Medicaid and access to health care--a proposal for continued inaction?

10.1056/nejmp1106046 nejm.org 1 severe shortages of physicians and hospitals in many low-income inner-city and rural communities; low rates of participation in Medicaid among available providers, owing to low payment rates; state administrative practices that drive providers away; and the economic, clinical, educational, and cultural characteristics of Medicaid beneficiaries.1 Where they are operating, federal programs such as community health centers, federally funded family planning agencies, the National Health Service Corps, local public health agencies, and public and children’s hospitals help to mitigate the situation. But thousands of U.S. communities lack such programs, and even where they do exist, they don’t address the specialized long-term care needs of beneficiaries with severe disabilities. For decades, as the access problem festered, successive federal administrations proved either unable or unwilling to act. Congress therefore entered the fray in 1989, enacting legislation that requires participating states to assure that payments to providers are not only consistent with efficiency, economy, and high-quality care, but also “sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area.”2 Ironically, this language was lifted verbatim from an earlier federal regulation that had been allowed to languish on the books.3 Congressional intervention did not, however, serve as a wake-up call. For the past 20 years, subsequent administrations have failed to firmly implement the 1989 amendments. No administration has issued regulations that delineate the standards by which access is to be measured, define the methods states must use for such measurement, set forth clear reporting requirements, or specify actions that the federal government will take to reduce or eliminate barriers to access. The federal government lacks a comprehensive body of research evaluating the effects of state policies and practices on access to care, and no administration has ever issued comprehensive recommendations aimed at guiding and encouraging imMedicaid and Access to Health Care — A Proposal for Continued Inaction?