What comes next after expanding Medicaid? How do we make the system even better?
On August 4th Missouri votes on whether to be the 38th state to expand Medicaid. By all accounts, this should be a no-brainer. Hundreds of thousands of currently uninsured Missourians would finally have access to medical care, potentially saving thousands of lives and improving the futures of many more children. Even conservative states like Idaho, Oklahoma, and Nebraska have opted to expand Medicaid, ten years after the Affordable Care Act offered it to them, with the federal government picking up most of the tab.
Jobs will be created, rural hospitals will get to stay open, bad illnesses will be stopped in their tracks, but much of the work in reforming healthcare remains to be done.
When Medicaid was created in 1965 it was an improvement over the sad state of affairs where people in poverty depended on the kindness of strangers and medical professionals to get the most basic medical care. While Medicaid has definitely helped, hospital emergency rooms have emerged as preferred providers for all sorts of ailments that should have been addressed earlier and by specialists. ER's were never meant to be dumping grounds, but rather to care for those in true emergencies.
While some hailed Medicaid as a vital safety net to save lives, others have cursed it as a redistribution of money from a hard-working majority to a lazy minority. Missouri has always been in the latter group, being one of the hardest states in which to get Medicaid. Their threshold of $5500 for a family is lower than 1/3 of the federal poverty level. Medicaid families are dropped from the rolls with no warning. Legislators in Jefferson City have cut Medicaid repeatedly because its a big target at $2 Billion and growing. (Mind you that $2 Billion is matched and results in $10 Billion of healthcare spending for Missourians.)
Workers whose jobs offer no healthcare (like minimum-wage employees), have had nowhere to go if they make too little for the Affordable Care Act marketplaces. They've been in an evil limbo of too poor for regular healthcare and not poor enough for Medicaid. Medicaid expansion plugs that cruel hole in Missouri's coverage system.
But here's the dirty little secret about Medicaid and health insurance in America- there aren't enough doctors, therapists, and dentists in America to treat everybody, even if they did have coverage. Studies show a shortage of over 100,000 doctors ten years from now. Rural areas have the hardest time finding and keeping general practitioners and specialists. As for dentists, Missouri is one of the bottom ten states for dental "deserts" according to the HRSA. According to Kaiser, over 1 in 4 Missourians live in areas with critical shortages of dental professionals. Over half of therapists and psychologists don't accept Medicaid, which means that many mental illnesses are never diagnosed are treated.
Universal coverage is the first step, but then we need to look deeper for better solutions. Throwing more money in a shrinking pot of health professionals just puts more pressure on them, especially when huge programs like Medicare and Medicaid don't pay nearly as well as private insurance. It's not fair to put the medical professionals in the middle of this battle. They sacrificed years and taken on huge debts to get where they are, and they can't be expected to solve America's ills alone.
So here are some suggestions to consider in the next decade as we question how to improve healthcare and access to healthcare. A yes vote on August 4 is only the beginning.
Alleviate some of the shortages by actively recruiting professionals from other countries, especially Asia, many of whom do their training in the US.
Allow paraprofessionals like Nurse Practitioners and Dental Therapists to have more opportunity and authority to practice routine care in poorly served areas, especially rural ones.
Subsidize future doctors by giving grants to students in medical school. It's unfair to expect them to take out huge loans, and then expect them treat people who can barely pay the bill. Poverty exacts a heavy toll on mental fitness, and special medical training is needed for those who will treat those who can barely take care of themselves.
Take a bigger public health approach to the four scourges now devastating America- Covid-19, opiates, obesity, and mental illness. More creative, comprehensive solutions need to be found, and big problems like these don't need to be dumped constantly on our overworked medical professionals.