Arkansas’ “Private” Medicaid Expansion Improved Access to Care (At A Very High Price)

doctor-mom-and-sonArkansas has a love-hate relationship with Obamacare. The previous (Democratic) governor, Mike Beebe, made a deal to accept Obamacare’s Medicaid expansion but with an interesting twist. Obamacare significantly increased the number of Americans who could become dependent on Medicaid by increasing the income cut-off for eligibility. Many governors rejected the federal funds offered to expand this welfare dependency.

Governor Beebe took the money, but instead of using it to expand Medicaid for the newly eligible, he used it to subsidize beneficiaries’ purchase of private plans in Obamacare’s health insurance exchange. His successor, Republican Asa Hutchinson, and the Republican-majority legislature, decided to continue the program.

According to new research published by the University of Pennsylvania, this “private option” yielded dramatically improved access to care. In a “secret shopper” survey, callers identifying themselves as dependents on traditional Medicaid were able to make appointments with primary-care physicians in 55.5 percent of attempts. Medicaid dependents enrolled in exchange plans got appointments 83.2 percent of the time.

That is good news. Traditional Medicaid offers poor access to care because it does not pay physicians enough to see patients. The exchange plans pay more, so enrollees were able to get care. On the other hand, they cost more. According to the Government Accountability Office, the “private option” will cost an extra $778 million over three years. With 200,000 enrollees, that amounts to an extra $1,297 per person per year.

That is a lot of money. Maybe Arkansas and the federal government could think of another option. These appointments are for primary care. Why do we need insurers or a Medicaid bureaucracy in the middle? How about just giving a sum of money to the patients and allowing them to pay primary-care doctors directly?

Comments (36)

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  1. Ron Greiner says:

    Taxpayers pay $6,500 per year for Medicaid then they can’t see a doctor. Medicaid is a scam to funnel billions into Medicaid companies like Blue Cross. It’s like the Mafia.

    See John, that’s why I say your idea to give money to the state politicians, in block grants, for Medicaid is a bad idea.

    Glad you are finally seeing the problem.

    • There would be nothing preventing the state politicians returning the block-grant money to the people.

      • Steve Swank says:

        When has the money ever been returned “to the people?” It always finds it’s way into pork or pocket change for our dedicated public “servants.”

        • True. Here is NCPA’s proposal in a nutshell. Every household gets a federal tax credit. For those who cannot or will not use the tax credit to pay for their own health care, it goes to the state in which they reside to pay for the safety net. Imperfect? Yes.

  2. Barry Carol says:

    “How about just giving a sum of money to the patients and allowing them to pay primary-care doctors directly?”

    Because many of them will just spend the money on other stuff. In Puerto Rico, according to a lengthy article in the NYT yesterday, residents of public housing get a utility allowance of $65 per month paid in cash. Many just spend the money on other things and stiff the Electric Power Authority. Fully 36% of public housing residents declare an income of zero and are required to pay only $25 per month for their apartment. The net result is they are paying a negative rent of $40 per month. Most of these folks are working off the books. Puerto Rico has an official unemployment rate of 12% but coffee growers can’t find nearly enough workers to harvest the crop. Crazy!

    Giving people a sum of money to pay for primary care directly doesn’t take into account that a lot of them won’t use the help as intended. They will game the system instead and, in the case of primary care, just go to the ER when they need it. With the ACA exchange plan, at least the providers will get paid.

    • Ron Greiner says:

      Barry is right, finally. Just give those poor Trump’s age-based tax credits so they can get real insurance so the medical providers will be paid.

      Barry is voting Republican now and has seen the light.

    • John Fembup says:

      Barry, seems to me the Puerto Rican poor, described in the NYT article, are making reasonably rational decisions about the money they have. Pay the power company $65 – get electricity. Don’t pay the power company – get electricity. I wouldn’t pay the power company. Would you?

      What’s the real problem here? Is it that the poor aren’t spending the cash grants the way the bureaucrats tell them to? King Canute, your palace is calling.

      What if the problem is that there are no consequences for not paying the utility bill? What if the poor in general are perfectly able to figure out the consequences – if they exist – and make reasonably rational fInancial decisions? What if Puerto Rico is a good example?

      What if providing cash benefits with strings attached Is just not a workable policy? What if, instead, benefits paid in cash were considered as regular, earned income? What if the government just left people alone to make their own spending decisions? I think there’s enough evidence to show the poor can figure out the incentives and make reasonably good decisions. The incentives matter.

      In this case, why not treat welfare recipients who don’t pay their utility bills, the same as anyone else who doesn’t pay their bills? Or is that just too extreme a social position to consider?

      Let’s keep in mind the government does not tell wage-earners how to spend their money. Perhaps it’s time to consider how the government could stop telling welfare recipients how they must spend their money.

      • Barry Carol says:

        John – Yes, incentives do indeed matter. That’s exactly the problem with giving the poor cash instead of insurance to pay for primary care. Suppose they spend the cash on other things. The consequence is that when they need primary care they go to the ER where the hospital must at least stabilize them under the rules of the EMTALA. The hospital will most likely be unable to collect much if anything from the patient and will write the unpaid bill off as uncompensated care. The rest of us will pay more for our insurance because the hospital has to charge more than it otherwise would to patients who can pay.

        If the society were willing to just let people die on the floor of the ER if they don’t have insurance or can’t pay out of pocket, the perceived consequences would be a lot different but we’re not willing to go there and I hope we never do. I know the conservatives will call me a collectivist but as a taxpayer, I would rather ensure that the poor at least have Medicaid. Private insurance at higher cost might be a bit too much for taxpayers to accept.

        • John Fembup says:

          “Suppose they spend the cash on other things.”

          Barry that is the very suppositition I’m questioning. Why is this always the supposition? Why not suppose low income people who are not on public assistance spend their cash on “other things”? Why not suppose middle-class or higher wage earners earners do the same? Why do we always suppose it’s only the poor who cannot make good personal financial decisions?

          I think one reason is incentives – in this case, disfunctional incentives that are largely created by government bureaucrats who suppose the poor must be told how to spend their money.

          Meanwhike there’s evidence that even the poorest people – those who require public assistance – are able to figure out the consequences and make rational decisions. If there are in fact, consequences – and if they are rational.

          Of course, basing policy on that different supposition about the poor would also mean actually enforcing the same consequences on the poor for bad decisions as are enforced on wage earners. I don’t believe the non-poor are expected to die on the emergency room floor if they just cannot afford insurance. I’m just suggesting the same consequences apply for everyone. Do you feel that’s far too extreme a social position to take vis-a-vis welfare recipients?

          • Barry Carol says:

            John – I’ll offer a couple of thoughts on this.

            First, I think there is a big difference between how people choose to spend money they earn themselves and how they spend money provided to them by taxpayers or a charity that’s intended for a specific purpose. If we want to help people afford food, we provide food stamps, not cash. If we want to help them cover the rent for an apartment, we give them housing vouchers, not cash. If we want to help poor kids go to college, we provide Pell grants or a student loan, not cash that can be used for any purpose. K-12 school vouchers can only be used to attend school, not for any purpose the recipient chooses.

            With respect to healthcare specifically, poor people use healthcare differently from the rest of us. In NYC at least, many of the poor see the ER as a one stop shop that provides better quality care in a more time efficient way than going to a primary care doctor or community health center. These people often don’t have private transportation available. They can’t afford to take time off from work to go to a primary care doctor during the day, then take more time off to see a specialist and then yet more time off to get an MRI at a hospital or imaging center. It’s a more rational decision for them to just go to the ER whether they have Medicaid, private insurance or no insurance at all.

            • John Fembup says:

              I tried to limit my remarks to payment for utilities in Puerto Rico – but food stamps, housing vouchers, Pell grants, and other payments in kind are equally questionable. And I think for the same reasons – they presume that only the poorest Americans are incapable of making reasonably rational personal financial decisions.

              Yet evidence exists almost everyone is capable of figuring out the incentives and making good decisions. That’s why I suspect the questionable, perhaps dysfunctional, part is the incentives – more than the people.

              Incentives matter. When we observe dysfunctional behavior that seems to be the consequence of dysfunctional incentives – should we not at least consider how those incentives might be changed?

              Specifically for medical care: is the problem that poor people have fundamentally different medical needs vs. anyone else? Is the problem that poor people use the medical system less efficiently?

              You suggest several social (not medical) incentives that help drive the inefficiency. Are those incentives dysfunctional? Are they worth keeping? Is it possible to change them? How might they be changed? I think these Q’s are at least worth considering.

    • I was hoping this would be the type of comment. So let me take another step: What if it were a debit card, like a SNAP card instead of food stamps, that could only be used at a health provider?

    • Steve Swank, MD says:

      It is quite difficult to get the payments from some patients who feel the insurance company paid them to see the doctor when they get their check. Chasing down these patients is costly and often fruitless for the provider.

      • Thank you. From who does the patient “get their check”? I don’t follow.

      • Allan says:

        I don’t think any business is without the problem of payment. Why should physicians be different? I am a physician that faces nonpayment problems as well, but I feel that we have to be in the free market place to function efficiently.

  3. Victor says:

    “Perhaps it’s time to consider how the government could stop telling welfare recipients how they must spend their money.”

    Except, it’s not “their” money: it’s the taxpayers.
    Rather than cash grants, instead accounts from which payments may be made for approved purposes (eg, paying utility bills).

    Giving cash leads to the unintended consequences the article describes.

    • John Fembup says:

      “Except, it’s not “their” money: it’s the taxpayers”

      Victor, I don’t believe that’s helpful and I’m not sure it’s even “true”.

      I once worked at XYZ Company. When I cashed my paycheck, was it still their money? Or was it mine?

      Do you really think XYZ would have been justified to insist I spend some of my salary for things it considered worthwhile?

      In fact, how did XYZ get the money to pay me in the first place? Why, selling its products to its customers, that’s how. And it’s customers are all taxpayers. Is it really your theory that when XYZ Company spends any money, it is spending “taxpayer money”?

      • Barry Carol says:

        John – When you received your paycheck, it was in exchange for value that you provided in the form of your time, knowledge and expertise. While your employer can set certain rules of employment such as work hours, compensation and benefits, etc. it has no expectation of having any influence over how you spend your paycheck. It doesn’t care nor should it.

        By contrast, receiving either cash or an in kind benefit from government or a private charity is different because no value was provided by the beneficiary. If a wealthy benefactor donates a large sum of money to a school or hospital, it’s rarely an unrestricted donation that can be spent as the recipient pleases. Instead, it’s usually earmarked for certain projects or programs that reflect the donor’s interests and priorities or is added to the endowment. By the same token, I think government can legitimately require that money intended for a specific purpose should be spent as intended. He who has the gold makes the rules when there is no contractual exchange of value for money.

        I also question the wisdom of many choices made by poorer people. For example, they have a considerably higher incidence of smoking than the rest of the population even though cigarettes are expensive now thanks to high taxes. They also have a higher incidence of alcohol and drug abuse. Maybe that’s partly related to the stresses of being poor but there is a lot of irresponsible behavior there. While a safety net shouldn’t be so generous and comprehensive that it turns into a hammock, I’m fine with requiring money, subsidies and vouchers provided by taxpayers or charities to be spent for their intended purpose.

  4. Ron Greiner says:

    Barry, you always want me to train you on medical underwriting. 1st of all this is a very large subject but one thing is very simple. Hillary could not pass medical underwriting to get Individual Medical insurance because she is on blood thinners.

    I understand Hillary is taking Coumadin, also known as Warfarin.

    Hillary is too sick to get insurance so maybe we should think twice about her becoming President.

    • John Fembup says:

      “Barry, you always want me to train you on medical underwriting”

      Well, Senator, Barry is not the only one.

      Besides, Senator, you invited him to ask when you said this:

      “I know much more than you about medical underwriting, exclusionary riders, medical rate-ups and declined consumers so I would be an excellent person to have ideas on how those with health issues can get health insurance.”

      • Ron Greiner says:

        Killer John, when you TERMINATED employees that were too sick to work they lost their health insurance after a short COBRA. We all know that not having health insurance may be deadly.

        So, if you sent Hillary one of your deadly TERMINATION notices she would not have been able to qualify for medically underwritten health insurance because she is on blood thinners.

        But of course you laughed all the way to the bank when you TERMINATED sick young women’s health insurance. That is why I call you Killer John.

        Underwriting Guides can be pretty long. This is just one example of the pain you caused people.

        How could you sleep at night Killer John?

  5. Ron Greiner says:

    Republicans and Trump want High Risk Pools so people like you Killer John can keep doing your deadly deeds.

    That’s 1 example on how to fix the deadly problems that you cause Killer John.

    • John Fembup says:

      Only one?

      Senator, you promised much more.

      • Ron Greiner says:

        Killer John, I think that you should be required to provide Full and Proper Disclosure when you enroll workers on your deadly insurance. How about:

        WARNING: If you get this health insurance and you get Ovarian Cancer and cannot work 30-hours-per-week you will be slammed on a Short Term COBRA for insurance TERMINATION. Losing insurance with a major sickness can be depressing at best and deadly at worst. SIGN HERE___________________

        I think a warning about your insurance should be mandatory.

        What do you think Killer John? Or do you not answer questions?

        • John Fembup says:

          It’s hard to be you, isn’t it Senator?

          I believe you said to Barry:

          “I know much more than you about medical underwriting, exclusionary riders, medical rate-ups and declined consumers so I would be an excellent person to have ideas on how those with health issues can get health insurance.”

          Indeed. Most excellent. You probably know much more than me, too, or anyone else for that matter.

          So Senator, it would be a great idea for you to show what ideas you have. And now would be a good time.

          • Barry Carol says:

            Maybe he has no ideas John. It’s probably not a subject he thinks much about or cares much about because his business is selling underwritten insurance to healthy people. If he has some ideas, let’s hear them.

            This constant crap about employer insurance being TERMINATED when the employee gets too sick to work is just diversionary changing of the subject. Maybe the blog operators should ask for a response from Mr. underwriting expert.

            • John Fembup says:

              “different because no value was provided by the beneficiary”

              Well, I don’t argue over “value” provided. I just don’t understand why that difference gives the government an ethical right to tell the recipient how the money they give out must or cannot be spent. It’s almost a veterinary approach to welfare – treat the clients like pets.

              The government has made a policy decision to make these grants. Why then not make them, and that’s that? The recipient would then be responsible for their decisions – including consequences that anyone else faces based on their spending decisions,

              I doubt you would like it if the government decided to develop ruies for every American on how we may spend the money we have – to require that our spending meet the intended criteria of a benevolent bureaucracy. Am I right? 😎

              Or, maybe, is the real problem something else? For example, could the real problem be that the government (and not just the government) believe there are inferior people who are simply incapable of making their own decisions and living by them?

              In contrast, I’m suggesting those same “inferior” people seem generally competent enough to figure out the incentives in present welfare rules and work them to their best advantage. And I’m asking how incapable is tha? Shouldn’t that prompt us to question at least the motives behind present welfare rules? If everyone agreed the present rules were working quite well, I wouldn’t be asking.

              • Barry Carol says:

                “In contrast, I’m suggesting those same “inferior” people seem generally competent enough to figure out the incentives in present welfare rules and work them to their best advantage.”

                That’s for sure as I’ve heard many stories along those lines over the years. However, figuring out how to game the system and get as much money or in kind benefits out of government / taxpayers as possible with help from others is not the same as making wise choices with respect to spending money or personal behavior.

                “I doubt you would like it if the government decided to develop rules for every American on how we may spend the money we have – to require that our spending meet the intended criteria of a benevolent bureaucracy. Am I right?”

                Yes, you are right. I would argue, though, that the government has no legitimate interest in how I spend money that I earned from work or investments. Moreover, it wouldn’t have any mechanism for enforcing an interest if it tried to assert one at least short of outlawing privately owned property. It does have an interest in how money that is distributed to lower income people for a specific purpose is spent and I think it has a right to do what it can to ensure the money allocated according laws passed by the legislature, signed by the president, and financed by taxpayers is spent as intended.

            • John Fembup says:

              “Maybe he has no ideas”

              Maybe. I’m just taking the Senator at his word that he does. And he writes a lot of words.

              In fact, that’s one of the reasons I call him “Senator”. Lots of talk, in the Senator’s case, hostile talk. Not much substance.

              And meanwhile:


              • Ron Greiner says:

                Killer John, you are a little slow. I gave you 2 ideas, 1. High-Risk Pools, 2 Warnings on your deadly employer-based insurance.

                Now you say, “Maybe he has no ideas”.

                Now you want me to continue and explain medical Rate-Ups next?

                You never answer a question, but I do.

                Killer John, do you think a Warning to employees would be a good idea? Anything short of Full and Proper Disclosure is a serious ethics violation under insurance law.

                Cough it up Killer John.

                • John Fembup says:

                  Senator those aren’t ideas, they’re slogans. If you have something consequential, please put it up.

                  And if you can’t put up, what do you do?


                  • Ron Greiner says:

                    YOU decide that Republican High Risk Pools are a slogan? Who made you dictator Killer John?

                    I answered your question now you answer mine. YOU never answer a question.

                    Killer John, you liberals say Republican ideas are just slogans. Did Hillary teach you that?

  6. Big Truck Joe says:

    Would this work like the old Medicare non-participating days when the Govt pays the patient and the patient is responsible for paying he provider? It could be done with a debit card that each Medicaid patient recieves. If the card could only be used for healthcare providers there would be no incentive to misuse the funds. Sounds like an interest idea.

    • Physicians can still decline to accept assignment to Medicare. In that case, the patient pays the doctor directly. As long as the doctor has not charged more than 10 percent above the fee-schedule, the patient can submit a claim to Medicare for reimbursement. It is a lot clumsier than that which I moot.

    • Allan says:

      Medicare should never have favored direct Medicare payments to physicians over patient responsibility. If anything Medicare should have deducted 5- 10% on direct payments and let the physician charge directly.