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DAVID ROSMAN: Medicaid reform must start with care providers

Wednesday, November 20, 2013 | 6:00 a.m. CST

There are two problems that need to be addressed: the expansion and the reform of the state Medicaid program.

The former, the expansion, is a lifeline to more than 861,000 Missourians who are on Medicaid and the additional 260,000 of your uninsured neighbors. That is about 20 percent of the state's population. That number, by the way, will remain high because without the Medicaid expansion, these men and women, mostly the working poor, will not qualify for the Affordable Care Act programs, even with the subsidies.

The unfortunate part of this discussion is that the Republican-led chambers under the Gray Dome have not come up with an alternative plan that would fit with the rules set forth by the ACA. In fact, the bills under consideration appear to demand fundamental changes to the ACA prior to state implementation. So the task of reform falls to the Senate Interim Committee on Medicaid Transformation and Reform, chaired by Sen. Gary Romine, R-Farmington.

To “transform” into and to “reform” what? To wait for a system to be 100 percent “perfect,” without err, or with 100 percent safeguards simply cannot be achieved. The federal plan is designed for all Americans to have access to health insurance sold by the retail insurers. To do so would mean to first expand Medicaid and then seek to understand who is ripping off the system.  

This is not saying the system is perfect, but what system is? As a former regulator of the insurance industry, I can say, without hesitation, everyone is looking to rip off the insurance company, including some of the companies themselves, the patient, the doctors (traditional and otherwise), nurses, attorneys, claims adjusters (captive, independent and those who represent the insured or claimant) … This list continues.

To say "managed care" is the best way to manage Medicaid is simply not understanding the role of the insurance company. First and foremost, they are in business to make a profit. That currently means that about one-half of the counties are not currently covered by the three managed care providers in Missouri. That means though covered by Medicaid, more than 450,000 Missourians — men, women and children — are without care providers.

Today, 60 counties are not served by managed care providers. A best guess is the profit margin is too low in those rural counties, if it exists at all. A true reform of the system would require each licensed managed care provider to provide care in all 114 counties in the state.

The second problem believes that “managed care” is different than standard insurance. Health Maintenance Organizations, HMOs, and managed care organizations were supposed to save money, provide all sorts of preventative services thus reducing the number of illnesses. In fact, they continue to operate as standard insurance companies, requiring the state to regulate coverages that should have been available from the beginning, like breast and prostate examinations.

Any transformation or reform of the Medicaid system must start not from the consumer but from the provider of the services. Reform is not eliminating more people from the multitude of insureds but to become more inclusive to the system.

Daniel Redwood, D.C., sat on the Interim Committee on Citizens and Legislators Working Group on Medicaid Eligibility and Reform and wrote an editorial for the Kansas City Star. He and his colleagues traveled the state taking testimony from all citizens concerning the expansion of Medicaid in the state.

“We heard from doctors, nurses, hospital administrators, clergy, people with disabilities, farmers, lawyers, laborers, Medicaid recipients, poor people who don’t qualify for Medicaid and many more. Nearly everyone expressed an opinion on Medicaid expansion under the Affordable Care Act. Most favored expansion…”

Fixing the system will require much more oversight of those who are working the system. It means more oversight of the insurance industry, of the medical providers, of the claimants and others who have their hand in the proverbial pie. Reform means stronger laws and the means to enforce those laws. It means more government employees and the means to pay these new enforcers. It does not mean reduce the eligibility based on some arbitrary income level all the while hoping that “Obamacare” will lose steam and magically disappear from the annals of law.

David Rosman is an editor, writer, professional speaker and college instructor in communications, ethics, business and politics.


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