Oregon's Medicaid Leaves Many in the Cold: No Spinal Surgery, Back Pain or Allergy Treatment

The Oregonian's Brent Hunsberger reports that Oregon's one-size-fits-all Medicaid will cover childhood dental care for elderly people with no children. Also, if you are a smoker or obese, you will get treatment and counseling.  But, tough luck if you have severe spinal problems, back pain or allergies. A panel decides what gets covered and what doesn't. Hunsberger sets up a silver lining assessment:

Their [older people with no children at home] concerns about the Oregon Health Plan [Oregon's Medicaid] might be slightly misplaced. It offers the same 10 essential health benefits that private insurance does – preventive care, mental health services and childhood dental care among them.
. . .

The plan also has prioritized health services that it can afford to cover.

But, the cloud is still there.

A panel of providers determines [covered treatment], based on prevalence of the disease and other factors. If your condition isn't on it, the plan won't cover it. Spinal surgeries and treatments for allergies and back pain, for instance, aren't covered, [Christine Senz of Tuality Health Alliance] said.

"Sometimes it seems really, really arbitrary," Senz says. "But it's all based on science and outcomes and actuarial outcomes."

Maybe it seems arbitrary because it doesn't conform to normal American needs. Webmd says 55% in the U.S. have allergies. Less than 2/3rds that number (36%) are obese. 116 million Americans have chronic back pain. Only about 1/3rd that number (43.8 million) use tobacco.  But, of course, you can die from the effects of tobacco, whereas you will only have severe daily suffering if you have chronic back pain.

Even Medicaid's one-size-fits-all treatment is iffy. It is only available if you can find a doctor/medical facility in your area to treat you. Since Medicaid pays only a third of what standard insurance pays, it can be a challenge* to find anyone in your area who will provide your "10 essential health benefits".

Access might be another issue. Medicaid pays doctors about one-third what commercial insurance pays for the same services, said Christine Senz, chief operating officer of Tuality Health Alliance, a Hillsboro-based provider network that includes Tuality Community Hospital. So, to make sure they bring in enough revenue, doctors often limit the number of Medicaid patients they'll take.

"They often close to Medicaid or Medicare patients before they close to commercial patients," Senz said. "Certainly access is a problem."

What a deal: ten essential health benefits (which may or may not cover what you need most) coupled with difficulty in finding someone to actually treat you. Showing up at the emergency room when you have problems does not sound like such a bad alternative.
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*From a 2010 study:

Sixty-six percent of those who mentioned Medicaid-CHIP (Children’s Health Insurance Program) were denied appointments, compared with 11 percent who said they had private insurance, according to an article being published Thursday in The New England Journal of Medicine.

In 89 clinics that accepted both kinds of patients, the waiting time for callers who said they had Medicaid was an average of 22 days longer.

From a New York Times article published Thursday:

. . . [I]n just five weeks, millions of additional Americans will be covered by [Medicaid], many of them older people with an array of health problems. The Congressional Budget Office predicts that nine million people will gain coverage through Medicaid next year alone. In many of the 26 states expanding the program, the newly eligible have been flocking to sign up.

But, doctors are not accepting lots of new patients. Specialists are especially difficult to schedule.

On top of that, only about 57 percent of doctors in California accept new Medicaid patients, according to a study published last year in the journal Health Affairs — the second-lowest rate in the nation after New Jersey. Payment rates for Medicaid, known in California as Medi-Cal, are also low here compared with most states, and are being cut by an additional 10 percent in some cases just as the expansion begins.
. . .

Dr. Paul Urrea, an ophthalmologist in Monterey Park, said he was skeptical of “blue-sky scenarios” suggesting that all new enrollees would have access to care. “Having been in the trenches with Medi-Cal patients who have serious eye problems,” he said, “I can tell you it’s very, very hard to get them in to see those specialists.”

Dr. Urrea said that when he recently tried to refer a Medicaid patient with a cornea infection to another eye specialist, he was initially informed that the specialist could not see the patient until February. “And this is a potentially blinding condition,” he added.