FEATURE
FIGURE 2.
The Medicaid Coverage Gap
In states that do not expand Medicaid under the ACA, there will be large gaps in coverage available for adults. The median Medicaid eligibility
limits include childless adults at 0 to 44 percent of the FPL. ACA marketplace subsidies kick in at 100 percent of the FPL to 400 percent of the
FPL. That leaves people at 45 to 99 percent of the FPL, an estimated 4 million adults, in the coverage gap.
expansion have been facing some new challenges when it comes to the care of their
condition.
Roughly 70 percent of Medicaid enrollees are enrolled in managed care programs.8
Managed care delivery systems are organized
in a way that manages cost, health care use,
and quality, and their plans are often capitated,
meaning that they receive a set per-member,
per-month payment for health-care services.
“The problem is that some of these plans
may be small county or regional plans with a
limited number of covered lives (i.e., 10,000
to 20,000 people),” Ms. Rice explained. “The
idea behind these capitated plans is that there
are low users and high users of medical care
and, therefore, costs will ‘average’ out over
the pool of insured patients. But, if there are
patients with hemophilia in the pool, even if
they do not go into the hospital and are receiving regular infusions, they are more than
likely going to exceed any capitated rate.”
While the practice of “carving out” the
clotting factors that patients with hemophilia
require – managing these types of regular
hemophilia treatments in a fee-for-service
plan separate from the managed care plan
– “seems to be working better,” there are
still concerns about placing restrictions on
treatments for unpredictable hematologic
diseases, Ms. Rice added. “If you take a highcost, pretty volatile disease like hemophilia
and place it into a capitated plan, you run the
risk of causing the plan to go under, affecting
care not only for hemophilia patients, but for
everyone else on the plan.”
Patients with hemophilia have also experienced narrowing networks under some
ASHClinicalNews.org
of the new Medicaid plans. According to
Ms. Rice, all drugs to treat hemophilia were
either included on the preferred drug list or
simply covered under the plans in the past;
however, more recently there has been a
push to start reviewing these drugs lists, with
some states placing hemophilia products on
preferred drug lists.
“The problem is that it is such a small
population of patients and there really are
no head-to-head trials to clinically show
the differences between these drugs. From
anecdotal evidence from patients, though,
we know that people respond differently to
different drugs,” she said. “Our doctors are
hesitant to switch patients between products
without forethought because the way you
know a clotting factor doesn’t work is with a
bleed. That treatment’s failure could be lifechanging for that person.”
The Future State of Medicaid
Expansion
Although in many states the decisions about
Medicaid expansion are already set, physician
advocacy in states that have not expanded is
important, Dr. Kahn said.
Prof. Alker agreed, adding that physicians
could play an important role in educating their
community and state legislators about the
importance of Medicaid expansion. “There are
many important reasons why states should be
accepting these federal dollars,” she said. “In
states that continue to carry a high level of uninsured people, refusing to expand Medicaid creates a considerable coverage gap and considerable risk for hospitals and health-care systems.”
At time of this writing, Prof. Alker said
that the debate about whether to expand
Medicaid is alive and well in Florida and
Alaska, with Montana just recently passing
legislation to expand the program in April.
—By Leah Lawrence ●
References
1.
Kaiser Family Foundation. Focus on Health Reform.
A guide to the Supreme Court’s Decision on the ACA’s
Medicaid Expansion. August 2012. Accessed April 22,
2015 from https://kaiserfamilyfoundation.files.wordpress.com/2013/01/8347.pdf.
2.
Memorandum to Members of the Joint Select Committee on Health Reform Implementation. Accessed April
22, 2015 from http://leg.wa.gov/JointCommittees/
HRI/Documents/July%202012/JSC%20-%20NFIB%20
summary.pdf.
3.
The Henry J. Kaiser Family Foundation. Cur