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In a good conversation with Becki Gray yesterday on News 14 we discussed the different visions for Medicaid reform proposed in the respective budgets of the Governor, House, and Senate. In particular, Gray, who works for the John Locke Foundation, noted that the state has a “rich” benefits package in Medicaid because we offer many optional services, that is, services that are not required to be covered by the federal government. The Senate, she correctly pointed out, wants to whittle away these optional services.

Ending optional services in Medicaid is a popular policy among conservative think tanks in the state. Apparently the Senate is listening.

As this debate progresses it is important that we know what services we are talking about when we talk about optional services. Let’s review a few: transplants, prescription drugs, dentures, hospice, prosthetics. None of these treatments are frivolous or lavish.

And that’s the trouble with optional services. If you want to get at some of the more expensive options then you are limiting life-saving care. Former Locke Foundation analyst Joe Colletti even praised Arizona for cutting optional services like transplants in a report on Medicaid reform. But these cuts inflicted so much pain in Arizona that the state made a volte-face on its decision.

That brings us to the Senate budget. Among other things the Senate wants to end the optional Medically Needy program in Medicaid. This program allows people who have enormous medical expenses, but earn too much to qualify for Medicaid, to apply these medical bills to their income to access Medicaid. This makes sense. If, for example, you earn $30,000 per year but need expensive drugs or nursing home care then these costs will quickly eat through your monthly income. Although you may have some money your medical needs erase it all. It’s not fair to tell this person that he or she is too wealthy for Medicaid when they effectively have nothing.

But this is exactly what the Senate aims to do.

As we have said many times before, “optional” refers to a regulatory requirement and does not mean anything about the necessity or quality of specific Medicaid services. You may call it foolish for the state to cover optional services. I call it basic human decency.

 

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Recent budget proposals out of the NCGA will eliminate Medicaid coverage for nearly 12,000 elderly blind or disabled people, cut $1 million from a popular program that delivers meals and provides in-home health services to the elderly, and shut down several regional offices of the state’s child-developmental services agencies that help babies and toddlers with disabilities.

One submission to N.C. Policy Watch’s “Your Soapbox” feature laments the difficulty in getting help even before the the proposed cuts.

I lost my insurance coverage under COBRA. I went for a year without insurance coverage. I didn’t qualify for Medicaid since I had over $2500.00 in the State Retirement system.

I had to fight tooth and nail to get help. Every way I went was a dead end. I was finally able to get help through Pender County for medical and meds.

It is a crying shame the way the poor and elderly are being treated; it’s like the legislature wants them to die.

Read the full submisson here.

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Do you have a story to tell? We want to hear more from people and their families who stand to be affected by the massive cuts proposed by our legislative leaders to Medicaid and other health and human services programs that serve the poor, disabled and elderly. What are your experiences? Tell us your story using this submission form.

To read personal stories from others affected by the cuts, click here.

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MedicaidThe following essay comes from Dr. William Dennis, President of the North Carolina Academy of Family Physicians:

Senate spending plan: The wrong treatment plan for an incorrect diagnosis

As a family physician, I am trained to process and understand the symptoms my patients present for the sole purpose of making a correct diagnosis. Once the correct diagnosis is made, it becomes my imperative to develop a treatment plan that addresses the underlying health concerns, not just remedy a patient’s symptoms. Only then can I deploy the necessary healthcare resources to ensure the best possible outcomes for my patients. Successful Medicaid reform is no different.

Over the past 16 months the state’s healthcare community, working closely with the General Assembly, the Governor, the Medicaid Reform Advisory Group and representative patient advocates, have made tremendous progress in diagnosing the ills of our Medicaid system and proposing priorities for reform and continued investment.

Some of these include:

• Improved Budget Forecasting – The actual spending per Medicaid recipient has been decreasing, with overall claims spending growing at a rate lower than the growth in the number of Medicaid recipients. The most significant cause for continued cost overruns is linked to budgeting inaccuracies, not care delivery.

• Continued Investment in “Medical Homes” – Community Care of North Carolina’s (CCNC) nationally recognized platform of “medical homes” provides services and care that is better coordinated to meet the needs of each patient. They leverage technology and care management to prevent chronic disease where possible, and maintain patient course of treatment where necessary, all of which reduces costly occurrences of hospital re-admissions and unnecessary emergency room visits.

• Adoption of New Payment Mechanisms – Movement away from the current fee-for-service model that ties compensation to volume of patients seen, towards physician-led accountable care organizations that reward improved health outcomes by focusing on prevention and chronic disease management.

But last week’s Senate Spending Plan is a complete departure from this process and the progress it has yielded. Senate leadership has developed an arbitrary treatment plan for an incorrect diagnosis that will ultimately damage the healthcare system that serves all North Carolinians. Read More

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Since assuming office Gov. McCrory has throttled the theme that Medicaid is broken and must be reformed. He began by offering a radical proposal of dismantling our current system and selling it off to private insurance plans. He has since backed away from that idea and now wants a more modest expansion of what currently works in Medicaid.

The House, in a bipartisan bill filed this session, clearly agrees with the Governor’s new approach. The legislation, spearheaded by Rep. Nelson Dollar, would build Accountable Care Organizations (or ACOs)  in Medicaid. These provider led ACOs would move us toward greater integration of care and away from fee-for-service medicine. Medicare is using the ACO model as are many private insurers. In fact, Medicaid is one of the only payers in the state not moving to this method of organizing care.

In its budget, the Senate flatly rejects this approach. That chamber wants Medicaid to move to full capitation. In other words, legislators want to provide a set budget to Medicaid. The insinuation is that the Senate prefers the Governor’s original plan to pay private insurers to care (or not care, as the case may be) for our most vulnerable citizens.

The Senate also engages in some fantasy by pulling Medicaid into a freestanding department that will engage the nation’s best health care minds in this ambitious reform effort. At least that’s how Sen. Louis Pate described the proposed process. The trouble, of course, is that the nation’s best health care minds consider North Carolina’s Medicaid program to be an important model and they aren’t interested in helping to dismember it. The nation’s best health care minds also aren’t interested in coming to our state and spending time tearing apart care for low-income people as the legislature reduces services, limits eligibility, and slashes the budget. We are, in short, engaged in the opposite of innovation.

Rep. Dollar is a smart chap and likely realizes that his ACO bill isn’t going anywhere as a piece of legislation. That means he will need to stick the proposal into the House budget to give it a fighting chance. Hence, the showdown mentioned in the title of this post.

Certainly the House is moving in a better direction. But it’s a good time to reflect that Virginia is having its own budget battle over Medicaid right now. Except instead of fighting over how to fiddle with (or blow up) a program that is working, Virginia’s leaders are having a serious discussion about using federal funds to expand Medicaid coverage to 400,000 people. If that happens it means that our tax dollars will help boost Virginia’s economy, bolster its rural hospitals, and support its citizens.

That will certainly be charitable of us, but not wise.

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Senate leaders are looking at major cuts to health and human services programs that serve the poor, disabled and elderly in order to pay for teacher raises and fund Medicaid to required levels.

DHHSThe North Carolina chapter of the AARP has a good rundown here on what some of the proposed cuts will do, and the group says it is “disheartened to see the Senate budget proposal doesn’t value our state’s older adults and those who are blind and disabled.”

The state’s doctors are also concerned about the cuts to Medicaid system, and how it will affect some of the most vulnerable North Carolinians.

Robert Seligson, the head of N.C. Medical Society, denounced the state Senate’s budget proposal Thursday, saying it offers “no solution to the big challenges we’re facing in Medicaid.”

“Patient care under the Senate plan will suffer, especially for the aged, blind and disabled citizens of our state, who will no longer be eligible for Medicaid if the Senate has its way,” Seligson said in a statement.

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