http://www.latimes.com/news/nationworld/nation/la-na-medicaid24apr24,0,3416218.story?coll=la-home-headlines
States Rein In Health Costs
Legislatures are looking to cut Medicaid or add fees. Missouri is poised to
end the program, which many of the poor rely upon for care.
By Stephanie
Simon
Times Staff Writer
April 24, 2005
SIKESTON, Mo. —
Hundreds of thousands of poor people across the nation will lose their
state-subsidized health insurance in the coming months as legislators scramble
to hold down the enormous — and ever-escalating — cost of Medicaid.
Here
in impoverished southeast Missouri, nurses at a family health clinic stash drug
samples for patients they know won't be able to afford their prescriptions after
their coverage is eliminated this summer. Doctors try to comfort waitresses,
sales clerks and others who will soon lose coverage for medical, dental and
mental healthcare.
"I don't know what cure to offer them," Dr. Hameed
Khaja said.
Lawmakers say they feel for those who will lose coverage. But
they say also that they have no alternative.
Prenatal checkups, care in
nursing homes and other health services for the poor and disabled account for
more than 25% of total spending in many states. Medicaid is often a state's
single biggest budget item, more expensive even than K-12 education. And the
price of services, especially prescription drugs and skilled nursing for the
elderly, continues to soar.
The federal government helps pay for
Medicaid, but in the coming fiscal year, the federal contribution will drop by
more than $1 billion because of changes in the cost-share formula. President
Bush has warned of far deeper cuts to come; he aims to reduce federal spending
on Medicaid by as much as $40 billion over the next decade.
"It's
frightening a lot of governors," said Diane Rowland, executive director of the
Kaiser Commission on Medicaid and the Uninsured.
Every state has frozen
or is trying to cut the fees they pay doctors to care for Medicaid patients.
More than a dozen states are looking for ways to cut the number of people
covered — or reduce their benefits. Several are proposing restructuring the
entire program.
In Tennessee, Gov. Phil Bredesen plans to end coverage
for more than 320,000 adults, many of them elderly. In California, Gov. Arnold
Schwarzenegger wants to shift more Medicaid recipients into managed care and
require some to pay monthly premiums.
Minnesota may stop insuring 27,000
college students and adults without children. Washington state may require
senior citizens to pay $3 for each prescription that Medicaid used to provide
for free.
South Carolina Gov. Mark Sanford and Florida Gov. Jeb Bush have
proposed privatizing Medicaid. Bush wants to give recipients vouchers so they
can shop around for their own insurance plans. Sanford wants to set up Medicaid
bank accounts; the state would deposit a fixed sum of money for each patient to
spend on medical expenses.
In Missouri, where nearly one in five
residents is enrolled in Medicaid, Gov. Matt Blunt is poised to sign the most
drastic overhaul of all: a bill that would eliminate the program entirely in
three years.
Blunt expects that by then, the state will have established
an alternative mechanism for helping the poorest of the poor. But the
legislation on his desk does not insist on it. It only states that Missouri
Medicaid will cease on June 30, 2008.
In the meantime, the bill severely
cuts the existing program, ending coverage for an estimated 65,000 to 100,000
people.
Legislators are still working out eligibility details. But under
one leading proposal a single mother of two who earns $3,800 a year would be
considered too wealthy to qualify for Missouri Medicaid. The woman's children
would still be eligible for free healthcare. But if she gets a better job and
starts earning $23,000 a year, they, too, would be bumped off Medicaid — unless
she's willing to pay as much as 5% of her income in monthly premiums. The state
expects many parents at that income level would be unable or unwilling to pay
the premiums, forcing about 24,000 children off the Medicaid
rolls.
Children who remain on Medicaid would continue to receive full
benefits, but under legislation expected to take effect this summer, most adults
would get a bare-bones package. The program would no longer pay for their dental
care, hearing aids, eyeglasses, wheelchairs, hospital beds or even
bedpans.
State Rep. Trent Skaggs, a Democrat from Kansas City, considers
the new rules cruel, especially at a time when more than 45 million Americans
lack insurance. He worries parents will stop working so their income will drop
low enough to qualify their family for free care.
Rather than raise costs
for minimum-wage clerks, Skaggs suggests increasing insurance premiums for
lawmakers who get health coverage through the state. He recently introduced a
measure that would have cost the average politician $115 a month — the measure
failed on a close vote.
"That made a complete mockery of the idea that
leaders sacrifice first," Skaggs said. "Times are tough, but not so tough that
we have to sacrifice?"
The Republican lawmakers who have been leading the
Medicaid overhaul drive say such criticism distorts their goals.
The cuts
are not just about balancing this year's budget, they say. They're about
steering Medicaid back to its original purpose: to serve as safety net for
citizens who are too young, too old, or too ill to help themselves. Turning
Medicaid into a welfare program for poor but able-bodied adults risks jacking up
the costs so high, they say, that the entire system could go bust — stranding
those who most desperately need the state's help.
The cost of Missouri
Medicaid has doubled in the last six years, to $5 billion. It eats up more than
30% of the state budget. More than 1 million people are
enrolled.
"Government is not here to do everything for everybody," said
state Rep. Jodi Stefanick, a Republican representing suburban St. Louis. "We
have to draw the line somewhere."
Medicaid was enacted in 1965 as a joint
federal-state program to provide basic care for poor children, pregnant women
and people with disabilities. States administer the program and pay 20% to 50%
of the total costs. The federal government funds the remainder. (The federal
contribution varies from state to state, with the poorest states receiving the
largest amounts.)
States can opt out of Medicaid, but since 1982 every
state has participated. By law, they must offer specific benefit packages to
certain groups, including poor pregnant women and young children. They are also
free to go beyond those minimum standards.
Historically, lawmakers have
considered it a bargain to go beyond because the federal government pays for so
much of the program. So states from California to Maine have expanded Medicaid
to cover working parents, lower-middle-class children and elderly citizens
struggling to pay for the many services not funded by Medicare.
The
result: Medicaid now covers 53 million Americans. The program pays the bills for
nearly 60% of all nursing home residents and finances 37% of all births. Because
most states have added prescription drug benefits, Medicaid covers the hefty
pharmacy bills for many patients with AIDS, many transplant recipients and many
senior citizens on dialysis or undergoing chemotherapy.
The program also
covers the more mundane medical expenses of low-income working
families.
Here in Sikeston, Dianna Dixon, 18, relies on Medicaid because
her 30-hour-a-week job at Wal-Mart does not come with insurance. Her mother,
Donna Sevic, uses Medicaid, too, now that arthritis has forced her to stop
working after years in low-wage restaurant, sales and factory
jobs.
Waiting in the Southern Missouri Health Network's clinic the other
day to ask a doctor about Dixon's headaches, the women said they expected to
lose their coverage this summer. Sevic, 50, said the loss would be devastating;
she wasn't sure how she would afford her medications, much less any doctor
visits.
"If they take it away from me, I'll just go downhill," Sevic
said. "I won't be here much longer. It's that plain and simple." Eyes weary, she
said she thought she deserved better: "If you get out and try, really try to
make a living, the government ought to step in and help you."
That
philosophy still resonates in some states.
In Kansas, Gov. Kathleen
Sebelius has proposed raising cigarette taxes to pay for expanding Medicaid to
cover more poor working adults.
In Illinois, an expansion is underway. In
the last two years, Gov. Rod Blagojevich has added tens of thousands of children
to the Medicaid rolls — and tens of thousands of parents, as well. "I can't
think of anything more important to do," he said.
"Healthy families are
working families," added Barry Maram, director of the Illinois Department of
Public Aid. "This makes all the economic sense in the world."
The
Republicans who dominate the state Legislature in neighboring Missouri offer a
different definition of economic sense.
"We're careening out of control,"
said state Sen. Michael Gibbons, who represents suburban St. Louis. "Taxpayers
are not an endless supply of money."
The cutbacks that Gibbons helped
craft will save the state $250 million next fiscal year.
They may also
cost 73-year-old Mary Bostic her dream of eating something other than soup for
supper.
Bostic, a retired garment-factory worker, has been coming to the
clinic in Sikeston for months. In the olive-drab dental exam rooms, Dr. Gail
Redman has extracted the crumbling stumps of her rotting teeth, one by
one.
Bostic's new top denture plate should be arriving soon. She was
expecting to get a bottom plate as well. "I was looking forward to a solid
meal," she said.
But the clinic is booked solid for the next six months;
there's no time to get her the bottom denture before her Medicaid coverage runs
out. Without the insurance, Bostic can't even contemplate paying for a bottom
plate; it would cost her $375 at the clinic's discount rate.
She has
trouble understanding why she's in this fix.
"I've worked all my life,"
Bostic said. "I've paid my taxes. And now, when I get down and out, they don't
want to help me."
The clinic's hygienists are starting to call other
patients who have been waiting for dentures, to break the news. Their list runs
seven pages long.
"It breaks your heart," Redman said, in tears. "They've
been waiting so long to get teeth."
In appropriations conferences this
week, Missouri legislators could restore some dental care or other benefits to
the Medicaid package. They may also ease up slightly on the eligibility
restrictions. But given the state's budget constraints — and the majority
party's philosophical stance on Medicaid — analysts don't expect a substantial
retreat.
That's as it should be, lawmaker Stefanick said. "Once you put a
benefit out there, reining it in is not easy," she said. "But it is the
responsible thing to do."
*
Major expenseFor most
states, Medicaid expenses are often the single largest line item on the budget,
exceeding K-12 education. States spending the most on Medicaid as a percentage
of fiscal 2004 budgets:
Tennessee... 33.3%
Missouri
...30.7
Pennsylvania ...29.5
Maine ...29.0
New York
...28.3
Illinois... 28.1
Vermont ...27.5
New Hampshire...
26.4
Mississippi... 26.3
Rhode Island ...25.5
Who
receives Medicaid
• 25 million
children
• 13 million low-income adults, including pregnant
women
• 15 million seniors and people with
disabilities
Medicaid benefits
By federal
law, states must provide certain benefits for Medicaid recipients,
including:
• Inpatient and outpatient hospital
services
• Physician, psychiatrist and nurse practitioner
visits
• Nursing home and home healthcare for adults
•
Family-planning services and supplies
• Lab and X-ray
services
• Transportation to medical appointments
Sources:
Health Management Associates; National Assn. of State Budget Officers; the
Kaiser Commission on Medicaid and the Uninsured
Times staff writer John-Thor Dahlburg in Miami contributed to this
report.
