州予算の削減により、血流を維持し足の潰瘍の悪化を予防するストッキングの代金は支払えないと州メディケイドからの連絡が77才の退職した栄養士Ms. Baugh にあった。1組あたり239ドルのストッキングは、彼女が暮らす毎月の社会保障費の3分の1以上になる。
Governors Fear Added Costs in Health Care Overhaul
By CLIFFORD KRAUSS
Published: August 6, 2009
Stuart Isett for The New York Times
Quincy Proctor has had a series of strokes. His financing for occupational therapy at a Seattle adult health center was cut off. More Photos >
SEATTLE ― The fraying of the nation’s Medicaid system has many indicators, and one of them is Connie Baugh’s stockings.
Connie Baugh of Seattle, center, wears compression stockings for leg ulcers, but Medicaid no longer pays for them. More Photos ?
Ms. Baugh received a letter the other day from the state saying that as a result of budget cuts, Medicaid could no longer pay for the compression stockings that support her circulation and keep her aching leg ulcers from flaring. “I thought, oh God, another problem,” recalled Ms. Baugh, a 77-year-old retired dietitian.
At $239 a pair, the stockings are more than one-third the value of the monthly Social Security check she lives on.
Such cutbacks, in response to the recession that has eroded state finances even while swelling Medicaid ranks, is the reason Washington’s Democratic governor, Christine Gregoire, is among governors from both parties who fear the implications of the health care overhaul now being devised in Washington, D.C.
The governors worry Congress will give the states expensive new Medicaid obligations without providing enough new money to pay for them.
“We can’t afford to have Congress raise the eligibility for Medicaid coverage without paying for it,” Ms. Gregoire said in an interview.
If anything, the states’ fears were stoked further last week when House lawmakers drafting health legislation reached a cost compromise with conservative Blue Dog Democrats that would force states to take on a greater Medicaid spending burden than an earlier version of the bill.
“This is profoundly disappointing and makes a bad situation much worse,” said Doug Porter, Washington State’s Medicaid director.
In most respects, Ms. Gregoire is an outspoken supporter of President Obama’s effort to overhaul health care. But she knows Washington State’s Medicaid program is already under strain. The state’s Medicaid enrollment has grown by more than 87,000 people since the recession began, to a current total of 951,543. Dental coverage, prenatal care and mental health care are among the medical and counseling services that have come under the budget knife.
And Mr. Porter, the state’s Medicaid director, warns that an increasingly thin safety net could break if Congress expands Medicaid eligibility.
“I can foresee a situation where states would say ‘I don’t have enough in general funds to put up my share of this new expanded Medicaid program, and I have to get out of the Medicaid program,’ ” he said. “That’s what I think the doomsday scenario is here.”
Under the various strands of legislation under consideration in Congress, as many as 11 million people who are now uninsured could become eligible for Medicaid. Currently, that program exceeds $340 billion in annual costs that are shared by the states and federal government.
The Congressional Budget Office had projected that federal Medicaid spending under the House bill could increase by over $430 billion over 10 years. The open question now is how much of that might become the states’ new burden.
Criticism from state governors resonates because of its nonpartisan nature. But it is especially significant coming from Washington State, which has a politically liberal tradition of broad support for health care.
Under the House legislation, after the Blue Dog compromise, Medicaid eligibility would be expanded to many more people under age 65 with incomes at or below 133 percent of the poverty level ― about $14,400 a year for an individual. States would pay a share of the additional costs, perhaps 7 percent, in future years. The original House bill had the federal government paying all additional costs, with the states responsible only for some extra administrative expenses.
Meanwhile, one of the plans being considered by Senator Max Baucus, chairman of the Senate Finance Committee, would have the federal government pick up the full bill for any extra Medicare costs for five years. But after that, the states would share the new obligation with the federal government at a proportion that would vary from state to state.
Senate staff members say the governors are being heard, and that measures to cut other health care costs in the legislation will eventually alleviate their concerns.
“We are in close contact with a number of governors and will continue working with them to ensure health care is more affordable for families, businesses ― and state budgets,” Mr. Baucus said in a statement.
No state has yet dropped out of the federal Medicaid program since it was created in 1965. So it seems unlikely that a liberal state like Washington would be the first to do so. It has a tradition of generous Medicaid services, as well as state-subsidized medical coverage for low-income working people who do not qualify for Medicaid.
But it is within every state’s power to slash its own Medicaid spending by tightening eligibility, limiting covered services and cutting reimbursement rates for health care providers. And during these fiscal hard times, that is precisely what Washington and many other states have done. Trimmed or gone altogether in various states is coverage for things like dental care, optometry, hearing aids and speech therapy, according to state Medicaid directors, who say that rising costs and expanding Medicaid rolls all but guarantee that more cuts will come.
Washington State, facing a $9 billion budget shortfall, has begun a planned $1.2 billion in cuts this year from its $6.6 billion Medicaid budget.
The cutting would have been even more drastic, state officials say, had it not been for the enactment of Mr. Obama’s stimulus package, which provided Washington an extra $2 billion in financing for Medicaid. And the officials say more cuts are inevitable once the stimulus package financing runs out in October 2010, unless a second package is enacted.
The cuts in Washington State seem to be affecting local clinics and other community health agencies that serve the poor.
Neighborcare Health, the leading provider of primary medical and dental care to low-income and uninsured patients in Seattle, relies on Medicaid reimbursements for more than 40 percent of its $35 million budget. As a result of the recent cuts, it is estimating a loss of $270,000 in monthly income, according to Katie Bell, the chief operating officer, even though patient volume is up this year by 7 percent.
Ms. Bell said she and her staff were trying to find ways to minimize the impact on the organization and its 15,000 Medicaid patients ― about one-third of its clients.
“It keeps me up at night thinking that some of these patients could go without a nurse when they need to figure out how to use new medication,” Ms. Bell said. “Or they won’t be able to get the dentures to fill in the gap in their front teeth so they can get a job and feed their families.”
Elderhealth Northwest, a nonprofit agency providing long-term care for elderly residents of Seattle, has already had to close two of its six adult day health centers this month, cutting the number of patients who receive nursing and rehabilitative services to 975, down from 1,300.
“I think these people will eventually end up in hospital emergency rooms and in nursing homes, where it will eventually cost the state more,” said Nora Gibson, executive director of the agency.
One of Ms. Gibson’s clients is Quincy Proctor, a 78-year retired Cadillac salesman who is afflicted by diabetes and various other ailments after a series of strokes.
His financing for occupational therapy at a Seattle adult health center was cut off because he already received funds to live in an assisted-living boarding home. But the boarding home offers only limited exercise therapy, and he is abandoning the hope of eventually being able to leave his wheelchair and walk again.
“This really hurts,” Mr. Proctor said, fighting back tears. “To stand up three times a week and get some of my strength back meant I could do some things by myself.”
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