THE RIGHT RX

State’s proposed Medicaid rules make fiscal sense

It’s been clear for years that New Mexico’s Medicaid program — which covers more than 40 percent of the state’s population and costs the state about $1 billion a year — is not sustainable at its current level. And with the vast uncertainty about health care emanating from Washington, it’s prudent for the state to propose ways to ensure the roughly 900,000 children, pregnant women, low-income adults and people with disabilities covered by Medicaid continue getting needed care.

Many of the proposals being put forth by Gov. Susana Martinez’s administration, which would generally apply to people above the poverty level and take effect in 2019 if the federal government approves them, have merit and should be given serious consideration.

Currently, most Medicaid recipients pay nothing for their health care, which gives them little incentive to stay healthy, seek out appropriate levels of care or make sure they show up for medical appointments. And that costs everyone else. By inserting a personal financial stake for some — albeit an extremely modest one — in their health care, recipients are far more likely to participate in their, and their family’s, well-being. Under the proposed revisions:

Recipients would be asked to pay premiums for ■ their care based on household income. Those range from $10 per month for individuals making roughly $12,100 to $18,100 a year, to $25 a month for someone making nearly $36,200 a year. A family of three in the lower bracket, for example, would pay $20 per month. Those rates could double in ensuing years but would still remain well below private insurance premiums.

Recipients would be required to pay minimal co-pays, ■ again based on family income. Individuals just above the poverty level — making about $12,100 a year — would pay $5 for basic office visits, $50 for hospital stays or outpatient surgeries and $2 for prescriptions.

Recipients would be encouraged to become better health ■ care consumers, with an $8 co-pay for brand-name drugs when a generic is available and $8 if they visit an emergency room when they don’t have an emergency. And if they miss three scheduled appointments without notifying the provider in advance, the provider would be allowed to charge them $5. Preventive services would not be subject to co-pays.

Even with the proposed changes, there would be exemptions: Most people who are disabled and most families with young children still wouldn’t pay copays or premiums.

In another cost-savings measure, the state could curtail or eliminate dental and vision benefits for adult Medicaid recipients but would have to develop and offer affordable dental and vision plans.

The state also plans to start prenatal and postpartum care — along with early childhood services — for women in two to four New Mexico counties. Providers would visit the women in their homes. The goal is to reduce pre-term births, low-weight infant births and similar health challenges.

Each of those proposals, when weighed against the possibility of a bankrupt state Medicaid program, are reasonable approaches to keeping the program solvent.

But the state is accepting public comment, and these can certainly be tweaked based on those comments. For example, the premiums may be too high for those having to stretch small paychecks so far. And the high mobility rate may make monthly billing a challenge.

But the co-pays and other measures help instill some personal responsibility into health care decisions while helping patients establish health-care homes rather than reliance on ERs.

While these changes impose some financial burden on recipients of modest income, they’re far from draconian.

The caveat, of course, is that none of the changes may become necessary if Congress finally acts on health care reform.

New Mexico is already pouring around one-sixth of the state budget into Medicaid, with the federal government kicking in billions more. Critics of the proposed reforms are ignoring the fact that there is only so much money in a budget to go around, and abuse and misuse of health care funding starves the bottom lines of other worthy programs that help New Mexicans.

Nobody is expecting New Mexico’s neediest residents to pay full freight for their health care. And yes, it’s hard to start paying for something you have gotten for free. But expecting New Mexico’s 900,000-plus Medicaid patients to spend a few dollars for doctor appointments, make better decisions about what constitutes an emergency, and keep or cancel their appointments is not unreasonable.

Especially because it will help ensure there’s enough funding for their health care coverage going forward.