Much has been said about the fact that the U.S. has millions of uninsured or poorly insured health care recipients despite being the richest economy in the world, and that health costs in most developed nations are only half of ours.
Fortunately, Virginia has taken steps to help rectify this by enrolling 325,000 adult Virginians through Medicaid expansion. Seventy percent of these people earn below the federal poverty level and 30% are slightly above. Some states have done the same, but many others either are struggling for approval of Medicaid expansion, or have developed alternative programs that are less effective. Most of the funds for Medicaid expansion come from the federal government (90% in 2020), and payments are passed to the six statewide private health insurers that reimburse providers.
Enrollees will be in a managed care plan and are covered for office visits, hospitals and emergency room trips, including primary and specialist care. Dental, vision, hearing and other add-ons are included in various policies.
The insurers have developed plans that provide a panel of doctors, including primary care physicians (PCPs) who care for most of their problems, and referrals to specialists and hospitals when indicated. Savings accrue to hospitals that have been beleaguered by patients with no PCP who go directly to an emergency room and receive costly and unreimbursed care. This is the source of many bankruptcies among working low-income people. Savings also occur when referrals to specialists are limited to true necessity, not simply chosen by the patient.
PCPs — family medicine, general internal medicine, pediatrics and geriatrics — are also able to provide disease prevention and wellness with assistance from nurse practitioners, social workers and wellness educators who ensure that patients adhere to medication and encourage healthy lifestyles, all of which can lead to lower long-term costs. Team efforts have been minimal in ordinary health insurance.
This is a win-win for Virginians whose insurance and hospital costs are now elevated to pay for indigent patients. Federal government funding for most of Medicaid expansion will make state tax increases less likely.
Another program now in place, Medicare Advantage, has some similar features, including a major role of PCPs in limiting unnecessary costs. “Medicare for All” is much touted by politicians who do not understand the current excess costs ($75 billion per year, according to the Government Accounting Office) which would be expanded to 160 million citizens. It also requires seniors give up their present health insurance — policies that many Americans find valuable.
Both Medicaid expansion and Medicare Advantage support the health care model, which we wrote about in the Richmond Times-Dispatch in November 2018 (https://besthealthcaremodel.org/), showing what will be necessary for reform of our chaotic health care system. The model emphasizes the central role of the PCPs in controlling overutilization and redefines the form of health care organization to relieve the present inefficiency and costs. Enhancing the stature and income of PCPs will also be necessary to ensure sufficient numbers.
Reform is also needed on the pervasive role of pharmaceutical and other professional organizations in providing millions of dollars annually to Congress to ensure that serious reforms are minimized.
The incremental changes in Virginia’s Medicaid expansion are a reasonable step toward more extensive reform in the future.