Money in the Bank and Boots on the Ground: A Law-
Policy Proposal to Make the Affordable Care Act
Work in Louisiana
TABLE OF CONTENTS
Introduction .................................................................................. 547
I. Louisiana Faces A Chronic Shortage of Doctors.......................... 549
A. Louisiana’s Doctor Shortage is Part of a National Trend ...... 550
B. Louisiana Faces a More Severe Healthcare Crisis than
the Nation as a Whole ............................................................ 551
II. The Affordable Care Act Will Increase Demand for Doctors ...... 554
A. The ACA Expands Healthcare Coverage ............................... 555
B. Fallout from NFIB v. Sebelius ................................................ 559
C. The Consequences of Expanded Coverage ............................ 561
D. Provisions in the ACA Aimed at Increasing the Doctor
Supply Fall Short ................................................................... 562
III. Louisiana’s Response to Doctor Shortage Is Exacerbating
Its Healthcare Crisis ..................................................................... 563
IV. Solutions to Louisiana’s Physician Shortage Must Involve
Increased Resources and Boots on the Ground ............................ 568
A. National Legislation to Supplement the ACA ....................... 568
B. Expand Medicaid ................................................................... 569
C. The Arkansas Plan: Using Medicaid Expansion Funds
to Purchase Private Insurance ................................................ 574
D. Increased Use of Non-Physician Healthcare Providers .......... 576
E. The Impact of Medicaid Expansion on Healthcare
Providers ................................................................................ 579
Conclusion .................................................................................... 581
INTRODUCTION
Kilbourne, a village in northeast Louisiana, lies snug against the
Arkansas border. This area is among the poorest in the country.1 Because
Copyright 2015, by LUCAS SELF.
1. Twenty-five percent of West Carroll Parish residents, of which Kilbourne
is a part, live below the federal poverty level. State & County QuickFacts: West
Carroll Parish, Louisiana, U. S. CENSUS BUREAU, http://quickfacts.census.gov
548 LOUISIANA LAW REVIEW [Vol. 76
it is a rural location, its residents find it difficult to access healthcare.2 They
must travel down miles of bumpy country roads to reach the nearest
hospital. Few here possess the luxury of private insurance, and Louisiana
maintains some of the strictest requirements for Medicaid eligibility,
leaving many without any healthcare coverage at all.3 In the 1920s, some
Arkansas families crossed the border and relocated from southern
Arkansas to Kilbourne to take advantage of Huey Long’s program that
provided free textbooks to students.4 Now, in 2015, a few families in
Kilbourne might look to move a few hundred feet north to take advantage
of Arkansas’s expansion of Medicaid that covers many of the working
poor Louisiana currently leaves behind.5
Louisiana, like Arkansas, is a state that has long struggled to provide
its citizens with access to adequate healthcare, but, with the passage of the
Affordable Care Act (“ACA”),6 these two states have taken radically
different approaches to healthcare policy. Louisiana has steadfastly refused
/qfd/states/22/22123.html [http://perma.cc/NS6K-R79E] (last updated Aug. 31,
2015, 1:06 PM).
2. A Health Professional Shortage Area (“HPSA”) encompasses all of West
Carroll Parish according to the Health Resources and Services Administration on-
line data warehouse. See HPSA Find, HRSA, http://hpsafind.hrsa.gov/HPSA
Search.aspx [http://perma.cc/PXA4-MFPK] (last visited Sept. 18, 2015) (select
“Louisiana” for state; then select “West Carroll Parish” for county; then select
“Primary Care” for HPSA discipline). An HPSA is determined by the Secretary
of Health and Human Services based on data provided by the state governments.
See 42 C.F.R. § 5.3 (2014). An HPSA is an area that has a ratio greater than or
equal to one primary care physician per 3,500 residents, or one primary care
physician per 3,000 residents if the area’s population has an unusually high need
for service. Id.
3. See Medicaid Income Eligib ility Limits for Adults as a Percen t of the Federal
Poverty Level, KAISER FAM. FOUND., http://kff.org/medica id/state-indicator/Medicaid
-income-eligibility-limits-for-adults-at-application-2014/ [http://perma.cc/C39W-A2
BZ] (last visited Sept. 18, 2015); Understanding the Impact of a Medicaid Expansion
in Louisiana: Considerations, Assumptions and Uncertainties, DEP’T HEALTH &
HOSPS. (2013), http://dhh.louisiana.gov/assets/medicaid/docs/mdcdexpntnimpct_mr
ch13.pdf [http://perma.cc/ASA6-W38B].
4. This author’s grandfather, the youngest of 10 children, moved from
Arkansas to Kilbourne with his family, because his father could not afford to send
his children to school if he had to purchase textbooks.
5. See ARK. CODE ANN. §§ 20-77-2401 to 20-77-2408 (West Supp. 2015).
Arkansas is the only Deep South state to expand Medicaid. Status of State Action
on Medicaid Expansion Decision, KAISER FAM. FOUND., http://kff.org/health-
reform/state-indicator/state-activity-around-expanding-medicaid-under-the-afford
able-care-act/ [http://perma.cc/69FS-8LN2] (last updated Sept. 1, 2015).
6. ACA refers to the Patient Protection and Affordable Care Act of 2010, as
amended by the Health Care and Education Reconciliation Act of 2010. Patient
Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010),
amended by Health Care and Education Reconciliation Act of 2010, Pub. L. No.
111-152, 124 Stat. 1029.
2015] COMMENT 549
to expand Medicaid while Arkansas has embraced the expansion but engaged
in negotiations to shift new enrollees into the private insurance marketplace.7
Although both states claim that they are moving towards privatization of
healthcare services,8 Louisiana is actually leaving itself vulnerable to changes
in Medicaid funding under the ACA that will cause Louisiana to have less
flexibility in meeting future healthcare needs. At the same time, Louisiana
faces a critical shortage of doctors, which hurts communities from Kilbourne
to New Orleans.9 Louisiana can best ensure access to healthcare services by
adopting a Medicaid expansion plan that uses federal funds to place eligible
recipients on a state-run insurance exchange, while expanding the scope of
practice for non-physician healthcare workers.
In Part I, this Comment reveals the scope of the challenge, highlighting
the factors that contribute to Louisiana’s shortage of healthcare providers. Part
II provides an overview of the ACA’s changes to Medicaid and the
legislation’s impact on doctors and hospitals. Part III discusses Louisiana’s
reaction to the ACA, focusing on how the state’s actions have decreased
available funding for healthcare providers. Part IV offers solutions to the
healthcare provider crisis, including a discussion about the benefits of
Medicaid expansion for Louisiana and the lessons Louisiana can learn from
Arkansas and other states grappling with similar doctor shortages.
I. LOUISIANA FACES A CHRONIC SHORTAGE OF DOCTORS
Louisiana’s chronic problems with poverty and sickness have plagued
efforts to ensure better healthcare coverage in Louisiana.10 The state is not
alone; many other states face similar shortages of healthcare providers.11
This shortage will become even more severe in the near future, as increased
demand for healthcare places further strain on an already overburdened
system.12 Although the entire nation faces this problem, Louisiana has an
7. See infra Part IV.E.
8. The Big Transition – Sizing Up Louisiana’s Private Approach to Public
Health Care, BUS. REP. (Aug. 19, 2014), https://www.businessreport.com/article
/the-big-transition-sizing-up-louisianas-private-approach-to-public-health-care
[https://perma.cc/4KUV-LJZE].
9. See infra Part I.B; Sabrina Tavernise & Robert Gebeloff, Millions of Poor
are Left Uncovered by Health Law, N.Y. TIMES (Oct. 2, 2013), http://www.nytimes
.com/2013/10/03/health/millions-of-poor-are-left-uncovered-by-health-law.html
?pagewanted=all&_r=0.
10. See Robin Rudowitz, Diane Rowland & Adele Shartzer, Health Care in New
Orleans Before and After Hurricane Katrina, 25 HEALTH AFF. 393, 394 (2006).
11. Jennifer Lorio, Comment, Physician Reimbursement, Impending Shortages,
and Healthcare Reform, 21 ANNALS HEALTH L. 11, 15 (2011).
12. Edward Salsberg & Atul Grover, Physician Workforce Shortages:
Implications and Issues for Academic Health Centers and Policymakers, 81 ACAD.
MED. 782, 782 (2006).