Poor, Not Dumb: Common Sense Reform for Medicaid
October 29, 2007
Within the national debate over
healthcare reform, an assumption
has been revealed in several proposals:
Healthcare decisions for poor Americans are best left to the U.S.
government.
As a
former rural breast cancer surgeon whose practice consisted largely of
uninsured and underinsured women, I am uncertain why the same group that
brought taxpayers $20,000 toilet seats should be in charge of the
medical treatment choices patients and their families make.
As a
provider of government medicine, I’ve seen the low quality of
decision-making offered when it is shifted from patients and their
doctors to Sacramento bureaucrats.
In
2006, Medi-Cal (California’s version of Medicaid) denied payment for one
of my patient’s breast cancer surgery due to “incorrect gender.” She was
as surprised as her doctor. After five appeals and nine months had
elapsed, Medi-Cal finally paid me $253 for the two-hour cancer operation
and 90 days of follow-up care.
So
forgive me if I am a bit skeptical at the reform proposals made by
California’s Republican Governor and at least three Democratic
Presidential candidates, all of which include a greater role for
government in funding and directing
medical care for lower-income
populations.
All
would swell the number of citizens whose coverage is subsidized and
managed under state and federal programs.
Medi-Cal
now covers one in six Californians, and the U.S. government currently
spends 45% of its healthcare dollars to cover 27% of the population via
Medicaid and Medicare. U.S. taxpayers watch their hard-earned dollars
wasted on inefficient, top-heavy bureaucracies with little
accountability as to how much is actually spent on patient care.
Earlier this year, the Centers for Medicare and Medicaid Services
admitted that millions of dollars were lost when the Atlanta-based
oversight firm hired to detect Medicare payment fraud wrongfully
rejected payments made to hospitals and doctors, making overpayment
allegations on cases they were not authorized to review. This increased
the corporation’s government-paid “bounty” for this work, a hefty
$0.25-0.30 for every dollar of overpayment supposedly uncovered.
Unraveling this attempt at accountability will likely take years.
Currently, Medicaid expenditure per enrollee is nearly $7,000 per year.
This high cost “health plan” gives recipients access to long wait times
for fewer doctors, guaranteeing little ability to make healthcare
decisions for themselves and their families. Arbitrary decisions made by
government employees—nearly 6,000 in California alone—overrule
recommendations made by doctors and nurses sitting beside their patients
in exam rooms across the state.
Medicaid’s astonishing administrative costs compound the problem.
According to 2005 data from the Center for Medicare and Medicaid
Services, over 31% of every dollar spent by Medicaid did nothing to
provide medical treatment.
There is a better way to help vulnerable Americans receive high quality
medical care while protecting the taxpayer, without expanding an already
bloated bureaucracy.
I
propose that the $580-plus per month now paid for every man, woman and
child covered by Medicaid would be more effectively, responsibly spent
as follows:
1.
Low cost private insurance plans are now available throughout the U.S.
Instead of funneling $580 to Medicaid, a private health insurance policy
with a $2,400 deductible could be purchased for less than $200/month for
most enrollees. Private plans for healthy, younger recipients often cost
less than $100/month.
2.
To cover this deductible for those without resources, a Health Savings
Account (HSA) would be funded according to poverty level guidelines now
used to determine Medicaid benefits.
For
example, Medicaid recipients at 200% of the federal poverty level would
have their HSA fully funded at $200/month to cover the entire
deductible, with a sliding scale for those with somewhat higher incomes.
3.
For high-risk patients with chronic medical conditions, a
risk pool
like California’s “Managed Risk Medical Insurance Board” would be used
to obtain more affordable policies than would otherwise be available.
This protects taxpayers from the expense associated with covering sicker
patients while ensuring that coverage remains available for those who
need it most.
Under this model of Medicaid reform, the worst-case scenario would bring
the $7,000 yearly federal and state expenditure down to $5,000 for every
person covered. For younger, healthier patients covered by the program,
costs would be considerably lower.
This
model, which uses low cost, high deductible plans with the
safety net
of a private Health Savings Account, reduces costs to the taxpayer. It
offers accountability by limiting HSA use for qualified medical
expenses.
It
protects vulnerable patients from financial disaster during years when
they need expensive medical care while lowering costs during “healthy”
years instead of mandating ever-expanding Medicaid funding. It restores
healthcare decision-making to patients and families with the guidance of
their doctors instead of relegating these choices to a faceless
“Treatment Authorization Request” form or government employee with the
power to interfere in the most private of decisions…those involving our
health.
Most
important to me as a doctor whose rural practice was destroyed by the
frustrating, unsustainable bureaucracy known as Medi-Cal, this model for
reform increases quality healthcare access for those with few other
options.
I
sustained a personal and professional loss when I was forced to stop
providing services as the only breast cancer surgery specialist in a
70-mile radius in central California who still accepted Medi-Cal. I
could no longer afford the $10,000-$15,000 monthly hemorrhage related to
reimbursement so low it would be cheaper to close my office doors.
My
own loss is nothing compared with what the women who will be diagnosed
with breast cancer in my community will face. “Coverage” with a
government-funded “insurance plan” for them offers no coverage, after
all.
The
stakes are high in the national healthcare reform debate. But the
rewards of improving the way we approach care for those without
resources are great. I hope our legislators are listening; my patients
surely are.