We propose that the Wisconsin's federally qualified community health centers (CHCs) should increasingly partner with Wisconsin Medicaid to achieve successful implementation of Medicaid expansion as well as care of our state’s other Medicaid beneficiaries. More of our Medicaid beneficiaries could be provided with accessible, integrated, and cost-effective care by modified CHCs, using nurse practitioners as additional primary-care providers directing team care in neighborhood outreach satellite clinics linked to core CHC sites.
As of December 2018, Wisconsin had enrolled approximately 1 million people in Medicaid and the Children’s Health Insurance Plan. Wisconsin is the only state in the country that expanded eligibility for Medicaid but did not accept the additional federal dollars available through the Affordable Care Act to cover most of the cost. About 147,000 adults without dependent children were enrolled in Badger Care Plus as of January. But because the state expanded coverage only to 100 percent of the federal poverty threshold, rather than 138 percent, the state was not eligible for additional federal dollars. Medicaid is funded by federal and state tax dollars and currently the federal government is paying Wisconsin 59 percent of Medicaid costs instead of the 93 percent it pays the 33 states that have expanded Medicaid. It is estimated that 82,000 people, including 30,000 currently uninsured, would be eligible for Medicaid if the state fully expanded eligibility.
Full Medicaid expansion in Wisconsin could provide coverage for these 30,000 uninsured. However, insurance without access to scarce providers will remain a problem in Wisconsin’s federally designated shortage areas where most of these beneficiaries live. A second problem for those eligible for Medicaid is whether providers will accept Medicaid patients. Recent national data indicate that office-based physicians were less likely to accept new Medicaid patients (68 percent) than Medicare (90 percent) or private insurance (91 percent). We are fortunate in Wisconsin because currently 88 percent of office-based physicians accept Medicaid patients, but geographic-based primary-care provider shortages remain.
The national data for mental health and dentistry is more concerning, with psychiatrists accepting new Medicaid patients at a rate of only 36 percent, and only 37 percent of dentists participating in Medicaid. We also face a shortage of providers who treat patients with substance use disorders. Availability of primary care from physicians in rural areas is of particular concern. Currently, 83 percent of Wisconsin physicians practice in metropolitan areas and less than 10 percent in rural areas, yet one-fifth of our population is located in small towns or rural communities. Demand for primary care is expected to increase, and major deficits will increase in some rural or small communities.
In the U.S. today there are more than 1,400 CHCs that provide primary care for over 27 million people in rural and urban medically underserved communities. CHCs are particularly well represented in rural areas. Today, Wisconsin’s 18 community health centers, with 120 delivery sites, serve over 314,000 patients; 59 percent are Medicaid beneficiaries. Providing high-quality, cost-effective care via CHCs has great potential in helping to ensure that expansion of Medicaid in Wisconsin translates to providing needed care.
However, expanding Wisconsin’s CHCs to increase access beyond their current capacity of Medicaid patients depends on increasing their primary-care provider workforce, which is currently inadequate. Increasing the development of neighborhood outreach satellite clinics affiliated with a core CHC site could help. Nurse practitioners could serve as primary-care professionals leading a local neighborhood provider team in collaborative practice. Nurse practitioners, with advanced competencies in primary care and leadership, could enlist pharmacists, dental hygienists, social workers, and psychologists in patient care. This neighborhood approach to comprehensive primary care, which effectively addresses social determinants of health, could be located in urban public housing developments or smaller rural communities.
Social determinants of health have an enormous effect on patient outcomes. Primary-care providers already suffering from administrative burnout may not see addressing these social issues as part of their duty of care. Medicaid, in partnership with CHCs, provides an ideal setting for addressing social determinants as an integral component of care.
The model that we propose could be powered by state demonstration projects that meet the objectives of state Medicaid innovation. Section 1115 waivers of the Social Security Act provides states with flexibility to design and improve their Medicaid programs and could be utilized to fund a demonstration of the Wisconsin model we have described. After three years, this demonstration likely would prove to be both cost-effective and to remediate current access-to-care barriers. As an incentive to pursue this demonstration, Wisconsin could request 100 percent federal support of state Medicaid benefits for expansion, with a nonprofit managed-care organization contracted to support care utilizing global payment for team care.
We believe Medicaid expansion in partnership with CHCs would be a more politically feasible pathway to universal health care than "Medicare-for-all.” Medicaid could provide cost-effective, high-quality coverage to millions of uninsured Americans in or near poverty without disrupting our employer coverage for 180 million Americans and producing chaos within the health care industry. This incremental approach to universal health care builds upon the Affordable Care Act; Wisconsin can take the lead in demonstrating its effectiveness.
The more than $190 million per year of federal subsidy derived from full expansion of Medicaid could be used for many health care benefits recently proposed by Gov. Tony Evers. Support for training more nurse practitioners should be included. The state could pursue authority to provide medication-assisted treatment to those suffering with opioid use disorders. Medicaid, in partnership with growth in our state's CHCs, would provide an infrastructure that could also be used to addresses the social determinants of health, as well as providing high-quality, cost-effective care. Medicaid should be expanded without further delay.
Richard Rieselbach, M.D., is professor emeritus of medicine, UW School of Medicine and Public Health in Madison. Greg Nycz is executive director, Family Health Center of Marshfield, Inc., in Marshfield.
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