This is the fifth entry in a series of posts highlighting GCO’s new report – Increasing Access to Quality Healthcare for Low-Income Uninsured Georgians. The first entry provided an overview of the report, the second looked at Georgia’s healthcare safety net, the third explained the impact of uninsurance, and the fourth focused on Medicaid and the Affordable Care Act.
Georgia faces many challenges and barriers to expanding access to quality healthcare for low-income uninsured individuals, particularly for those in the Medicaid expansion coverage gap.
State Fiscal Constraints
Preliminary estimates projected that providing Medicaid to newly eligible adults through the expansion would cost the state approximately $2.1 billion from 2014 to 2023. Since the federal government covers 100 percent of the cost for the first three years and then slowly reduces its contribution until it is set at 90 percent in 2020, expansion is projected to first cost the state about $120 million in 2017. In 2023, the final year of the projection, state costs will have risen to almost $406 million.[i]
Governor Deal and other state leaders maintain that the state cannot afford Medicaid expansion and have expressed serious concerns that the federal government will be unable to live up to its obligations under Medicaid expansion. Therefore, any policy or program that would improve access to healthcare for low-income uninsured Georgians must cost significantly less than Medicaid expansion and must rely upon state-based sources of funding.
Georgia ranked 41st in the country in active physicians and 44th in primary care physicians per capita in 2010.[ii] According to the U.S. Department of Health & Human Services, almost 2 million Georgians live in a “Primary Care Health Professional Shortage Area,” meaning there are a low number of primary health professionals relative to the population.[iii] In 2010, 31 of Georgia’s 159 counties did not have an internal medicine physician; 63 did not have a pediatrician; 79 did not have an OB/GYN; and 66 did not have a general surgeon.[iv]
Georgia’s Fiscal Year 2015 budget allocates $2 million in additional funds to develop new graduate medical education programs to train residents.[v] While an important step, the state must continue to pursue efforts to address its shortage of primary care providers. Without more providers, many Georgians may not have access to primary care, even if they have health insurance coverage.
Limits to Nurse Practitioner Scope of Practice
Nurse practitioners (NPs) are an important provider of primary care across the country. In many states, NPs evaluate and diagnose patients, order and interpret diagnostic tests, and initiate and manage treatments. A literature review by the National Governor’s Association found that most studies show that NPs provide comparable care to physicians and achieve equal or higher satisfaction rates among their patients. The review did not find any studies that raised concerns about the quality of care offered by NPs.[vi]
Georgia’s laws and regulations for NPs are more restrictive than almost any other state. A 2007 study ranked Georgia’s NP regulations 48th in the country because the state’s NP limitations affect patients’ freedom to choose providers and NPs ability to provide primary care.[vii] Georgia’s restrictions include requiring NPs to be supervised by a physician and to have a collaborative agreement with a physician or a physician’s supervisor/delegation in order to prescribe drugs. These limitations do not exist in over one-third of states.[viii]
Fiscal Challenges of Safety-net Hospitals
Hospitals that serve a large number of Medicaid and low-income uninsured patients receive state and federally funded supplemental payments from state Medicaid programs. Called disproportionate share hospital (DSH) payments, the funding offsets the disadvantaged financial situation of hospitals that provide large amounts of uncompensated care to uninsured individuals and serve a substantial number of patients in the relatively low-paying Medicaid program.[ix]
The ACA was expected to reduce the number of uninsured individuals and, therefore, reduce hospital uncompensated care costs. This would create less need for DSH payments. Thus, the ACA required annual aggregate reductions in federal DSH funding from FY 2014 through FY 2020.
In 2011, almost 40 percent of Georgia hospitals lost money. Rural hospitals are in an even worse financial situation as 55 percent had negative total margins.[x] Given their financial struggles, Georgia hospitals have expressed concern regarding the DSH reduction. Since Georgia does not plan to expand Medicaid, the reduction in DSH payments would not be offset by an increase in revenue through having more patients being covered by Medicaid. Thus, the hospitals are likely to receive less funding, while the demand for uncompensated care is expected to persist.
[i] Georgia Department of Community Health, “Preliminary Estimate on the Impact of Federal Health Care Reform on the Georgia’s Medicaid and PeachCare Program,” Handout, April 2012.
[ii] Center for Workforce Studies, 2011 State Physician Workforce Data Book, Association of American Medical Colleges, November 2011, 8-11, https://www.aamc.org/download/263512/data.
[iii] Bureau of Clinician Recruitment and Service, “Designated Health Professional Shortage Areas Statistics,” U.S. Department of Health & Human Services, Health Resources and Services Administration (HRSA), as of May 30, 2014, accessed May 30, 2014, 2, http://ersrs.hrsa.gov/reportserver/Pages/ReportViewer.aspx?/HGDW_Reports/BCD_HPSA/BCD_HPSA_SCR50_Smry_HTML&rs:Format=HTML4.0.
[iv] Georgia Board for Physician Workforce, Georgia Physician and Physician Assistant Professions Data Book 2010/2011, December 2013, i, https://gbpw.georgia.gov/sites/gbpw.georgia.gov/files/related_files/document/2010-2011%20Physician%20and%20Physician%20Assistant%20Data%20Book.pdf.
[v] Governor Nathan Deal, Office of the Governor, “Deal: Budget includes half a billion dollars in k-12 education,” Press Release, April 28, 2014, accessed May 23, 2014, https://gov.georgia.gov/press-releases/2014-04-28/deal-budget-includes-half-billion-dollars-k-12-education.
[vi] National Governors Association, The Role of Nurse Practitioners in Meeting Increasing Demand for Primary Care, December 20, 2012, 5, http://www.nga.org/cms/home/nga-center-for-best-practices/center-publications/page-health-publications/col2-content/main-content-list/the-role-of-nurse-practitioners.html.
[vii] Nancy Rudner Lugo et al., “Ranking State NP Regulation: Practice Environment and Consumer Healthcare Choice,” The American Journal for Nurse Practitioners 11 (2007): 16, http://www.eileenogrady.net/upload/Ranking%20of%20states%20AJNP_April_07_%5Bfinal%5D.pdf.
[viii] Barton Associates, “Interactive Nurse Practitioner (NP) Score of Practice Law Guide,” accessed February 27, 2014, http://www.bartonassociates.com/nurse-practitioners/nurse-practitioner-scope-of-practice-laws/.
[ix] Georgia Department of Community Health, “Georgia Medicaid: SFY 2013 Medicaid DSH Allocation,” http://dch.georgia.gov/sites/dch.georgia.gov/files/related_files/document/Preliminary_SFY2013_Allocation_of_DSH_Allotment.pdf.
[x] Ibid., 14.