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This year is a turning point for Medicaid and managed care, a time when administrations are changing places and bringing with them a chance to put a new mindset into the mix. There is an evolution to another level of government and health care.
But evolving into what? Those
gathered at the 5th Annual Congress
on Managed Care and Medicaid in Washington, DC, held in January, had a chance to hear from leaders in the field, both private and public, who voiced their views and concerns while government changed hands at 1600 Pennsylvania Ave.
Many conceded that how the Bush administration deals with health care can have a ripple effect on the rest of the country.
The appointment of Gov. Tommy Thompson of Wisconsin to head Health and Human Services got many nods of approval, especially for his positive record of handling Medicaid and the federal government through BadgerCare, his home state's program for insuring low-income families. Some conference attendees and speakers see Thompson working to shift responsibilities from the federal government to individual states.
"The new president could redesign the Medicare programs," said Judith Moore, co-director at the National Health Policy Forum in Washington, DC, a nonpartisan education program serving senior federal, state legislative, and regulatory health staff.
Thompson will not shift Medicare responsibility to the states in a sudden move, said Alan Weil, director of the Assessing the New Federalism project at the Urban Institute in Washington, DC. If there is a shift in power, he said, it will be a gradual one.
In a shift of power to states, added Vernon Smith, a principal with Health Management Associates in Lansing, MI, the federal government must look at the combination of Medicare and Medicaid to determine the proper amount of responsibility. In 1996-97, Medicaid program costs were flat, he said, adding that the Congressional Budget Office had forecast an increase of 8% to 9% for the program.
The cost increases will create trouble, Mr. Smith predicted, and states will eventually want more flexibility to solve the problems created by the high prices.
Leonard Kirschner, principal with William M Mercer, a global consulting firm, added that Mr. Thompson had looked at programs in Wisconsin that combined both Medicaid and Medicare.
Whatever combination is considered, according to Ray Hanley, director for Medical Services, with the Arkansas Department of Human Services in Little Rock, the new presidential administration must be more flexible than the previous administration in finding ways to cover the uninsured.
The threats of recession and inflation, or a combination of the two, looming over the country could unveil a hard truth in the national health that has been hidden behind 10 years of fabulous economic growth; there are still millions of people who do not have proper health care.
A recent Commonwealth Fund Task Force on the Future of Health Insurance reports that roughly 30% of Americans ages 19 to 29 lack health insurance.
The task force added that the number of older adults and children without health insurance is about half of the total number of young adults reported without insurance. The Children’s Health Insurance Program (CHIP), available through state programs, is working to cover entire families, not just children. Will the trend to cover parents through the efforts of the states continue?
Patricia MacTaggart, senior advisor, for the Center for Health Plan and Providers at the Health Care Financing Administration in Baltimore, sees the programs continuing to make children's health care their priority.
"The new president and Congress might throw more money at the problem," Mr. Weil added. "There will be a scramble, and states will then begin to change programs to cover parents."
Bruce Vladeck, senior vice president for policy at Mount Sinai New York University Health and director of the Institute for Medicare Practice, sees a recession as inevitable.
Either this year or next, since no one has repealed modern economic principles, a recession will come along, bringing with it a change in the country's health care priorities, he predicted.
A recession will show the limits of states’ abilities, and there will be lots of action in state legislatures to handle increasing number of uninsured, Vladeck added.
He also said to expect the expanded use of Medicaid waiver authority.
More must be done with waivers, Mr. Hanley said, because it will give more flexibility to states.
Two keys to covering more of the uninsured, according to Mr. Weil, were:
• The new administration needs to be more flexible in finding ways to cover those without insurance.
• The administration must find ways to help employers make CHIP more successful.
Flexibility was a word often used by speakers and attendees when discussing new ways to handle old business. Prescription drugs got the same treatment. "When it comes to prescription drugs, states must have more flexibility in dealing with costs," Mr. Hanley said.
The Blue Cross and Blue Shield Association annual "State of the States" report showed that drug formulary legislation is near the top of the list of priorities. Last year, according to the study, 23 states tried to control prescription drug costs by creating or expanding public subsidy programs.
"Inflation never went away in drug costs," Mr. Hanley said. A prescription drug benefit for managed care is on the table in Washington, DC, and it is up to President Bush to turn it into law, he pointed out. "It is up to the president. Without presidential leadership, nothing will get done on this issue."
The complexity of rules governing health care providers and state authorities has not gone away, either. Increasingly rules and regulations are added to the books across the country, sometimes clarifying health care procedure but oftentimes complicating them.
Margaret E. O’Kane, president
of the National Committee
for Quality Assurance talked about attending
a conference on MediCal in California recently. She said she was struck by the number of people who came to her complaining of the labyrinth of rules and regulations they must negotiate every day in order to do their jobs.
"We are wasting a lot of money and driving a lot of people nuts," Ms. O'Kane added.
The call for more legislation continues. Mr. Hanley said states must continue to resolve conflicts that are created by the legislative branch of government. "Are there too many regulations?" he asked. "We need to question this."
[Contact Mr. Hanley at (501) 682-1197, Mr. Kirschner at (602) 522-6539, Ms. Moore at (202) 872-1390, Mr. Smith at (517) 482-9236, and Mr. Weil at (202) 261-5709.]