THE MEDICAID MELTDOWN

Reality is finally biting

Hundreds of thousands of poor people across the nation will lose their state-subsidized health insurance in the coming months as legislators scramble to hold down the enormous - and ever-escalating - cost of Medicaid. Here in impoverished southeast Missouri, nurses at a family health clinic stash drug samples for patients they know won't be able to afford their prescriptions after their coverage is eliminated this summer. Doctors try to comfort waitresses, sales clerks and others who will soon lose coverage for medical, dental and mental healthcare. "I don't know what cure to offer them," Dr. Hameed Khaja said.

Lawmakers say they feel for those who will lose coverage. But they say also that they have no alternative. Prenatal checkups, care in nursing homes and other health services for the poor and disabled account for more than 25% of total spending in many states. Medicaid is often a state's single biggest budget item, more expensive even than K-12 education. And the price of services, especially prescription drugs and skilled nursing for the elderly, continues to soar.

The federal government helps pay for Medicaid, but in the coming fiscal year, the federal contribution will drop by more than $1 billion because of changes in the cost-share formula. President Bush has warned of far deeper cuts to come; he aims to reduce federal spending on Medicaid by as much as $40 billion over the next decade. "It's frightening a lot of governors," said Diane Rowland, executive director of the Kaiser Commission on Medicaid and the Uninsured.

Every state has frozen or is trying to cut the fees they pay doctors to care for Medicaid patients. More than a dozen states are looking for ways to cut the number of people covered - or reduce their benefits. Several are proposing restructuring the entire program.

In Tennessee, Gov. Phil Bredesen plans to end coverage for more than 320,000 adults, many of them elderly. In California, Gov. Arnold Schwarzenegger wants to shift more Medicaid recipients into managed care and require some to pay monthly premiums.

Minnesota may stop insuring 27,000 college students and adults without children. Washington state may require senior citizens to pay $3 for each prescription that Medicaid used to provide for free.

South Carolina Gov. Mark Sanford and Florida Gov. Jeb Bush have proposed privatizing Medicaid. Bush wants to give recipients vouchers so they can shop around for their own insurance plans. Sanford wants to set up Medicaid bank accounts; the state would deposit a fixed sum of money for each patient to spend on medical expenses.

In Missouri, where nearly one in five residents is enrolled in Medicaid, Gov. Matt Blunt is poised to sign the most drastic overhaul of all: a bill that would eliminate the program entirely in three years. Blunt expects that by then, the state will have established an alternative mechanism for helping the poorest of the poor. But the legislation on his desk does not insist on it. It only states that Missouri Medicaid will cease on June 30, 2008. In the meantime, the bill severely cuts the existing program, ending coverage for an estimated 65,000 to 100,000 people.

Legislators are still working out eligibility details. But under one leading proposal a single mother of two who earns $3,800 a year would be considered too wealthy to qualify for Missouri Medicaid. The woman's children would still be eligible for free healthcare. But if she gets a better job and starts earning $23,000 a year, they, too, would be bumped off Medicaid - unless she's willing to pay as much as 5% of her income in monthly premiums. The state expects many parents at that income level would be unable or unwilling to pay the premiums, forcing about 24,000 children off the Medicaid rolls.

Children who remain on Medicaid would continue to receive full benefits, but under legislation expected to take effect this summer, most adults would get a bare-bones package. The program would no longer pay for their dental care, hearing aids, eyeglasses, wheelchairs, hospital beds or even bedpans. State Rep. Trent Skaggs, a Democrat from Kansas City, considers the new rules cruel, especially at a time when more than 45 million Americans lack insurance. He worries parents will stop working so their income will drop low enough to qualify their family for free care. Rather than raise costs for minimum-wage clerks, Skaggs suggests increasing insurance premiums for lawmakers who get health coverage through the state. He recently introduced a measure that would have cost the average politician $115 a month - the measure failed on a close vote. "That made a complete mockery of the idea that leaders sacrifice first," Skaggs said. "Times are tough, but not so tough that we have to sacrifice?"

The Republican lawmakers who have been leading the Medicaid overhaul drive say such criticism distorts their goals. The cuts are not just about balancing this year's budget, they say. They're about steering Medicaid back to its original purpose: to serve as safety net for citizens who are too young, too old, or too ill to help themselves. Turning Medicaid into a welfare program for poor but able-bodied adults risks jacking up the costs so high, they say, that the entire system could go bust - stranding those who most desperately need the state's help. The cost of Missouri Medicaid has doubled in the last six years, to $5 billion. It eats up more than 30% of the state budget. More than 1 million people are enrolled. "Government is not here to do everything for everybody," said state Rep. Jodi Stefanick, a Republican representing suburban St. Louis. "We have to draw the line somewhere."

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REPORT-CARD FOR BRITISH NHS

Not good, Mr Blair

Dirty hospitals and a lack of information about medical treatments are among patients' top concerns about the NHS, according to an authoritative survey. They are also worried about a lack of involvement in decisions about medication and other NHS care. The service has improved, in some cases markedly, says the report from the Picker Institute Europe, but only in areas directly targeted by the Department of Health.

In other areas the service has languished or even become worse, according to the views of nearly a million patients who have contributed to surveys conducted since 1998. Angela Coulter, chief executive of the charity, said: "The most disappointing thing is that all the rhetoric about creating patient-centred care hasn't led to improvements across the board. "Only where specific targets have been set - in waiting times and in cancer and heart disease - are we seeing big improvements. Where there are no targets, in areas such as cleanliness and access to a GP, the service has not improved and in some cases has got worse. Many aspects of patients' experience still need urgent attention."

The charity has designed a series of national patient surveys for the NHS for the past seven years. Data collected by NHS trusts has been issued in reports from the Commission for Health Improvement and its successor body, the Healthcare Commission. Picker has now summarised the results in a new report - Is the NHS Getting Better or Worse? - in an effort, it says, to inject some facts "into the current poliical knockabout on the state of the NHS".

Areas in which things have become worse include family doctor services. In 1998, 87 per cent of GP patients said that they had sufficient time with the doctors, but by 2004 this had fallen to 74 per cent. Between 2002 and 2004 the proportion of patients complaining about inconvenient opening hours had increased from 20 per cent to 22 per cent. Professor Coulter said that she expected criticism to increase as the effect of the new GPs contract was felt. Reports from patients indicated increasing difficulties with getting an appointment at a convenient time. The disappearance of Saturday surgeries was a particular complaint, she said.

Hospital cleanliness is another problem. In 2004 only 54 per cent said that the ward they were in was very clean, 2 per cent less than in 2002. Only 48 per cent said that bathrooms and lavatories were very clean, 3 per cent less than in 2002. There is little evidence in the report that the NHS is becoming more patient-friendly. More than a fifth of inpatients and a quarter of A&E patients said in the 2004 survey that staff did not always listen to what they said - which represents no improvement since previous surveys.

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

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