Medicaid Expansion in Arizona
By Colar Kuhns, DMD and MPH candidate, A.T. Still University
Digital Exclusive - December 2022
The National Health Expenditure (NHE) or portion of the United States budget allocated towards healthcare including public and private insurance, health research, and public health activities such as the CDC accounts for nearly twenty percent of the annual federal budget.(1) Medicare and Medicaid spending combine for roughly thirteen percent of the NHE and are projected to grow by approximately five and a half percent annually through 2028.(2) Increased Medicare and Medicaid spending has also been noted in Arizona, which correlates with the additional seven hundred and twenty thousand people that have moved to Arizona since 2010.(3) Medical providers may gain insight about the future trends in Arizona’s public health insurance through an understanding of Arizona’s Medicaid system and areas of the state where coverage has expanded.
Arizona Medicaid or Arizona’s Health Care Cost Containment System (AHCCCS) was formed in 1982 to provide health care access to low-income individuals and their families.(4) To qualify for Medicaid, income, and the number of dependent(s) of a taxable entity (individual or family) are compared to the federal poverty level (FPL), and both the Affordable Care Act (ACA) as well as the COVID-19 pandemic(5) have increased the number of individuals who qualify.(6) Application for Medicaid coverage occurs through the AHCCCS website. Qualified applicants may also apply for additional monthly stipends which are offered through the AHCCCS namely nutrition assistance, cash assistance, and tuberculosis assistance for individuals who cannot work due to a tuberculosis infection.(7) Individuals who do not qualify for Medicaid coverage because their annual income is between 138% and 400% of the FPL can purchase health coverage through the AHCCCS and receive premium subsidies, which effectively pay for 80-90 percent of a health plan’s monthly premium.(8) When the COVID-19 pandemic began, the federal government’s declaration of a Public Health Emergency (PHE) resulted in the enactment of new legislation namely the Families First Coronavirus Response Act, which increased federal Medicaid assistance to states by 6.2 percent.(9) As the national PHE comes to an end, the same Medicaid funding allotted to states during the pandemic will no longer be available, so maintenance of eligibility is currently being evaluated to determine revised Medicaid qualifications and how to restructure spending to serve the most deserving individuals.(10)
Reports have been conducted to track the growth of public health coverage in Arizona. The Arizona Department of Health Services evaluated medically underserved areas within metro, rural/frontier, and tribal geographies utilizing several metrics namely population-to-primary care physician ratio, travel distance to nearest primary care physician (PCP), poverty, and health insurance status.(11) As of October 2022, roughly twenty-three percent of Arizona had less than one PCP per five thousand people, or no PCP was reported for a population of Arizonans at all.(12) Although many tribal areas were deemed as medically underserved, the more notable urban medically underserved areas were Glendale, Tucson, and Guadalupe.(13) Flagstaff, Mesa, Scottsdale, and Phoenix are Arizona cities where public health insurance coverage has expanded over the last decade.(14) Figure 1 displays the change in Medicaid coverage versus uninsurance rates across Arizona since 2008, where the general trend has been that the uninsurance rate across Arizona has decreased while Medicaid enrollment has increased.(15)
There have been several proposed ideas to improve coverage across medically underserved areas in Arizona. One thought is to expand the Arizona Area Health Education Centers Program in conjunction with the Rural Health Professions Program, which is set to receive over seven million dollars in combined state and federal funding over the next five years. The programs provide over three thousand community-based experiential training rotations focused on serving rural and urban medically underserved communities, so by expanding the programs, Arizona increases its medical care offerings across underserved areas.(16) Another idea is allocating state funding to a pathway program. Other states, Virginia most notably, have established pathway programs, which introduce kindergarten through college age students to careers in health care. Established pathway programs have been shown to improve health care provider recruitment and retention, which benefit Health Professional Shortage Areas.(17) Additionally, in February 2022, Senator Nancy Barto proposed Senate Bill 1331, which grants internationally trained physicians the ability to practice in Arizona, albeit in rural areas of the state.(18) Senate Bill 1331 outlines provisions for internationally trained physicians to bypass medical residency in America, offering a sort of reciprocity to physicians who successfully obtained their medical practice license internationally.(19) The challenge with such a bill is that there is currently a lack of residencies for medical students to attend20 , so creating an influx of physicians in Arizona would further limit the available job opportunities for graduating US medical residents that wish to practice in the state.
Statistically speaking, some of the most medically underserved areas of Arizona exist in metropolitan areas(21) and while physicians preferentially elect to practice in urban areas of the state compared to rural or tribal areas,(22) only physicians who have completed their clinical training in Federally Qualified Health Center based programs favor job opportunities with medically underserved populations.(23) Therefore, for Arizona to improve coverage across medically underserved areas of the state, increased state funding of teaching health center residencies(24) should be considered as the residencies produce more physicians who are inclined to choose a career with underserved populations. Additionally, restructuring medical residencies to produce more practicing physicians would benefit Health Professional Shortage Areas across the state. While the state of Arizona may not have the funding necessary to create more medical residencies, private insurance carriers that operate in Arizona could be contracted by the state to fund new medical residency programs which would produce more practicing physicians in Arizona. Even if graduating physicians of the health insurance carrier backed residency programs would have some time commitment to be in-network providers of a carrier, Arizona would have more practicing physicians, which is a win-win situation for Arizona and medical insurance carriers alike.(25)
Citations
1. Centers for Disease Control and Prevention. (2022, August 12). Health Care Expenditures. Centers for Disease Control and Prevention. Retrieved November 16, 2022, from https://www.cdc.gov/nchs/hus/topics/health-care-expenditures.htm#ref1
2. NHE Fact Sheet. CMS. (2022, August 12). Retrieved November 16, 2022, from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet
3. Arizona population by year, county, race, & more. USAFacts. (2022, November 15). Retrieved November 16, 2022, from https://usafacts.org/data/topics/people-society/population-and-demographics/our-changing-population/state/arizona
4. A Brief History of AHCCCS Highlights. AHCCCS. (2022, July). Retrieved November 16, 2022, from https://www.azahcccs.gov/AHCCCS/Downloads/ABriefHistoryOfAHCCCS.pdf
5. Sacia, E. (2022, April 14). Covid-related Medicaid coverage extended – for now – for 500,000 Arizonans. Arizona Mirror. Retrieved November 16, 2022, from https://www.azmirror.com/2022/04/14/covid-related-medicaid-coverage-extended-for-now-for-500000-arizonans/
6. Affordable care act (ACA). HealthCare.gov. (2022). Retrieved November 16, 2022, from https://www.healthcare.gov/glossary/affordable-care-act/
7. Arizona Department of Economic Security. healthearizonaplus.gov. (2022, October). Retrieved November 17, 2022, from https://des.az.gov/sites/default/files/dl/FAA-0001A.pdf
8. What are premium subsidies? healthinsurance.org. (2022, July 7). Retrieved November 17, 2022, from https://www.healthinsurance.org/glossary/premium-subsidies/
9. Musumeci, M. B. (2021, January 25). Key issues for state Medicaid programs when the COVID-19 Public Health Emergency ends. KFF. Retrieved November 17, 2022, from https://www.kff.org/medicaid/issue-brief/key-issues-for-state-medicaid-programs-when-the-covid-19-public-health-emergency-ends/
10. Musumeci, M. B., & Dolan, R. (2020, December 17). Medicaid maintenance of eligibility (MOE) Requirements: Issues To Watch. KFF. Retrieved November 17, 2022, from https://www.kff.org/medicaid/issue-brief/medicaid-maintenance-of-eligibility-moe-requirements-issues-to-watch/
11. Arizona Medically Underserved Areas. azdhs.gov. (2022, October). Retrieved November 17, 2022, from https://www.azdhs.gov/documents/prevention/health-systems-development/data-reports-maps/reports/datadocu.pdf
12. Ibid
13. Ibid
14. Ibid
15. Health insurance coverage of the total population (CPS). KFF. (2022, September 21). Retrieved November 17, 2022, from https://www.kff.org/other/state-indicator/health-insurance-coverage-of-the-total-population-cps/?currentTimeframe=0&selectedDistributions=medicaid--uninsured&sortModel=%7B%22colId%22%3A%22Location%22%2C%22sort%22%3A%22asc%22%7D
16. Bauzá, M. (2022, October 26). $7.2m in funding will boost health care workforce in rural, underserved communities. UArizona Health Sciences. Retrieved November 25, 2022, from https://healthsciences.arizona.edu/newsroom/news-releases/1022/72m-funding-will-boost-health-care-workforce-rural-underserved
17. Garcia, A., & Enlund, S. (2017, October 10). Improving Access to Care in Rural and Underserved Communities: State Workforce Strategies. ncsl.org. Retrieved November 25, 2022, from https://www.ncsl.org/research/health/improving-access-to-care-in-rural-and-underserved-communities-state-workforce-strategies.aspx
18. Arizona needs more doctors. Arizona Capitol Times | Your Inside Source for Arizona Government, Politics and Business. (2022, February 6). Retrieved November 17, 2022, from https://azcapitoltimes.com/news/2022/02/06/arizona-needs-more-doctors/
19. Ibid
20. Bernard, R. (2021, April 14). Match day 2021 brings uncertain future for many graduating medical students. Medical Economics. Retrieved November 17, 2022, from https://www.medicaleconomics.com/view/match-day-2021-brings-uncertain-future-for-many-graduating-medical-students
21. Arizona Medically Underserved Areas. azdhs.gov. (2022, October). Retrieved November 17, 2022, from https://www.azdhs.gov/documents/prevention/health-systems-development/data-reports-maps/reports/datadocu.pdf
22. Rosenthal, M. B., Zaslavsky, A., & Newhouse, J. P. (2005, December). The geographic distribution of physicians revisited. Health services research. Retrieved November 17, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361233/
23. Davis, C. S., Roy, T., Peterson, L. E., & Bazemore, A. W. (2022, October 14). Evaluating the teaching health center graduate medical education model at 10 years: Practice-based outcomes and opportunities. Allen Press. Retrieved November 17, 2022, from https://www.meridian.allenpress.com/jgme/article/14/5/599/487458/Evaluating-the-Teaching-Health-Center-Graduate
24. Ibid
25. Gonzales, A. (2017, February 10). Physician bottleneck: Why Arizona must seek more ways to educate new doctors. Bizjournals.com. Retrieved November 25, 2022, from https://www.bizjournals.com/phoenix/news/2017/02/10/physician-bottleneck-why-arizona-must-seek-more.html