How Medicaid is under political attack

by Rishi Manchanda, MD, MPH

Mr. M walked into the community clinic where I work with a portable oxygen tank in tow. At 62, he’s gaunt and winded, battling a disease that is progressively scarring his lungs. Every breath is a fight. Instead of the clear flow of air, I hear the sound of velcro ripping when I place my stethoscope on his chest. In medicine, his illness is idiopathic, which means the cause is a mystery.

But the cause of his distress yesterday was clear. Medicaid, which helps nearly one in every four Americans and could be a lifeline for my patient, is under attack.

Despite working hard for most of his life, Mr. M is uninsured. His medicines are expensive and, without insurance, the odds of getting more intensive treatment are slim. Hoping to change the odds, he applied for Medicaid. But now plans like the State Flexibility Act are working their way through Congress, on the heels of the recently defeated Ryan budget plan. And 2012 federal budget negotiations are starting with a $100 billion cut to Medicaid. These proposals will make it easier for states to kick people off Medicaid and reduce eligibility, keeping people like Mr. M away. Instead of trying to improve health care and help those in need, some are debating ways to take the lifeline of Medicaid away from seniors, the disabled, low-income adults and children. That’s a prescription for disaster.

Most Americans agree. A poll by the Kaiser Family Foundation found that only 13 percent of Americans would support major reductions in Medicaid spending as part of Congress’ efforts to reduce the deficit. A majority, 53 percent, want to see no reductions in Medicaid spending at all.

This support is well-founded. One out of every two Americans has either received Medicaid benefits, like direct health coverage, long-term care, or Medicare premium assistance, or knows a relative or close friend who has. Many realize what the Center on Budget and Policy Priorities has confirmed. Medicaid is cost-effective. After adjusting for health differences among enrollees, the per-capita costs of Medicaid for children and adults are 27% and 20% cheaper, respectively, compared to private insurers.

Yet, at a time when Americans like Mr. M need it most, Medicaid is under attack. At least 25 states are trying to further cut benefits and provider rates, restrict eligibility or increase cost-sharing for the poor. Through the State Flexibility Act, some lawmakers want to repeal a component of the Affordable Care Act which requires most states to preserve current eligibility levels and enrollment procedures for most adults and children. If passed, it will mean that community clinics like ours which have managed to stay open despite massive state budget cuts will have a hard time staying afloat. Without access to care, Mr. M is more likely to end up in overburdened emergency rooms or hospitals.

Whether by intent or irony, these and similar block-grant plans will restrict opportunity in the name of “state flexibility” by cutting care, prolonging illness, and driving up health care costs. The risk is real. If Congress jettisons Medicaid in budget reconciliation or in a deal to extend the debt limit, tens of millions of children, seniors and the disabled will face catastrophic threats to their health and security.

Lawmakers would be wise to protect Medicaid, heed voter sentiment and consider smarter approaches to save costs and improve health care. First, states should take advantage of available enhanced federal funding to set up “health homes.” These models not only better coordinate the care of chronically ill Medicaid beneficiaries but also drive down costs. A pilot Medicaid medical home program saved North Carolina nearly $170 million in its first year. Illinois saved $220 million in a similar program over two years and an additional $300 million over 3 years by helping Medicaid patients with chronic diseases adhere to their medicines. States should also align funding and “health home” models to scale up prevention initiatives like Community Transformation Grants, made available under health reform to help local communities address root causes of costly disease. With fast-track support offered by the US Department of Health and Human Services, states can scale up community-based care managers, who can significantly reduce unnecessary patient visits to emergency rooms and hospitals by coordinating prevention and treatment. A care management initiative in California reduced hospital admissions due to asthma by 90%. Lastly, states should raise the bar set by the Affordable Care Act by further incentivizing Medicaid providers to reduce avoidable complications, like hospital-acquired infections. These measures will lower costs and improve outcomes for our sickest relatives, neighbors, and communities.

Protecting and improving Medicaid is an uphill battle, in large part because children and the disabled lack political power. So efforts to bring the voices of patients like Mr. M and providers into the democratic process are vital. The question is whether our leaders have the political and moral courage to listen. Our nation’s health depends on it.

Rishi Manchanda is founder of Rx Democracy!

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  • ninguem

    Sounds like the patient in question is a candidate for Social Security disability. I hope they’re working on that. I have to remind patients of this, on many occasions. It’s not a perfect fix, it takes a couple years for Medicare to kick in, but it’s better than nothing.

  • Deep Ramachandran

    I enjoyed your insightful article, and indeed I see many of the same situations in my practice. (I recently wrote a post at my blog from a societal perspective specifically related to the increasing costs of medicare.)
    Unfortunately I think the scenario you described is one which we will see with increasing frequency. While innovative strategies like the ones you describe are essential to get more for our health care dollar, I think ultimately much of the low hanging fruit of cost control seems to have been already picked. Ultimately we can not get away from the fact that the current level of health care spending can not be sustained indefinitely. In order to preserve our health care system there will likely need to be a combination of decreased spending (i.e. reduced benefits and provider payments) and increased revenue (i.e. taxes).

  • Dorothy Green

    I agree that so much more has to be done to fix healthcare in the US – as you demonstrated with the man who has a horrific disease of unknown origin trying to navigate a disorganized, cost-inefficient, poorly funded part of US healthcare. I don’t know where the “100 billion” is being cut in Medicaid and a great deal of Medicaid goes to long-term care – but it should be where there is fraud, overuse, etc as that is what the 500 B cuts are seem to be in Medicare.

    I too believe that the raising revenue (i.e. taxes) will be necessary, even with all the changes. However, I truly believe it is time to stop taxing middle income to pay for increasing cost of health care when it is now well known that sugar, fat and salt, primarily in processed food are the major culprits of RISK to the diseases that eat the most healthcare dollars. Smokers now must fork over a lot up front to pay for their risk and it has had a huge impact on decreasing the number of smokers and helping pay the health care costs.

    Second, a VAT tax – it’s time to collect revenue up front and personal. There are a lot of people in the US who have a lot of stuff who pay little to no income taxes.

    Other rich countries are way ahead of the US in using VAT AND in battling Big Ag. While they too have problems with their healthcare systems, none of these problems are as pervasive as the US and their primary goal is to have a healthy population – which includes people like the man you described in the this article – he wouldn’t have had to go through all the hassles of getting, keeping healthcare that worsen his condition.

  • Penny

    Sad but it’s happening all over now. Same thing in Canada. I don’t care what stats say. They can make any data show anything they want, true or false. It’s my feeling they have been trying to wipe out everyone over 60 for the last several years by denying treatment. I suppose they figure that if they kill off enough seniors they can recover the economy by saving on their pension plans. Never before have I seen so many people under 65 ending up in palliative care, and of course once they get there, they’re finished off pretty quickly.