Findings from the Field: Medicaid Delivery Systems and Access to Care in Four States in Year Three of the ACA

With three years of expanded coverage under the ACA in place, many states have shifted focus from outreach and enrollment to strengthening delivery systems and enhancing access to care to meet the needs of their growing covered populations. Based on case studies and focus groups, this brief reviews delivery systems and access to care for Medicaid enrollees in Colorado, Connecticut, Kentucky, and Washington as of Spring 2016. Each of these states expanded Medicaid and experienced large gains in Medicaid enrollment. The findings provide an on-the-ground view of Medicaid delivery systems and enrollees’ experiences accessing care three years after implementation of the Medicaid expansion. This brief builds on previous reports that examined states’ preparation for implementation prior to the initial ACA open enrollment period and their experiences after completion of the first and second open enrollment periods. Together, this work provides an in-depth understanding of ACA implementation from multiple perspectives, tracking and documenting experiences that may help shape efforts moving forward. Key findings from this brief include the following:

The study states use varied models to deliver care to Medicaid enrollees. Kentucky and Washington provide care through Medicaid managed care plans, while Connecticut and Colorado rely on fee-for-service models. Connecticut administers services through four administrative services organizations (ASOs) for medical services, behavioral health, dental care, and non-emergency transportation.

While the Medicaid delivery systems vary across the study states, they all have features to coordinate care and provide targeted case management to high-risk individuals. These include connecting individuals to medical homes, linking individuals to other services to address their broad needs, and utilizing care managers to help reduce emergency department use. Colorado and Washington are using regional approaches to coordinate care. In Colorado, most enrollees receive care on a fee-for-service basis, but enroll in one of seven Regional Care Collaborative Organizations (RCCOs). The RCCOs are designed to connect enrollees to Medicaid providers, including a primary care provider to serve as their medical home, and social services and to coordinate their care. In Washington, regional Accountable Communities of Health (ACHs) work in tandem with the managed care plans to identify regional priorities, coordinate activities, and distribute funds to help integrate health care and social services and improve population health.

Overall, stakeholders and focus group respondents report Medicaid enrollees in the study states have generally good access to primary and specialty care, although there are some access challenges. Stakeholders, focus group respondents, and state data suggest that enrollees generally are accessing needed services, including primary and preventive care as well as most specialty services and prescription drugs. Stakeholders also indicated that Medicaid expansion has significantly increased individuals’ access to specialty care, since many individuals were unable to access specialty services while uninsured. However, they also point to some access challenges, including limited availability of providers and inaccurate provider directories. Some of these challenges reflect limited provider participation in Medicaid, while others are access challenges that extend beyond Medicaid, such as overall provider shortages in rural areas. Stakeholders also pointed to the importance of being able to measure and monitor access over time.

Enrollees appear to face particular challenges accessing dental and behavioral health services. All four study states provide adult dental benefits. Focus group respondents indicated that they highly value this coverage and many had obtained services, including cleanings, fillings, and extractions. However, respondents and stakeholders identified some challenges accessing dental care, including limited availability of dentists accepting Medicaid patients and long waits for appointments. Focus group respondents and stakeholders also pointed to challenges accessing behavioral health services. Stakeholders indicated a need for additional behavioral health providers, particularly addiction treatment providers given the current heroin and opioid addiction crisis.

The study states have pursued initiatives to increase provider participation in Medicaid. Connecticut moved to streamlined, statewide policies, including a statewide fee schedule and drug formulary, and bi-weekly provider payments, which state officials believe helped increase provider participation. It also extended the temporary increase in primary care rates established under the ACA. Colorado also maintained the temporary primary care rate increase, and state officials noted that they are conducting a broader review of provider rates. Colorado is also working to expand capacity in rural areas by enabling primary care providers to consult electronically with specialists. In 2014, Kentucky expanded access to behavioral health providers by allowing Medicaid to contract with individual providers (rather than through community mental health centers), creating additional provider types (such as licensed drug and alcohol counselors), and adding coverage of additional behavioral health services to Medicaid. Washington has sought to ensure provider participation by adopting strong network adequacy standards for managed care plans.

Community health centers (CHCs) in the study states reported they have made a variety of investments to expand access to care, in part, due to enhanced revenues from the Medicaid expansion. However, some respondents cited challenges to meeting increased demands for care and continued growth, including increasing competitive pressures for clinical staff and a need for funding to support capital development.

Looking ahead, the states are pursuing changes to their Medicaid delivery systems. The Governor in Kentucky is seeking to make changes to its Medicaid program under a waiver, which may affect enrollment and access to care moving forward. Connecticut, Colorado, and Washington are pursing initiatives to transform their health care delivery systems, including Medicaid, with a focus on integrating physical and behavioral health care, adopting new payment models, and addressing social determinants of health. A growing set of initiatives at the federal level are helping to facilitate these state efforts through both technical assistance and funding. These delivery system reform efforts are broad-based efforts that are still in early stages of implementation. It will take time for the states to fully implement these initiatives and for impacts on health outcomes to materialize. Continued monitoring of these initiatives over time will be important to assess their effects on access to care.

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