that we’re already paying for and we’re already taxed for. And that’s outrageous. As a healthcare worker, I’ve been through four or five layoffs with coworkers, some of them hired back without healthcare coverage. So this is affecting the solid middle class.”