Countercycling with Medicaid

The state of Washington’s going extreme on solving Medicaid: it’s planning on severely limiting its payments for emergency room visits by specifying certain events they absolutely will not pay for. (In this article, they manage to turn up the rhetoric to about eleven, saying “We will not pay for diaper rash treated in the emergency room” and claiming that ER physicians and hospitals are “abusing their privileges” in charging so much to Medicaid. It’s typical lazy, shiftless poor rhetoric, and they claim it costs the state $21 million. The total deficit is $2 billion.)

Ultimately, emergency rooms will still be forced to take care of the poor who can’t pay for care, so the change amounts to the state taking $21 million from its hospitals, assuming their numbers are correct.

The situation highlights two discrete problems: first, it’s still somewhat odd that Medicaid is administered by the states in the first place. A program that has to care for the poor shouldn’t become stingier when there are more poor—it’s a countercyclical no-no. (You also wonder what happens as the ACA pushes more people into Medicaid.) This probably makes sense in light of Medicaid’s history as a virtual afterthought, but probably should’ve gotten taken care of at some point afterwards. Second, shouldn’t people be thinking about ways to make sure such unnecessary visits to the ER not happen in the first place?

I’ve written a bit on the potential of retail clinics to fill a niche in health care, and this seems like a situation they’d be helpful—I suspect there’s a lot of care out there that’s urgent but not an emergency. Or some of the solutions doctors are pitching make some sense here too:

The doctors have offered what they call a physician-developed plan they say would reduce narcotic-seeking behavior, coordinate ER visits with primary-care access, spearhead a "generics first" effort, develop a statewide preferred-drug list, and institute a case-management system for frequent users.

(The case-management system sounds a lot like Atul Gawande’s “Hot Spotters” New Yorker article, so there you have that.)