The health care program for the poor is straining the state budget. The ugly solution: cutting programs or participants.
By ALISA ULFERTS
Published March 29, 2004
TALLAHASSEE - It is the backdrop for every budget debate: Medicaid spending is out of control and must be checked before it overwhelms Florida's ability to pay.
The state has no choice. Anyone who qualifies for the federal-state health care program for the poor must be served.
But what is rarely mentioned is how little of Medicaid's almost $14-billion in services actually are required. Most are considered optional by the federal government. State lawmakers could drop them tomorrow.
"We don't like to talk about the optional programs, but it's true," said health care advocate Karen Woodall.
But even paring back the optional programs is political dynamite, as last year's debate over the Medically Needy program demonstrated.
Medically Needy, created in 1986, covers drugs and hospital care for extremely sick people, such as organ transplant recipients who can't get insurance. Lawmakers tried to save about $50-million by tightening eligibility for its 27,000 participants, but backed down after a public outcry.
The optional programs like Medically Needy account for all of the $2.5-billion the state is spending on prescription drugs this year, as well as much of the $2.3-billion being spent on nursing home care - the two items state officials blame the most for Medicaid's spiraling costs.
Lawmakers can tighten the eligibility and scope of optional services but they still must cover every person who qualifies, making future costs unpredictable.
Reining in Medicaid's costs will bring potentially painful cuts, such as a Senate proposal to eliminate prenatal care for 7,000 pregnant women.
Bush is proposing a far more radical idea: a spending cap that would mean some poor people could be left without medical care.
The governor has dispatched state health officials to Washington, D.C., to talk to federal Medicaid administrators about making Florida a pilot program for reengineering Medicaid, which is straining state budgets across the nation.
The plan would allow Florida to keep Medicaid programs while serving fewer people.
"We always want to do our best to avoid it, but when you have a Medicaid budget that's growing by double digits, and we don't deal with it through reform . . . we're always going to have the issue of whether to cut back on providers or cut services," Bush told reporters last week.
Health care advocates are now raising the elimination of optional programs as the lesser of possible evils. Even lawyers who represent Medicaid patients say optional programs, though vital, that are removed now can be restored later.
"These designations are from a long time ago," said Anne Swerlick, a Florida Legal Services lawyer who represents Medicaid patients. The things considered optional when Medicaid was created are now essential to health care, such as prescription drugs. Still, she's willing to talk about beginning Medicaid reform with those programs.
She fears that Bush's approach would unravel a safety net that could never be pieced back together.
Optional programs added
Florida launched its Medicaid program on Jan. 1, 1970, five years after Congress created it. Most of the participants have always been poor children and their mothers.
Doctors visits, hospitalization and skilled nursing services have long been Medicaid's primary services.
But as health care practices changed and Florida's population aged, lawmakers added optional programs, piece by piece. Optional programs now account for almost 60 percent of Medicaid spending in Florida.
Some optional programs and their start dates include:
1986: Medically Needy
1987: Prescription drug and health care services for the elderly and disabled with incomes less than 90 percent of poverty level, later reduced to 88 percent
1995: Assisted living services for poor elderly
1996: School health services for qualified kids
2001: Breast/cervical cancer treatment for women up to 200-percent of poverty level
2001: Inpatient psychiatric treatment for children
Last year the Legislature approved yet another optional program, prescription drugs for low-income seniors. Federal officials have not yet approved the program for funding.
Lawmakers say the optional programs can't simply be cut out because regular Medicaid hasn't kept up with the changing health care scene. Just because the program is considered optional by the feds doesn't mean sick people can go without, said Sen. Durrell Peaden, R-Crestview.
"Somehow, we've got to cover their needs. They're still out there getting sick," Peaden said.
Peaden is sponsoring a bill that would reopen the state's high-risk health insurance pool, to help people affected by Medicaid cuts.
Still, the speed with which Medicaid is gobbling up spending is panicking state officials, who have watched the program double in size in just six years. It is projected to reach $53-billion by 2015.
So alarmed are state lawmakers that even moderate Senate Republicans, normally stalwart defenders against social service cuts, are getting in line to support Bush's plan to revamp Medicaid.
"The Senate is the black knight this year," said Mary Ellen Ross, executive director of the Florida Transplant Survivors Coalition, a grass roots group formed in 2001 to fight cuts in the Medically Needy program. Many of the coalition members who have had organ transplants rely on the program to pay for their antirejection drugs, which often range from $1,000 a month to $3,000.
"I thought they'd leave us alone because it's an election year," said Ross, a liver transplant recipient.
Senate President Jim King just shakes his head. "We have got to make cuts, if not there, then somewhere," said King, R-Jacksonville. "You can't do what we're doing and satisfy everyone."
