The New York State Senate Majority Task Force on Medicaid has proposed changes in the Medicaid program. The following are comments on the proposals, by Assembly Health Committee Chair Richard N. Gottfried:
The Senate Majority report keeps the Medicaid program about 99% intact, which reflects a bipartisan consensus that New York's Medicaid program provides urgently-needed health care and support for our health care system. Seventy percent of Medicaid spending pays for health care for the elderly and disabled, and half of the rest is for children. Medicaid provides essential funding for hospitals, nursing homes, home care agencies, and community health centers. If their funding is cut – whether by Medicaid cuts or more patients being uninsured – then staffs are cut and services are stretched thinner. Even the wealthiest patient will get poorer quality care and some people will die.
While the report talks about "fundamental restructuring" of Medicaid, and mentions dozens of topics, most of its "recommendations" only vaguely refer to "encouraging" this or "expanding" that, with few specifics. Some of the Senate proposals are in line with Assembly initiatives, including legislation to create a Medicaid preferred drug list and ease the cost of Medicaid for counties and New York City. But some of the proposals would unfairly increase the cost and limit access to care for working people and their families and senior citizens with limited incomes.
Comments on Specific Proposals:
Senior citizens' income and assets. The Senate report would lower income eligibility levels and encourage seniors to strip the equity out of their life insurance policies and homes. Proposals to make it harder for senior citizens to transfer assets to become eligible for Medicaid coverage for
long-term care have been made for years - and repeatedly rejected by the Legislature for good reason. People who can afford lawyers can use trusts and other arrangements to get around these proposals. The Senate's proposals require people of modest means to impoverish themselves, or pressure family members to give up careers to care for an elderly relative.
Non-institutional care. The Senate report talks about "encouraging" non-institutional care – i.e., home care instead of nursing homes. But the Senate proposals to tighten the rules on spousal support and disposing of assets would actually discourage home care use.
Better management of care. The Senate report talks about better "disease management," use of technology to manage care, etc. Effective management of care requires that a patient be covered by a plan over a period of time. But today, patients are constantly dropped from Medicaid rolls and re-enroll months later, because of outdated red tape. The Assembly has fought to simplify this process to promote stable coverage and better management under Medicaid managed care. The Senate has refused to support these reforms.
Child Health Plus and Medicaid. The Senate proposes to move some children from Medicaid to Child Health Plus. The Governor proposed this in 2003 and both houses rejected it. The main difference between Medicaid and Child Health Plus is that Child Health Plus does not cover home care services that are needed by severely disabled children. The effect of this change would be to deprive severely disabled poor children of the care they need.
Easing local cost of Medicaid/Family Health Plus. The original bills for the recent expansions of Medicaid – Family Health Plus and the "buy-in" for working disabled people – were Assembly proposals that did not require any "local share." It was Governor Pataki and the Senate who insisted on requiring local governments to pay part of the cost. I welcome the Senate's support for the Assembly's position on funding Family Health Plus without a local share.
Preferred drug list/prior authorization. The only Medicaid providers whose services and rates of payment are virtually unregulated by New York's Medicaid program are the ones who happen to be huge for-profit corporations – drug companies. A preferred drug list/prior authorization program – if done right – can be an effective way to reduce what we pay to drug companies and encourage prescribers to focus on effectiveness and cost, without restricting access to drugs. The Assembly worked hard to negotiate this legislation with the Governor and the Senate, and it will be a high priority for us in 2004.
Cutting Family Health Plus. Family Health Plus, originally proposed by the Assembly, has been so successful that Governor Pataki takes credit for it. It provides health coverage to low-income working people who would otherwise be uninsured. The Senate proposal would unfairly eliminate covered services and increases costs for taxpaying New Yorkers who are barely above the poverty level. I welcome the Senate's support for the Assembly proposal to let people above the Family Health Plus eligibility level buy into the program at their own cost.
"Right-sizing" nursing homes. Many nursing home patients do not really need nursing home care and could be cared for at less cost in other settings. My bill (A.8815), which passed the Assembly in 2003 and is sponsored in the Senate by Sen. Ray Meier, would enable nursing homes to take beds out of circulation as patients are moved to other settings. I welcome the Senate's support.
Medical savings accounts (MSAs). MSAs give a tax benefit to people who put money aside to pay for higher deductibles in the health insurance. MSAs make it easier for people who are wealthier and healthier to leave the ordinary health insurance market. Unfortunately, that means more insurance policies will have higher deductibles, health insurance will be more expensive for average working people who can't afford a high deductible, and more people won't be able to afford insurance. MSAs may work for wealthier people, but only at the expense of everyone else. It is unclear how the Senate thinks MSAs relate to poor people on Medicaid, who cannot afford to have substantial savings accounts.
Encouraging long-term care insurance. New York's public-private partnership long-term care insurance program is good program that helps hold down the cost of long-term care insurance and Medicaid's long-term care costs. The Senate report does not say how it proposes to encourage long-term care insurance.
"Seamless" long-term care. The Legislature enacted a Managed Long Term Care law in 1998 to encourage "seamless" long-term care. Implementation of the law has been hobbled by the Pataki Administration. I look forward to working with the Senate in developing specific ways to overcome these administrative obstacles.
The "California" question
People often ask why New York Medicaid spends so much more than California per Medicaid recipient. There are good and important reasons. California may call itself the Golden State, but its Medicaid program is actually one of the worst in the country – spending less per recipient than any state, including Mississippi. New York's Medicaid spending is not much different from our neighboring states like Connecticut, New Jersey and Massachusetts.
New York has shifted most of its mental health spending into Medicaid, in order to draw down massive Federal matching funds. We're smart to do that. California doesn't. Mental health patients consume a lot of resources and increase our "per recipient" cost. New York provides good care for elderly and disabled patients, including much more home health care than California. It's good that we do. That also drives up our "per recipient" cost.
New York's payments to hospitals, nursing homes, home care agencies, and health centers are more closely related to the real cost of providing care than California. If we were to slash those rates, we would devastate the health care system that we all depend on.
Why does New York require counties to pay part of the cost of Medicaid? In the 1960s, when New York State's Medicaid legislation was first passed, New York City was already providing extensive health care for the poor at its own expense, through public hospitals and clinics. Many upstate legislators objected to having the state pick up a cost that had been carried by New York City. The compromise was to require local governments – counties and New York City – to pick up half the non-Federal cost of Medicaid. Today, the "local share" is overwhelmingly borne by New York City – three quarters of Medicaid "local share" dollars come from New York City.