Patients With Medicaid Cards, but No Specialist to See

LAFAYETTE, La. Eight-year-old Draven Smith was expelled from school last year for disruptive behavior, and they is being expelled again this year. But his sister and his pediatrician cannot discover a mental health specialist to treat him because they is on Medicaid, and the program, which provides health coverage for the poor, pays doctors so tiny that plenty of refuse to take its patients. The issue is common here and across the country, as states, scrambling to balance their budgets, look for cuts in Medicaid, which is one of their largest expenditures. And it presents the Obama administration with a major challenge, since the new federal health care law depends heavily on Medicaid to cover plenty of individuals who now lack medical health insurance.

Having a Medicaid card in no way assures access to care,said Dr. James B. Aiken, an emergency physician in New Orleans.

From her pocketbook, they pulls an insurance card issued by the Louisiana Department of Health and Hospitals.

Nicole R. Dardeau, 46, a nurse in Opelousas, La., in the heart of Cajun country, can attest to that. They said they could not work because of unbearable pain in her right arm. Doctors have found two herniated discs in her neck and recommended surgical procedure, but cannot discover a surgeon to take her as a Medicaid patient.

My Medicaid card is useless for me right now, Ms. Dardeau said over lunch. Its a useless piece of plastic. I can't find an orthopedic surgeon or a pain management doctor who will accept Medicaid.

Medicaid, which is paid for jointly by the federal and state governments, is the subject of an intense debate in Washington over how to make it more efficient as Congress addresses the budget deficit and the growing federal debt.

How can an already overtaxed Medicaid process handle such a large inflow of people? asked Dr. Michael A. Felton, a relatives doctor in Church Point, La., near Lafayette.

But for now the administration is relying on Medicaid to play a vital role in expanding access to care under the law President Obama signed last year. The program is already a major presence here, paying for 70 percent of births in Louisiana. State health officials estimate that the Medicaid program will grow by over 40 percent because of the federal health law, with the addition of 467,000 new recipients to 1.1 million now on the rolls.

It is a query being asked in plenty of states. With the expansion of Medicaid to cover  all people under 65 with incomes up to 133 percent of the official poverty level (up to $29,330 a year for a relatives of three), Medicaid will soon be the nations largest insurer. It accounts for  half of the increase in coverage expected under Mr. Obama's health law, but has received less attention than other parts of the law regulating private insurance.

The Congressional Budget Office predicts that average every month Medicaid enrollment, now 56 million, will rise to 71 million by 2016, with another three million people added to the rolls in the three years after that.

Louisiana officials said the cuts were necessary for three reasons: to keep away from a budget deficit in the Medicaid program and to comply with a state law that limits Medicaid spending to amounts appropriated by the State Legislature.

Like plenty of states, Louisiana has been struggling with a fiscal crisis. To hold down costs, it's cut Medicaid payments to doctors, dentists, hospitals and other health care providers several times in the last three years. Plenty of providers document that the cuts, taken together, total 15 percent to 20 percent.

I devote one afternoon a week, every Wednesday afternoon, to looking for specialists for my patients a pulmonologist for kids with chronic persistent asthma, a neurologist for kids with seizures or developmental delays, a psychiatrist for kids with serious mental health issues, a hematologist for patients with sickle cell disease, Dr. Chatters said.

For patients like Draven Smith, whose sister said his behavior issues stemmed from attention-deficit hyperactivity disorder, the result is lack of access to doctors, specialists. For Draven's pediatrician, Dr. Rachel Z. Chatters in Lake Charles, La., caring for poor kids is a mission. About 80 percent of her patients are on Medicaid. It is, they said, frustrating to beg and plead with other doctors to see Medicaid recipients.

Some uninsured people will certainly receive better care when they gain Medicaid coverage, doctors say. The new health law calls for a temporary two-year increase in Medicaid payments for some primary care services, but this does not affect specialists.

Draven's sister, Ana M. Smith, said: I have tried for over a year to discover a kid psychiatrist or psychologist to get Draven evaluated, but the mental health professionals in this area have told me they absolutely do not take Medicaid. If Draven could get the help they needs, I think it would be unbelievably beneficial to him.

With the expansion of Medicaid in 2014, Louisiana officials expect to enroll two groups: 260,000 newly eligible parents and childless adults, 20,000 parents now eligible but not enrolled and 187,000 adults and kids who drop private coverage and sign up for Medicaid.

Bruce D. Greenstein, secretary of the Louisiana Department of Health and Hospitals, said, We have a hard time finding specialists for Medicaid enrollees.

In passing the new health law, Congress desired to make definite current Medicaid recipients would not lose coverage. Under the law, states usually cannot roll back Medicaid eligibility, but they can cut Medicaid in other ways  by reducing provider payment rates or by eliminating optional benefits.

Mr. Greenstein said the state expected to improve care and economize by enrolling most Medicaid recipients in managed care, an approach adopted by plenty of states in recent years. In return for fixed every month fees paid by the state, private health designs would coordinate the care of Medicaid patients, using networks of providers.

Gov. John Kitzhaber of Oregon, a Democrat, proposed cutting Medicaid payment rates for doctors, dentists, hospitals and nursing homes by 19 percent. Christine Miles, a spokeswoman for Mr. Kitzhaber, said his priority was to preserve eligibility.

About 20 states cut Medicaid payment rates for doctors last year, according to a survey by the Kaiser Relatives Foundation. At least 16 governors have proposed rate reductions this year for health care providers.

In California, Gov. Pat Quinn, a Democrat, has proposed reducing Medicaid reimbursement rates by 6 percent for hospitals and nursing homes.

Gov. Brian Sandoval of Nevada, a Republican, has proposed cutting Medicaid rates by 5 percent for hospitals, 15 percent for nonprimary care doctors and 25 percent for dentists.

States have broad discretion in setting Medicaid payment rates. Federal law sets standards, but they are vague. Rates are supposed to be consistent with efficiency, economy and quality of care, and sufficient to make definite that services are available to Medicaid recipients at least to the same extent as to the general population in the area.

In South Dakota, Gov. Dennis Daugaard, a Republican, signed a budget bill cutting Medicaid rates for doctors, dentists, hospitals and nursing homes  even primary care physicians and pediatricians.

Dr. Kim A. Hardey, an obstetrician-gynecologist in Lafayette, said they received about $1,000 from the Louisiana Medicaid program for providing prenatal care and delivery for a full-term pregnancy, compared with $2,400 from private insurance.

In a few states, Medicaid recipients and providers have blocked cuts or secured higher reimbursement through litigation. But in plenty of states, the promise of equal access remains unfulfilled.

With the expansion of Medicaid eligibility, they said, more of his patients will be on Medicaid, and fewer will have private insurance, which helps offset the financial losses doctors maintain on their Medicaid business.

Already, Dr. Hardey said, plenty of of his patients have jobs with private insurance but switch to Medicaid when they become pregnant, avoiding premiums, deductibles and copayments.