By JULIE MINDA
Louisiana has seen swift changes in the demographics of health care since it expanded Medicaid last year. The number of uninsured people in the state is down by nearly half. And more than 430,000 people are newly insured under Medicaid, bringing the proportion of Louisiana's population that is insured under the program to about 30 percent.
Gov. John Bel Edwards and Dr. Rebekah Gee, center, secretary of Louisiana's Department of Health and Hospitals, chat with a participant of a May 2, 2016, press conference on Medicaid expansion in Louisiana. The press conference took place at CareSouth Center, a Federally Qualified Health Center in Baton Rouge, La.
But "a stroke of a pen could change all of that," if legislative efforts to repeal and replace the Affordable Care Act are successful and if such legislation decreases the availability of affordable and accessible insurance, says Scott Wester, president and chief executive of Our Lady of the Lake Regional Medical Center in Baton Rouge, La., one of five hospitals in the Franciscan Missionaries of Our Lady Health System.
With the future of the Affordable Care Act in question, "there is a lot of instability; and that creates anxiety — for people with Medicaid and for organizations like ours" that treat large numbers of Medicaid-insured patients, says Wester.
Political winds
Among many other provisions, the 2010 Affordable Care Act expanded Medicaid eligibility to almost all Americans with a household income at or below 138 percent of the federal poverty level. A 2012 U.S. Supreme Court decision affirmed the constitutionality of the act, but said states could decide whether or not to implement the Medicaid expansion. In January 2014, the expansion went into effect for states that chose that path. Since the Supreme Court ruling, 31 states and the District of Columbia have expanded Medicaid eligibility, and 19 states have not.
Wester
Republican Piyush "Bobby" Jindal, governor of Louisiana from January 2008 to mid-January of 2016, was adamantly opposed to Medicaid expansion. Wester says during Jindal's term, it was assumed expansion would not happen, because there was not enough support in the Louisiana State Legislature to pass legislation enacting expansion and to override a gubernatorial veto.
It was not until Jindal reached the end of his term that expansion became possible. Wester says at that time public support for Medicaid expansion was growing. John Bel Edwards, the Democratic candidate for governor, ran on a pro-Medicaid expansion platform; and, significantly, Republican contenders for governor were indicating support for expansion, albeit under a waiver that would allow implementation to be tailored in Louisiana. Edwards prevailed in the election and became governor in January 2016. On Jan. 12, his second day in office, Edwards held his first news conference as governor. He signed an executive order expanding Medicaid eligibility under the ACA. People eligible under the expansion began enrolling in June 2016 for coverage that took effect as early as July 1.
As Catholic Health World went to press, Edwards was slated to appear at the Catholic Health Assembly in New Orleans.
Unflagging commitment to coverage
CHRISTUS Health of Irving, Texas, operates six hospitals and a network of other care sites in Louisiana. Gabriela Saenz, CHRISTUS Health vice president of advocacy and public policy, says during the lead up to expansion in Louisiana and since then, "our message has remained constant; we are committed to health reform that will expand access to care to all citizens."
Saenz
She says CHRISTUS advocacy representatives have been communicating that message to Louisiana and federal lawmakers, emphasizing that "it is crucial to our mission that all our patients, regardless of economic status, have the best access to care in the most appropriate setting."
Wester says once the governor gave the green light to expansion, the U.S. Department of Health and Human Services and its Centers for Medicare and Medicaid Services did much to speed up enrollment processes in the state. For instance, they supported a program to simplify Medicaid enrollment, by requiring enrollees to answer just four questions for initial application. The agency also supported auto-enrollment in Medicaid for any adult already covered by the federal Supplemental Nutrition Assistance Program.
Wester says since Medicaid expansion, Our Lady of the Lake Regional Medical Center has seen a substantial decrease in bad debt.
Funding threats
Despite all the work to expand Medicaid last year, Medicaid funding — as well as other health care dollars — is newly threatened in Louisiana because of a significant state budget deficit, according to information from CHRISTUS' advocacy arm. A state House bill, HB1, would reduce funding for health care services, with deep cuts to Medicaid funding. CHRISTUS has major concerns with the bill, and is underscoring with lawmakers its potential significant harm to the uninsured, underinsured and other vulnerable groups.
CHRISTUS also is advocating with state lawmakers for increased Medicaid reimbursement rates, arguing current rates only reimburse at just over 60 percent of the actual cost of providing care.
Uncertain future
Beyond these state-level funding concerns, greater potential threats loom at the federal level, with efforts underway to repeal and replace the ACA. Under the U.S. House of Representatives-approved American Health Care Act of 2017, Louisiana could lose as much as $18.5 billion in federal funding for the state's Medicaid program over 10 years, should the state discontinue its Medicaid expansion. That is according to Lisa Smith, CHA senior director of government relations, who said the bill's federal funding cuts to Medicaid would be devastating to that program.
CHA is opposing repeal efforts that would undermine coverage gains made under the ACA, including the expansion of Medicaid eligibility.
CHRISTUS and Franciscan Missionaries of Our Lady Health System have been advocating with their U.S. congressional delegates for strengthening the nation's health care system, including by strengthening Medicaid. CHRISTUS regularly sends out action alerts for its associates to email to their congressional representatives, to register their support for this position.
Saenz says CHRISTUS sees much potential benefit if Louisiana retains expanded Medicaid: "Besides reducing the number of uninsured, we firmly believe better access to the best health care can help counter many of the state's wellness woes."
According to the Henry J. Kaiser Family Foundation, "Louisiana falls well below national averages in rankings of state population health … with relatively higher rates of diseases of the heart, HIV, and drug-related mortality compared to national averages."
Saenz says community health assessments reflect that these and other health issues urgently need to be addressed, and Medicaid expansion is helping to do so. She says, "Increasing the number of people insured helps steer those in need toward preventive care, making them less likely to end up at an emergency room as a last resort. This allows providers to focus on containing costs and keeping patients healthy, not just treating them when they become ill."
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