The Mess that is Medicaid

My sister is legally blind. Without glasses or contacts, Jerri can’t read a page held an inch from her nose. If you point at an object 20 feet away, she can’t tell you if it’s a bush or a Clinton. For that matter, she can’t even tell you’re pointing. You’d have to take her chin in hand and point her face in Hilary’s direction. Even then she might mistake her for a Juniper.

She’s been wearing the contact in her left eye for 4 months. The same lens for 4 months. A lens that is supposed to be discarded and replaced every 2 weeks. She doesn’t have any glasses. Her frames broke quite some time ago. She still has the lenses and when she’s really desperate, she tapes them on to the frames of her sunglasses.

Jerri hasn’t seen an ophthalmologist in two years. Despite the fact that at her last visit, she was diagnosed with glaucoma. She doesn’t use the drops that were prescribed because you can’t use them with contacts.

Now that she’s in her right mind, Jerri is trying to take better care of her eyes. She knows she needs to treat the glaucoma which means she needs glasses. But when you’re as near-sighted as she is, a basic pair of no-frills glasses costs about $300. Medicare and Medicaid do not cover this.

Completely on her own, Jerri researched potential venues for financial help. She contacted the Department of Social Services and was able to obtain a voucher for eye glasses from the NC Division of Services for the Blind. But she had to have an eye exam to get a prescription. In NC, Medicaid used to cover routine eye exams for adults but not any longer thanks to legislation (House Bill 200, Section 10.37.(a)) effective October 1, 2011. Fortunately, and who’d have ever thought I’d be making a statement like this, Jerri has glaucoma. If you have a medical eye condition, Medicaid will still pay for the exam.

So I talked to my ophthalmologist, Dr. Jill Bryant, about Jerri, her disability, and her financial situation and Dr. Bryant agreed to see her. (Not every doctor will you know, given Medicaid is her insurance for eye care.) Not only did Dr. Bryant give Jerri a complete and thorough exam but she treated her with dignity and respect. From the minute we walked into the office, everyone, from the office manager to the eye technician, looked her in the eye, appropriately directed their questions to her (not to me), and were transparent about what Medicaid would and would not pay. For example, contacts are considered to be cosmetic so Medicaid does not cover contact lens fitting but Jerri really wanted a contact lens prescription in addition to one for glasses. That part of the visit was $80 typically payable same day. The office manager told us to stop by after the exam to discuss a payment plan. Dr. Bryant, knowing Jerri’s situation, reduced the cost of the lens fitting to $55. But when we spoke with the office manager, she just waved her hand and said not to worry about it! Dr. Bryant also filled a bag with saline solution and glaucoma medication samples.

I left Dr. Bryant’s office with two thoughts competing for attention. One – what a beautiful gift Dr. Bryant had given Jerri by simply treating her like a human being. And two – what in the world will Jerri and others like her do when Medicaid crashes and burns?

It’s virtually impossible this close to November not to be concerned about Medicaid. No worries, I’m not going to go all political on you. Frankly, I don’t think either candidate has a good plan for this one. Medicaid is broken. It has been for years.

Medicaid is a jointly funded cooperative venture of the federal government and state governments to assist the states in providing medical care to people in need. Because the federal government contributes funding, it also regulates how it is appropriated. For example, the federal government legislates who is eligible for Medicaid. States cannot limit enrollment to manage costs. The primary means that States have to manage Medicaid costs is to reduce the amount of payment for services to doctors. So every year, most States cut this payment. Because of this, Medicaid pays physicians way below the market rates to care for Medicaid patients. In 2008 (when this was last measured), according to the Centers for Medicare and Medicaid Services (CMS), Medicaid paid physicians approximately 58% of what private insurers paid for comparable services. Low payment, the excessive paperwork required to file for Medicaid reimbursements, and the amount of time it takes CMS to pay are all reasons why many physicians choose not to see Medicaid patients.

source: Manhattan Institute for Policy Research

When physicians do see Medicaid patients, the care they provide is often substandard resulting in poorer outcomes. One study in the Annals of Surgery examined outcomes for 893,658 individuals undergoing major surgical operations from 2003 to 2007. [LaPar DJ et al., Primary payer status affects mortality for major surgical operations. Annals of Surgery. 2010 Sep; 252(3): 544–51.]

In summary: Medicaid patients were almost twice as likely to die as those with private insurance; their hospital stays were 42 percent longer and cost 26 percent more. Compared with those without health insurance, Medicaid patients were 13 percent more likely to die, stayed in the hospital for 50 percent longer, and cost 20 percent more.

It only took a couple of doctor visits with Jerri for me to see that she gets fewer tests and referrals than I do with my private insurance and we see the same doctor.

In 2009, there were over 50 million Americans with Medicaid. Currently, Medicaid provides health care coverage to low-income families with dependent children, pregnant women, children, and aged, blind and disabled individuals.You may be aware that one provision of the Affordable Care Act ( aka Obamacare) expands Medicaid coverage in 2014 to low income individuals without dependent children, an additional estimated 17 million people. Add that to the people already receiving Medicaid and that’s over 20% of Americans. That’s a lot of people!

Perhaps you see my concern. In a system where it’s already difficult to find a doc who accepts Medicaid, how will these people get care? What additional services (like eye exams) will have to be cut to keep the program solvent?

It’s disturbing that so many people are so poor. I struggle sometimes with “entitlement” programs. I’ve met people who are working the system. At the beach, I have a neighbor who’s a veteran. He broke his back in Basic training before active duty and was honorably discharged. He had a number of surgeries and appears completely healed. He kayaks, cycles, runs and lifts weights. But he chooses not to work. He’s living on VA benefits and disability.

To me, that’s wrong. He might not be able to serve in the military but he CAN work. He chooses not too.

But I also know many people with mental illness who would be on the streets without these programs. For example, Jerri and her neighbor with schizophrenia, Catherine, who is in the hospital again because her medications aren’t working. There will always be poor people, legitimately poor people, and we need a way to take care of them. I hate that this responsibility falls to our government, but the practical side of me acknowledges if the government doesn’t do it, no one will. Sadly, I’m not sure either candidate has a friend or family member who is legitimately poor. I think that’s a basic requirement to even understand the problem.