WASHINGTON — Enrollment in Medicaid is surging as a result of the Affordable Care Act, but the Obama administration and state officials have done little to ensure that new beneficiaries have access to doctors after they get their Medicaid cards, federal investigators say in a new report.
The report, to be issued this week by the inspector general at the Department of Health and Human Services, says state standards for access to care vary widely and are rarely enforced. As a result, it says, Medicaid patients often find that they must wait for months or travel long distances to see a doctor.
The inspector general, Daniel R. Levinson, said federal and state officials must do more to protect beneficiaries’ access to care, in view of the program’s rapid growth.
Just since October, the administration says, 8 million people with low incomes have enrolled. By 2016, the Congressional Budget Office estimates, one in four Americans will be on Medicaid at some time during the year.
Twenty-seven states have expanded Medicaid eligibility since the passage of the health care law in 2010, and President Obama is urging other states to do so.
Most states hire insurance companies to manage care for Medicaid patients. In return for monthly fees, the insurers provide comprehensive services through networks of selected doctors and hospitals. Federal rules say managed-care organizations must “provide adequate access to all services covered,” but states can define what “adequate” means.
Some states set time and distance standards for access to doctors. Other states specify the maximum number of days that a Medicaid patient should have to wait for an appointment. Still others require a minimum number of doctors and other providers, based on the number of people in a health plan.
In some places, insurers must have at least one primary care provider for every 100 Medicaid beneficiaries, while other states require at least one for every 2,500. Some states say Medicaid patients should be able to see specialists within 15 days, while others allow waits up to 60 days.
In any event, the inspector general said, most states have not cited any insurers for violations in the last five years, and the federal government “provides limited oversight of state standards for access to care.” Three states, Georgia, New York, and Ohio, accounted for three-fourths of violations reported in the past five years.
The federal government “uses a checklist to confirm that states have access standards,” but does not analyze whether the standards ensure access to care, Levinson said. Federal officials, he said, view the setting of standards as “primarily a state responsibility.”
In assessing whether health plans have enough doctors, states typically rely on information from insurers, Levinson said, but “this information is often inaccurate or out of date.” Some doctors are no longer in health plan networks. Some are not taking new Medicaid patients. Some were never at the address listed in the insurer’s directory of providers.
Only a few states try to verify the information reported by insurers — for example, by making “secret shopper” calls to doctors’ offices, the report said.