Report: Many Medicaid fixes not effective
Profiles of six Medicaid high-cost populations released near the end of 2006 make the point that Medicaid "plays a unique and critical role in meeting the acute care and long-term services needs of millions of seniors and people with disabilities with high costs, offering protection when no other system exists to serve them."
The report, by Georgetown University Health Policy Institute project director Jeffrey Crowley and Kaiser Commission on Medicaid and the Uninsured's Molly O'Malley, was released by the Kaiser Commission. Mr. Crowley tells State Health Watch the profiles had been worked on for some time, but it seemed important to release them at the end of the year so they could play a role in the public policy debate over Medicaid changes.
"People don't have a full understanding of Medicaid's role in the health system and with people with high costs," Mr. Crowley says. "To more efficiently and fairly finance acute-care and long-term services for all Americans, as the population ages and disability rates increase, policy changes may be needed to help expand the financing base for long-term services and strengthen financing for Medicaid programs. This may include reforming Medicare so that its benefits package more appropriately matches the needs of its beneficiaries. It could also include private sector initiatives or other efforts to promote planning for or insuring against future needs for long-term services. … As these populations will show and as policy-makers think about the type of health care system our nation needs, it is important to consider Medicaid's role in anchoring the broader health system."
Medicaid assists people with financially catastrophic needs at all stages of life. While it is a program for low-income people, virtually anyone except the extremely wealthy could be just one accident or illness away from needing Medicaid assistance, the report said.
For some, purchasing private insurance coverage in advance of onset of disability could provide important protection. But some conditions are so costly that even private insurance may not be able to effectively finance all the costs. Thus, people with spinal cord and traumatic brain injuries may face health and long-term services costs exceeding several million dollars over their lifetime. And as Alzheimer's disease progresses and families determine that nursing home care is necessary, they find it can cost more than $70,000 per year. Even individuals who planned for increased long-term services needs as they age may find that after several months or years they need to rely on Medicaid's assistance.
The individuals profiled in the report have very complex, extensive, and specialized needs, according to Mr. Crowley. They have a broad range of needs for acute medical care as well as long-term services and supports. For example, people with intellectual disabilities may have co-occurring physical health problems requiring specialized services to assist the individuals in performing activities of daily life and adapting to physical limitations.
Public responsibilities
Medicaid has uniquely public responsibilities in that it is responsible for ensuring that children receiving foster care obtain the acute care and long-term services they need; providing coverage for young adults who experience traumatic brain injuries; and providing a safety net for individuals and families who planned for their long-term services needs but whose resources have been exhausted by the high cost of services, such as some people with Alzheimer's disease who eventually require 24-hour supervision or assistance.
Medicaid provides the coordination of many services not available elsewhere. Mr. Crowley said disability and chronic conditions produce overlapping needs involving both acute care and long-term services.
"The availability of both types of services through Medicaid makes it especially well suited to people with high costs and complex needs," he said. "Medicaid has adapted to the diversity of needs of the Medicaid population by providing cutting edge services not often provided by other payers. For people with mental illness, the integrated services delivery models developed by Medicaid programs provide a way for people who have mental health service needs to remain in the community and continue to have their needs met."
A critical Medicaid role is as a safety net for people who need assistance with acute and long-term services needs. Mr. Crowley noted that the private long-term care insurance market isn't available to those who already have long-term services needs. For the populations described in the report, he said, there often are no other major public or private sector programs for comprehensively meeting their acute care and long-term services needs. For example, children who were born prematurely and have ongoing needs often turn to Medicaid only after running into gaps in private health insurance coverage, and people with Alzheimer's disease may start out using savings or private long-term care insurance to finance services, but then turn to Medicaid after other resources have been exhausted. For people with intellectual disabilities and co-occurring developmental disabilities such as epilepsy or cerebral palsy, Medicaid provides a comprehensive set of services including day habilitation, occupational therapy, skilled nursing, speech therapy, and case management services that may enable them to live in their community rather than having to enter an institution.
Pre-term birth problems
Comments on the profiled populations included:
1. Pre-term births occur with increasing frequency and people who are born prematurely often have lifelong acute care and long-term services needs. Each year, according to the research, 100,000 children develop health problems because of their early births. A study of low-birth weight babies found that 20 years after birth, they continued to have significantly higher rates of chronic conditions than control subjects. Pre-term infants have an increased risk of hospitalization during the first few years of life and increased use of outpatient care. Among the conditions leading to poorer health are reactive airway disease, recurrent infections, and poor growth.
2. Children receiving foster care often have extensive needs and the state has taken responsibility for protecting their welfare. Each year, the report says, more than 800,000 U.S. children spend time in foster care. Many have experienced abuse or neglect. In other cases, however, parents have turned to the child welfare system as a last resort to gain access to mental health services they are not able to obtain for their children elsewhere. Many of the children involved have extensive needs for health and long-term services. Case management services also play a critical role in coordinating service needs and helping ensure that children actually receive the services prescribed by doctors and other service providers.
3. People with spinal cord and traumatic brain injuries have unexpected and financially catastrophic health and long-term services needs. Some 250,000 Americans have spinal cord injuries, with about 11,000 new injuries each year. More than half of all spinal cord injuries occur in young people between the ages of 16 and 30. First-year treatment costs range from an estimated $219,000 to $741,000, depending on the severity of injury. Ongoing costs for each succeeding year range between $15,000 and $130,000.
4. People with mental illness expose the potential need for increased public costs when individuals cannot access the services they need. Some 20% of the U.S. population is believed to have some form of mental health disorder and 5% is believed to have a serious mental illness such as schizophrenia, major depression, or bipolar disorder. Recognizing that many diagnoses are lifelong conditions, access to a continuum of care that includes preventive services and screenings, medical and social interventions, crisis management, and inpatient services is important.
5. People with intellectual disabilities have specialized needs that would not be met in the private health insurance system or a long-term service system developed to meet the needs of people with physical disabilities. Studies demonstrate that 1% to 3% of the U.S. population has an intellectual disability. A common need of people with intellectual disabilities is for supervision and cueing, in which they are prompted to perform various activities of daily living. For example, some people may be physically able to maintain appropriate hygiene and dress themselves, but they need cues to remind them when they should perform certain actions, such as showering. Also important are habilitation services that assist in acquisition, improvement, and retention of skills needed to maximize the ability to function.
6. People with Alzheimer's disease and related dementias need a safety net because increasing services needs and high costs can be overwhelming, even when individuals have saved for their retirement needs. An estimated 4.5 million Americans have Alzheimer's disease, and the number has more than doubled in the last 25 years. Over time, individuals in this category need increasing levels of assistance with maintaining a home, managing finances, and then personal activities such as bathing, dressing, and feeding. As Alzheimer's disease progresses, individuals eventually require round-the-clock supervision and assistance.
Mr. Crowley tells State Health Watch that while various states organize their Medicaid programs differently, there are common needs and common truths that should be recognized. "Every state has these high cost populations," he says. "Placing arbitrary limits on benefits, such as pharmacy benefits, is not working well. Denying people with chronic problems benefits ends up costing more. It's important that state policy-makers understand that their interests are not served by arbitrary limits."
It's also important to acknowledge, Mr. Crowley says, that Medicaid is different from private insurance and states need to make it work as well as possible.
Download the profiles from www.kff.org/medicaid/7565.cfm. Contact Mr. Crowley at (202) 687-0652.
Profiles of six Medicaid high-cost populations released near the end of 2006 make the point that Medicaid "plays a unique and critical role in meeting the acute care and long-term services needs of millions of seniors ..."You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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