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MACPAC Leaders Hit the Start Button

By John Reichard, CQ HealthBeat Associate Editor

September 23, 2010 -- On a day when Republicans across town were proudly proclaiming plans to repeal the health care overhaul, a new Medicaid commission created by the measure rumbled into motion, with its chairwoman, Diane Rowland, cheerfully anticipating the work ahead despite the uncertain fate of the law and the new organization it funds.

Both Medicaid and the Children's Health Insurance Program (CHIP) are poised for sharp expansion under legislative wins for the Obama administration and congressional Democrats.

The tide could be turning against Democrats and their expansion efforts, with Republicans threatening to try and gut the law if they make significant gains in the midterm elections.

But the need met by the new Medicaid and CHIP Payment and Access Commission (MACPAC) for much greater official scrutiny of the two programs suggests MACPAC will be around for a long time, whatever the fate of the law.

In an interview Thursday morning before the panel's inaugural public meeting, Rowland said, "We want to look at the access issue. What do we really know about it? What are states trying to do to address it?"

It's one thing to have an insurance card and another to actually see a doctor or a specialist. So the panel's early work will center on pinpointing gaps in access to care around the country, and the specific nature of those gaps. Analysts often cite Medicaid's low payment levels as the reason enrollees can't find doctors. But Rowland says the commission will also explore what role administrative hassles play in the reluctance of doctors to treat Medicaid patients. And the congressional advisory panel will examine to what extent the lack of geographic proximity of patients to doctors is the real problem.

Rowland says she's aiming to make commission meetings a window not only on research relating to the programs, but also on Medicaid as it is actually operating "on the ground."

For example, Thursday's session included a presentation by Julie Hudman, director of the District of Columbia's Department of Health Care Finance, on a program to expand Medicaid eligibility to 133 percent of the federal poverty level for childless adults.hat's the threshold for Medicaid eligibility in 2014 under the overhaul law, but federal funds are available before then for childless adults. Both the District of Columbia and Connecticut are taking advantage of that.

Research Findings Presented

The first day of the Sept. 23-24 meeting, Genevieve Kenney of the Urban Institute and Peter Cunningham of the Center for Studying Health System Change will present policy research findings.

Cunningham's data concludes that the "low overall supply of physicians may be more of a problem than low fees in some areas." There is also variation among the types of providers who will accept Medicaid patients. Younger doctors, larger practices and practices in rural areas are more likely to take Medicaid patients, he notes.

Sixty-five percent of practices specializing in pediatrics take Medicaid patients, compared with 42 percent of psychiatric practices and 40 percent of those in internal medicine.

The fact that many doctors don't take Medicaid doesn't mean there isn't considerable access to care in the program, Cunningham's data also suggests. Fifty-three percent of all doctors accept most all or most new Medicaid patients, it says.

According to Kenney, "Nationally, access to routine primary care is fairly strong in Medicaid and CHIP, especially for children, when compared to care received by other groups." But compared with people with private coverage, enrollees in the programs have high rates of emergency-room use, a higher rate of dental problems, a greater reliance on safety net providers and more problems getting access to specialty care.

Kenney's data also suggest that enrollment in Medicaid or CHIP is far better in terms of access to care than having no insurance at all. The data show for example that 32 percent of non-elderly adults with no insurance in 2007 made one or more visits to the doctor, compared with 71 percent in Medicaid.

And 63 percent of children in Medicaid or CHIP had one or more visits to the doctor, compared with only 33 percent of uninsured children.

Overall data on Medicaid released at the meeting showed the program's big share of national health spending in various categories. The program funds 41 percent of nursing home care in the U.S., 17 percent of hospital care, 13 percent of other professional services and 8 percent of prescription drug purchases. Medicaid covers about 60 million people, more than Medicare, and one-third of all children.

Study Gaps

While MACPAC will bring much more data to bear on policy decisions, big gaps remain in research on Medicaid, which consists of 51 different programs because of variations in how states and the District of Columbia run the program.

Officials with the Government Accountability Office and the office of the Assistant Secretary for Planning and Evaluation at the Department of Health and Human Services are scheduled to make presentations Friday on their research priorities to help commissioners evaluate remaining research needs—which are expected to be huge.

According to Kenney, "most studies examine access to care at the national level or focus on just one state. So we have limited information on how access to care varies across the 51 different Medicaid and CHIP programs."

Rowland emphasized Thursday that children's health coverage will be an important focus despite the major advisory challenges awaiting the panel with respect to Medicaid. And a huge part of the Medicaid program, she also noted, consists of long-term care.

Rowland said the panel will meet more or less monthly, with the next meetings planned for October and December to help make recommendations for a report to Congress due March 15. Another report to Congress is due June 15 of each year. Transcripts of meetings will be posted at the commission's new web site,

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