Disaster Deepens MH Crisis For Poorest Citizens
Katrina's ill winds brought small pieces of good news. The critical importance of mental health services for evacuees and others affected by the disaster was quickly recognized by speakers at “Safeguarding the Health of Katrina's Victims,” a forum presented on September 12 by the Alliance for Health Reform and the Kaiser Commission on Medicaid and the Uninsured (KCMU).
U.S. Surgeon General Richard Carmona, M.D., said that ultimately mental health and social service issues could outweigh the current problems associated with meeting acute survival needs.
“We can fix people up [temporarily], but psychological wounds [can] go on for a lifetime,” he said. “Depression is to be expected.”
Carmona added that studies show that suicide and divorce rates go up after people are “back on their feet.”
Senate Majority Leader William Frist, M.D. (R-Tenn.), told attendees that he wanted to “underscore the importance of mental health problems... .They will have to be dealt with,” he said.
Frist also acknowledged the imprudence of cutting federal Medicaid expenditures in the face of the rapidly escalating need for health care services.
It would “absolutely be the wrong thing to do,” Frist said, if such cuts resulted in “cutting back on care.” However, he would support cuts directed at waste, fraud, and abuse.
Congressional legislators had agreed to cut $10 billion in federal expenditures from Medicaid over the next five years (Psychiatric News, September 16) but had not decided how to make the cuts when Katrina hit the Gulf Coast.
Speakers emphasized the unprecedented nature of the devastation and the severity of problems to be addressed.
Carmona said that after most disasters, such as the terrorist attacks on September 11, 2001, an infrastructure remains. In the areas affected by the flood, however, “the infrastructure has been decimated.”
Health care and social service needs were acute in the region, even before Katrina's impact. Diane Rowland, KCMU's executive director, told the audience that 22 percent of the population in Louisiana was subsisting below the poverty level, as defined as a monthly income of $1,300 for a family of three.
KCMU material for 2002-2003 shows that the state ranked fourth in the country in terms of the percentage of people in poverty and third in terms of the percentage of people without insurance. It ranked 11th in terms of the percentage of people on Medicaid.
Mississippi ranked first in terms of the percentage of residents living below the poverty level and on Medicaid and 12th in the percentage who had no health insurance.
States' fiscal problems will be exacerbated by the loss of tax revenue from oilrelated industries in Louisiana, the casinos in Mississippi, and individuals who are no longer employed.
Those who became evacuees often come from “at-risk” populations, according to several speakers. Definitions of “at risk” varied, but included those with chronic conditions, such as high blood pressure and diabetes, and the very old and very young.
Frist said that when he visited the Louis Armstrong Airport in New Orleans, he observed that about one in three of the evacuees was labeled as having“ special needs” (see story on page 7).
Wading Through Bureaucracy
The KCMU hosted a telephone conference briefing with Medicaid officials from Louisiana and Ohio on September 9 to examine bureaucratic hurdles in providing Medicaid and other services to evacuees and to those who stayed in the hurricane-ravaged states.
A looming problem concerns “dual eligibles,” those who are eligible for both Medicaid and Medicare. They are scheduled to lose Medicaid prescription drug benefits on January 1 and to receive them through Medicare (see story on page 10). However, the information sent through the mail to help them make choices and navigate the transition might not reach them.
These were among the questions identified in the discussion:
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Will all evacuees be eligible for Medicaid? How will states determine who is a genuine evacuee?
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Will Medicaid benefits for evacuees be portable? A family, for example, might first receive benefits in Texas, decide to live with relatives in Florida, and then return to Louisiana. States vary in terms of standards of eligibility and benefit structures.
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What level of federal reimbursement will states receive for evacuees? The level of federal match for Medicaid varies from state to state. How long will an increased level of federal reimbursement last if it becomes available?
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Medicaid reimbursement is low for health care providers, limiting access to care. How can the overburdened public mental health system meet the needs of new beneficiaries?
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Which policies and reimbursement provisions will require congressional action and which can be implemented by executive order or administrative action by the Centers for Medicare and Medicaid Services?
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What provisions for ensuring continuity of care could be made for evacuees and those who remained in the affected states and received insurance through their jobs but now are unemployed?
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How can evacuees eligible for both Medicaid and Medicare (dual eligibles) transition successfully from Medicaid drug coverage to the new Medicare drug program scheduled to begin January 1? Medicaid drug coverage for these individuals ends December 31. They will be enrolled automatically in a Medicare prescription drug plan if they do not select one. However, an evacuee from Louisiana living in Texas might be automatically enrolled in a Louisiana plan or not enrolled at all if the Louisiana Medicaid bureaucracy is dysfunctional.
APA Supports Emergency Medicaid
APA joined more than 100 other organizations to send a letter on September 14 to Congress asking that the federal government provide full financial support for emergency Medicaid and urging that eligibility and documentation requirements be streamlined.
The signers wrote that emergency Medicaid should include “coverage for all survivors, not just those categorically eligible; enrollment regardless of assets or income; suspension in scheduled reductions in the FMAP [federal medical assistance percentage] for one year; and postponement of the end of Medicaid drug coverage for dual eligibles in or from the affected states transitioning to the new Medicare drug benefit.”
These issues were unresolved at press time. Congress was considering several approaches to some of them (see story on page 7).
Numerous reports and news accounts about federal and state responses to Katrina's devastation are posted at<www.kaisernetwork.org>.▪
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Published online: 7 October 2005
Published in print: October 7, 2005
Notes
Officials grapple with unprecedented problems in Katrina's wake and acknowledge the long-term need for mental health services.
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