Navigating Medicaid Turbulence: What Community Providers Need to Know

Originally Published on First Report Managed Care

Please introduce yourself by stating your name, title, and any relevant experience you’d like to share.

Jeff Brandes: I'm Jeff Brandes. I'm the president and CEO at Azara Healthcare.

Safety-net providers across the country are facing immense pressure from the combination of expiring Affordable Care Act (ACA) premium tax credits and recent Medicaid cuts. What are you seeing as the most immediate impacts on patient access and care delivery?

Brandes: The most immediate thing that we're seeing is fear of the unknown. “How does that impact me?” It, of course, starts with the patient, in particular.

What does everything we hear on the news mean? How is that going to affect coverage? Do they have to fill out new paperwork? What are these work requirements that they’re hearing about? If they're in the ACA marketplace classification, why is their premium jumping so much, and what do they do if they can't afford it? Because that group doesn't quite qualify for Medicaid, but with a large increase in premium, they may not be able to afford that plan that's in the middle.

In states like Michigan, tens of thousands of patients are losing coverage, with significant revenue losses for community health centers. How widespread is this issue nationally, and what does it mean for the long-term stability of safety-net systems?

Brandes: The impact of HR 1 on Medicaid does vary from state to state, and certainly it has higher impact on those states that have Medicaid expansion. The impacts are across all states, but I don't think it's equally proportional. In a state like Michigan, among their federally qualified health centers, they're anticipating that it will impact 55 000 patients—just the Medicaid pieces, not including the marketplace.

Again, these are procedural things. These are people that are, for the most part, still eligible for Medicaid; however, they have to go through the paperwork and requalification not once, but twice a year. These things get hung up in procedural and paperwork issues all the time, causing people to lose coverage.

At the Michigan federally qualified health centers, there are another 22 000 individuals who look to be impacted by the marketplace and ACA changes. That's in a state like Michigan, and that's just among their 40 or so federally qualified health centers. But I think, proportionally, you spread that out across the state to their full Medicaid populations and it affects all providers who are operating in the safety net.

With so many coverage programs in flux, how can community-based providers prepare for—or adapt to—these policy shifts without compromising care quality or access?

Brandes: I would say they should be putting in place an infrastructure to support their patients in making sure they're reminded that they're coming up for redetermination and by doing anything they can to help make it easy for them to fill out the paperwork, get the paperwork, get their questions answered, and do so in the patient’s native language and in a way that they can easily understand.

Some states have very nice portals where individuals can go and renew their coverage. Some are quite difficult to navigate and are confusing. Definitely, in those places, many are trying to put in place the resources for their patients.

I heard one leader say to his health center members—and this is an organization that represents the federally qualified health centers within the state—he said, "Historically, when times get tough, we have cut administrative expense in order to preserve clinical delivery capacity. But in this particular situation, we can't afford to do that."

At federally qualified health centers, they're going to see the patients, whether they have insurance or not. That's their ethos. That's why they're there. If they don't invest or at least maintain the administrative services to make sure people that are eligible maintain their coverage, they're going to serve themselves towards bankruptcy. They're going to provide what would've been a reimbursable visit as an uncompensated visit because they took away the administrative expense.

Frankly, for even the smallest centers, the return on investment in maintaining that administrative assistance for patients is there in just the number of visits that will be compensated.

What actions would you most like to see from policymakers and health plans to stabilize funding and ensure that low-income and underserved populations don’t fall through the cracks in 2025 and beyond?

Brandes: Removing the roadblocks to allow people who are eligible and who meet the criteria to stay on. It's my belief that fraud is a tiny portion of what's behind this, but it's played up to be a large one—that we have to do this multiple times a year to prevent it from being taken advantage of. No system is perfect, but by and large, we're just making it difficult for people who are already faced with difficulties to maintain their health coverage.

The long-term impact of this, whether it's their insurance and them not coming in for regular checkups or when they're not feeling well, is that they'll present themselves with much more complex conditions. They'll present themselves without regular preventative care, and then we will be in a situation with people who are less healthy and who need more expensive care to just bring them back to the norm. We saw that during the COVID-19 pandemic, for different reasons, when access was squeezed because of COVID.

People deferred regular preventative care, and they let even more acute things get more and more acute and deferred that care. As the COVID-19 pandemic lifted, they showed up a whole lot less healthy than they were at the beginning of the pandemic. We're still unwinding that now, even for things as simple as childhood vaccinations for things that we know work, and we know are proven in keeping kids healthy and developing along the normal course.