Money in the Bank and Boots on the Ground: A Law-Policy Proposal to Make the Affordable Care Act Work in Louisiana

• Author: Lucas Self
• Position: J.D./D.C.L., 2016, Paul M. Hebert Law Center, Louisiana State University.
• Pages: 547-581

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 online 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 Eligibility Limits for Adults as a Percent of the Federal Poverty Level , KAISER FAM. FOUND., http://kff.org/medicaid/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). 550 LOUISIANA LAW REVIEW [Vol. 76 even greater challenge because of the severity of the state’s preexisting healthcare shortage. 13 A. Louisiana’s Doctor Shortage is Part of a National Trend The entire nation suffers from a critical shortage of doctors that will only grow more severe if significant numbers of new physicians do not enter the workforce rapidly. Over one quarter of the nation’s physicians are 60 or older, so many doctors are curtailing their practices and preparing for retirement. 14 Estimates place the current physician shortage at approximately 7,000 doctors. 15 The Association of American Medical Colleges (“AAMC”) predicts that the country will face a shortfall of over 90,000 doctors by 2020. 16 A national shortage of healthcare providers means patients have to wait longer to see a physician because a doctor can only see so many patients in a day. 17 Although sheer numbers are important when determining whether there is an adequate supply of doctors, numbers alone do not tell the whole story. 18 In addition to the sheer number of doctors, both geographic location and specialization of physicians play a critical role in determining whether there 13. See, e.g. , Campbell Robertson, Louisiana Has Much at Stake in Healthcare Debate , N.Y. TIMES (Dec...