Medicaid revamps spark access worries

Washington -- Sweeping proposed changes in Tennessee's and Florida's Medicaid programs have raised concerns that states are moving from smaller cuts to major overhauls to rein in growing costs in this area. Physicians worry that, as a result, hundreds of thousands of people will lose health coverage and that doctors' ability to care for patients will be harmed.

"It's probably the short-term wave of the future, but it's all going to blow up in our faces very quickly," said Georganne Chapin, president of Hudson Health Plan, a nonprofit managed care company serving Medicaid patients in New York State.

Some doctors fear that reform talks at the federal level will further encourage states to take drastic steps that will mean the loss of coverage among the working poor.

Governors and various national and state medical and advocacy groups are already trying to head off talk of capping the amount of federal Medicaid money. Such limits could exacerbate states' funding problems and force more program cuts.

The American Medical Association opposes cuts to Medicaid eligibility unless accompanied by broader health insurance reforms that allow more low-income individuals to obtain other coverage.

TennCare on the chopping block

The nation's most generous Medicaid program, TennCare, which currently serves one in four Tennessee residents, provides perhaps the most prominent case of fallout from the states' financial difficulties and a troubling harbinger for what is in store for Medicaid, experts said.

Gov. Phil Bredesen recently announced that the state would be implementing an eligibility retrenchment that will save the state an estimated $575 million in the next fiscal year. As many as 323,000 adults will lose their coverage in the next six months. Tennessee Medical Assn. officials said they are disappointed by the move.

For patients cut from the program, getting care will be much more difficult, said Fred Ralston, MD, Tennessee chapter governor of the American College of Physicians. Doctors will continue to provide care to these patients, but physician services are a "small piece of the pie," he said. The real hurdle will be getting surgical procedures and hospital beds for these people.

Inevitably, the lack of coverage will lead to delays in care, which in turn will lead to patients presenting with more advanced and usually more severe illness, he said.

Tennessee's plan does preserve coverage for about 112,000 children who would not otherwise be eligible for basic Medicaid.

However, having their parents get knocked off the rolls raises concerns. Research has shown that adults with health coverage are more likely to bring their children in to seek care.

The enrollment cut in Tennessee touched a nerve in other states.

"We're happy that very few of those apparently were children, but it has a tremendous impact on families," said Mark Rosenberg, MD, president of the Illinois Chapter of the American Academy of Pediatrics.

The enrollment cuts just shift the problem onto doctors and hospitals, some experts said.

"You can cut Medicaid eligibility, but that doesn't make the person not get sick, and then when they get sick, it doesn't make them not go for care," said Hudson Health Plan's Chapin.

State actions spread

The worries about Medicaid access have already spread to Florida, where Gov. Jeb Bush earlier this month asked the state Legislature to overhaul Medicaid by allowing patients to choose from three levels of state-endorsed private health plans or to apply their Medicaid premium to insurance in the private market.

"Florida's Medicaid system will collapse under its own weight if we do not fundamentally transform the way it operates. The changes we're proposing will help create more predictable and sustainable growth in Medicaid costs and ensure the program meets the needs of Floridians who rely on it for health care," Bush said in a statement.

He did not offer an estimate of how much his plan would save, but the program currently costs $14 billion, split between the state and federal government. Other details of the proposal are also scant, but Florida physicians are not optimistic that things will change for the better.

"Instead of us going to the state and getting payment, which is very hard to get, we'll go to the HMOs and see if they make it hard to get," said David McKalip, MD, a St. Petersburg neurosurgeon.

Even now, the situation under Medicaid is far from rosy. Physicians may have been able to overlook the traditionally low reimbursement rates, but the red tape is often the last straw.

"I take Medicaid because I feel it is my moral responsibility to do so, but every time I get a darn letter from them saying what I did was medically unnecessary, it's just insulting. I can see why most people just drop it, or they don't bother to put up with the hassles," said Dr. McKalip.

"The government in general does a very bad job at administering health care programs," he said.

Tennessee's Dr. Ralston agreed.

"TennCare was an example of bureaucracy run amuck," he said.

The physicians said that they were not averse to reforming the program.

The Tennessee Medical Assn. had supported the original plan for TennCare changes, not because it was the perfect approach, but because it knew something needed to be done, and at least coverage was preserved for the bulk of patients.

Unfortunately, state governments seem to rarely take into to account physicians' perspectives when formulating such changes, said Dr. Ralston.