Undercurrents: Medicaid Expansion Presages Healthier Bottom Line, More Robust Community

A regular Source column, Undercurrents explores issues, ideas and events as they develop beneath the surface in the Virgin Islands community.

While the national debate still rages over the Affordable Care Act, aka Obamacare, in the Virgin Islands it has resulted in widening the scope of Medicaid and giving thousands of people access to basic medical care they didn’t have before.

Unlike Medicare, which is age-based, Medicaid is a government-sponsored health insurance program for the needy and eligibility is income-related.

Besides relaxing income eligibility requirements, the ACA is allowing the local government to short-circuit the certification process; residents who already qualify for such programs as SNAP (food stamps) or TANF (Temporary Assistance for Needy Families) or for Adult Blind and Disabled programs are automatically considered eligible for Medicaid; all they need due is register.

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In 2010, shortly before the Affordable Care Act was implemented, between 7,000 and 8,000 people in the territory received Medicaid benefits, according to Lennox Zamore, director of Family Assistance at the V.I. Department of Human Services. The numbers have already doubled and are expected to more than triple soon.

“We currently have some 15,400 beneficiaries and this is expected to increase to over 25,000 to 30,000 by 2016,” Zamore said.

Not only is the number of participants increasing, so are the services covered by Medicaid and the number of health care workers who are providing them.

The changes stem in part from a special ACA pool of federal funds that was made available, with some strings, in 2011, and will remain available through 2019. In all, there is $298.7 million available, but the territory can only draw on it when it provides a local match at a rate of 42.8 percent. It also cannot use ACA funds until it has exhausted the regular Medicaid allotment for a given year.

The regular allotment is based on a formula involving the consumer price index; the amount was $16 million in Fiscal Year 2014 and is $16.4 million this fiscal year.

So far, the territory has used approximately $14.4 million of its ACA funding, Zamore said. This was matched by about $11.4 million of local funds.

“While we have focused on coverage expansion, we have also utilized the funding to expand services and increase provider rates,” Zamore said.

“The majority of the care for Medicaid beneficiaries is provided through the hospitals, FQHCs (Federally Qualified Healthcare Centers) and our Department of Health clinics, which see both Medicaid and Medicare patients,” he said.

Private health care providers are not required to accept Medicare or Medicaid patients, but if they wish to participate in either of those programs, they have to enroll to do so. Historically Medicare has paid claims at a higher rate than Medicaid, and some doctors accept Medicare but not Medicaid.

“We most recently increased physician Medicaid rates to 100 percent of the Medicare rates to encourage more of them to participate in Medicaid,” Zamore said.

“Additionally, we are increasing rates to the hospitals under Medicaid to more accurately reflect their Medicaid costs and to help improve their overall financial situation,” he said. “In general, we expect that the increased coverage should reduce the amount of uncompensated care that providers are faced with, and the increased rates should more adequately reimburse providers for their services.”

Representatives of local government clinics and hospitals have often blamed their operating budget deficiencies largely on the fact that they cannot legally turn away patients for lack of payment. It has been up to the V.I. government – that is, the Virgin Islands taxpayer – to subsidize the facilities to cover that cost.

“We would expect that as more people become Medicaid eligible and we receive federal matching funds for their care, that the number of uninsured should decrease and serve to reduce the overall amount of the V.I. subsidies,” Zamore said. “To further support this effort …our plan is to implement presumptive eligibility at the hospitals over the next couple of months.”

That is, the hospitals can identify potential Medicaid-eligible patients based on their inability to pay and notify Human Services who can then work to get the people on the Medicaid rolls – and thus get the bills paid.

While the benefit to local government facilities is substantial, the impact on the beneficiaries themselves is immeasurable.

“The main impact on those not receiving Medicaid before is that they will now have health care coverage where they have not seen any before,” Zamore said. “We would expect that this coverage will lead to better preventive health care for this population and a willingness to seek health care earlier.”

“We would hope such access, coupled with our implementation of care management and care coordination processes, will lead to overall better health outcomes and a reduced growth rate in health expenditures by the V.I.”

Even those who were already on Medicaid have benefitted from the program, Zamore said. There’s no hard data yet, but “we expect that they have seen improvement in program administration efficiencies, increased coverage of services, and increased provider participation … (as well as) increases in rates and improved claims processing through the implementation of our MMIS (Medicare Management Information System.) ”

What happens after 2019? Will there be further funding?

That’s an unknown, Zamore said. What he does know is that “the continuation of this funding is critical to the V.I. being able to maintain and expand its program.” He’s expecting that the current administration will work closely “with our delegate and other key Congressional allies in Washington to support such funding legislation.”

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