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Latest ACA problem: New Medicaid enrollees may find their coverage is limited

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Expanding eligibility for Medicaid was one of top features of The Affordable Care Act. But now even it is running into problem.

Those now eligible for Medicaid are concerned they won't find as wide a choice of physicians in the Medicaid program as they can find in the commercial health insurance market.

Insurance broker Eileen Shrem said one of her clients earns about $10,000 a year and is eligible for Medicaid. If that client decides instead to remain in the commercial market, her premium will be about $349 a month, and she won't get a subsidy to buy commercial coverage, since people who are eligible for Medicaid can't get a subsidy.

Shrem's client, however, has health problems and she's not sure she can get what she needs through Medicaid.

"So what she is doing is calling her doctors to find out if they take Medicaid or not before she makes the decision," Shrem said.

Medicaid eligibility in 2014 rises to 138 percent of the federal poverty level. Between 138 percent and 400 percent of poverty, federal subsidies are available under the ACA to help people afford coverage in the commercial insurance market.
But will it help?

Joel Cantor, director of the Center for State Health Policy, said it isn't clear.

Cantor cited a paper published earlier this year in Health Affairs that found more than half of New Jersey primary care doctors did not accept new Medicaid patients in 2011 and 2012, compared to about 33 percent nationwide.

Cantor, however, said the Health Affairs analysis may over-state the problem in New Jersey.

"We have fewer Medicaid beneficiaries than other states and we have robust safety net clinics which see many of these patients," he said.

Cantor said he hopes to have data in January on reports of access problems by patients with different kinds of (health plan) coverage which "will be more directly relevant to this question."

Larry Downs, chief executive of the Medical Society of New Jersey, said reimbursement is the problem.
Downs said fewer doctors take Medicaid in New Jersey than accept Medicare and commercial insurance for reason.

"Medicaid (in New Jersey) has been woefully underfunded from a physician fee perspective," he said.


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For 2013 and 2014, the ACA increased payments for certain primary care services to the same level as Medicare, with the federal government picking up the tab. But Downs said the enhanced payments do not apply to specialists who treat Medicaid payment. In 2015, the additional federal payments end and the states will have to decide whether or not to continue them.

Downs said before the enhanced payment took effect in 2013, Medicaid rates were about half of the Medicare rates. For example, if Medicare was paying about $80 for a general office visit, Medicaid was paying between $38 and $42.

Dr. Thomas Ortiz, a family physician in Newark who participates in the Medicaid program, said the increase in payments has been extremely helpful.

"Now we are getting 100 percent of Medicare, which is a nice increase for the doctors that have for so many years been serving the underserved Medicaid population," he said.

Unfortunately, Ortiz said, specialists don't get these enhanced payments and "in many case do not accept referrals" of Medicaid patients.

Downs can't understand it.

"(Medicaid) is not a solely primary care endeavor," he said. "(The ACA) has expanded a program that is fundamentally flawed in the way it is designed and it has been underfunded for a decade."

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