Monday, May 30, 2011

Texas Politicans Produce Medicrud

U.S. Representative Mike Conaway (R-TX) announced at his Health Care Open House that 23% of uninsured Texans qualified for Medicaid but weren't enrolled.  He suggested Texas didn't need national health reform, that existing programs could address a large chunk of the problem.  Despite identifying a glaring need in his district, Conaway never went town to town signing up constituents for coverage. 

The Texas Legislature sees this pool of uninsured Texans as a flock of golden geese.  House Bill 13 wants the federal government to give Texas matching Medicaid funds (FMAP) based on:

A modification to the formula prescribed by federal law for determining this state ’s FMAP to achieve a formula that would produce an FMAP that accounts for and is periodically adjusted to reflect changes in the following factors in this state:
(1) the total population;
(2) the population growth rate; and
(3) the percentage of the population with household incomes below the federal poverty level.
For twelve years the State of Texas mostly sat on its backside regarding its legions of uninsureds.  Now it wants federal money for low income people it hasn't bothered to cover. 

HB13 aims to gain control over Medicaid "disproportionate share" and "upper payment limit" funds.  Fitch Ratings said Shannon Medical Center received $15.5 million in DSH/UPL payments in 2010.  Major tampering with this funding stream could jeopardize Shannon's safety net hospital role for the Concho Valley.  First, who would be covered under the Legislature's alternate methods, which:

(1) provide flexibility to determine Medicaid eligibility categories and income levels

I expect Texas, with the highest percent of uninsured citizens, to continue underachieving by setting bare bones eligibility categories and income levels.  The bill will also:

(2) provide flexibility to design Medicaid benefits that meet the demographic, public health, clinical, and cultural needs of this state or regions within this state;
Texas redefined public health in 2000, dropping "access to primary care" as an essential public health service.  How will they redefine other needs to the state Treasury's advantage?

The bill goes on to identify coverage elements under Medicaid's alternative methods.  Low income people can expect:

(3) encourage use of the private health benefits coverage market rather than public benefits systems;
(4)  encourage people who have access to private employer-based health benefits to obtain or maintain those benefits;
(5) create a culture of shared financial responsibility, accountability, and participation in the Medicaid program by:
(A) establishing and enforcing copayment requirements similar to private sector principles for all eligibility groups;
(B)  promoting the use of health savings accounts to influence a culture of individual responsibility; and
(C) promoting the use of vouchers for consumer-directed services in which consumers manage and pay for health-related services provided to them using program vouchers
Ignore that Texas legislators favor private health insurers, responsible for distortions making coverage nearly unaffordable for many.  The above language has local implications.  The City of San Angelo sent 200 people from the ranks of the insured with draconian premium sharing for early retirees and dependents.  Oddly, the City participated in a program encouraging employers to maintain affordable health coverage for early retirees.  The City did the exact opposite.  How would reformed Medicaid "encourage" low paid COSA workers to obtain or maintain health insurance benefits?

Cost sharing mechanisms, copayments, health savings accounts and vouchers, mean more work for Shannon's Business Office.    Recall that Medicaid is already a notoriously poor payor to hospitals.  Add the 8% hospital payment cut in the Texas budget and Medicaid becomes a larger deadbeat.

Reformed Medicaid would have hospitals chasing low income people for copayments and distributions from likely empty HSA's,  Hospitals would compete for low income consumers and their likely measly payment vouchers.

Let's hope the following fable doesn't come true, although it's entirely predictable:

Once upon a time hospitals existed to serve all people, providing high quality health care regardless of ability to pay.  Then the Legislature privatized everything, with pay for performance permeating the system.  Intrinsically motivated organizations and workers found themselves under Rube Goldberg financial complexification, which killed their internal desire to do good work. They eventually said, "You can't pay me enough to deal with this crap." So, they quit or sold out to for-profiteers.
That's when the heart of health care died and was replaced by a mechanical version.  Should the fable come true, be sure to thank the system's deformers, your elected representatives.

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