the second opinion

How to cover Medicaid during campaign season

March 25, 2015

Amid the abundance of presidential campaign coverage, stories that examine what type of a president a candidate might be—what he or she might do, policy-wise—are often hard to come by. The horse race dominates, but there is much more to cover and the super-charged topic of healthcare and the Affordable Care Act is a compelling place to start. With a recent piece for Bloomberg View, Christopher Flavelle demonstrated why Medicaid—and efforts to reform it—needs to be on the story list.

Flavelle tackled Jeb Bush’s Medicaid program during his tenure as Florida’s governor and concluded it’s “a mess.” He examined a number of health indicators and found that in 2013 the Medicaid plans taking part in Bush’s reform program ranked below the national Medicaid average on 21 of the 32 quality indicators reported by the state. “In some cases, those results were dramatically worse than in other states,” he wrote. How bad is it? Almost one-third of pregnant women got no prenatal care in the first trimester and only 50 percent had a postpartum visit between three and eight weeks after giving birth. Half of adults ages 46 to 85 diagnosed with high blood pressure did not get adequate treatment. Fewer than half the children covered by Medicaid plans saw a dentist. With numbers like these, you have to ask: How good is the care Florida’s Medicaid recipients are getting? Yet Bush, campaigning in Iowa in early March, told his audience Obamacare should be replaced and proposed his own Medicaid program as a model.

What exactly did Bush do to produce such results? In an attempt to lower the state’s outlay for the program, he allowed insurance companies to design benefit packages to compete with one another. The idea for this “empowered care” program was to let Medicaid recipients shape and improve the market rather than have the government tell those plans what to provide. Insurers could choose what coverage to offer and recipients would select benefits that best fit their needs. Over time, the theory went, plans would compete and produce better health results. Three years ago, Bush told health policy experts the newly revamped program resulted in better health outcomes, more satisfied beneficiaries and better cost control for the state. The numbers say otherwise. Joan Alker, a Medicaid expert at Georgetown University, told Flavelle that people do a poor job of predicting what kinds of healthcare services they will need and trying to understand the different options is hard. In this case, consumer engagement sounded good but resulted in worse care.

Flavelle points out that the state did indeed get a better grip on costs. While the national per capita spending on Medicaid has increased, Florida per capita spending has gone down. Between 2007 and 2013, Flordia’s spending fell about 20 percent. “It’s all about money,” said one pediatrican who observed what was happening. And that’s where reporters come in. Following the Medicaid dollar is a good story no matter what state you live in.

Flavelle’s use of state Medicaid quality data prompted me to check in with Politico reporter David Pittman who covers health and technology policy and recently completed an Association of Health Care Journalists fellowship during which he studied state Medicaid data. Pittman identified some reporting possibilites for local reporters who too often shy away from this complex topic (there are exceptions). With the caveat that the available data varies state to state, he suggests focusing on three areas:

ACCESS How easy is it to get needed care? Doctors are notorious for not taking patients because they complain state reimbusements are too low. Finding dentists in some areas is practically impossible. How long does it take to get an appointment? If a state has embraced Medicaid managed care, what’s the adequacy of doctors in a particular plan network? Are patients facing limited choices like many are with Obamacare exchange policies? State physician groups may be helpful here. Pay particular attention to churning, meaning when Medicaid recipients move in an out of the program as their financial circumstances change and they may experience gaps in care. This is expected to continue even as millions of new Medicaid enrollees have joined their states’ program.

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In states that have expanded Medicaid but are using non-traditional approaches (Michigan, Arkansas, and Indiana), are patients facing barriers to care? One woman I interiewed about Indiana’s expanded Medicaid program told me that even though she paid her required premiums, doctors had been asking for copayments and have been billing her for these amounts. The other day she got a $258 bill for lab tests. The state Medicaid office says she is not required to pay these amounts. Are others experiencing this problem? This is something for local reporters to tackle. Have the doctors gotten the message they aren’t supposed to charge copays for these services?

QUALITY State Medicaid offices may have data on such things as hospital readmission rates, prevalence of obesity, premature births, numbers of recipients receiving particular services like prenatal exams and vaccinations. How does your state rank on such metrics? Are Medicaid recipients newly insured in the last year under the Affordable Care Act getting the required exams and services? Pittman recommends checking the Kaiser Family Foundation’s managed care market tracker, which offers an array of managed care data including quality rankings and access standards.

COST Here, reporters may want to investigate how their state compares with others when it comes to spending. Flavelle found Florida did cut spending but that this affected the health of Medicaid recipients. State pols forever complain Medicaid budgets are crowding out other services. Are they? What’s the evidence? If your state is using managed care organizations to run the program, how good a job have they done? Have they really saved money or simply added more bureaucracy to an already bureaucratic process to get poor people covered?

Reporters who know how their state’s Medicaid programs are actually working will be better prepared when the 2016 campaign truly revs up. When they hear vague campaign talk about “reforming Medicaid,” “needing flexibility,” “personal responsibility,” they’ll be equipped to ask sharp questions.

Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for CJR's Covering the Health Care Fight. She also blogs for Health News Review and the Center for Health Journalism. Follow her on Twitter @Trudy_Lieberman.