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COMMENTARY |
a Committee on Federal Government Affairs, American Academy of Pediatrics, and Children's Healthcare Associates, Chicago, Illinois
b Goldberg Kohn, Chicago, Illinois
Abbreviations: EPSDT, Early Periodic Screening Diagnosis and Treatment
As Medicaid reaches its 40th birthday, the future of the program is less certain than it has been for years. Congress recently passed the Budget Reconciliation Act, which could signal the beginning of a restructuring and retrenchment of the Medicaid program. Under this act, individual states will have the option of reducing benefits and imposing significant costs on Medicaid recipients, including copayments. New procedural barriers such as a rigid demand for a birth certificate to establish eligibility will make it harder for eligible people to access the program. These provisions will likely result in fewer enrollees. Yet, at the same time that Congress is allowing or requiring states to make these changes that may result in drastic reductions in their Medicaid programs, Illinois has enacted the All Kids program, which is a major expansion of Illinois' publicly supported health coverage programs. Under All Kids, Illinois will offer Medicaid-type benefits to all children who are currently uninsured.
Illinois is bucking the trend by increasing its eligible populations but not increasing its spending. Illinois' All Kids program is designed to expand access to health care while offsetting the costs of expansion through cost savings. Illinois intends to generate those cost savings by implementing primary care case management and disease management programs, all based on physician payment on a fee-for-service basis. Illinois will also require that families who are currently uninsured and not currently covered by a public program make payments to participate in the program. Families will pay premiums, copays, and coinsurance on a sliding scale based on income, although to encourage well-care, Illinois is not implementing copayments for preventive services and immunizations.
Over the past few years, employer-based dependent coverage has decreased, leaving more families without health coverage for their children. This trend has been moderated by timely increases in publicly supported insurance for children over the past several years. Nonetheless, in 2006 the health of children has been threatened in a significant way.
Policy makers are concerned that the growth of Medicaid is unsustainable in the long-term as a result of the increase in health care costs and the erosion of private health insurance. In the current fiscal year, all 50 states and the District of Columbia have implemented some degree of cost control. Although controlling prescription drug costs and freezing provider payments were the 2 most frequent cost-reduction measures, many states also have reduced benefits, restricted eligibility, and increased copayments as a means of controlling the costs of Medicaid.
The basic framework of Medicaid benefits for children is laid out in the Early Periodic Screening Diagnosis and Treatment provisions of the Medicaid Act. These provisions, which are frequently referred to by their acronym EPSDT, require that states provide a comprehensive umbrella of prevention and treatment services for children. Nonetheless, despite the comprehensive nature of EPSDT benefits, low-income children covered by Medicaid are much less likely to be fully immunized or receive timely preventive care than children who are covered by private insurance. One of the main factors in these poor results for children on Medicaid is that recipients only get treatment if providers are willing or able to meaningfully participate in the Medicaid program and provide care. Physicians' willingness to participate is based in large part on the reimbursement that a state Medicaid program provides. Lawsuits attacking state failures to provide EPSDT services have been filed in several states relying on, among other things, the low level of Medicaid reimbursement rates that the states offer to health care providers and the difficulties and delays that providers face in actually getting paid for services that they have provided.
In Illinois, for example, the majority of pediatricians participate in Medicaid to some degree. A significant number, however, have historically limited the portion of their practices devoted to children on Medicaid as a consequence of low reimbursement, slow payment cycles, and administrative hassles.1 A class action lawsuit was brought on behalf of all of the children on Medicaid in Cook County against the State of Illinois (Memisovski v Maram), asserting that these factors resulted in unequal access to health care as well as care that was far short of that required by the EPSDT provisions of the Medicaid Act. (Mr Cohen was lead trial counsel in the case of Memisovski v Maram.)
The health care results produced by the Illinois Medicaid system were sobering. The plaintiffs' attorneys presented evidence that less than half of the children on Medicaid received even a single screening examination during their first year of life after leaving the hospital. Overall, a majority of Medicaid-enrolled children in Cook County did not receive sufficient medically necessary preventive health care, and a significant number (one third or higher) did not receive any preventive health care at all. Doctors in emergency department practices and other hospital-based care testified at the trial that when they tried to make discharge referrals to primary care doctors, they faced severe difficulties in finding physicians who were willing to provide care to patients on Medicaid. These doctors did not face these difficulties in finding physicians who were willing to accept referrals for patients with private insurance.
Because of constraints in the system, an increasing number of children on Medicaid receive health care at tertiary institutions and the so-called safety net. These resources are increasingly strained and provide limited access to pediatric subspecialists.2
The federal court in Chicago addressed the merits of the class action lawsuit after a nearly month-long trial in 2004. In a forceful opinion, Judge Joan Lefkow ruled that children in Cook County (which includes the city of Chicago and its inner ring of major suburbs) were unable to secure the Medicaid health care services to which they were entitled because, among other things, the reimbursement rates that Illinois paid to providers was so low and, in addition, the program created administrative disincentives to providers. After long negotiations, the court entered a consent decree on November 18, 2005. That decree will result in a substantial reimbursement-rate increase and, hopefully, will result in many more pediatricians and family physicians being willing to provide health care to the increasing numbers of Medicaid participants.
The future success of All Kids will depend on the assurance of sufficient reimbursement to pediatricians and pediatric subspecialists. Without increases in reimbursement and a reasonable payment cycle, it is unlikely that access to care by Medicaid recipients could be ensured.
The state of Illinois has approached the issue of the uninsured as a societal responsibility to the future generation by offering health care coverage to low-income families and those who are uninsured. By providing broad health insurance coverage and increasing access to care with higher reimbursement rates, the state has taken a chance that its model of care will save costs while allowing greater numbers of the uninsured population to afford health care, even as Congress acts to restructure Medicaid on the federal level in the opposite direction.
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FOOTNOTES |
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Address correspondence to Mark Rosenberg, MD, MA, Children's Healthcare Associates, 2835 N Sheffield Ave, #501, Chicago, IL 60657. E-mail: markrosenbergmd{at}aol.com
The authors have indicated they have no financial relationships relevant to this article to disclose.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
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