Waiting for Action
Right Words but Little Practical Help for Poor
By David S. Broder
The Washington Post
September 22, 2005
Medical care for the evacuees from Louisiana, Mississippi and Alabama is urgently required. As Mark McClellan, the top federal health official in the Department of Health and Human Services (head of CMS), said last week, “The best and fastest way to provide help to evacuees is to support the state programs in place and support the local health care providers already in place, not to take time to build major new systems.”
The way to do that, he said, is to make the evacuees eligible for Medicaid for the next few months so they will know that their hospital, doctor and medication bills will be paid.
The governors, through their national association, agreed, and a measure to make all the evacuees Medicaid-eligible for the next five months (with an option for the president to extend the time) is pending before the Senate in a bill sponsored by the leaders of both parties and the chairman and ranking Democrat on the Finance Committee.
But it appears that the Bush administration, rather than backing this simple and effective measure, is insisting on a slower, more cumbersome approach, requiring each state to negotiate its own waiver from the rules limiting eligibility for Medicaid benefits.
Officials at the National Governors Association, who back the bipartisan bill, said they are not clear why the administration is balking at this simple solution. McClellan told me in an interview that “we’re meeting all the needs” with the waiver approach. But with evacuees spread among all the states, it’s hard to believe that’s true.
http://www.washingtonpost.com/wp-dyn/content/article/2005/09/21/AR2005092102510.html
Comment: Waivers? What is so urgent about waivers that the process of providing health care coverage for the evacuees should be delayed until waivers can be negotiated? Well, let’s take a look at these Medicaid waivers.
When the government is controlled by people who don’t believe in government, one of the first priorities is to cut wasteful spending. And what could be more “wasteful” than Medicaid, a program to fund health care for a sector without a political voice, those living in poverty?
Since its enactment almost four decades ago, the government has used a passive but highly effective mechanism of controlling Medicaid spending:
inflation. Without adequate adjustments for inflation, many providers now fund part of the care for their Medicaid patients since their overhead expenses are greater than their Medicaid reimbursement. Normally, an administration looking for methods to reduce costs in a welfare program would immediately target profits, but that is not an option since profits disappeared many years ago. So what other option might there be?
When Medicaid was established, it was recognized that the individuals living in poverty did not have affordable access to any health care services (except “county,” and anyone who was around then remembers that “county” did not equate with access). Consequently, the benefit package established by the enabling legislation was very generous, including most services that were appropriate. The budget cutters of today recognized that they could sell the concept that these benefits were more generous than what the poor folks should be “entitled” to, and thus trimming benefits became another mechanism of containing Medicaid spending. The problem is that the benefits were fixed in law, and so a waiver process had to be established in order to circumvent the requirements.
It was decided that the waiver process should be budget neutral, that Medicaid funds could be shifted to the growing numbers of low-income uninsured individuals, as long as the process did not increase total Medicaid spending. As an example, then-Governor Michael Leavitt obtained a waiver for Utah from HHS (federal Health and Human Services) that would expand coverage to more individuals, but exclude coverage for hospitalization and specialist services. Although this was disastrous for Medicaid beneficiaries, it suited the administration’s agenda so well that Michael Leavitt was appointed Secretary of HHS.
Now the administration would like to provide waivers (i.e., cut benefits) in every state. As another example, California Gov. Schwarzenegger’s administration has been negotiating a waiver in which HHS would require that California’s high-cost patients with severe chronic disabilities be moved into HMOs. Currently they are receiving as appropriate care as possible by well qualified, dedicated private sector providers who have a mission to do their best in an environment of limited financial resources. Under the waiver, these Medicaid beneficiaries would be shifted from their current continuing care, which is working for them, to HMOs, regardless of whether they’re even accessible, and which must make a profit with the paucity of Medicaid funds provided. Obviously, these unfortunate individuals would lose their essential supportive medical services. The California legislature rejected this requirement, and negotiations on waivers are currently at a realtive impasse.
So why are waivers more urgent than providing health care coverage for the victims of Katrina? Well, of course, they aren’t. But what an opportunity! Got those states right where we want them! You want us to help you pay for health care for those “underprivileged” evacuees? We have just the answer, and it is budget neutral. We’ll authorize you to quit wasting money on all of the unnecessary care for those other welfare folks so you can spend it on the evacuees.
Any after the Katrina crisis is over? Hey, you signed on to the waiver, Buddy!