Trumpcare would destroy Louisiana’s fragile coverage gains for the poor

The state’s belated Medicaid expansion is especially vulnerable under the Senate GOP’s Obamacare repeal plan.

Administrator of the Centers for Medicare and Medicaid Services Seema Verma listen at right as President Donald Trump speaks during a meeting in the Roosevelt Room of the White House in Washington. CREDIT: AP Photo/Evan Vucci
Administrator of the Centers for Medicare and Medicaid Services Seema Verma listen at right as President Donald Trump speaks during a meeting in the Roosevelt Room of the White House in Washington. CREDIT: AP Photo/Evan Vucci

In 2009, Louisiana legislators were ardent defenders and critics of the Affordable Care Act (ACA), and often time at the center of the national debate. Former New Orleans congressman Anh “Joseph” Cao was the sole Republican to vote for the ACA. Former Senator Mary L. Landrieu (D-LA) became a crucial vote in favor after winning additional state Medicaid funds.

Then there’s former Governor Bobby Jindal (R), who was among the first governors to opt-out of Medicaid expansion. Louisiana lawmakers were present, mic in hand.

Eight years later, health care is yet again at the forefront of national policy. But this time around, Louisiana legislators don’t appear as fervent. Senator John Neely Kennedy (R-LA) has been largely absent from any debate. More surprisingly, Senator Bill Cassidy (R-LA) — who previously worked as a doctor at a Louisiana charity hospital and his written his own health legislation — has not taken a definitive position on the Senate GOP’s ACA replacement plan, the Better Reconciliation Act (BCRA).

In the balance: 1.2 million Louisianians, who depend on either the ACA marketplace or Medicaid for health coverage, both of which would be drastically changed under either the House or Senate bills. No health care system is harder hit than Medicaid — under both Republican bills, cuts from the program account for the bulk of federal savings.

In fact, the Republican plan to cut the Medicaid expansion and cap federal funding altogether is perhaps the largest change to the 1965 entitlement program ever.

Why? Conservatives often describe the program as substandard, citing federal red tape, poor quality coverage, and a restricted list of doctors. But to characterize the entire Medicaid program this way is a gross oversimplification. “Many in the United States benefit from Medicaid without knowing it,” wrote two former Administrators of the Medicare and Medicaid programs. “One reason is that Medicaid often goes by many different names in different states.”

In Louisiana, the Medicaid program is Healthy Louisiana. The federal-state program has a been a modest lifeline for 921,700 residents. Louisiana went from 50 in 2015 to 47 in 2017 for overall health in America because of improvements to health delivery, among other things.

“Hate to short circuit what we are doing after only a year or two years,” Alma Stewart, president of Louisiana Center for Health Equity,” told ThinkProgress, “And start rolling back this progress until had a chance to really evaluate, to really evaluate the success that we will see.”

Medicaid is more flexible than its detractors acknowledge

Under current law, states can exercise flexibility by amending Medicaid or waiver authority, as long as it is within federal standards. Louisiana has amended its Medicaid program eight times in 2017; the amendments focused primarily on restructuring fiances and federal reimbursements to certain programs. Under Governor Jindal, Louisiana sought a waiver in 2011 that moved the state’s Medicaid program to a managed care model. As such, Healthy Louisiana contracts with five private insurance companies.

“Everyone who gets Medicaid, except nursing homes, get it through managed, privately run care,” Jan Moller, director of the Louisiana Budget Project, told ThinkProgress, “It’s a government program, government financing contracting with private operators.”

Medicaid expansion’s unacknowledged successes

Due to Jindal’s anti-Medicaid position, Louisiana was the last of 31 states and the District of Columbia to expand the entitlement program’s eligibility. On January 12, 2016, newly-elected Democratic Governor John Bel Edwards signed an executive order, accepting federal dollars to pay for expanded Medicaid coverage. In July 2016, the Medicaid expansion program went live, and newly eligible Medicaid beneficiaries began to reap the rewards of health insurance.

Under the House and Senate health care bill, Louisiana’s late start means it would receive less federal Medicaid money. The BCRA’s per-capita cap calculation uses states’ most favorable eight quarters of Medicaid enrollment data. For Louisiana, the bill could only calculate three quarters of expansion data, Louisiana Department of Health Secretary Rebeckah Gee told the Advocate.

“That includes the early days when the program was just ramping up and excludes the most recent quarter, the one with the highest enrollment,” Gee said.

As of June 2017, 433,000 adults gained coverage under the expansion. And the Louisiana Department of Health, given the aforementioned criticism during expansion talks, has been documenting health improvements. They found that 16,330 women received breast cancer screenings or diagnostic breast imaging, 168 of which were diagnosed with breast cancer as a result of imaging, and that 2,840 adults newly diagnosed with Diabetes are now being treated.

Jindal’s stated justification for his refusal to expand Medicaid: that studies of the program “found absolutely no improvement in physical health outcomes.”

A dwindling supply of caregivers

Capping federal Medicaid funding could make an existing problem worse. In Louisiana, Medicaid pays providers 71 percent on average of what Medicare pays, and just 57 percent of physicians in the state are accepting new Medicaid patients, one of the lowest rates in the country, according to the Kaiser Family Foundation. With federal caps, the governor and state legislators, who set Medicaid reimbursements, wouldn’t be able to increase provider rates and promote provider participation to the program.

Generally, when patients say there is a problem, you have to drill by specialty care, Susan Todd, executive of 504HealthNet, told ThinkProgress. Meaning, the doctor problem is specific to each patient and the specialized care required.

For one Medicaid patient living in Baton Rouge with multiple sclerosis, a chronic disease in which the immune system eats away at the protective covering of nerves, access to specialized care has been their Medicaid program. They asked not to be identified due to stigma against people with MS. They needed to travel an hour away to Ochsner Medical Center in New Orleans for a neuropsychologist.

In Baton Rouge, it was up to the discretion of the neuropsychologists, who largely work in private facilities, if they wanted to take Medicaid insurance.

“If you pay them, they will play,” Stewart told ThinkProgress about physicians who take Medicaid. “There’s something called fair market value. They set their rates for their services, and they expect to be paid. And they should be paid. Pay them, fairly.”

In Louisiana, as in most states, the Medicaid program can be improved. But the question is whether conservatives want to improve it.

“The question is are we taking the right approach to address them? As I see what’s being proposed in [House health bill] and [Senate health bill], the answer is no,” said Stewart.