Senator Sounds Alarm On Medicaid's Future

America's public health safety net is under assault, said Sen. Hillary Rodham Clinton (D-N.Y.). Keynoting a conference sponsored by Families USA in Washington, D.C., in January, Clinton sounded a chord that would reverberate throughout the meeting—a combination of grim foreboding about the intentions of a second-term Bush administration toward the public health systems that have been the legacy of the liberal Democratic establishment and a defiant resolve to protect those systems against Republican efforts to privatize and downsize.

“These are perilous times for America's health care infrastructure,” the former first lady told a crowded ballroom at Washington's Mayflower Hotel. “We are about to experience one of the most aggressive assaults on the structure and funding of public health programs in our history.”

Clinton focused especially on administration proposals to cap Medicaid funding through block grants to states—effectively overturning the system of matching funding that has been in place since the program began 40 years ago—and the new prescription drug benefit under the Medicare Modernization Act (see page 10).

Famlies USA, calling itself “the voice for health care consumers,” is a network of grass-roots advocacy groups that champion public funding for Medicare, Medicaid, and the State Children's Health Insurance Program, as well as such issues as minority health, access to prescription drugs for the elderly, and relief of medical debt incurred by individuals with and without insurance.

Echoing many others at the conference, Clinton said the new Medicare drug benefit is rife with potential pitfalls and complications that could leave some beneficiaries with much higher costs and a far less generous benefit than has been touted.

She especially highlighted the subgroup known as “dual eligibles,” who qualify for both Medicaid and Medicare; when the new Medicare drug benefit is initiated in January 2006, the Medicaid drug benefit for those who are dually eligible will end, and the transition from one program to the other is expected to be fraught with problems and uncertainties.

“If the transition from Medicaid to Medicare doesn't go smoothly, if [there are] implementation problems that are just bound to occur when the Medicare prescription drug benefit takes place, and if some of the problems embedded in the prescription drug benefit come to pass, these individuals could be left with no or inadequate coverage,” Clinton said.

Clinton noted that most seniors in the Medicare program will have six months to enroll in a prescription drug plan. The plans will be announced October 13, and enrollment will begin November 15. Those who are dually eligible have far less time to make a selection, however. They must be enrolled in one of the new plans by January 1, 2006, since their Medicaid coverage ends on December 31.

In response to this problem, the Centers for Medicare and Medicaid Services (CMS) said it will automatically enroll dual eligibles into a prescription drug plan. But that could create problems, Clinton said.

“When seniors are randomly enrolled in a drug plan, there is no guarantee that the plan chosen is the one that will fit their specific prescription drug needs,” she said. “And, remember, we are talking about a population that is juggling multiple chronic conditions and multiple medications.

“If seniors are placed in a plan that is not a good fit, it is going to require a lot of paperwork and research to find the right plan, assuming it's in the right region where they live and that they can even get into the plan,” Clinton continued. “Can we really place that burden on our already overburdened caregivers or medical professionals? Are we going to turn doctors and RNs and nursing home administrators into government bureaucrats, going through all the plans and trying to find the one that will fit the person in need of continuity?

“I also think there will likely not be enough targeted public education to help the dual eligibles with this transition process.”

Even beyond the likely problems associated with dual eligibles, the new prescription drug benefit received a thumbs-down review from Clinton—who voted against the measure—and from many others at the Families USA conference.

A principal complaint throughout the conference was the enormous complexity of the benefit, with multiple plans expected to offer different formularies at varying costs. “Just because a drug is on the formulary at the beginning of the year doesn't even mean it stays on the plan for all of the year, or that it's on the plan next year, or that the plan you signed up for is available [the next year],” Clinton said.

“If this is confusing for you, imagine what it would be like for people in their 80s or 90s, or a person with a disability, or a middle- or low-income family trying to keep a loved one at home to walk through all of this and make sense of it,” she said. “We have larded in so much extra cost into this drug benefit instead of providing a straight benefit at the lowest possible cost to cover the maximum number of seniors.

“I think there is about $150 billion going to insurance companies and related entities to provide this service,” Clinton said.

But it was looming cuts to the Medicaid program, and especially administration proposals for replacing federal matching funds with block grants, that elicited the greatest foreboding among participants at the conference, along with a sense of an impending showdown that would engage fundamental values about how the nation intends to care for its poor.

One plenary at the conference that was closed to the press—a strategy-making session to help grass-roots organizations in states challenged by Medicaid cuts—was called “The Mother of all Medicaid Fights.”

“Block grants are a bad idea from nearly every angle,” Clinton said. “Currently, the federal government and the states share the risks of greater-than-anticipated increases in Medicaid enrollment and costs... so federal payments rise as a state's costs increase. A block grant would end this federal commitment by providing states with a fixed amount of Medicaid funding each year without regard to the state's costs or enrollment figures.

“This would freeze Medicaid programs over time and erode quality and access, and states would have limited capacity to incorporate advances in medical treatment and other proven remedies and interventions into their programs due to cost,” Clinton said. ▪