North Carolina’s Medicaid system is working just fine. Republicans want to “reform” it anyway. | Citizen | Indy Week
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North Carolina’s Medicaid system is working just fine. Republicans want to “reform” it anyway. 

It started with an experiment.

Hospital emergency rooms in Wilson County were overwhelmed with patients who didn't need to be there, but they didn't have a doctor, so they hadn't been getting preventive care. Long, sad story short: Lack of proper care leads to crisis leads to ambulance leads to—best case—expensive hospitalization.

Expensive, and paid for by Medicaid, the much-misunderstood government health care program that covers some, but not all, of our poorest citizens, many of whom have serious disabilities.

So in 1983, doctors in Wilson created a pilot program in which 1,500 Medicaid patients were assigned to a specific primary-care physician.

You may have heard the term "medical home." This is what it means. Physicians were paid a small sum per patient. In the first year, ER admissions dropped 58 percent compared to those with no "home," saving the state $300,000.

Three decades later, the pilot has grown and flourished and is now known as Community Care of North Carolina. I didn't know this, but it turns out CCNC is 14 separate but affiliated networks of doctors and hospitals. Together, they enroll 80 percent of the now 1.9 million clients covered by Medicaid in North Carolina at any given time.

CCNC's networks employ about 600 care managers who visit with the sickest of their Medicaid clients, the ones with multiple chronic conditions, often accompanied—as you might imagine—by severe depression or substance abuse. One big problem: Multiple conditions mean multiple prescriptions from different specialists, and they may clash, or the patient may not understand how to take them.

Coordinating patient care yields better outcomes for the patients—while saving money.

Another 200 CCNC aides are assigned to county health departments. Their job is to spot high-risk cases. For example, expectant mothers who smoke or have high blood pressure are much more likely to give birth to a low-weight baby. Not all such births can be prevented, but many can, with substantial savings.

"The whole idea was that if we have high-quality health care, it will cost less," says CCNC Vice President Paul Mahoney. Which, Mahoney adds, was counterintuitive in 1983 and still is. "Most of us think better is more expensive. But it really isn't, because our health care is so fragmented and wasteful."

Here's something else I didn't know. Medicaid, because of relatively generous income eligibility standards for expectant mothers, pays for 55 percent of all births in North Carolina. Ditto the standards for minor children, who thus account for half of our Medicaid clientele.

No surprise then, Mahoney told me, that CCNC pediatricians screen extensively for treatable conditions among kids 5 years old and younger. Or that pediatricians and OB-GYNs drove CCNC's expansion.

click to enlarge State Medicaid costs have fallen in North Carolina despite higher numbers of adults and children ("members") enrolled. - GRAPHIC COURTESY OF COMMUNITY CARE OF NORTH CAROLINA.
  • Graphic courtesy of Community Care of North Carolina.
  • State Medicaid costs have fallen in North Carolina despite higher numbers of adults and children ("members") enrolled.

That CCNC saves money isn't in doubt. A raft of studies show it, most recently an audit ordered by the General Assembly and conducted by a private firm working with State Auditor Beth Wood. It found that CCNC saves more than $300 per patient per year, which shaves at least $400 million annually off the state's current Medicaid bill of $3.4 billion.

CCNC has a shelf full of awards, is praised by Republicans and Democrats alike, and you may know where I'm going with this. Unless the General Assembly changes course, CCNC is about to be dumped and replaced by some giant, for-profit insurance companies, augmented by—on a local basis—a few big hospital "systems."

Yes, Medicaid "reform" is coming, thanks to a determined group of Republican senators convinced that Medicaid, because it's "government," must be wasteful and should therefore be privatized. But wait, isn't CCNC a form of privatization—with doctors in charge?

Yes, it is. And Republicans in the House seemed inclined to leave CCNC in charge prior to this legislative session. But their Senate counterparts took the state budget hostage, and they aren't budging until they get their way on a host of issues, Medicaid included.

The Senate Republicans make two points, taken directly from an organization, NC Medicaid Choice, that consists of five giant insurers including Aetna and United Health Care. The first is that the state's Medicaid costs are spiraling up. The second is that costs can be suppressed by handing control to insurers, who are willing to accept a fixed fee-per-client that's less than the state is currently spending.

The first point is not true. North Carolina's Medicaid costs are below the national average and dropped slightly between 2010 and 2014, from $3.6 billion to $3.4 billion, despite more people being on Medicaid. There's confusion about this because federal stimulus money given to the state for Medicaid in the first two years of the Obama administration kept state appropriations down. But, bottom line, state Medicaid spending dropped.

The second point, however, may be true. Insurance companies have their ways of cutting costs, including denying care to patients. They do so in other states, and in fact, North Carolina is almost unique in trusting its doctors to care for the poor rather than simply slamming a lid on their health care costs and paying for-profit insurers to keep it slammed.

I actually agree with the Republicans that trusting doctors to keep their own costs under control isn't easy. But CCNC has earned our trust. More than any insurance company I know, anyway.

This article appeared in print with the headline "If it ain't broke..."

  • By “reform,” they mean “privatization”—i.e., putting patient care under insurance companies’ control

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