Medicaid "Flexibility"

Part of Bush's plan to "reform" Medicaid is to give states more flexibility in how they administer the program in their states. This could be good, let states try things out that they know will work for their people: like allowing Medicaid to pay for Home and Community Based Services as opposed to institutionalizing everyone they can; or it could be disastrous, and end up killing the basics of the program.

One of the more recent examples of this is what is happening in West Virgina. Under the auspices of "incentivisimg" prevention and health maintenance, the Medicaid program in West Virgina has begun to implement a program which would require recipients to sign a pledge "that they will do their best to stay healthy" in order to continue to receive certain health benefits from their coverage.

The incentive effort, the first of its kind, received quick approval last summer from the Bush administration, which is encouraging states to experiment with "personal responsibility" as a chief principle of their Medicaid programs.

Those signing and abiding by the agreement (or their children, who account for a majority of Medicaid patients here) will receive "enhanced benefits" including mental health counseling, long-term diabetes management and cardiac rehabilitation, and prescription drugs and home health visits as needed, as well as antismoking and antiobesity classes.

In future years, those who comply fully will get further benefits ("like a Marriott rewards plan," Ms. Atkins said), their nature to be determined but perhaps including orthodontics or other dental services.

OOOO aren't you fancy? Giving out the rewards of dental care. Now that's an "extra" for you! And mental health benefits, cardiac rehab? Cadillac coverage if I've ever seen it. And how exactly does taking away some one's long term diabetes management services mean that you are punishing them for not taking care to prevent worse problems? Of course none of this takes into account the lack of transportation/child care issues etc. that many people face.

And then there are two other states that I would like to discuss when it comes to Medicaid "flexibility." First off is California. If you read my blog ever, you know that an issue of contention with me is the new federal Medicaid citizenship verification requirements that will actually do more to hurt citizens than non-citizens, and leave newborns out in the cold. California, along with about 20 other states have postponed implementation of the law until they can figure out what kind of guidance to give to Counties on the issue, but say that they are showing a "good faith effort" to comply with the federal regs. However, because they haven't yet gone forward gung ho, patients be damned, they are faced with the possibility of audits and loss of FMAP monies (federal Medicaid $). Never mind that when someone in CA applies for Medicaid, their Social Security #s are automatically checked with the federal government, verifying their citizenship. Not good enough. Forget flexibility, its ridiculous rigidity that we are witnessing here.

Meanwhile, the little old Federal Medicaid Commission has some suggestions on this whole issue of flexibility. Of course, flexibility in this sense means, how can we spend less money, even if it means providing less services, and shittier health care to recipients? Like enrolling the people with the most complex health cases (so called dual eligibles) into HMOs that we all learned to love. Shit, in Ohio mandatory enrollment in Medicaid HMOs for the Aged Blind and Disabled populations are going to happen starting this month (we are already mandatory managed care for covered families and children, the majority of Medicaid recipients, who are also the simplest to manage, and we have done a shitty job doing that to date). I will keep my eye out to see how flexible everyone who has complex health histories feel about being told by an HMO what medicines they must try and in what order, what procedures are and aren't necessary, and what health care provider they can or can't go to. This is sure to go over swimmingly.

I guess the point of this post is that when the government talks about flexibility in Medicaid, it means the flexibility to keep people away from the care they need, and the inflexibility to get as much care to folks as needed. That's my take on it anyways.