"No guarantees" for PWAs in Congressional Medicaid bill
Analysis: Medicaid gutted by Congressional plan
Widening gap between sick and health feared
Managed care lowers MD incomes
Patients, doctors don't agree on communication: poll
Employment: A Treatment That Works
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In agreeing to the bill, the President cut a deal to negotiate with Congress on a seven-year plan to balance the budget with some latitude on what economic assumptions will inform the process. Also included is a requirement from the President that the cuts not threaten the integrity of Medicare, Medicaid, education programs, and the environment.
Meanwhile, the Budget Reconciliation bill conference report was approved by both the House and Senate last Friday, with the Senate eliminating several anti-trust provisions that were challenged on a procedural basis. The House accepted the Senate amendments on the conference report on Monday.
The proposed Budget Reconciliation bill repeals the current Medicaid program and replaces it with a Medigrant program to states with very few federal requirements. The Medigrant program also cuts $163 billion in projected Medicaid spending over the next seven years. Under Medigrant, states are required to provide some level of coverage to pregnant women and children under 13 who live at or below the federal poverty line. States are also required to provide coverage for disabled individuals, although each state will have complete authority to determine its own definition of disabled.
This bill provides no guarantee that any low-income man, woman or child living with HIV/AIDS will receive the health care services they are now eligible to receive under the existing Medicaid program.
The bill is now ready to go to the President, who has promised to veto it.
Housing bill delayed again
Although the rule for the VA/HUD FY 96 appropriations bill conference report -- which includes AIDS housing funding -- was approved in the House November 20, the vote on the report has been delayed until after the Thanksgiving recess.
In the report, the Housing Opportunities for People With AIDS (HOPWA) program will get a separate line item funding level for FY 96 and receive funding at the FY 95 post-rescission level of $171 million. The McKinney/Homeless Assistance Grants program will receive an increase in FY 96 funding to the FY 94 level of $823 million. President Clinton has stated that he will veto the bill.
Also, the conference for the Department of Defense FY 96 authorization bill has not been completed, but AIDS advocates remain hopeful that it will not contain the Dornan provision which would mandate the immediate discharge of HIV-positive service members. In an effort to further educate members of Congress, AIDS Action Council accompanied an HIV-positive member of the United States Navy on lobby visits to key members of the House and Senate last week.
The center says that is because the congressional plan would not only cut in half the growth of federal spending on Medicaid, but also lower the minimum amounts that states are required to contribute.
Two dozen states are now required to contribute more than 40 cents of each dollar spent on Medicaid. They include the District of Columbia and 13 states that must match federal contributions on a 50-50 basis. But the plan to convert Medicaid into block grants to the states would lower the matching requirements for all but 14 states. The minimum matching contribution would go from 50-50 to 60 percent federal and 40 percent state. That means the states would get at least $1.50 in federal money for every $1 spent from their own revenues.
In states with the highest matching rates, such as Mississippi, Arkansas, Louisiana and West Virginia, two-thirds or more of the Medicaid budget is paid with federal dollars. All told, the changes in Medicaid would allow 36 states and the District of Columbia to draw federal matching money on more favorable terms, according to the center's analysis.
If every state contributed the bare minimum to qualify for the federal block grants under the new formula, the states could reduce their Medicaid spending by $257 billion, the center said. That would boost the total spending reductions to $420 billion.
The bill, adopted by the Congress last week, would achieve the projected $163 billion in savings by dividing $791 billion in block grants among the states over the next seven years rather than a larger amount that would be spend without changes.
Under the Medicare provision, 37 million elderly Americans would be allowed to leave the traditional Medicare program and use money from that program to sign up for managed care plans; plans of various sorts run by doctors; plans offered by unions and associations; traditional plans where members pay for each service they receive, or medical savings accounts, a favorite of Speaker Newt Gingrich and the Republican leadership.
But critics worry that healthier Medicare recipients would join private plans, which would court them actively, leaving most of the sickest people isolated in the government-run program.
This, they say, could threaten the viability of the traditional program over time by causing escalating deficits. One result, they say, would be lower payments to doctors and hospitals that could lead them to leave the program.
The critics also contend that cuts in anticipated growth in Medicaid would lead states to curtail their rolls, creating what some social scientists predict would be millions more uninsured.
A 1993 study of Medicare recipients who had joined health maintenance organizations found that healthier people disproportionately were attracted to the plans, causing the government to lose rather than save money. Indeed, critics say, plans often target the healthy by offering items like credit for exercise classes.
While the managed care industry disputed the findings of the 1993 study, Randall Brown, of Mathematica Policy Research Inc., who headed the effort, said he believed that sicker recipients stayed in the conventional program to insure that they could keep their own doctors, which is often impossible in managed care plans.
"If you're an 80-year-old person and you suffered a heart attack three years ago and a doctor saved your life, you're not going to give up that doctor for $50 a month," he said.
The ability of private associations to organize coverage for their members is a particular concern to many who are critical of the privatization, because, they say, groups representing the more affluent, who are generally healthier, could negotiate for better coverage. This would cause their members to leave the general pool even more quickly. Uwe Reinhardt, a health care economist at Princeton University, also said cost figures almost compelled private plans to seek out the healthy.
In 1993, when the average Medicare expenditure per person was $4,030, the average for the healthiest 90 percent of recipients was only $1,430; the average for the sickest 10 percent was $28,000.
If some experts worry that managed care plans would skim healthy recipients from the conventional Medicare program, many of the large plans are concerned that the healthy would be skimmed from them by medical savings accounts.
These accounts have been championed by Golden Rule Insurance Company of Indiana, whose political action committee contributed $621,775 to the Republican and Democratic National Committees since 1991, according to the public interest group Common Cause. All but $46,000 went to Republicans.
Since 1985, the committee has given $309,526 to Congressional candidates, including Gingrich. In addition, Golden Rule was the sponsor of a television show Gingrich hosted, and company officials gave $35,000 this year to GOPAC, the political committee Gingrich headed until last May.
The speaker praised the savings account idea in his recent book.
Under the legislation, Medicare recipients could buy a high deductible plan, contributed to by Medicare, as long as they opened a medical savings account that the program could help fund with money left over after the insurance premium was covered. Interest on account balances would be tax free and surpluses could be rolled over each year. Account money could be spent on anything, but nonmedical expenses would be subject to income taxes.
E. Richard Brown, head of the American Public Health Association, which represents public health professionals, said that in addition to siphoning the healthy and putting the traditional Medicare program at risk, the account concept "creates all the wrong incentives, incentives for people not to get preventive care" by allowing them to keep money they do not use.
The bill would also broaden the range of policies that could legally be sold to the elderly. And, in the eyes of critics, it would weaken a requirement that other policies include cautionary statements that they could duplicate coverage under Medicare or other plans.
Gail Shearer of Consumers Union, an advocacy group, said this provision would open up the sale of hospital indemnity and dread disease policies to older people. Because these policies are more profitable to insurers than other types of insurance, Consumers Union has called them the worst buy in the market. State insurance commissioners have also criticized these policies.
From the mid-'70s to the late '80s, scandals erupted in many states when older people, pressured by fear-mongering sales tactics, bought stacks of these policies, which often proved worthless.
Aflac, a Columbus, Ga., insurance company whose political action committee has contributed at least $1.76 million to candidates since 1987, is the country's largest cancer insurance carrier and has lobbied to relax restrictions on these policies.
In the Medicaid proposals, the $170 billion cut in projected spending over seven years has led many experts to fear that millions would become uninsured.
The Urban Institute, a Washington research organization, estimated that more than eight million people who would have been covered by Medicaid in 2002 would likely be without insurance because hard-pressed states would be forced to keep them from the rolls.
In a recent paper for the Robert Wood Johnson Foundation, Kenneth Thorpe, of Tulane University, estimated that the number of people with no health insurance could rise from roughly 40 million to as many as 66 million in 2002, when changes in Medicaid are combined with the rising number of employees who do not receive coverage through work.
A spokesman for the two groups said that people with weakened immune systems should drink bottled water or boiled tap water. The alert was prompted by continuing problems with bacteria in the District's aging drinking-water pipes.
In October, standard tests of tap water throughout the city found unusually high levels of bacteria.
But officials from both the Environmental Protection Agency (EPA) and the city claim there is no reason for panic. W. Michael McCabe, the EPA's regional administrator, said, "I want to emphasize that at the present time, we don't feel there is a public health threat."
The median earnings of all physicians dropped 3.8 percent last year to $150,000, from $156,000 in 1993, according to preliminary results from the AMA's latest annual survey.
And with managed health care spreading, employers are demanding lower insurance premiums, and insurers are leaning on health-care providers to cut costs.
One physician said under the latest insurance company payment schedules said "I won't be able to maintain the level of care I am giving, just to make the overhead costs" in the home office that took all her savings to build and furnish.
One company is offering a low $7 a month, or $84 a year, for each child enrolled aged 2 or older. "What am I supposed to do if the child comes in to see me four times?" Dr. Leeds asked.
Another factor is at work from within: an explosion in America's doctor population over the last 30 years. The number of physicians has soared to 660,582 today, or 252 for each 100,000 Americans - not counting federal government doctors - compared with 266,045, or 139 for each 100,000, in 1965.
Although 99% of doctors believe they communicate well with their patients, only 80% of patients think the same of their physicians, according to a nationwide Roper poll released this week.
The study, which was conducted for Hippocrates magazine, also shows that more than a quarter of the 200 doctors surveyed believe that "most of their colleagues" have problems communicating with their patients.
According to the poll, the biggest complaint of the 750 patients who were surveyed was that visits to the doctors are "rushed." Possibly because they feel rushed, 75% of patients said they often don't mention "specific doubts or questions" during an exam.
Seventy-four percent of doctors said they "appreciate" it when patients come to exams with books, magazines or "otherwise informed questions" about their medical care. The survey also found that almost one-third of women surveyed said their doctors "don't take their complaints as seriously" as the complaints of men, with an equal number of doctors conceding the disparity.
And while 85% of patients said they were "candid" about their sex lives, 60% of doctors said that patients "