Yes, You Still Have to Worry About the Uninsured After the Mandate

On Thurs., April 18, three panelists at a session hosted by the Chicago Health Executives Forum discussed the state of healthcare for uninsured and underinsured patients and how the delivery system with adapt to an influx of newly insured patients after the Patient Protection and Affordable Care Act is fully implemented.

Raymond J. Swisher, branch manager at the Medicare Advantage Centers for Medicare and Medicaid Services, moderated the panel and kicked off the session by explaining that many people mistakenly assume the majority of uninsured are healthy 25 years-olds that don't want to fork over money for insurance. Instead, he said, "it's a family of four with two working parents because they can't afford health insurance."

Ramanathan Raju, MD, CEO of Cook County Health and Hospitals System in Chicago, the third-largest public hospital system in the nation, said a major challenge for his system will be enrolling the newly eligible for Medicaid in the system. He explained that although the expansion will apply to many Cook County patients, they are likely to require guidance in how to enroll, and may not even be aware of their new eligibility. He also cautioned that the expansion of Medicaid won't eliminate the need for uninsured care. He expects 500,000 residents of Cook County to remain uninsured after the PPACA mandate goes into effect, either because they will make too much to qualify for Medicaid but will still be unable to afford coverage or because they are undocumented.

David Ansell, MD, senior vice president of clinical affairs and CMO at Rush University Medical Center in Chicago, who has served on Chicago's struggling west side for 35 years, said that the number of uninsured people in Chicago after Medicaid expansion will actually be about the same as the number of uninsured in the city during the Regan era, when the Emergency Medical Treatment and Active Labor Act was introduced.

Cristal Thomas, MPP, deputy Governor for the State of Illinois, then discussed some of the reforms the state is implementing as a result of the PPACA. Currently, legislation has been passed in the Senate and is awaiting passage in the house that would expand the Medicaid program as originally intended by the PPACA before the Supreme Court made doing so optional. The state is also focused on care coordination for Medicaid enrollees. A 2011 law now requires that 50 percent of Medicaid recipients be enrolled in a care coordination program, such as a managed care program or accountable care organization, by 2015.

The panelists agreed that there are two major challenges facing healthcare delivery for the uninsured and under insured, even after coverage is mandated. First, safety-net providers will still have a considerable number of uninsured patients entering their doors. Second, there is likely to be a shortage of providers to treat a greater number of Medicaid patients. In order to address these issues successfully, Dr. Ansell said, "We have to break through historic models of competition and instead collaborate."

Dr. Raju also warned against assuming simply expanding managed care programs will be the answer to Medicaid troubles. "Managed care will fail so long as it is managing cost. We need to figure out how to manage care," he said. The panelists agreed that transforming from providing sick care to health systems that help maintain patients' health is the key tenet for success in managing the uninsured and under insured — as well as paying patients — in the future.

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