Medicaid budgets undergo surgery
By Stephanie Simon
Los Angeles Times
ELAINE THOMPSON / AP
Possible changes: co-pays, new rules on assets
Church clinics help bridge gap for working uninsured
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 southeastern 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 soon will lose coverage for medical, dental and mental-health care.
"I don't know what cure to offer them," Dr. Hameed Khaja said helplessly.
Lawmakers say they feel for people who will lose coverage. But they say they have no alternative.
Prenatal checkups, nursing-home care and other health services for the poor and disabled account for more than 25 percent 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 due to 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 an estimated $40 billion over the next decade.
Every state is looking for ways to cut its own Medicaid costs.
In Tennessee, Democratic Gov. Phil Bredesen plans to end coverage for more than 320,000 adults, many of them elderly.
Minnesota might stop insuring 27,000 college students and adults without children.
Washington state might require senior citizens to pay $3 for each prescription that Medicaid used to provide free.
South Carolina Gov. Mark Sanford and Florida Gov. Jeb Bush, both Republicans, have proposed privatizing Medicaid. Bush wants to give recipients vouchers so they can shop around for their own insurance plan. 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, Republican Gov. Matt Blunt is poised to sign the most drastic overhaul of all: a bill that will 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 states only 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.
A single mother of two who earns $3,800 a year will be considered too wealthy to qualify for Missouri Medicaid under the legislation, which is due to take effect this summer. The woman's children will be eligible for free health care. But if she gets a better job and starts earning $23,000 a year, they, too, will be bumped off Medicaid — unless she's willing to pay as much as 5 percent 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 will continue to receive full benefits, but most adults will get a bare-bones package. The program no longer will 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 raising 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.
"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 drive to change Medicaid 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 a safety net for citizens 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 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 past six years, to $5 billion. It eats up more than 30 percent of the state budget. More than 1 million people are enrolled.
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 percent to 50 percent 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.
Medicaid now covers 53 million Americans. The program pays the bills for nearly 60 percent of all nursing-home residents and finances 37 percent 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 seniors on dialysis or 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 recently to ask a doctor about Dixon's headaches, the women said they expect to lose their coverage this summer. Sevic, 50, said the loss would be devastating; she's not sure how she will afford her medications, much less any doctor visits.
"If they take it away from me, I'll just go downhill," she said. "I won't be here much longer. It's that plain and simple." Eyes weary, she said she thinks she deserves 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, Democratic Gov. Kathleen Sebelius has proposed raising cigarette taxes to pay for expanding Medicaid to cover more poor working adults.
In Illinois, an expansion is under way. In the past two years, Democratic 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," said Barry Maram, who runs the Illinois Department of Public Aid. "This makes all the economic sense in the world."
The Republicans who dominate the Legislature in neighboring Missouri offer a different definition of economic sense.
"We're careening out of control," said state Sen. Michael Gibbons. "Taxpayers are not an endless supply of money."
Copyright © 2005 The Seattle Times Company
seattletimes.nwsource.com |
