Separated and Unequal: Time to Invest in Medicaid
Health equity is the key principle for strengthening the delivery of health services in this country. The question—and the opportunity—is whether we can turn health equity from a beautiful idea into a national achievement.
Here’s a simple idea: create parity for underserved communities. Pay doctors who treat Medicaid patients at the same rates Medicare pays them.
While health care providers largely accept the federally administered Medicare program, Medicaid — public insurance for the poor — is a different story. In many states, Medicaid pays providers a fraction of what Medicare and commercial insurance pay. As a result, these communities are health care deserts. Medicaid patients seek doctors willing to treat them, wait months for appointments and forego services that would prevent disease progression, making them needlessly sicker. Medicaid becomes an illusory benefit system when care is delayed and denied. The results of this separate and unequal structure are evident in poor health outcomes in black and brown communities.
Administered state by state, Medicaid strategies vary as states try to balance tough choices and stay within their budgets. Whatever the strategy – limiting the number of people covered, the services covered, or the fees paid to providers for their services – patients end up being the losers of these policy decisions.
California has long made a trade-off between scope of coverage (who is included in coverage and what services are covered) and provider payments. The ranks of those covered are broad and inclusive. The range of services covered by the program is also generous. This benefits populations who have no other options — but too often, care remains inaccessible.
Medi-Cal, California’s version of Medicaid, offers the third lowest provider payment rates in the nation. An efficient, integrated healthcare system like Kaiser wastes $1.8 billion a year on its Medi-Cal patients. How can a healthcare system like mine, which treats an entire Medicaid community, afford to treat them?
California Advancing and Innovating Medi-Cal, the state’s newest version of Medicaid, aims to reduce health disparities by funding nonclinical interventions that address the social determinants of health, such as affordable housing. It also expands eligibility to make health coverage in California nearly universal. These are laudatory goals that should be replicated across the country. However, these changes will not improve access and quality of services if provider payments remain low, especially in communities of concentrated poverty where providers cannot subsidize Medicaid losses with higher Medicare payments. and commercial insurance. Without investment in providers, equity in health cannot be achieved.
Our South Los Angeles community is short of 1,300 physicians. The rate of diabetes is three times the state average and life expectancy is 10 years less. Diabetic amputations are among the most frequently performed surgical procedures in our hospital. Without access to community providers, more than 100,000 patients visit our emergency department each year. Nearly 50% of these patients could be treated in emergency care or in a doctor’s office. For hospitals serving communities with sufficient access to services, this number ranges from 12% to 20%.
Payment disparities are at the root of this reality. At MLK Community Hospital, we receive about $2,000 from commercial insurance for an emergency department visit. Medicare pays $650 for the same visit. Medi-Cal provides $150. While safety-net hospitals receive additional funding for inpatient care — care that meets crisis conditions — no supplements are available for physicians providing community care that could prevent a crisis.
Every community deserves integrated health systems that provide access to the full spectrum of health promotion services, from disease prevention and management to crisis prevention. To achieve this, we must overcome the barrier of underpayment.
Our nation is emerging from a pandemic that has shone a light on the vulnerability of communities like South Los Angeles. A lack of access to lifelong healthcare has led to mixed outcomes for COVID-19. Investing in communities heavily dependent on Medicaid can change that picture for the future.
Creating parity in Medicaid takes work, many say it is impossible to accomplish. It is high time for us to prioritize the needs of people who depend on it for their care.
Elaine Batchlor, MD, MPH, is CEO of MLK Community Healthcare and MLK Community Hospital in South Los Angeles.