Before expanding Medicaid, Alaska should ask some hard questions

I have been waiting for someone to ask the hard questions about Medicaid expansion and for someone to provide some real answers. Here is a start:

Will all payers pay less for health care under expansion?

Has everyone forgotten what cost-shifting means? Cost-shifting is standard terminology in health care finance classes. Simply put, it means rolling up the uncompensated costs of care into the price or insurance premium of those who actually pay for health care. It has been many, many decades since cost-shift pricing has been in existence and took a sophisticated leap forward when Medicare and Medicaid were created in the 1960s. Retail stores do the same type of pricing when they roll up losses due to damage and theft. The store always gets what it needs to make a profit as does your local health care provider. And no one reduces prices when the losses are less. There is just more profit.

The reality is that cost-shifting is a more efficient way to pay for the uninsured than Medicaid. Filtering your health care dollars through a government agency will peel off a significant percentage of your dollars to pay for government overhead but will not reduce the cost of health care, increase access, or increase health care outcomes.

Will uninsured have better health care access with expansion?

Have you heard of EMTALA which was passed into law in 1986? The Emergency Medical Treatment and Active Labor Act (EMTALA) is a federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay. Uninsured does not mean "no access to health care." EMTALA requires hospitals to see anyone who presents at the emergency department. Those expenses are rolled up (cost-shifted) into the health care prices you and I pay.

In addition, there are numerous federally qualified health centers, Indian Health Service funded facilities, veterans facilities and other programs such as the beautiful, new Anchorage Neighborhood Health Center (ANHC) for primary care and Anchorage Project Access for specialty care. Both of the last two programs care for those with incomes less than 200 percent of poverty level. (Medicaid expansion less than 133% of poverty level.)

ANHC serves over 12,000 patients through over 40,000 visits per year. Anchorage Project Access arranges with physicians to provide hundreds of thousands of dollars of specialty health care each year. Uninsured does not mean health care is not available.


Why is Alaska Medicaid reimbursement higher than Medicare?

That is an anomaly. It is not the federal government paying for that difference in Alaska. The state of Alaska is one of two states in the U.S. that decided to reimburse providers substantially more than Medicare. In addition if you qualify for both, Medicaid will pay for most Medicare Part A and B premiums, deductibles, and copayments.

Is Alaska thinking of capping Medicaid reimbursement?

Your personal commercial insurance policy gives you a lifetime cap. Oregon Medicaid does, Germany does, United Kingdom does. Why? Free health care means people are prone to unlimited use. Whether Alaska shares at 50-50 with the Federal government or 90-10, 10 percent of infinity is still a lot of money.

Does Medicaid have more coverage than your commercial insurance policy?

You would be surprised if you knew of the expansive coverage you pay for Medicaid patients that you don't get from your commercial insurance. Oregon and California have been leaders in state Medicaid management since the 1980s. They both either cap the Medicaid budget or have reduced coverage for treatments, services, and equipment.

Uninsured does not mean health care is unavailable. Before anyone expands Medicaid, we should know the answers to these questions.

Brent A. Fisher is a resident of Alaska, a fellow in the American College of Healthcare Executives and a fellow in the American College of Medical Practice Executives. He is an Assistant Clinical Professor at Loma Linda University. He can be contacted at bafisher@byu.net

The views expressed here are the writer's own and are not necessarily endorsed by Alaska Dispatch News, which welcomes a broad range of viewpoints. To submit a piece for consideration, email commentary(at)alaskadispatch.com.