Medicaid changes will hurt patient access, doctors say

Washington -- Physicians worry that because Medicaid has opened the door to charging low-income beneficiaries more, they might start to see these patients coming through their own doors a whole lot less.

The deficit-reduction legislation President Bush signed earlier this month will for the first time give states the option of increasing premiums and co-payments on most types of beneficiaries in the program. States also will be able to move beneficiaries into special managed care plans that could offer less-generous benefit packages than they do at present.

The Bush administration said the revisions, which are part of a net package of about $4.8 billion in Medicaid reductions over five years, are necessary to slow the rate of growth in the federal-state health program. But physicians said it would take the public health system down a very dangerous road by putting the nation's poorest citizens at risk.

"This is a devastating blow delivered right to children," said Eileen M. Ouellette, MD, the American Academy of Pediatrics president. "I am outraged knowing that a majority of our congressional members believe sacrificing children's health care is acceptable."

The Congressional Budget Office predicted last month that roughly 9 million Medicaid beneficiaries, fully half of whom are children, will be subjected to co-payments for the first time under the new state flexibility. But only about 20% of the savings derived from this change will come from the collection of the payments. The remainder will come from the decreased use of medical services by this population, CBO said.

Pediatricians and other physicians worry that this means millions of poor children will forgo the care that is essential to maintain their health into adulthood. The families of nearly 40,000 children will be unable to pay their increased premiums and will be dropped from Medicaid altogether, according to the budget office.

The situation has all of the makings of a public health crisis, said Georges C. Benjamin, MD, the American Public Health Assn.'s executive director.

The savings from the Medicaid cuts "will be overshadowed by the bill's consequences -- current Medicaid beneficiaries joining our nation's uninsured ranks, children not having access to the medical and preventive services they need, and ... Medicaid beneficiaries not being able to afford the prescription drugs they need to maintain or improve their health," he said.

Opposition in vain

Many physicians, including delegates from the American Medical Association, tried unsuccessfully to drum up enough opposition to torpedo the Medicaid cuts late last year. The AMA approved a resolution at its Interim Meeting last November that condemned the House-passed deficit-reduction bill's proposed increases in cost sharing on children at or below the federal poverty line -- provisions that made it into the final package.

A group of physicians led by the pediatrics academy expressed frustration that the Medicaid issue was tied into the same measure that would determine Medicare physician pay for 2006. Their resolution prompted assurances from Association leaders that the AMA remained engaged on the issue and opposed to the Medicaid reductions.

Already, beneficiary groups that vigorously opposed passage of the Medicaid cuts are looking to repair the damage that already might have started. For instance, the AARP plans to spend considerable energy and resources taking aim at a provision to save the federal government billions by making it harder to spend down assets to qualify for Medicaid.

"Working with our members, AARP will continue the fight to have this ill-conceived policy reversed," said Bill Novelli, the organization's CEO.

Taking a stand

Other groups are focusing on guiding the discussion on Medicaid in the year ahead. The AMA and others are gearing up to participate in the debate on the fiscal 2007 budget, for which President Bush already has proposed another round of Medicaid cuts.

Of particular interest to the AMA is the work of the federal Medicaid advisory commission, which plans to release a report in December that will recommend long-term structural changes to the program. AMA Immediate Past President John C. Nelson, MD, MPH, is one of four physicians serving as nonvoting members of the panel.

This year also marks a congressional election season, and some physicians are trying to use their clout in a different way to get the results they want on protecting Medicare beneficiaries.

"Children may not vote, but the pediatricians who care for them do," Dr. Ouellette said. "We know how Congress voted, and in this election year, we'll vote for those who protect, not sacrifice, children's health care."