Medicaid: States Made Multiple Program Changes, and Beneficiaries Generally Reported Access Comparable to Private Insurance
Released: 2012-11-15T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: Medicaid enrollment has grown significantly in recent years due to the economic downturn. This growth is expected to continue as the Patient Protection and Affordable Care Act potentially extends Medicaid eligibility in 2014 to millions of uninsured individuals. To better understand whether states are providing adequate access to medical care for beneficiaries, this report examines (1) states' experiences processing Medicaid applications, (2) states' changes to beneficiary services and provider payment rates, (3) the challenges states report to ensure sufficient provider participation, and (4) the extent to which Medicaid beneficiaries reported difficulties obtaining medical care. To examine the first three objectives, GAO administered a nationwide web-based survey to Medicaid officials on states' experiences from 2008 through 2011 and obtained a response rate of 98 percent. To examine the last objective, GAO analyzed data from the 2008 and 2009 Medical Expenditure Panel Survey, the most current available at the time of our analysis, to assess Medicaid beneficiaries' reported difficulties obtaining care, and the 2009 National Health Interview Survey to assess their reasons for delaying care. To provide context, we compared their experiences to those of individuals with private insurance or who were uninsured.

section_title: What GAO Found
paragraphs: From 2008 to 2011, more than half of states reported maintaining or decreasing their average Medicaid application processing times--the average number of calendar days between the receipt of a new application and the final determination of eligibility. The average processing times reported by 39 states ranged from 11 to 45 calendar days. For the same time period, however, GAO was unable to assess whether states processed applications at a rate that kept pace with the number of new applications received each month, because most states provided incomplete or inconsistent data.

States reported making numerous changes to provider payments, provider taxes, and beneficiary services since 2008. While more states reported provider-rate and supplemental payment increases each year from 2008 through 2011, the number reporting payment reductions and increased provider taxes also grew. More states reported increasing services than limiting them.

Over two-thirds of states reported challenges to ensuring enough Medicaid providers to serve beneficiaries--including dental and specialty care providers. States cited Medicaid payment rates and a general shortage of providers as adding to the challenge. To attract new providers, over half the states reported simplifying administrative requirements or increasing payment rates.

In calendar years 2008 and 2009, less than 4 percent of beneficiaries who had Medicaid coverage for a full year reported difficulty obtaining medical care, which was similar to individuals with full-year private insurance; however, more Medicaid beneficiaries reported difficulty obtaining dental care than those with private insurance. Beneficiaries with less than a full year of Medicaid coverage were almost twice as likely to report difficulties obtaining medical care as those with full-year coverage. Medicaid beneficiaries reported delaying care for reasons such as long wait times and lack of transportation.

The Department of Health and Human Services reviewed a draft of this report and provided technical comments, which GAO incorporated as appropriate.

section_title: Letter
paragraphs: Enrollment and expenditures in Medicaid, a federal-state health financing  program for certain categories of low-income individuals, have grown  significantly in recent years. During the nation’s recent economic crisis,  Medicaid enrollment grew 14.2 percent from October 2007 through  February 2010. During this time, total Medicaid expenditures grew nearly  21 percent, from $332.2 billion in 2007 to $401.5 billion in 2010. Since  then, enrollment growth has slowed—averaging around 4 percent  nationally—yet the growth in Medicaid spending continues to be a source  of concern. Economic downturns can create challenges for states  because tax revenues can decrease, while unemployment—and  enrollment in Medicaid—can increase. To reduce program spending,  states generally may make certain changes to their Medicaid programs,  such as altering payments to providers, limiting eligibility, eliminating  optional services, or reducing the amount, duration, or scope of services.

While recent laws have provided some fiscal relief to states through the  provision of additional federal funding for Medicaid, they have also limited  the ability of states to alter their programs. For example, the American  Recovery and Reinvestment Act of 2009 (Recovery Act) provided a  temporary increase in the rate at which the federal government matched  state expenditures, but required states to maintain Medicaid program  eligibility in order to receive the additional funding. The Patient Protection and Affordable Care Act of 2010 (PPACA) requires states to expand  their Medicaid programs to cover additional individuals and provides an  enhanced federal match for this coverage. PPACA also makes other  changes to Medicaid eligibility and payment, such as requiring states to  maintain their current levels of eligibility for Medicaid beneficiaries and  increasing payment rates for Medicaid primary care services in 2013 and  2014.result in enrollment of about 7 million additional individuals in 2014   Potential Medicaid expansions under PPACA are estimated to  growing to 11 million in 2022.which states will expand Medicaid coverage to this newly eligible  population, any growth in Medicaid is likely to place additional pressure  on states to manage their programs, maintain or increase their pool of  providers, and ensure access to needed health care services for Medicaid  beneficiaries.

While it is too early to assess the extent to  In October 2010, we reported on changes states were making to sustain  their Medicaid programs after certain federal funding increases from the  Recovery Act lapsed. Some of these changes could affect beneficiaries’  access to care.changes that could affect Medicaid application processing time, such as  decreasing the number of staff or staff hours available for processing  Medicaid applications and increasing furlough days. Additionally, states  reported changes to certain services and payments to providers that  could affect beneficiary access. Such changes raise questions about  whether Medicaid is meeting the health care needs of the current  beneficiaries and whether the expansion of Medicaid may further  exacerbate issues of access for beneficiaries. To assess factors that can  affect access and beneficiaries’ experiences obtaining care, this report  examines (1) states’ experiences processing Medicaid applications,   (2) changes that states have made to beneficiary services and provider  payment rates, (3) the challenges states report with regard to ensuring  sufficient provider participation, and (4) the extent to which Medicaid  beneficiaries’ reported difficulties obtaining medical care.

Over half of the states reported making administrative  To address the first three objectives, we administered a web-based  survey from February 2012 to May 2012 to Medicaid officials in the   50 states, the District of Columbia, and the 5 largest U.S. territories, and  obtained a response rate of 98 percent. In this survey, we generally  asked about states’ experiences from 2008 through 2011. For the web- based survey, we relied on the survey response reported by the primary  contact for the state’s Medicaid program. When we asked states about  implementing various efforts, such as application processing  improvements, we generally gave a time frame for implementation, and  state efforts implemented prior to that time frame are not included in the  report. We did not independently verify the accuracy of the data reported  by states, but we reviewed all survey responses for internal consistency.  In addition, we completed our state survey field work prior to the June 28,  2012, decision by the Supreme Court on certain aspects of PPACA,  including the Medicaid expansion provision. Accordingly, state responses  were provided to us before they had analyzed any potential effect of the  decision on their own state. To address the fourth objective, we analyzed  two national surveys, the National Health Interview Survey (NHIS) and  the Medical Expenditure Panel Survey (MEPS), to examine the extent to  which Medicaid beneficiaries reported difficulties obtaining care. Our  MEPS analysis was based on national survey data from 2008 and 2009,  the most recent data available at the time of our analysis. Our NHIS  analysis was based on the 2009 survey. Both of these national surveys  rely on information reported by individuals. To provide context for  difficulties obtaining care reported by Medicaid beneficiaries, we  examined the extent to which individuals with private insurance or those  who are uninsured reported such difficulties. We also conducted the  analysis across different age groups, including children, working-age  adults, and those 65 and older, but small sample sizes limited the  reliability of some analyses, and therefore we did not report them. For the  MEPS analysis, children with Medicaid also included those with coverage  under the State Children’s Health Insurance Program (CHIP). We  examined differences in reported difficulty obtaining care between  beneficiaries reporting fair or poor health and those reporting better health  and between those with full-year coverage and less than full-year  coverage. For the NHIS and MEPS surveys, we reviewed relevant  documentation describing how these data are collected and processed,  and examined other research that has used these data to report on  potential delays in obtaining health care services to check our results  against similar analyses. We determined that the data we used in this  report were sufficiently reliable for the purposes of our engagement. (See  app. I for additional information on our scope and methodology.)

We conducted this performance audit from December 2011 through  November 2012 in accordance with generally accepted government  auditing standards. Those standards require that we plan and perform the  audit to obtain sufficient, appropriate evidence to provide a reasonable  basis for our findings and conclusions based on our audit objectives. We  believe that the evidence obtained provides a reasonable basis for our  findings and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: Medicaid finances health care for certain categories of low-income  individuals, including pregnant women, children, certain low-income   In  parents, persons with disabilities, and persons who are elderly.addition, states can expand Medicaid eligibility to other individuals,  including children and eligible parents with incomes above the current  minimum levels. Under broad federal requirements, states administer the  day-to-day operations of their Medicaid programs; activities that include  determining whether applicants are eligible for Medicaid, setting the  scope of covered services, paying providers, and ensuring access to  covered services. The Centers for Medicare & Medicaid Services (CMS),  a federal agency within the Department of Health and Human Services  (HHS), oversees state Medicaid programs at the federal level. States are  required to ensure that all individuals who want to apply for Medicaid  coverage have the opportunity to do so and must, with reasonable  promptness, provide coverage to applicants who are determined  eligible. In general, states are required to determine eligibility for  individuals who apply for Medicaid within 45 days from the date of  application, and within 90 days for those who apply on the basis of  disability. In some states, Medicaid applications are reviewed and  eligibility is determined at the county level, while other states have  centralized their eligibility determination processes.

States’ Medicaid programs must cover a set of mandatory services,  including those provided by primary and specialty care physicians, as well  as services provided in hospitals, clinics, and other settings. States may  elect to cover additional optional benefits and services, such as home and  community-based services, personal care, and rehabilitative services,  under their Medicaid programs. In some cases, not all beneficiaries are  eligible for all services. For example, Medicaid requires states to cover  necessary dental care for children, but dental coverage for adults is  optional. Subject to federal requirements, states may establish the  amount, duration, and scope of the mandatory and optional services  covered in their Medicaid programs. For example, states may limit the  number of visits or the days of care that are provided.

States are responsible for setting Medicaid provider payment rates within  certain federal requirements. Specifically, federal law requires that state  Medicaid payments to providers are consistent with efficiency, economy,  and quality of care and are sufficient to enroll enough providers so that  services are available to beneficiaries at least to the extent that they are  available to the general population in the same geographic area. In  addition, states must identify the methodologies for making provider  payments in their state plans, and such methodologies must be approved  by CMS.

In addition to payments made directly to providers for services to  beneficiaries, most states also make supplemental payments that are  separate from and in addition to regular Medicaid payments.  Supplemental payments include Disproportionate Share Hospital (DSH)  payments, which states are required by federal law to make to hospitals  that treat large numbers of Medicaid and low-income individuals; DSH  payments cannot exceed the unreimbursed cost of furnishing inpatient  and outpatient services to Medicaid beneficiaries and the uninsured.  Many states also make other optional supplemental payments that are  above the standard Medicaid payment rates but within the Upper   We refer to these payments as non-DSH  Payment Limit (UPL). supplemental payments. In fiscal year 2010, states and the federal  government made at least $32 billion in supplemental payments— representing over 8 percent of the Medicaid program’s total  expenditures—with a federal share of at least $19.8 billion. CMS is  responsible for overseeing these payment arrangements, including  whether states are appropriately financing their share.

States may also use provider taxes and certain other sources of revenue  to finance their Medicaid programs. Provider taxes are taxes, fees,  assessments, or other mandatory payments that states may impose on  the provision of or payment for certain types of health care items or  services, such as inpatient hospital and nursing facility services. States  may use revenue from provider taxes for their state share of Medicaid  expenditures only if the taxes meet certain criteria. Many states use  revenue from a provider tax on a certain type of provider to increase  Medicaid payment rates for the same type of provider, and a state could  effectively increase a payment rate for a provider without using additional  state funds to finance the increase if the revenue from the provider tax  and the federal share of the payment rates account for the total  increase.

See Pub. L. No. 111-3, § 104, 123 Stat. 8, 17-23. States are eligible for these  performance bonuses for fiscal years 2009 through 2013. Under continuous eligibility,  states allow children to remain eligible for Medicaid or CHIP for a full year before any  redetermination of eligibility, regardless of changes in household income. Under the  express lane eligibility option, states may rely on findings, including income data, from  certain other state agencies for Medicaid or CHIP eligibility determination. For  presumptive eligibility, states may allow qualified entities, such as, community-based  organizations or schools, to screen for eligibility and immediately enroll eligible individuals  for a defined period of time. apply for or renew enrollment in Medicaid using an electronic signature  beginning in 2014.

section_title: Some States Did Not Report Certain Application Processing Data; Most Reported Decreasing or Maintaining Processing Times
paragraphs: Of the 55 states that responded to our survey, 39 states provided specific  data on average application processing times for new Medicaid  applications in 2012, and 43 were able to report generally on whether  average application processing time increased, decreased, or remained  the same since 2008. The average application processing time is the  average number of calendar days between the receipt of a new  application and the final determination of eligibility. Among the 39 states  that reported data, the current application processing ranged from 11 to  45 calendar days, with a median of 25 calendar days.could not report their average processing times, of which about half noted  that they do not track these data or that they track them differently than  how they were requested in our survey. For example, 4 states noted that  they only tracked whether an application met the mandated time frames  for the application—not the specific number of days. Another state  reported that its data on application processing times were not reliable  because of differences in the way the data were reported by counties.

We also asked more generally whether states’ application processing  times changed since 2008. Of the 55 states that responded, 30 reported  decreasing (19 states) or maintaining (11 states) their average processing  times for new Medicaid applications, 13 states reported increased  processing times, and 12 states reported not knowing whether their  processing times had changed.

Among the 19 states that reported decreased average processing times  for new applications, 15 states attributed the decreases to efforts to  streamline application procedures. These 15 states most frequently  cited the use of electronic applications and the elimination of face-to-face  interviews as streamlining procedures that facilitated decreases in  application processing times. (See fig. 1.) Some of these 15 states also  cited a decrease in documentation requirements, use of express lane  eligibility, revised or shortened applications, or use of presumptive  eligibility for helping decrease application processing times. Specifically:

Six states reported that the use of express lane eligibility—the  reliance on findings from certain other state agencies or state income- tax data to determine eligibility for Medicaid—helped decrease  application processing time.

Five states reported that their decreased processing times were  related to the use of presumptive eligibility procedures, in which  authorized entities, including community-based organizations and  schools, can screen and immediately enroll eligible individuals into  Medicaid for a defined period of time.

A few states also attributed decreases in application processing times  to other factors not directly related to streamlining application  procedures, including additional staff or staff hours (3 states), more  intake facilities (2 states) or a reduction in the volume of new  applications received (1 state). (See app. II for further information on states’ efforts to use electronic  application processing and streamlining the renewal application process.)

Almost all of the 13 states that reported an increase in average  processing times since 2008 attributed these increases to a growth in the  volume of new applications received. (See fig. 2.) States could cite more  than one factor, and 9 of these states also identified reductions in staff as  a result of layoffs, hiring freezes, or furloughs as factors related to  increased application processing time. One state that reported an  increase in application processing times indicated that, in addition to an  increase in the volume of applications received, its staff were learning to  use a new computer system to process applications.

Because of data limitations, we were unable to assess the extent to which  the number of applications states processed kept pace with the number of  new applications received each month from January 2008 through  December 2011. Most states provided incomplete or inconsistent data on  new applications received and processed. For example, 25 states  provided incomplete data for 2008 and 15 states provided incomplete  information for 2011. States cited various reasons for providing  incomplete applications data, including upgrades to their data systems  since 2008 and data systems that do not differentiate between  applications received and applications processed. For the states that did  submit monthly applications data, there were differences among states in  the way these data were reported. For example, one state reported totals  of Medicaid applications processed that were cumulative over time, rather  than just those processed within a month. (For more information, see   app. I.)

section_title: States Made Numerous Changes to Provider Payments and Beneficiary Services
paragraphs: States reported changes—both increases and decreases—to provider  payment rates, provider taxes, and beneficiary services since 2008. In a  given year, states could make both increases and decreases; for  example, states could reduce payment rates to certain types of providers,  while increasing payment rates to others. Overall, more states reported  payment and service increases than decreases. However, the number of  states reporting payment decreases and service limitations grew since  2008.
subsections: section_title: The Number of States Reducing Providers’ Payments or Implementing Supplemental Payments Grew
paragraphs: The number of states that reported making at least one payment rate  reduction grew from 13 in 2008 to 34 in 2011, while the number of states  increasing at least one provider payment rate fell over the same period.  Overall, more states reported increasing provider payment rates in 2011  than reducing them. (See fig. 3.) States most frequently reported  reducing payment rates for hospitals across all 4 years. For example, in  2011, 19 states reported payment rate reductions for inpatient hospitals  and 17 reported reductions for outpatient hospitals. Of the states that  increased provider payment rates, more states generally reported  increasing payment rates for nursing facilities than any other provider  type across all 4 years. For example, in 2011, 19 states reported an  increase in rates for nursing facilities, 18 states reported increased  payment rates for Intermediate Care Facilities for Persons with  Intellectual Disabilities (ICF/ID), and 14 states reported increased  payment rates for clinics.

From 2008 through 2011, 20 or more states reported increasing their use  of supplemental payments, which are payments separate from and in  addition to regular Medicaid payments. This included both states that  added new supplemental payments or increased existing ones. The  number of states that reduced supplemental payments was greater in  2011 (10 states) than 2008 (4 states). (See fig. 4.) States most often cited  inpatient hospitals, outpatient hospitals, and nursing facilities as recipients  of new or increased supplemental payments across all years. These  increases in additional supplemental payments coincided with states  reporting more payment rate increases for nursing facilities and more rate  decreases for inpatient and outpatient hospitals.

The number of states implementing new or increasing existing provider  taxes more than doubled from 12 states in 2008 to 26 states in 2011. In  contrast, the number of states that reported decreasing or eliminating  provider taxes fell during the same time period—from 13 states in 2008 to  4 states in 2011. (See fig. 5.) Almost all of the provider taxes that states  reported implementing or increasing were for institutional providers— inpatient hospitals, outpatient hospitals, nursing facilities, inpatient mental  health providers, and ICF/ID. States most frequently reported that the  purpose was to avoid cuts in services or payment rates, rather than  expanding services or increasing provider payment rates.

The number of states reporting service increases was relatively stable— ranging from 26 to 31 states—while the number of states reporting  service limitations generally grew from 2008 through 2011. (See fig. 6.)  From 2008 through 2011, states reported making more changes to  coverage for dental, primary, and specialty care services and prescription  drug benefits than for other services. For example, in 2011, six states  reported increasing coverage for dental services, and nine states reported  decreases. Similarly, eight states reported that they increased  prescription drug formularies, and seven states reported that they limited  them in 2011. From 2008 through 2011, states reported the fewest  changes to coverage for ICF/ID and nursing facility services.

section_title: States Reported Challenges Ensuring a Sufficient Number of Providers
paragraphs: Thirty-eight states reported that they experienced challenges ensuring   In general, states attributed  enough participating Medicaid providers.these challenges to a shortage of providers and Medicaid payment rates,  but also cited other issues, such as missed appointments and  administrative burden, as factors that influenced provider participation.  States reported efforts to simplify administrative processes to retain and  attract Medicaid providers and, to a lesser extent, reported efforts to  increase payment rates or other financial incentives.
subsections: section_title: Over Two-Thirds of States Reported Challenges Ensuring Sufficient Providers, Including Dental and Specialty Providers
paragraphs: Of the 55 states responding to our survey, 38 states reported  experiencing challenges to ensuring enough participating providers for  Medicaid beneficiaries. Ensuring sufficient dental providers was  particularly challenging—but states also reported that ensuring sufficient  provider participation in specialty care was problematic. Specifically,  states most frequently reported having difficulty ensuring sufficient  Medicaid providers for psychiatry, obstetrics and gynecology, surgical  specialties, and pediatric services. To a lesser extent, states also cited  challenges ensuring enough dermatology and orthopedic service  providers. In contrast, fewer states indicated challenges to ensuring  adequate nursing facility and community long-term care providers. (See  fig. 7.)

To monitor provider participation, states reported using provider  enrollment data, utilization or claims data, and datasets such as the  Healthcare Effectiveness Data and Information Set. For example,   34 states reported that they analyze provider enrollment data and   24 states reported that they analyze utilization or claims data to monitor  provider participation in primary or specialty care, or both.18 states indicated that they have identified data sources that they plan to   Additionally,  use to meet future requirements to measure beneficiary access to  services under CMS’s proposed regulation, which if finalized, would  require states to conduct access reviews for a subset of services each  calendar year and release the results to the public. Most states reported  that they will analyze claims data or provider enrollment data to meet this  requirement. To a lesser extent, states noted that they will assess other  sources such as provider and beneficiary surveys as a means to measure  access to services in the state. States that use managed care  organizations also cited oversight of contract requirements as a way to  ensure access.

Our prior work also found that physicians reported difficulties referring Medicaid children  to specialists. See GAO, Medicaid and CHIP: Most Physicians Serve Covered Children  but Have Difficulty Referring Them for Specialty Care, GAO-11-624 (Washington, D.C.:  June 30, 2011). factors, such as the structure of the practice and Medicaid administrative  requirements can affect the decision to participate as well.

Another study of physicians found that, in light of the multiple factors that  may influence willingness to serve Medicaid beneficiaries, an increase in  Medicaid payment rates must be accompanied by other program  simplifications in order to influence physician participation. Similarly, in a  study on dental care, states reported particular challenges ensuring  enough participating dental providers. While this study found that dental  provider participation increased following rate increases in the states  examined, the rate increases were not sufficient on their own to improve  Medicaid beneficiaries’ access to dental care. The study also noted that  streamlining administrative processes and changing dentists’ perception  of Medicaid could improve participation among them as well.

section_title: States Implemented Administrative and Payment Changes to Encourage Provider Participation
paragraphs: Thirty-eight states reported making at least one administrative or payment  rate change to encourage provider participation. These efforts included  streamlining enrollment, increasing payments, increasing the speed of  claims processing, and reducing administrative burdens. (See fig. 8.)  Other efforts cited by states included direct recruitment of providers,  improved prior authorization of services, and assistance to providers  through training, education efforts, and improved claims resolution.

PPACA provided an increase in Medicaid payments for primary care  services in 2013 and 2014, and we asked states the extent to which these  payments will assist in increasing primary care participation. Of the   55 states that responded to this question, 24 indicated that they were  uncertain whether such an increase would assist the state in boosting  participation of Medicaid primary care providers. Seventeen states  reported that the increase will help to some extent, while 3 reported it will  help a great extent. Nine states reported that the increase will not help  with participation. Various states reported a number of possible reasons  that the increase may not help with provider participation, including its  temporary nature, because provider payment with the increase will still fall  below commercial rates, and because of a provider shortage in the state,  among other reasons.

section_title: Few Full-Year Medicaid Beneficiaries Reported Difficulty Obtaining Care, but Experiences Varied
paragraphs: In calendar years 2008 and 2009, less than 4 percent of all Medicaid  beneficiaries enrolled for a full year reported difficulty obtaining necessary  medical care or prescription medicines, a percentage similar to individuals  with full-year private insurance. The extent to which Medicaid  beneficiaries reported difficulties obtaining medical care varied by age  and whether they were enrolled for a full or partial year. Medicaid  beneficiaries also reported delaying care for a variety of reasons, most  commonly due to not having transportation, a long wait once at the  doctor’s office, and being unable to get an appointment soon enough.
subsections: section_title: Full-Year Medicaid Beneficiaries Reported Similar Difficulty Obtaining Needed Medical Care as Privately Insured Individuals
paragraphs: Beneficiaries covered by Medicaid for a full year reported low rates of  difficulty obtaining necessary medical care and prescription medicine,  similar to those with private insurance for a full year.2008 and 2009, approximately 3.7 percent of Medicaid beneficiaries  enrolled for a full year and 3 percent of individuals enrolled in private  insurance for a full year reported difficulties obtaining needed medical  care; the difference between these two groups was not statistically  significant. In addition, 2.7 percent of full-year Medicaid beneficiaries  reported difficulty obtaining needed prescription medicines and about   2.4 percent of individuals with full-year private insurance reported the  same issue—also not statistically significant. Full-year Medicaid   In calendar years  beneficiaries did however, report experiencing greater difficulty obtaining  necessary dental care than those with full-year private insurance. (See  fig. 9.) Individuals who were uninsured for a full year reported the greatest  difficulty obtaining medical care, prescription drugs, and dental services— at least twice the reported rate of full-year Medicaid beneficiaries.

The percentage of individuals experiencing difficulty accessing needed  care was higher for those who reported fair or poor health status, with  little difference in the rates between those with Medicaid or private health  insurance. Approximately 9.9 percent of full-year Medicaid beneficiaries  and 8.4 percent of individuals with full-year private insurance reporting fair  or poor health indicated difficulty obtaining necessary medical care;  again, the difference between these two groups was not statistically  significant. The percentage of individuals who were uninsured for an  entire year, reported being in fair or poor health, and indicated difficulty  obtaining medical care was significantly higher—approximately   29.3 percent.

section_title: Working-Age Adult Medicaid Beneficiaries Reported Greater Difficulties Obtaining Care Than Those with Private Insurance
paragraphs: When looking specifically at the experience of working-age adults,  individuals aged 18 through 64, we found differences between those  with Medicaid and those with private health insurance. Working-age  adults with full-year Medicaid coverage reported greater difficulty  obtaining needed medical care than similar adults with private health  insurance. Specifically, about 7.8 percent of working-age adults with full- year Medicaid reported difficulty obtaining care compared with   3.3 percent of similar adults with private insurance—a statistically  significant difference. With respect to dental care, working-age adults  with full-year Medicaid were nearly three times more likely to report  difficulty obtaining services than similar adults with private insurance, and  about six times more likely than children with Medicaid. Children with full- year Medicaid were reported to have no greater difficulties obtaining  dental care than children with full-year private insurance. (See fig. 10.)

Individuals with partial year health insurance—coverage for between 1  and 11 months—were more likely to report difficulties obtaining needed  care, whether covered by Medicaid or private health insurance. In  calendar years 2008 and 2009, the percentage of Medicaid beneficiaries  enrolled for a partial year who reported difficulties obtaining needed medical care was almost double that of full-year Medicaid beneficiaries.Similarly, individuals with private insurance for a partial year also reported  difficulties at more than double the rate of those with full year coverage.  Finally, individuals who were uninsured for a partial year reported less  difficulty obtaining care than those uninsured for a full year—likely  because they had some type of insurance for part of the year. There were  no statistically significant differences across all groups with partial year  coverage. (See fig. 1.)

Among working-age adults with Medicaid, 7.8 percent with full-year  coverage and 11.9 percent with partial-year coverage reported difficulty  obtaining necessary medical care. Those with partial year Medicaid were  more likely to report difficulty obtaining medical care than those with  partial year private insurance or who were uninsured for part of the year.  (See fig. 12).

Medicaid beneficiaries were more likely than individuals with private  insurance to report factors such as lack of transportation and long wait  time as reasons for delaying medical care. In 2009, approximately   9.6 percent of Medicaid beneficiaries reported delaying medical care  because they had no transportation, compared with less than 1 percent of  individuals with private insurance. Similarly, about 9.4 percent of Medicaid  beneficiaries indicated that they delayed medical care because they could  not get an appointment soon enough, or once they arrived for the  appointment, the wait was too long. In contrast, 4.2 percent of individuals  with private insurance reported delaying care because, once they arrived  for the appointment, the wait was too long. Individuals who were  uninsured were the most likely to cite cost as a reason for delaying care.  (See fig. 13.)

We provided a draft of this report to HHS for its review and comment.  HHS provided technical comments, which we incorporated as  appropriate. This report is intended for use by HHS management. We are  sending copies of this report to interested congressional committees and  members, and other interested parties. The report is also available at no  charge on the GAO website at http://www.gao.gov. If you or your staff  have any questions about this report, please contact me at (202) 512- 7114 or yocomc@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. Key contributors to this report are listed in appendix III.

section_title: Appendix I: Scope and Methodology
paragraphs: To examine states’ experiences processing Medicaid applications,  changes states made to provider payment rates and beneficiary services,  and challenges, if any, states face ensuring sufficient provider  participation, in February 2012 we surveyed Medicaid officials in all    The  50 states, the District of Columbia, and the 5 largest territories.survey was e-mailed to the Medicaid officials on February 22, 2012.  Respondents were initially given 3 weeks to respond, and extensions  were granted to encourage survey participation. The survey was available  online through May 22, 2012. Fifty states, the District of Columbia, and   4 U.S. territories completed the survey, for a response rate of 98 percent.  The U.S. Virgin Islands did not complete the survey.
subsections: section_title: Development and Analysis of GAO Survey of States
paragraphs: To examine states’ experiences processing Medicaid applications, states  were asked to report their current average processing time for new  regular Medicaid applications—those not based on disability—and how  those times changed since 2008.about the factors states attributed to any reported changes in the average  processing time for Medicaid applications. In addition, to assess the  extent to which states were keeping pace with processing new  applications, the survey asked for monthly data on the number of new  regular applications received and processed from January 2008 through  December 2011.

The survey also included questions  The survey also asked states about changes to benefits, provider  payment rates, provider taxes, and supplemental payments in each year  from 2008 through 2011. The questions in this section asked about  changes by provider and benefit type, including both those benefits that  are mandatory and optional. The survey asked, generally, about any changes by provider type (i.e., increased, decreased, eliminated, etc.)  and did not ask states to report the details of these changes. States could  report more than one type of change for a provider type in a year. For  example, a state could report both an increase and a decrease in a  provider payment rate for a given provider type in a year. The survey  asked whether the state made a particular change for a provider type in a  year and did not ask for the actual number of those changes it made in a  year or the magnitude of those changes. The survey also asked about the  purpose of any new or increased provider taxes, including avoiding cuts  in benefits, expanding benefits, avoiding cuts in payment rates, increasing  payment rates, or other purposes. Finally, states were asked to report any  changes to supplemental payments by provider type and the role of  provider taxes or county and local government funds in any changes to  the supplemental payments.

To examine any challenges to ensuring sufficient provider participation,  the survey included questions asking how states monitor whether they  have sufficient providers, which provider types are challenging for states  to ensure sufficient participation, and any steps the states have taken  since January 2008 to maintain their existing pools of providers. The  survey asked how the states monitor the sufficiency of providers across  three service delivery arrangements—fee-for-service, primary care case  management, and risk-based managed care organizations. The survey  included questions about any planned efforts to meet potential increases  in demand for primary care providers due to the Medicaid expansion  under the Patient Protection and Affordable Care Act as amended by the  Health Care and Education Reconciliation Act of 2010 (PPACA), and  whether the increase in payment rates for primary care providers under  PPACA would likely assist in increasing provider participation in Medicaid.  The survey also asked states about plans to measure access to care for  Medicaid beneficiaries in response to recently proposed federal  regulations that, if finalized, would provide a framework under which  states can demonstrate Medicaid payments are adequate for access to  providers.

We took steps in developing the survey and collecting and analyzing the  data to minimize nonsampling errors. However, any survey may  introduce nonsampling errors, such as difficulties in interpreting a  particular question or limited sources of information available to  respondents. We pretested the draft survey with Medicaid officials in  three states in January 2012 to ensure that the questions were relevant,  clearly stated, and easy to understand. The states selected for a pretest  were diverse with respect to the population size, geography, and total  Medicaid spending in 2009. We modified the survey as appropriate as a  result of the pretests. Finally, since this was a web-based survey,  respondents entered their answers directly into the electronic survey,  eliminating the need to key data into a database, which helps to minimize  error. We did not independently verify the data reported by states in the  survey; however, we reviewed published data submitted by state  Medicaid programs to us for another engagement and to outside  researchers to assess the reasonableness of the data reported. We also  assessed the internal consistency of answers to certain questions. We  determined that the data from the survey included in this report were  sufficiently reliable for the purposes of this report.

We used data provided in response to our 2010 survey of Medicaid directors to  determine any changes in states’ application processing volumes and rates between  October 2007 and February 2010. See GAO, Recovery Act: Increased Medicaid Funds  Aided Enrollment Growth, and Most States Reported Taking Steps to Sustain Their  Programs, GAO-11-58 (Washington, D.C.: Oct. 8, 2010).

One state official was not certain why the data would be reported  differently in the prior survey and suggested that it could be related to  interpretation of the prior survey question because the state does not  collect information in the way we requested it.

Officials from two states noted that there were changes in the staff  that responded to the survey and could not be certain why the data  reported were different.

An official from a third state indicated that the data provided to us in  2010 appeared to have included a broader array of applications (such  as those for disability, long-term care, and food stamps), noting that  the same application process is used for multiple programs in the  state.

section_title: Analysis of Other Federal Health Care Consumer Survey Data
paragraphs: To examine the extent to which Medicaid beneficiaries reported difficulties  obtaining care, we analyzed data from the Medical Expenditure Panel  Survey (MEPS) and the National Health Interview Survey (NHIS). MEPS  is administered by the Department of Health and Human Services’ (HHS)  Agency for Healthcare Research and Quality and collects data on the use  of specific health services; NHIS is conducted by the National Center for  Health Statistics, Centers for Disease Control and Prevention. We  analyzed results from the MEPS household component, which collects  data from a sample of families and individuals in selected communities  across the United States. These families and individuals are drawn from a  nationally representative subsample of households that participated in the  prior year’s NHIS.

Our MEPS analysis was based on data from surveys conducted in 2008  and 2009, the most recent data available at the time of our analysis.  MEPS includes insurance status for respondents for each month of the  year and NHIS includes respondent information on insurance status at a  point in time. Analyzing MEPS allowed us to use information on insurance  status for each month to create variables for full-year and partial-year  coverage. As a result, we determined that the MEPS insurance status  data provided more options to report on the extent to which Medicaid  beneficiaries reported difficulties obtaining medical care. In addition to  determining the extent to which full-year Medicaid beneficiaries had  difficulty accessing care, we also compared Medicaid beneficiaries’  reported experiences to the experience of respondents with private  insurance and respondents who were uninsured, in order to provide  context.Medicaid for a full year reported greater difficulty accessing medical care  than children in Medicaid or full-year Medicaid beneficiaries 65 and older.  We also compared full-year and partial-year Medicaid beneficiaries, to  determine if the extent of reported difficulties obtaining care varied by  length of coverage. Finally, we compared responses from full-year and  partial-year privately insured individuals, and full-year and partial-year  uninsured individuals to provide additional context for the Medicaid  beneficiaries’ reported difficulties.

Further, we examined whether working-age adults 18 to 64 in  The MEPS household interviews feature several rounds of interviewing  covering 2 full calendar years. MEPS is continuously fielded; each year a  new sample of households is introduced into the study. MEPS collects  information for each person in the household based on information  provided by one adult member of the household. This information  includes demographic characteristics, use of medical services, reasons  for medical visits, and health insurance coverage. We analyzed  responses to MEPS questions about individuals’ reported delays and  inability to obtain necessary medical care, dental care, and prescription  medicine, the reasons for those delays, and the perceived health status of  those individuals who delay or are unable to obtain care.

For the delays and inability to obtain care measures we used responses  to the following questions:  In the last 12 months, was anyone in the family delayed in getting  medical care, tests, or treatments they or a doctor believed  necessary?

Which of these best describes the main reason (PERSON)  (were/was) delayed in getting medical care, tests, or treatments  (he/she) or a doctor believed necessary?

In the last 12 months, was anyone in the family unable to obtain in  getting medical care, tests, or treatments they or a doctor believed  necessary?

Which of these best describes the main reason (PERSON)  (were/was) unable to obtain medical care, tests, or treatments  (he/she) or a doctor believed necessary?

We also analyzed responses to similar questions related to delays or the  inability to obtain needed dental care and prescription medicines. To  address sample size concerns and obtain frequencies above 100  responses, we combined data from 2008 and 2009 and the responses  from the questions on both the delays and inability to obtain needed  health care.

We examined the insurance status of respondents who answered that  they delayed or were unable to obtain needed health care. To  understand the differences in responses by insurance status we identified  the percentage of respondents who delayed or were unable to obtain care  with a variety of insurance statuses as well as those who were uninsured.  We looked at those respondents who indicated they had Medicaid and  private insurance for each month of the year, as well as looking at the  responses for those with Medicaid or private insurance for a partial year  (1-11 months). We also examined the percentage of respondents who  were uninsured for a full and partial year as well as those with mixed  insurance statuses, such as Medicaid part year and uninsured for part of  the year. In addition, we examined demographic variables—such as age,  sex, education, and perceived health status—for those respondents who  indicated they delayed or were unable to obtain care as well as those that  did not delay care. We also looked at responses to the questions by age  group and insurance status to identify potential differences. Small sample  sizes for some analyses limited the reliability of the results, and in those  cases, we did not report the analyses. In this report, we used a   95 percent confidence level and compared upper and lower confidence  intervals to determine whether any differences we found were statistically  significant. Statistical significance indicates that the difference between  observations is unlikely due to chance alone.

We supplemented our MEPS analysis with analysis of data from the 2009  NHIS survey. NHIS data are collected continuously throughout the year  for the National Center for Health Statistics, Centers for Disease Control  and Prevention, by interviewers from the U.S. Bureau of the Census.  NHIS collects information about the health and health care of the civilian,  noninstitutionalized U.S. population. Interviews are conducted in  respondents’ homes, but follow-ups to complete interviews may be  conducted over the telephone. We analyzed NHIS data to obtain  information on reasons Medicaid beneficiaries reported delays obtaining  needed medical care, and compared those to privately insured individuals  and the uninsured, for context. We analyzed NHIS data for these  questions because the sample size for those questions in NHIS was  larger than for similar questions on delays or the inability to obtain care in  MEPS. Because NHIS asks about insurance coverage at a point in time,  individuals identified as Medicaid beneficiaries would include those with  full-year and partial-year coverage. Data from the 2010 NHIS survey were  available, but we chose to analyze the 2009 survey so the time period  would be compatible with the MEPS analysis.

NHIS collects information from the civilian, noninstitutionalized population  about demographic characteristics, use of medical services, and health  insurance coverage and organizes the data into several data files. NHIS  collects information on each family member. More information is collected  on a randomly selected adult (the Sample Adult component) and a  randomly selected child (the Sample Child component) within each family  if a child is present. More information is collected on a sample of adults  and children within each family and household. To match the insurance  status variables with the answers to the selected questions, we merged  data from the Person file, which has information on each family member,  with the Sample Adult file, which has more information on sampled  adults. We analyzed responses to the following NHIS question from the  Person file of the survey: During the past 12 months, [have you delayed  seeking medical care/has medical care been delayed for anyone in the  family] because of worry about the cost?

From the Sample Adult component of the survey, we looked at the  following questions:

Have you delayed getting care for any of the following reasons in the  past 12 months?

You couldn’t get through on the telephone

You couldn’t get an appointment soon enough

Once you get there, you have to wait too long to see the doctor

The (clinic/doctor’s) office wasn’t open when you could get there

You didn’t have transportation.

We examined the insurance status of respondents to those questions  using the suggested variables for Medicaid, private insurance, and  uninsurance.

For all estimated percentages for both MEPS and NHIS, we calculated a  lower and upper bound at the 95 percent confidence level using the  appropriate sampling weights and survey design variables provided for  each survey.
subsections: section_title: Data Reliability for MEPS and NHIS
paragraphs: To determine the reliability of the MEPS and NHIS data, we reviewed  related documentation, and identified other studies that used MEPS to  address similar research questions to compare the published data with  our findings. We determined that the MEPS and NHIS data were  sufficiently reliable for the purposes of our report.

section_title: Appendix II: States Use of Electronic Medicaid Application Processing and Renewal Procedures
paragraphs: Given the potential of electronic application processing to reduce  processing time and related provisions of the Patient Protection and  Affordable Care Act of 2010 (PPACA), we asked all of the states about  their use of electronic application processing. PPACA required states to  begin to accept electronic signatures by 2014, as part of a coordinated  enrollment process that includes using a federally defined uniform  application and verifying income electronically through a federally  managed data hub.

We found states varied in the extent to which new Medicaid applications  were currently available and processed electronically. (See table 2.) For  example, fewer states reported that the application is submitted  electronically with an electronic signature than those reporting that the  application is available electronically. Twenty-six states reported the  percentage of their new Medicaid applications that were accessed,  signed, and submitted electronically. In these 26 states, the median  proportion of applications accessed, signed, and submitted electronically  was 25 percent. Only 11 states reported that the applications were  approved or denied electronically.

We also asked all states about their efforts to streamline processing  through improved renewal procedures, and a number of states reported  implementing procedures to streamline the renewal application process  for adults and children since 2008. (See table 3.) Such efforts can help  limit interruptions in Medicaid coverage for beneficiaries. For children, the  streamlined procedures states most frequently reported using were   12-month renewal periods, as opposed to shorter renewal periods;  telephone or electronic renewals, or both, instead of in-person interviews;  and prepopulated renewal forms.most commonly reported efforts were 12-month renewal periods and  telephone or electronic renewal, or both, instead of in-person interviews.

section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact

section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Sheila K. Avruch, Assistant  Director; Carolyn Fitzgerald; Sandra George; Mollie Hertel; Joanne Jee;  Eagan Kemp; Drew Long; JoAnn Martinez-Shriver; Janet Sparks; and  Hemi Tewarson made key contributions to this report.


Question-summary annotations: questions: question: What happened to average Medicaid processing times from 2008 to 2011?
answer: From 2008 to 2011, more than half of states reported maintaining or decreasing their average Medicaid application processing times--the average number of calendar days between the receipt of a new application and the final determination of eligibility. The average processing times reported by 39 states ranged from 11 to 45 calendar days.
child_questions: question: How is Medicaid processing time defined?
answer: From 2008 to 2011, more than half of states reported maintaining or decreasing their average Medicaid application processing times--the average number of calendar days between the receipt of a new application and the final determination of eligibility.

question: Why was GAO unable to assess whether states processed applications at a rate which kept pace with new applications?
answer: For the same time period, however, GAO was unable to assess whether states processed applications at a rate that kept pace with the number of new applications received each month, because most states provided incomplete or inconsistent data.

questions: question: How did Medicaid beneficiaries compare to individuals with private insurance in 2008 and 2009?
answer: In calendar years 2008 and 2009, less than 4 percent of beneficiaries who had Medicaid coverage for a full year reported difficulty obtaining medical care, which was similar to individuals with full-year private insurance; however, more Medicaid beneficiaries reported difficulty obtaining dental care than those with private insurance.
child_questions: question: How did beneficiaries with less than a full year of Medicaid coverage compare to those with full year coverage?
answer: Beneficiaries with less than a full year of Medicaid coverage were almost twice as likely to report difficulties obtaining medical care as those with full-year coverage.

question: Why did Medicaid beneficiaries delay care?
answer: Medicaid beneficiaries reported delaying care for reasons such as long wait times and lack of transportation.

questions: question: Why has Medicaid enrollment increased?
answer: Medicaid enrollment has grown significantly in recent years due to the economic downturn.
child_questions: question: Why is this growth expected to continue?
answer: This growth is expected to continue as the Patient Protection and Affordable Care Act potentially extends Medicaid eligibility in 2014 to millions of uninsured individuals.

question: What is the goal of this report?
answer: To better understand whether states are providing adequate access to medical care for beneficiaries, this report examines (1) states' experiences processing Medicaid applications, (2) states' changes to beneficiary services and provider payment rates, (3) the challenges states report to ensure sufficient provider participation, and (4) the extent to which Medicaid beneficiaries reported difficulties obtaining medical care.
child_questions: question: How did GAO gather data for this report?
answer: To examine the first three objectives, GAO administered a nationwide web-based survey to Medicaid officials on states' experiences from 2008 through 2011 and obtained a response rate of 98 percent. To examine the last objective, GAO analyzed data from the 2008 and 2009 Medical Expenditure Panel Survey, the most current available at the time of our analysis, to assess Medicaid beneficiaries' reported difficulties obtaining care, and the 2009 National Health Interview Survey to assess their reasons for delaying care. To provide context, we compared their experiences to those of individuals with private insurance or who were uninsured.