Yesterday the New England Journal of Medicine published a study entitled "Auditing Access to Specialty Care for Children with Public Insurance." While it’s well established that families on public medical programs face many theoretical barriers to receiving medical care—language, literacy, and so forth—the purpose of the study was to eliminate all but one question: how hard is it to get in the door if you’re on Medicaid or CHIP, even if you have all your ducks in a row: "research on children’s access to specialty care has not adequately distinguished between provider-related barriers and patient-related ones."
The answer? It’s harder, at least in Cook County. The authors’ assistants got more rejections when posing as mothers paying with Medicaid/CHIP rather than private insurance:
66% (179) of the callers reporting Medicaid–CHIP coverage were denied an appointment for specialty care, as compared with 11% (29) of the callers reporting Blue Cross Blue Shield insurance…. When calls to the same clinic were analyzed as matched pairs, there were 5 discordant pairs (2%) in which children with Medicaid–CHIP obtained an appointment but those with private insurance did not, and 155 discordant pairs (57%) in which the clinic accepted privately insured children but not Medicaid–CHIP enrollees….
And when they were able to get an appointment, the wait was longer:
On average, children with public insurance waited 42 days for an appointment with a specialist, whereas privately insured children waited 20 days….
This may not come as a surprise to you. It certainly didn’t to the director of specialty medical care at Stroger Hospital, who told the New York Times: "It’s interesting to think you even need a study to prove that. It’s pretty much common knowledge." The Times also notes that it’s even harder to gain access in the less densely served suburbs, a problem given current demographic trends.
But it’s not just a medical issue; it’s a significant budget issue. Medicaid reimbursement—both rates and promptness—has long been a problem in the state. Medicaid reimbursement lags well behind Medicare reimbursement in Illinois. As Illinois Statehouse News reported last month:
The Illinois House Human Services Appropriations Committee is proposing a $463 million payment reduction of Medicaid to hospitals for next year’s budget. But the Illinois Hospital Association is offering an alternative – why not delay reimbursement payments than making deeper cuts?
If you cut, you have to provide less care. If you delay payments, you have to borrow. What sort of costs does borrowing entail?
Quinn, as is his pattern, is talking more about the nifty things he could do with $2 billion than about the huge interest payments that already choke spending on Illinoisans’ priorities. He wants this "emergency," short-term borrowing to pay some Medicaid bills before July 1, when the federal reimbursement rate will drop. Borrow and pay now, Quinn says, and Illinois will recapture $175 million it otherwise won’t receive. Trouble is, paying the expected 6 percent annual interest — remember interest? — on this $2 billion would deeply diminish that $175 million payoff — and would divert still more budget money to bondholders.
Meanwhile, on the national level, it’s starting to look like Medicaid might be the "sacrificial lamb," in Jay Rockefeller’s words, in the fight over the debt limit and the related budget cuts. Ezra Klein argues that the best compromise is to spend more on public medical assistance upfront to prevent greater emergency costs, and better management for "dual-eligible" patients—the very sickest and poorest patients. It’s clear that’s not happening: federal government funding is dropping, which threatens to delay or reduce doctor reimbursement on the state level even further, and the delays and denials ultimately get passed on to the patients.
Photograph: -Tripp- (CC by 2.0)