Government sponsored health care coverage programs like Medicare and Medicaid survive only because they are able to control spending by dictating what providers get paid, limited only by countervailing political pressure from those providers. Consequently, Medicare and especially Medicaid, pay providers much less for the same services and products than commercial health insurers pay and a tiny fraction of what a self-paying consumer would be charged. This disparity, and the fact that many providers say they make little or no money on these government payments, has raised concerns that many providers may refuse to see patients covered by these government programs, creating an access to care issue. The Government Accounting Office released its latest report examining access to care in the Medicaid program. (GAO Report) Over the last few years, since the recession, states have received significant additional federal assistance with Medicaid costs, assistance which eventually will stop, likely putting more downward pressure on payments. Some states have increased provider payments during this period but just as many have reduced them.
The number of states making at least one provider payment decrease grew from 13 in 2008 to 34 in 2011, and increases in rates fell over the same period, although more states reported increasing provider payments in 2011 than decreasing them. Decreases were most common for hospital inpatient and outpatient services. Increases were most common for nursing facilities. States also created a number of supplemental payments designed to help specific providers or reward certain services or outcomes. On the other side, however, states have greatly increased the use of provider taxes to fund Medicaid payments and these taxes come from somewhere. In the end it seems silly to increase Medicaid payments and provider taxes at the same time. A large percent of states, 38, reported having difficulty finding enough providers willing to serve Medicaid recipients, especially in certain specialties. The access problem is likely understated in regard to fee-for-service Medicaid, because many enrollees are in managed care plans, which typically pay providers more to help meet access requirements. While reimbursement affects physician willingness to participate, administrative hassles are also a significant factor. While relatively few Medicaid beneficiaries covered for a full year report having access problems, those newer to the program and covered for less than a year had more problems with access, as did the working age Medicaid population and those beneficiaries in poor health. Many beneficiaries also report access problems related to long wait times and lack of transportation. It is hard to believe that this access problem won’t become a serious crisis as the federal and state fiscal woes intensify and demands for services increase.