• In The Trenches

    Strengthening the ACA Starts With Payment Parity

    If you’re among the limited populace who has ever tried to choose a wedding anniversary gift according to the so-called traditional list, you might know that the substance for marking 11 years of matrimony is steel.

    Capitol building undergoing renovations

    So it’s fitting that House Democrats last week marked the 11th anniversary of the Patient Protection and Affordable Care Act with a number of bills meant to reinforce the law the way a truckload of steel plates might.

    One of those is all but engraved with the Academy’s initials: H.R. 1025, the Kids’ Access to Primary Care Act, which would restore badly needed Medicaid payment parity for primary care services, and which has received the AAFP’s full-throated endorsement. I’ll tell you more about that in a minute.

    First, let me back up a moment and address those members leery of the ACA by extending the anniversary metaphor. This is not about the Academy’s desire to stay wedded to one law, especially one I know many of you have found problematic over the years. But it remains our position that the ACA represents a historic net positive for U.S. health care, that its most significant deficiencies can be corrected, and that our efforts to achieve the latter are worthwhile.

    It’s unfortunate that, in recent years, we’ve had to express this support from a defensive position, in various “friend of the court” filings on the side of the ACA as attacks against it have spun through legal channels. But, as we said in a statement last November, “The ACA has contributed to the forward progress of the health care system, including recognizing the need to train a more robust primary care workforce through the Teaching Health Center Graduate Medical Education Program, and has encouraged innovation through the creation of the Center for Medicare and Medicaid Innovation.”

    Simply put: The Academy wants health care for all, and as long as it is the law of the land, the ACA gets us closer to that goal than we would be in its absence.

    H.R. 1025 — which, again, would require state Medicaid programs to reimburse primary care services at least at the Medicare rate — would inject some strong steel into the ACA by recognizing that primary care is at its very foundation. (We liked similar legislation last year, not least because its aims were identical to those of good bills that fell by the way in several previous sessions since the payment rate went askew.)

    At a March 23 hearing of the House Energy and Commerce Committee’s Health Subcommittee that was convened to discuss H.R. 1025 and other legislation introduced this month to improve the ACA, powerful testimony echoed our support.

    “On this 11th anniversary of the ACA I speak as both a pediatrician and a lawmaker when I say: All of the data (show that) affordable coverage leads to better access to care, which leads to better health outcomes and lower costs,” said Kim Schrier, D-Wash., one of H.R. 1025’s authors (along with Kathy Castor, D-Fla., and Brian Fitzpatrick, R-Pa.). She noted that, in her state, more than 800,000 children access care through Medicaid and added, “Shoring up this access to care by raising Medicaid reimbursement to match Medicare reimbursement rates will help kids grow up healthy and should play a vital role in reducing the health disparities by reaching underserved populations.”

    Schrier then called on Cindy Mann, a former CMS deputy administrator and director of the Center for Medicaid and CHIP Services who is now a partner at the law firm Manatt, Phelps & Phillips.

    “Access issues can in many cases be traced back to the payment rates,” Mann said. “Just as important, the adequacy of that payment level can help provide that platform for a high-performing pediatric primary care system,” she added — one that explores development and is alert to social determinants of health. “Making that investment saves dollars while strengthening systems of care.”

    Mann’s written testimony for the hearing offers a deeper view of what she meant by “access issues” with a potted history of the ACA’s Medicaid-expansion mandate. She notes there that coverage for adults has led to children receiving greater preventive care. “For example, children in poverty in Louisiana were more likely to have well-child visits after Medicaid expansion as compared to children in Texas and Mississippi,” she writes.

    “In many instances, care gaps can be traced to payment rates, especially primary and pediatric care,” she told committee members during the hearing — to reimbursement far too low to sustain care that those patients need.

    The American Rescue Plan, which this month delivered some strong wins to primary care, addresses access gaps with a temporary 5% increase in federal Medicaid matching funds for states that expand their program’s eligibility. As I said in this space last time, it’s a strong incentive for the 12 states that haven’t yet expanded Medicaid.

    Tuesday’s hearing, which kicked off discussion of 18 bills written to gird and improve the ACA, included a bill that would send the same level of increased federal funding to every state that expands Medicaid coverage, and separate legislation penalizing states that fail to expand Medicaid with new reporting requirements.

    Predictably, some Republicans on the committee sounded skeptical about whether Medicaid is worth the money.

    It is.

    There’s no shortage of research I could point out to verify just how critical the ACA’s expansion of Medicaid has been, but let me linger on a couple of studies.

    It saved the lives of at least 19,200 55- to 64-year-old adults from 2014 to 2017, said one landmark 2019 study, which also noted that 15,600 older adults had “died prematurely because of state decisions not to expand Medicaid.”

    Beyond that demonstrable reduction in annual mortality rates for newly covered older adults, a 2020 study found that Medicaid expansion in Southern states had slowed low-income adults’ rates of health decline.

    “The magnitude of estimated reductions in health declines would meaningfully affect a non-expansion state’s health ranking in our sample if that state elected to expand Medicaid,” the authors of that research concluded. “Our results suggest that for low-income adults in the South, Medicaid expansion yielded health benefits — even for those with established access to safety-net care.”

    I also like this broadly explicative Commonwealth Fund primer, which, among other things, refutes the old “this costs too much” bugbear, with help from data published in 2018. “Some Medicaid expansion states project they will continue to realize net budget savings even when the federal contribution for covering the newly eligible falls to 90 percent,” it says. “There is also evidence that Medicaid expansion provides an economic boost to states.”

    Given these facts, the clear move is toward Medicaid payment parity. Congress must ensure that primary care physicians are empowered to care for Medicaid patients by paying them at least Medicare’s payment rate.

    It’s something the Academy has been talking about a lot lately. That’s because Medicaid pays, on average, 66% of the Medicare rate for primary care services (with some states setting Medicaid rate at just 32% of Medicare’s), leading to gaps in patient access and coverage.

    We know it doesn’t have to be this way. We know that Medicaid patients’ access to care improved when there was payment parity under the ACA. We also know that permanently extending payment parity and ensuring compliance by managed care organizations would magnify the benefits. And we know that COVID-19 has been disproportionately deadly to Black, Indigenous and Hispanic patients — more than 30% of whom have Medicaid coverage.

    Vulnerable populations need coverage that allows affordable, comprehensive, high-quality care. Family physicians remain best equipped to deliver that care and must be compensated appropriately.

    Your Turn

    Earlier this month, we centered an AAFP Speak Out campaign on supporting H.R. 1025. As of March 30, 302 of you had already sent messages to 180 members of Congress. I urge you to keep up the pressure by adding your voice today.

    Stephanie Quinn is senior vice president of advocacy, practice advancement and policy.


    The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.