http://archive.nytimes.com/2003/03/06/opinion/06COHN.html
How Medicaid Was Set Adrift By JONATHAN COHN ANN ARBOR, Mich. � As President Bush kicked off his plan to reform Medicare and the country's malpractice laws on Tuesday, he didn't mention one of the most important policy achievements of recent years: the expanded role of Medicaid, which provides health care to low-income Americans. But then, Medicaid is the success story that almost nobody has paid attention to. Since the late 1980's, the proportion of Americans receiving health insurance through their jobs has declined. So during the late 1990's, the Clinton administration and the states tapped their unexpected budget surpluses to make Medicaid more widely available. They eased eligibility requirements and got more aggressive about enrolling people. As a result, 47 million people receive Medicaid today, up from 40 million in 1998. Despite the waste and abuse common to public and private health programs, Medicaid has done a remarkably good job of serving a low-income, poorly educated and multicultural population. And without it, the high number of Americans without health coverage today � some 42 million � would likely be a few million higher. Unfortunately, that progress is now in jeopardy. With more people out of work and private health insurance increasingly unaffordable, there is a new wave of struggling Americans looking to the government for help. But the states, suddenly beset by budget deficits, are in no position to provide it this time around. That's why the country's governors went to Washington last week, literally begging for temporary assistance, and why even normally spendthrift Republicans in Congress seemed inclined to support them. President Bush, however, has proposed something quite different. Instead of helping states bolster Medicaid, he wants to help them cut it. It's an odd way to preserve such an important piece of public policy; then again, preserving Medicaid may not be the precise goal Mr. Bush has in mind. When he first unveiled his Medicaid plan in January, he boasted of its generosity, since it included more than $3 billion in new money for the states next year � part of an additional $13 billion they would receive over the next seven years. But given that the states are looking at about $70 billion in overall deficits next year, that's hardly enough to keep Medicaid going as is, let alone allow it to accommodate additional needs while unemployment remains high. (By comparison, a bipartisan bill would give the states an immediate infusion of $20 billion, half of it explicitly dedicated to Medicaid.) And when you read the fine print in the president's plan, you discover the real dangers. Like a bank making a loan � or, as critics have put it, like a loan shark exploiting a client's vulnerability � the president would require the states to pay back all of the $13 billion in the three years that follow the initial seven. In addition, states accepting the upfront money would have to sign off on a major shift in the program's overall financing scheme: Washington would stop providing the bulk of its Medicaid financing as matching funds, which rise as states enroll more people. Instead, it would provide a fixed sum each year, based on a formula that could easily underestimate the true need for services. When asked about these reductions, Bush administration officials have insisted they won't really hurt � that through "innovation" the states would learn to do more with less money. But a look at the regulatory changes in the plan suggests just what sort of innovations they have in mind. The Bush scheme would make it easier for the states to cut services like prescription drug coverage, prosthetics, eyeglasses and most nursing-home care. Although this may not sound like "compassionate conservatism," it's entirely consistent with the administration's broader approach to health policy. President Bush has repeatedly made it clear he wants the government out of the business of providing health insurance � if the poor find themselves uninsured, he'd prefer the government give them tax credits to buy private policies. But while that private-sector approach may sound appealing as part of a stump speech, in the real world it doesn't work. Mr. Bush's tax credit proposal, for example, would give individuals up to $1,000 annually to buy a policy � which would cover only a few months of decent insurance in most parts of the country. In addition, Mr. Bush has shown no willingness to enact the kinds of regulations necessary to guarantee that insurance is available to the people who need it most, including those with pre-existing conditions like chronic diabetes. It was precisely because the poor couldn't afford health insurance that the federal government created Medicaid in 1965. It's also the reason that, in trying times like these, previous administrations have dipped into the treasury to keep the program going. Maybe President Bush just doesn't understand this history. Or, sadly, maybe he's intent on reversing its course. Either way, his plan would force many states to cut back a vital and effective health insurance program at the very moment their citizens need it most. _______________________________________________ http://www.mccmedia.com/mailman/listinfo/brin-l
