In Medicaid, Access to Coverage Does not Equal Access to Care

This summer marks the 50th anniversary of President Lyndon B. Johnson signing the Medicaid program into law. Throughout its existence, Medicaid has been widely praised as extending health care insurance to low-income individuals and families who would otherwise be unable to afford coverage. Today, nearly 70 million individuals, including 30 million children, rely on Medicaid and Children’s Health Insurance Program (CHIP) for accessing care. These figures include the additional 10.8 million enrollees from expansion of the program under the Affordable Care Act (ACA). As recent reports have shown, however, adding more enrollees and making piecemeal improvements is not enough to repair this failing public health program.

One of the objectives of the ACA was to ease the burden on emergency rooms, which historically have provided care for non-emergency healthcare needs for those who lack access to primary care providers. ACA supporters have contended that providing lower income Americans with Medicaid coverage would shift the flow of those individuals to primary care offices, where they would receive the preventive care necessary to ward off many emergency room visits and treatment for non-urgent ailments.

But according to a poll released earlier this month by the American College of Emergency Physicians, 75% of surveyed physicians have experienced an increase in overall emergency room visits since the ACA took effect, with 28% experiencing large increases in emergency room visits. Over half of the survey respondents indicated that the number of Medicaid patients in the ER is increasing. The article accompanying the poll emphasizes that the overall shortage of primary care providers and the number of providers who are not accepting Medicaid patients due to inadequate payment rates (which pose serious barriers to timely care for these individuals) are likely the primary causes of the increase in ER visits.

These troubles were predicted long before coverage expansion began. A 2011 study published in the New England Journal of Medicine found that children with Medicaid and CHIP coverage have been denied appointments with specialists more frequently and face longer wait times than children with private insurance. This trend stems from lower rates of provider participation in Medicaid relative to private insurance. Direct studies of access to care for adults have similar findings.

The Supreme Court hasn’t helped the issue. The Court held in March’s Armstrong v. Exceptional Child decision that providers may not sue states to enforce the “equal access” standards in the federal Medicaid statute. The equal access provision requires states to offer sufficient Medicaid payments so that Medicaid beneficiaries in a particular area have the same access to care as the general population.

In 2011, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that would have required states to monitor Medicaid beneficiaries’ access to care. The rule also proposed to bar states from reducing provider payment rates without an access study showing how the rate reduction would impact care access in the area. Four years later, CMS has never issued the final rule. This leaves states without clear federal guidance on how to measure access, which leaves Medicaid beneficiaries without sufficient care.

Although the Medicaid pay bump for primary care providers under the ACA seems to have improved beneficiaries’ access to care, it is a patchwork provision that is inadequate for solving this massive problem. A survey published in the New England Journal of Medicine showed that the availability of primary care appointments for Medicaid beneficiaries grew from 58.7% to 66.4% after the pay bump went into effect. But the federal payment increase expired in 2015.

Although the Administration has touted its Medicaid enrollment statistics, increased enrollment does not mean sufficient access to care. Rather than spending the fiftieth anniversary focused solely on lauding the successes of the program, policymakers should use this time to take a serious look at the ways the program is failing the most vulnerable populations in America. A health care coverage program is without meaning if it cannot serve its most basic underlying purpose: providing access to care when a patient is in need. Too many Americans are learning the unacceptable lesson that access to coverage does not lead to access to care.


Jeffrey J. Kimbell is the founder and President of Jeffrey J. Kimbell & Associates, a Washington-based consulting firm focused on the executive and legislative branches of the U.S. federal government.

James J. Hennelly is Senior Manager of Health Policy & Reimbursement at the firm.

Morning Consult