For much of the last legislative session, debate over extending Medicaid coverage to childless adults focused on the bottom line for the state: more than $50 million in federal reimbursement for assistance the state already is providing.
But putting recipients of State Administered General Assistance under the Medicaid umbrella, approved this week in Washington, also means elimination of a flawed system that shortchanged both the poor and the doctors who cared for them, advocates of the move say.
“Basically, SAGA is being put in the dustbin of history, where it richly belongs,” said U.S. Rep. Joe Courtney, D-2nd District, a vocal proponent of the health care overhaul.
Sheldon Toubman, a lawyer for New Haven Legal Assistance who has been outspoken in his criticism of SAGA and other state-run health programs, was even more blunt.
“They have wiped away all this crap that was called health care and started over,” he said. “This population will now have real health coverage.”
Extending Medicaid to childless adults nationwide is a key step in implementing the new health care reform law, making the program a more fundamental part of providing care to low-income Americans.
There’s no question that the change will mean improved coverage for some 45,000 SAGA patients, including more physicians to choose from and more covered services. And it won’t add a burden to the Medicaid system: Most doctors who see SAGA patients also participate in the federal program.
But some worry that the reform law isn’t doing anything now to address the problems that already exist in the system.
“It’s barely functional now,” Ellen Andrews, executive director of the Connecticut Health Policy Project, said of Connecticut’s Medicaid program. She said providers and consumers alike have difficulty navigating the system, and too few doctors participate in the program.
The problem has been exacerbated by the economy: Connecticut’s Medicaid rolls have swelled by at least 53,000 patients in the last 18 to 20 months, DSS Commissioner Michael P. Starkowski said. And he said he expects to enroll another 7,000 to 12,000 people in Medicaid over the next year, in addition to the 45,000 low-income childless adults who will be rolled over from SAGA.
Andrews and other advocates hark back to a 2006 survey that found only about one in four physicians participating in the Medicaid program actually were accepting new patients.
“Overall, access to care was found to be deficient across all health plans and provider groups,” the report concluded.
David Dearborn, a spokesman for the Department of Social Services, said accessibility is no longer an issue in Connecticut because doctors are reimbursed for the services provided more appropriately now. And Starkowski dismissed the study, saying many doctors’ offices probably did not understand what program they were being asked about.
But Andrews said there is no evidence, either from state officials or her clients’ experiences, of any improvements since that study was done.
More recently, a 2008 national survey compiled by the Center for Studying Health System Change, a nonprofit think-tank, found 28 percent of physicians reported they were accepting new Medicaid patients compared with almost 90 percent accepting new privately insured patients.
As part of health care reform, Congress approved increased Medicaid payment rates to doctors for primary care, but those boosts don’t kick in until 2013 and 2014. In the meantime, however, the gap between needy patients and willing doctors is likely to persist.
“Concerns about provider networks are widespread, and whether there are enough providers currently in the Medicaid program to absorb an influx of new enrollees is a big question,” said Rachel Klein, deputy direct of health policy at Families USA, a consumer health care advocacy group based in Washington.
The Connecticut Medical Society, which represents more than 7,000 physicians, said Medicaid’s low reimbursement rates result in low physician participation. Ken Ferrucci, vice president of public policy for the society, said the average reimbursement rate for the society’s physicians participating in Medicaid is about 56 percent of actual costs.
But the SAGA rates were even worse, he said: about 43 percent of costs. Shifting SAGA patients to Medicaid will expand their physician choices to 17,090 participating doctors.
The low SAGA reimbursement rate was particularly troublesome for patients seeking specialized care, advocates say. While primary care was available, getting to see specialists such as neurologists or dermatologists was problematic.
“You need these services? Well, you are just out of luck. That’s just bad policy,” Toubman said. “What’s the point of saying you cover something if you can’t find a doctor?”
Ron Dunhill, who works to get SAGA clients at Cornell Scott Hill Health Center in New Haven the health services they need, cited the case of a client who had fluid on his brain. There were plenty of doctors in New Haven capable of handling the case who accepted Medicaid, but the nearest SAGA-enrolled physician was 90 minutes away.
And while Medicaid would have paid for transportation to medical appointments, SAGA wouldn’t, except for emergencies. Medicaid also covers such things as nursing home care, at-home care, and durable equipment such as a walker or wheelchair, which SAGA doesn’t.
“It’s not like Medicaid is perfect,” said Toubman. “It is better than SAGA though, so it’s a step up.”