Medicaid expansion moves forward

Friday, March 01, 2013 12:12 PM

Chet Seward, Senior Director, Health Care Policy

In early January, Gov. John Hickenlooper announced his support for the expansion of Medicaid coverage for low-income Coloradans as called for by the Affordable Care Act. The January 3 announcement ended months of speculation about the fate of Medicaid in Colorado and accelerated work on a number of fronts to ensure access to cost-effective, quality health care for low-income Coloradans. Two weeks later the CMS board of directors voted to support the expansion based upon a policy platform that strongly supports the ongoing transformation of Medicaid through the Accountable Care Collaborative (ACC), while underscoring the need for work on other critical areas including increasing physician reimbursement, liability protections, administrative simplification and enhanced patient engagement.

The governor’s announcement kicked off a flurry of policy and political work to develop a bill for consideration by the legislature. While no bill has been officially released at press time, it is clear that it will have strong legislative champions with Sen. Irene Aguilar, MD, expected to serve as lead sponsor in the senate and Speaker Mark Ferrandino as lead sponsor in the house. Both have indicated an interest in not rushing the development of the bill in order to craft it in a way to meet Colorado needs and obtain bi-partisan support. Political tensions continue to break along two camps, with some leaders arguing that this is the best deal possible to cover the uninsured and substantially limit cost shift to private payers, while others assert that the expansion represents a huge government overreach that threatens the state budget.

What the expansion means

CMS physician members are similarly concerned about what the expansion means for Medicaid and health care in Colorado (see sidebar for details). That’s why the expansion policy platform approved by the CMS board of directors is so important given its emphasis on improving upon the ACC, the state’s pivotal initiative to reform Medicaid using seven regional care coordination organizations, payment reforms and providing information technology and data support to drive informed decision-making. The platform also serves as a clarion call to develop and follow a clearly defined path to address urgent, systemic issues that threaten the success of the expansion including appropriate physician reimbursement rates, enhancing patient engagement, simplifying administrative requirements and preserving and innovating liability protections.

Sue Birch, executive director of the Colorado Department of Health Care Policy and Financing, which oversees the Medicaid program, spotlighted current work on some of these issues during her presentation to the CMS board of directors on January 18. She touted the state’s work on the “Medicaid Five,” five efforts to enhance the value of the program including:

• Strengthening efforts to prevent unnecessary or duplicative services;
• Ensuring the most effective services are delivered at the lowest cost;
• Increasing the effectiveness of care delivery through the ACC;
• Evolving payment systems to reward value instead of volume; and
• Leveraging health information technology to improve quality and efficiency of care, and redesigning administrative infrastructure.

More questions, more work

Many questions remain about how the Medicaid expansion in Colorado will ultimately look and work. Details of the bill (or bills) that is expected to be released in the next month are still being hashed out and therefore its impact on the ACC and a myriad of other state programs has yet to be assessed. These programs will play a central role in attaining much-needed cost savings, while ensuring access to high quality care. The fate of the 2009 hospital provider fee as a funding mechanism for the expansion will also generate much interest, especially given Gov. Hickenlooper’s pledge that the expansion will not cost the state another dime of general funds.

While many questions remain, one that seems to be settled is whether or not the bill will pass given Gov. Hickenlooper’s support and the Democrats’ control of the House and Senate. In a statement responding to the governor’s announcement, CMS President Jan Kief, MD, emphasized the importance of the work ahead: “We may not see another opportunity in our lifetimes to close the coverage gap and to reinvent Medicaid in innovative ways that guarantee a meaningful return to taxpayers and to our patients.”

Sidebar: Members weigh in on CMS position to support Medicaid expansion

Kate Alfano, CMS contributing writer

In early January, Gov. John Hickenlooper announced that the state would expand Medicaid coverage for adults as called for under the A¬ffordable Care Act. Experts estimate this would add roughly 160,000 Colorado adults to the program. Colorado Medical Society’s support of the expansion hinged on a months-long process to develop and broadly vet a policy platform that emphasizes the need to accelerate transformations currently underway in Medicaid thanks to the Accountable Care Collaborative and the need for increased physician reimbursement, liability protections, administrative simplification and patient responsibility.

CMS polled physician membership on this position in December, asking if CMS was on the right track. Nearly 700 physicians from around the state responded to this survey, which showed substantial support for the expansion.

Respondents were also given the opportunity to share comments about the expansion. They fell into two general categories in support or opposition of the policy, either reflecting a personal philosophy or focusing on operational factors, with some responses in between. Across all categories, Colorado physicians favor increasing physician payment for Medicaid services and ensuring patient accountability, and many express concerns with payment reform.

Expressing support for expansion and CMS’ position were comments similar to this: “Access to care is one of the single biggest ethical and economic issues facing our state and our nation. By supporting this expansion and calling for sensible changes to payment structures and utilizing pilot programs, CMS has struck just the right chord in terms of expanding access while not jeopardizing payments. Hopefully this will be widely supported and the people of Colorado will reap the benefits.”

Expressing concern with expansion were comments similar to this: “I think it is right on as an idea, but I am doubtful that it can actually be implemented. Our system is so broken that I don’t know that it can be fixed and just adding more people to the already bulging ranks does not lend itself to making the system work better. I hope it does, but I am doubtful.”

Other members voiced their opposition to the expansion as summarized by this comment: “I disagree with supporting bureaucratic nonsense. Yes, CMS needs to support cutting the red tape, establishing standardized forms and streamlining approval processes. Additionally, CMS must push back on government involvement. Remember, we are the experts on health care.”

After reviewing the survey results, the board voted to approve the advocacy position developed by the Council on Legislation and the Committee on Physician Practice Evolution to support the expansion and urgently address the necessary systemic reforms. Read more about the board discussion and action at www.cms.org.