The Oklahoman: One Million Oklahomans May Go on Medicaid

WASHINGTON — Nearly one-third of Oklahomans — or roughly 1 million people — could be on Medicaid when the new health care law is fully implemented, eventually costing the state about $93 million more each year, according to a state official trying to plan for the increased enrollment.

Though the Medicaid expansion alone could dramatically lower the number of the state’s uninsured, Sen. Tom Coburn warned last week that new Medicaid patients will have trouble finding doctors because many already won’t see patients in the program. Moreover, Coburn said the low physician and hospital rates paid by Medicaid will cause more costs to be shifted to those who are covered by private insurance.

The new health reform law is expected to mean coverage for 32 million more Americans. But half of those are anticipated to be in the Medicaid program, the federal-state health care program for low-income people

Beginning in 2014, people with incomes up to 133 percent of the federal poverty level — $29,326 for a family of four — will be eligible. The Oklahoma program currently is limited to children, pregnant women and disabled people — it also helps pay nursing home costs for the elderly — but the new federal law will make anyone eligible who meets the guideline for income.

Should every Oklahoman who currently is eligible for Medicaid but not signed up, and everyone who is newly eligible participate, the state could be paying an additional $66 million a year from 2014 and 2017 and an additional $93 million for each year after that.

Nico Gomez, deputy chief executive officer at the Oklahoma Health Care Authority, said "there’s an element of mystery” about how all the pieces of the health reform law will work together.

Will the mandate to buy health insurance, which takes effect in 2014, drive eligible people to sign up for Medicaid, when many who are eligible today don’t enroll?

"The mandate provision is going to change behavior,” Gomez said. "This is a game-changer in terms of health insurance.”

Another big question for the agency is whether the economy turns around, raising incomes and making fewer Oklahomans eligible for Medicaid.

The most recent projections by the authority for the program’s participation and cost are based on today’s economic assumptions; a lot could change in the next few years.

But, Gomez said, "In the next 10 years, assuming there’s no change in the law, the state Medicaid program will have more than 1 million people.”

There are nearly 600,000 Oklahomans on Medicare, the government insurance program for seniors. So, if Medicaid expands to cover more than 1 million people and Medicare enrollment stays near the current level, about half of the people in the state will be in one of the two programs.

The health care authority is estimating that the Medicaid expansion under the new law will reduce the rate of uninsured people in the state from about 17 percent to around 11 percent. The law’s subsidies to individuals and small businesses to buy private insurance are expected to reduce that rate further.

At one time or another in the last fiscal year, the Oklahoma Medicaid program, SoonerCare, had 825,000 participants. This month, there are about 680,000 Oklahomans on Medicaid and an estimated 51,000 children whose parents have no other insurance who could be, but aren’t, enrolled.

When the new eligibility guidelines begin in January 2014, there will be 265,000 newly qualified Oklahomans, according to the health care authority.

For the first three years, the federal government is going to pay 100 percent of the costs for the newly eligible, but that doesn’t mean it won’t cost the state anything.

In part because of the individual mandate, the authority has to assume that everyone who is already eligible but not on the program will enroll, and the federal government only pays from 64 percent to 75 percent of those costs. Also, the state must pay half of the new administrative costs, and the state’s share will be nearly $18 million each year for that.

Starting in 2017, the federal payments for the newly eligible Medicaid recipients go down on a sliding scale until they reach 90 percent in 2020 and remain there.

Rep. Frank Lucas, R-Cheyenne, said last week, "For the 2010 fiscal year, the state of Oklahoma has required a 7.5 percent cut to all state agencies, which equals about $385.8 million in cuts to many important programs like our senior nutrition program.

"It is unacceptable that the federal government will now mandate even more costs onto our states to enact a federal law that a majority of the American people oppose. … And this is just the tip of the iceberg. No one will be able to calculate the impact the new mandates will have on small businesses and the dramatic increase of participants in Medicaid when these businesses either fold or push their employees onto the federal plan,” Lucas said.

Beginning next month, Gomez said, physicians taking SoonerCare patients will have their payment rates cut by 3.25 percent because of the state’s budget woes.

It is unknown, Gomez said, whether more cuts will be necessary.

In his criticism of the new health care law last week, Coburn, a physician, said, "Forty percent of the primary care doctors don’t see Medicaid patients because the price that is paid for the coverage doesn’t cover the cost, let alone any margin. It doesn’t cover the cost of nurses, the rent, the malpractice, and everything else.

"The second point is: Of the specialists who are available, 65 percent of the specialists in this country won’t see Medicaid patients. So when I am taking care of Medicaid patients, I have trouble finding somebody better than me in a specialized area to care for my patients. … You are not going to be able to find a doctor. You may have coverage, but you won’t be able to get anybody to care for you. Is that coverage? Is that care? Is that prevention? Is that management of chronic disease? No. None of that will happen.”

Gomez said he doesn’t have any Oklahoma figures to support or dispute Coburn’s assertions.

"I can tell you that we have over 10,000 physicians enrolled in the (state Medicaid) program,” he said.

Finding specialists, Gomez said, can be a problem for people with all types of health coverage.

Coburn also predicted that, because the Medicaid payment rates don’t cover health care providers’ costs, the expanded enrollment will "increase the cost shifting from government programs to the private sector” and "insurance rates for everybody else in the country are going to go up.”

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