Med­i­caid Pro­grams ‘Se­verely Chal­lenged,’ Re­port Says

The Washington Post Sunday - - National News - By David Brown

State Med­i­caid pro­grams, which pro­vide health care to some of the na­tion’s poor, vary wildly in their el­i­gi­bil­ity cri­te­ria, the scope and qual­ity of their care, and the amount they re­im­burse physi­cians pro­vid­ing it, ac­cord­ing to an in­de­pen­dent as­sess­ment pub­lished last week.

Over­all, the pro­grams are “ se­verely chal­lenged,” with the best scor­ing the equiv­a­lent of a low D and the worst way be­low an F.

“ This eval­u­a­tion demon­strates a bleak pic­ture for mil­lions of peo­ple in many states,” wrote the au­thors of the 143- page eval­u­a­tion, pro­duced by Pub­lic Cit­i­zen’s Health Re­search Group.

The top five pro­grams, in or­der of rank, were in Mas­sachusetts, Ne­braska, Ver­mont, Alaska and Wis­con­sin. The bot­tom five, with low­est- ranked last, were in South Dakota, Oklahoma, Texas, Idaho and Mis­sis­sippi. Mary­land ranked 15, the Dis­trict 27, and Vir­ginia 37.

Med­i­caid is paid for by both state and fed­eral tax rev­enue. The fed­eral gov­ern­ment spec­i­fies the min­i­mum ser­vices that must be of­fered, which states can broaden but not nar­row.

For ex­am­ple, states must cover chil­dren on wel­fare and poor preg­nant women. All states and the Dis­trict also choose to cover unin­sured poor women need­ing care for breast or cer­vi­cal can­cer, even though this is not a re­quire­ment. Thir­teen states and the Dis­trict also cover unin­sured peo­ple with tu­ber­cu­lo­sis. ( There are many other el­i­gi­ble groups, as well.) States may also ap­ply for waivers to try ex­per­i­men­tal strate­gies for de­liv­er­ing ser­vices.

The pro­gram cov­ers 55 mil­lion Amer­i­cans and ac­counts for about 20 per­cent of U. S. health- care spend­ing. It is the largest source of fed­eral grants to states.

The anec­do­tal dif­fer­ences be­tween states can be dra­matic.

For ex­am­ple, a preg­nant wo­man in a fam­ily of three must have a house­hold in­come of less than $ 22,128 to qual­ify for Med­i­caid in Wy­oming. In Min­nesota, she could qual­ify with an in­come of $ 45,650, ac­cord­ing to the re­port.

“ We know that the dif­fer­ences be­tween pro­grams re­flect both dif­fer­ences in pri­or­i­ties and re­sources, but no­body knows the ex­tent of them. The pro­grams haven’t been sub­jected to a uni­form scor­ing scheme,” said An­nette B. Ramirez de Arel­lano, a health- pol­icy ex­pert who headed the project.

The au­thors used pub­lished data to mea­sure Med­i­caid per­for­mance in 55 ar­eas. In cal­cu­lat­ing a fi­nal score out of a pos­si­ble 1,000 points, they weighted is­sues of el­i­gi­bil­ity and re­im­burse­ment more heav­ily than breadth of ser­vices and qual­ity of care.

The high­est- and low­est- ranked states dif­fered in their scores by a fac­tor of two — 646 for Mas­sachusetts vs. 318 for Mis­sis­sippi. There was even more vari­a­tion in the com­po­nents that went into the to­tal scores.

For ex­am­ple, the top- ranked state for the breadth of its el­i­gi­bil­ity cri­te­ria ( Rhode Is­land) scored 3.3 times higher than the low­est- ranked state ( In­di­ana) in that cat­e­gory. In the re­im­burse­ment com­po­nent of the score, there was a 20- fold dif­fer­ence be­tween Alaska, which had the most gen­er­ous re­im­burse­ment, and New Jer­sey, which had the least.

“ Most of the states are fail­ing in one or more ar­eas, and some of them are fail­ing in most ar­eas,” Ramirez de Arel­lano said.

Pub­lic Cit­i­zen’s Health Re­search Group did a sim­i­lar anal­y­sis and rank­ing 20 years ago. Four states in the top 10 now were in the top 10 then. Five states in the bot­tom 10 now were in the bot­tom 10 then.

The au­thors ad­mit­ted they were op­er­at­ing off in­com­plete in­for­ma­tion on many sub­jects, which made their task dif­fi­cult.

For ex­am­ple, the qual­ity as­sess­ment was largely based on nurs­ing home per­for­mance and the suc­cess of child­hood im­mu­niza­tions, al­though Med­i­caid pays for the en­tire range of med­i­cal care. The re­im­burse­ment com­par­isons were based only on Med­i­caid pro­grams us­ing a fee- for- ser­vice pay­ment scheme. How­ever, 60 per­cent of Med­i­caid pa­tients are in man­aged­care schemes in which physi­cians or clin­ics get a flat fee to pro­vide all med­i­cal ser­vices to a client. The re­port got mixed re­ac­tions. Den­nis Smith, an of­fi­cial at the fed­eral Cen­ters for Medi­care and Med­i­caid Ser­vices, said he thinks it “ misses the fun­da­men­tal na­ture of Med­i­caid and the 40- year his­tory that states have author­ity to ad­min­is­ter the pro­gram within a fed­eral frame­work.”

Alan Weil, ex­ec­u­tive di­rec­tor of the Na­tional Academy for State Health Pol­icy, called the re­port “ mildly help­ful” but added that for un­avoid­able rea­sons, “ it is a lit­tle too much of a rearview- mir­ror pic­ture.”

He said the re­port fails to cap­ture Med­i­caid’s cut­ting edge — ex­per­i­men­tal cov­er­age pro­grams, man­aged- care re­im­burse­ment schemes and home- based care — be­cause there are no data col­lected in all states that can serve as grounds for com­par­ing those com- po­nents.

Ron Pol­lack, who heads the ad­vo­cacy group Fam­i­lies USA, said the harsh judg­ment by Pub­lic Cit­i­zen to some de­gree masks the good Med­i­caid does.

“ The over­whelm­ing ma­jor­ity of peo­ple who are on Med­i­caid to­day would join the ranks of the unin­sured if that pro­gram didn’t ex­ist. It truly has be­come the life­line,” Pol­lack said. “ In the ab­sence of Med­i­caid, a very trou­ble­some sit­u­a­tion would be truly cat­a­strophic.”

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