by John Geyman, M.D.

The Affordable Care Act (ACA), now labeled “ObamaCare”, set out to increase access to health insurance within the framework of existing health insurance—the private insurance industry’s some 1,300 insurers and public programs such as Medicaid. Over a 10-year period (2009-2019), the original plan would have provided coverage for about 30 million uninsured Americans, about one-half of that number through expansion of Medicaid. States were offered new federal money, starting at 100 percent of the costs of expansion, then dropping to 90 percent of costs after the first two years. How could that not be a good thing, and why wouldn’t all states jump at this opportunity?

As usual, incremental “reforms” around the edge of our complex and dysfunctional “system” cannot be counted upon as progress, despite the hype of their proponents. In almost every case over the last 30 years, these incremental steps have failed to address the fundamental problems of our system—lack of universal access, high and unaffordable costs, inconsistent quality, and profiteering at the expense of patients and their families.

Here is how the Medicaid expansion part of the ACA will fall far short of its intended results:

•  The U. S. Supreme Court ruled in 2012 that states can elect to forego Medicaid expansion. 

•  Most Republican governors have refused the 100 percent federal money for Medicaid expansion under the guise of controlling the deficit and avoiding uncontrolled growth of  “another entitlement program”.  

•  As of June 6, 2013, 14 states had decided to opt out of Medicaid expansion, 6 were still undecided, and 3 were leaning against it.

•  In Georgia, where the Governor has refused to expand Medicaid, Atlanta-based Grady, as the state’s largest hospital (950 beds serving 600,000 patients a year, including more uninsured patients than any other hospital in the state and training one-quarter of Georgia’s physicians) is facing the loss of ACA Medicaid expansion funding and the need to cut back vital services.

• Actual coverage varies widely from one state to another, and is often completely inadequate. Federal waivers are being given to states to modify their eligibility and coverage requirements, even to the point of eliminating hospital coverage and restricting the number of physician visits per year.

•  Many states are cutting already low Medicaid reimbursement rates to physicians, so that only 43 percent  of practicing physicians across the country accept patients on Medicaid ; a Federal Court recently upheld a 10 percent provider rate cut in California’s Medi-Cal, its Medicaid program. 

•  Although the ACA gives primary care physicians a two-year upward adjustment in their reimbursement rates, for many physicians this barely covers their costs in providing care.

•  The national shortage of primary care physicians continues to grow: the Association of American Medical Colleges has projected a shortage of 45,000 primary care physicians by 2020.

Medicaid expansion is currently a hot and unresolved topic in the health care debate, especially at federal and state levels. Republican opposition is likely to derail much of the potential effectiveness of this part of the ACA, as is also likely for other of its provisions.

Is there any larger solution to this impasse, as just one more example of many such issues? Yes, on the matter of access to care, we could develop a universal system of access through a publicly-financed single-payer system that would be more efficient, less bureaucratic, more fair, and more sustainable at lower cost. H.R. 676 (the Expanded and Improved Medicare for All Act), introduced in this 113th Congress with a growing number of co-sponsors, would provide such coverage for all Americans. Most other advanced countries around the world have moved to one or another variant of universal coverage many years ago. A majority of the public has favored such an approach in the U. S. for more than 40 years. Why can’t we join this more civilized group of countries? Why can’t we elevate our debate above partisan politics and incremental tweaks of our “system” to more fundamental fixes, such as changing how we finance care?


Suggested Reading

1. Levey, NN. Medicaid opposition underscores states’ healthcare disparities. Los Angeles Times, May 18, 2013.

2. Nardin, R, Zallman, L, McCormick, D et al. The uninsured after implementation of the Affordable Care Act: A demographic and geographic analysis. Health Affairs Blog, June 6, 2013.

3. Blau, M. This Georgia hospital shows why rejecting Medicaid isn’t easy. Washington Post Wonkblog, June 26, 2013.

4. Geyman, JP. Health Care Wars: How Market Ideology and Corporate Power Are Killing Americans, Copernicus Healthcare, 2012, pp 179-181.

5.  Pugh, T. Most doctors still reject Medicaid as program expansion nears. McClatchy. May 13, 2013.

6, Kaiser Health News. Federal Court upholds 10 % provider rate cut in California: Mich, senior care suffers under sequestration. May 29, 2013.

7. Krupa, C. Physician shortage projected to soar to more than 91,000 in a decade. American Medical News. October 11, 2010.