Can Medicaid Expansion Address the Doctor Shortage?

Teresa Gardner Tyson, executive director of Health Wagon. Photo credit: Virginia Business

With Virginia on the cusp of Medicaid expansion, it is heartening to see someone asking the obvious question: What good is Medicaid coverage if you can’t find a doctor? Bob Burke at Virginia Business states the obvious:

Getting a Medicaid card doesn’t necessarily mean you have a doctor at hand. Plenty of places in Virginia — especially rural areas — already are short of health-care providers. Oftentimes, people there depend on nonprofit community health centers or free clinics (both of which are chronically underfunded) scattered around the state, or they just go without. This is the true access challenge.

Virginia has a network of clinics, health wagons and other services that provides basic care to poor Virginians, but the system operates on a shoestring, and thousands of people fall between the cracks. An important question is what happens to the existing medical infrastructure for the poor, as inadequate as it is, when Medicaid comes along?

Teresa Gardner Tyson runs The Health Wagon, a mobile clinic that delivers care to people in Southwest Virginia. Medicaid expansion would be favorable to the people she treats, she says, but it’s not a panacea. Some of Health Wagon’s patients are already Medicaid patients — and they can’t find any other health provider.

About five years ago, Health Wagon hired a consultant to run the numbers on how best to take advantage of Medicaid dollars if they started flowing. “We’d have to go back and look at those numbers again” and see whether becoming a Medicaid provider makes sense, Tyson says. “We’re sustained by donations and grants, and at the end of the day, though, we do give free care, [but] the care that we give is not free.”

Here is my question: What happens to those donations and grants if Medicaid expansion is enacted? Will Health Wagon still have a purpose? Perhaps it will, if nothing is done to address the shortage of health care practitioners in Southwest Virginia and there’s nowhere else to go. But if that shortage isn’t addressed and patients still can’t find doctors, is anyone better off?

The Virginia Community Healthcare Association (VCHA), which has 29 member organizations at 147 sites, serves about 100,000 uninsured people every year. CEO Neal Graham estimates that of that number, about 70,000 would be eligible for Medicaid after expansion. He also estimates that expansion will bring an additional 100,000 patients into the clinics and community centers. But it’s not clear at all from Burke’s article that the clinics will have the resources to staff up to meet the extra demand.

There are two problems in rural Virginia: a lack of health coverage and a shortage of health care practitioners. Medicaid expansion fixes the first problem. But as long as the program pays less than Medicare and private insurance — typically forcing medical providers to operate at a loss — Medicaid expansion will do nothing to recruit new practitioners to under-served areas. If lawmakers want the expansion to work, they must address the shortage of doctors, nurses, and technicians. Otherwise, they’re just perpetrating a cruel hoax on Virginia’s poor.

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8 responses to “Can Medicaid Expansion Address the Doctor Shortage?

  1. re: ” But as long as the program pays less than Medicare and private insurance — typically forcing medical providers to operate at a loss ”

    This is only if you believe that the solution is to use traditional medical providers.

    This is actually an opportunity to “disrupt” the current Health Care model and to deliver high quality care at lower costs and what better population to pursue that goal than the already-underserved?

    what better than traveling clinics especially if the individual’s medical record is “portable”?

    So – no – you don’t need nor should try to provide a traditional Medical Care Practice.. Why not provide Nurse Practitioners, Physician-assistants, Medical School Grads working on their debt?

    See.. one can see this as a half-glass full… with ample opportunities rather than a half glass full.. “we’re gonna fail”… proposition.

    The Medicaid Expansion is rocket fuel for success not cause for more hand-wringing.

  2. For a blog that trumpets free market solutions to resource allocation issues such as this, I am astounded the words “free market” appear nowhere in this post. Indeed, you point to “lawmakers” as the ones obliged to solve their “cruel hoax”!

    If there’s a demand for more doctors to serve the needs of Medicaid patients, the stability of the patient and cash flow under Medicaid, relative to donations to the stop-gap providers you profile, will go a long way towards enabling new doctors to enter the workforce and solve that problem. I expect some of them will come from those stop-gap providers; many will be net additions to the medical establishment. Some will be full medical doctors, and some will be non-traditional PAs and NPs. Some of the institutions that have grown up to support these stop-gap providers may transition into Medicaid-accepting clinics. The market will sort this out eventually. Sure, this transition may have a few bumps, but don’t they all?

  3. I doubt the free clinics or community health programs providing free or minimal-cost services will lose either business or financial support. There remain many services Medicaid does not cover (dental, for example). I do not expect the supply of MD’s and family practices willing to accept Medicaid patients will grow that much, because of the low reimbursements. So finding routine care or a “medical home” will remain a challenge for Medicaid families. When something big happens, a trip to the emergency department, surgery or some other major medical crisis – that’s when having Medicaid may mean the situation is dealt with without the patient inviting bankruptcy.

    I hope it does mean more routine preventive care and screenings delivered by a family practice or a community outreach arm of a major medical institution. That would be a great outcome of the decision to expand. But I’m not sure it will.

    Like Acbar I also think more of these non profit volunteer clinics may find a way to tap into the Medicaid system for revenue, as the woman interviewed indicated. I don’t see Medicaid expansion as rocket fuel for anything but simply a recognition that the argument over government involvement as a third party payer is over (Medicare, Medicaid, CHIP, Champus, the VA System, ACA etc.) and now the challenge is to make it work for those people who do not have employer-provided coverage or a small fortune in the bank.

    When this Congress and this president failed in their effort to repeal ACA, that was the end of the debate. Anybody out there still railing against government control of American health care needs to wake up and smell the napalm. Ya lost.

  4. re: rocket fuel, napalm and government “involvement” in health care.

    People who work for a living should have some level of equivalent access to health care as those who also work but have employer-provided.

    We have a system that essentially penalizes those who do work but their employers do not offer insurance. It’s not just “insurance” that is the issue. It’s that the insurance is purchased with untaxed dollars – Not Federal, nor State nor FICA – so that their insurance costs about half what it would without those credits. How many who actually do get employer-provided – could afford it if it cost about 40% more? That’s a govt subsidy to one group that is not provided to others.

    Second – all those who get employer-provided are guaranteed coverage – by the government whereas those who do not get employer-provided – are not guaranteed coverage if there is no ACA or Medicaid Expansion.

    What if people who worked – instead of getting MedicAid – just got the same benefits from the govt that the govt gives to those who do have employer-provided? i.e. the ability to purchase it with untaxed dollars and guaranteed access to coverage?

    If the folks who are so convinced that the expansion is bad policy – would actually advocate for a fair and equitable policy that applied to all who work regardless of whether their employer-provides the insurance or not – perhaps that would be another – better approach that might actually lead to more competition.

    The basic problem is a lack of access to health care – because we have a system that favors some and denies it to others.

    • Yep. And on top of the tax-free employer-provided health insurance premiums (provided by taxpayers in the case of government employees or retirees), people with means and a bit of cash flow can then set up a health savings account and use pre-tax dollars for co-pays or for medical services not covered by their plans (dental, vision, nonprescription meds). The HSA balance accrues tax-free interest or can be invested for tax-free dividends. Is this a great country (for some) or what!

      With all that I can’t agree with the Republicans who are falling on their swords to prevent coverage for somebody working for minimum wage at a place with no coverage plan. There is a legitimate debate going on about how to pay for Virginia expansion, and I see the problems with the new tax on private hospital revenues. If existing revenues can’t do it (they are stretched) then a broader net should be thrown.

      • Steve – if Virginia doesn’t tax the health care industry, all we’ll see from an economic perspective is a transfer of money from ordinary taxpayers to the health care industry.

        • Businesses don’t pay taxes, they collect them from customers. One way or the other this is a transfer program. But there have been discussions of ending the general sales tax exemption that applies across the board to health care (not in this context) and I would prefer that approach to a targeted tax on that one small segment – private hospitals. Any serious discussion of tax reform has to include looking at expanding the services that incur sales tax. Good place to start.

  5. Why do they look to NP’s and PA’s to fill the gap? Most are not going into primary care. Unless you subsidize the money and ask them to be primary care for X # of years to repay what you paid for educating them, you aren’t going to get what you think in there.

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