Last week, in a footnote to this column, I referenced that new research on Medicaid expansion had been released by the Georgetown University Health Policy Institute. The study provides a powerful comparative between expansion and non-expansion states, including the very real differences in health care developing north and south of the Missouri-Arkansas border.
The new research is based on interviews with leaders from safety-net hospitals and Federally Qualified Health Centers in seven states. Researchers sought out leaders from expansion and non-expansion states with common borders — including Missouri and Arkansas — and where possible, with providers that had clinics or hospitals in both states.
Four main “impacts” were found. The first two affirm conventional wisdom —safety-net providers in expansion states experience a drop in uncompensated care and an increase in institutional financial security. The second two, community efforts to integrate and improve care, and expansions in access to specialists, are more aligned with the direction of the future of care.
As I mentioned last week, Paul Taylor of Ozarks Community Hospital in Springfield, Mo. was featured on the media call announcing the research. OCH was referred to by the researchers as a “living experiment” of the differences between expansion and non-expansion states because of its locations in both Missouri and Arkansas. Geography isn’t the only thing that makes OCH relevant. According to Taylor, the hospital system’s 90 percent government payer and uninsured patient population makes it especially susceptible to the expansion decision.
Taylor reflected on the two hospitals’ uninsured ED utilization, stating that before Medicaid expansion in Arkansas, both the Missouri and Arkansas hospitals had about a 30 percent uninsured rate for ED visits. Since Arkansas expanded Medicaid, their rate at the hospital in Gravette, Ark. is approximately 10 percent. OCH in Springfield has seen its rate increase to as much as 40 percent during the same period.
Taylor has been an outspoken advocate for Medicaid expansion in Missouri. However, in its absence, the hospital in Springfield became less sustainable at the same time as the hospital in Gravette was increasing its margin. According to Taylor, “Two years ago — during a six-month period of time — we decreased our FTEs in Missouri by 100, and at the same time increased our employment in Arkansas by about the same.”
“If we hadn’t reduced our payroll in Missouri, we were jeopardizing the entire system,” Taylor added. “If it weren’t for the positive operating margin we’re experiencing in Arkansas, the entire system would be out of business.”
Taylor’s experience at OCH affirms the researchers’ conclusions on the first two impacts defined in the study. It also reflects the second two.
Although, OCH remains committed to improved care delivery — its innovative model of addressing behavioral health needs alongside physical health in their Missouri clinics — this activity in Missouri is now subsidized by positive margin in Arkansas. “We made a commitment to do that systemwide, and so we’re doing that even in Missouri, even though a number of the patients that are getting that model of care are uninsured,” Taylor said.
Taylor indicates that the situation is influencing the workforce as well. “We’re seeing a brain drain,” he said. “Providers, when they have a choice about which state to go to, are choosing the state that has expanded Medicaid — the state that seems to have a brighter economic future. I have a number of specialists who are based in Springfield, Missouri where our hospital is, who are now traveling to Arkansas and providing specialty care to the patient population down there.”
“It’s been very real… It’s been an almost horrific experiment to have to live through, but so far at least, we’re holding on,” he concluded.
NPR covered the story, and OCH provided the context for how the differences were felt by communities. The most powerful reflection on the chasm between expansion and non-expansion states also came from Taylor:
“There’s an imaginary dividing line in the border between Missouri and Arkansas, but there’s a real qualitative difference in what’s going on in health care right now.”
Thanks again for your leadership on this issue, Paul.
If you have thoughts on the research, or anything else, send me a note.
In This Issue
Herb B. Kuhn
MHA President and CEO
Inspector General Reports On Provider-Based Payments
Supreme Court Restricts Use Of Implied Certification Theory
CMS Releases Additional Information On Partial Hospitalization Program