Welfare reform could reverse gains in TB control
States may treat immigrants regardless of payment
After implementing extensive revisions in its tuberculosis laws to improve treatment benefits for low-income residents, California TB officials face an unanticipated barrier at the federal level - a welfare reform law that excludes Medicaid to legalized immigrants. If Congress fails to adopt efforts to restore those benefits, the state could see a reversal in the substantial decreases in TB cases reported in the past two years, says the state’s TB controller.
"We have adopted a program to get Medicaid reimbursement for low-income persons with TB not otherwise eligible for Medicaid, but we still face two big barriers, and one of them is federal welfare reform," says Sarah Royce, MD, MPH, chief of TB control for the California Department of Health Services in Sacramento. "Some health departments were using the TB Medi-Cal program for newly arrived legal immigrants, and it appears this legislation will make them ineligible."
In 1995, 60% of newly diagnosed TB cases in California were among residents born outside the United States. As many as half of those residents had resided in the country less than five years.
As in California, Texas TB officials also are concerned over the adverse impact of the welfare exclusion for legal immigrants, says Walter Page, executive director for National TB Controllers Association in Atlanta. The association is polling its members before taking a position on the issue, but in its last newsletter, Page wrote:
"We are very concerned that this legislation may have a detrimental impact on efforts to control TB. This legislation will greatly reduce Medicaid reimbursement for expenses incurred in the treatment, screening, or preventive therapy of legal immigrants."
Benefits stripped from half a million
Based on the welfare reform law, most immigrants arriving in the United States on or after Aug. 22, 1996, will not be eligible for services under the TB Medicaid program or for other medical services during their first five years of service, Page says. Refugees, people seeking political asylum, and U.S. military forces veterans are exempt, he adds.
Government agencies estimate that the welfare reform law eventually will remove health and disability benefits from 500,000 immigrants, the majority coming from California, followed by New York, Texas, and Florida each among the top 10 states for TB rates in 1995. The legal immigrant exemption would make up an estimated one quarter of the projected $54 billion savings under the welfare reform law over the next seven years.
Even though restoring Medicaid benefits to legal immigrants appears to be a political long-shot, experience from past benefit restrictions on immigrants indicates that state health departments will not turn these patients away if they have active TB, Page says. For instance, when California exempt Mexican nationals from health benefits 30 years ago, "We went ahead and treated them until they were no longer communicable," says Page, who worked then for the state’s TB program.
Climbing the wall of paperwork
While California TB officials likely will take the same position today, they face another barrier to enrolling low-income patients in care, Royce says. The state’s TB legislation reform has created a new funding source for TB treatment, but too much paperwork has kept patients from seeking treatment and has kept providers from obtaining reimbursement for directly observed therapy (DOT), she explains. To help remedy the later problem, the state has developed a fee-for-service reimbursement category for DOT that will pay $19 per visit either to the home or a clinic, Royce says.
The state is benefiting from other TB legislation reform brought on in 1994 after the state health department convened a statewide TB Elimination Task Force with the California Tuberculosis Controllers Association and the American Lung Association of California. Through mobilizing a broad-based public/private partnership of 54 organizations, the task force succeeded in increasing TB awareness among policy makers and making changes in areas such as:
• TB case reporting.
In 1994, 10% of pulmonary TB cases were reported to local health departments four weeks after the start of treatment. New regulations have mandated that TB cases be reported within one working day and require that labs conduct and report drug susceptibility testing on initial isolates.
• Hospital discharge.
In 1993, only 26% of California counties had more than 90% of their cases complete therapy within 12 months. Also, 16% of counties had less than 70% of their TB patients complete therapy within 12 months.
A major deterrent to completion was the loss of patients to follow-up care after they were discharged from hospitals, Royce says. To improve quality of care, the new law requires hospitals to receive approval from health officers before they discharge patients. The same notification procedure is required of correctional facilities before they transfer patients with known or suspected TB back into communities or to other state and local correctional institutions. Also, providers must report to health officers when a TB patient, for any reason, discontinues therapy.
"What would happen in the past and hopefully a lot less now is that a suspected TB patient would be started on medication and discharged before the health department had made a viable discharge plan, like arranging for DOT, housing, substance abuse treatment, and so on," Royce says. "This ensures that the hospital calls the department right away so planning can begin before the patient has left and it becomes difficult to find them again."
The state TB program also has set up a patient tracking system based on the Centers for Disease Control and Prevention’s reporting system, says Royce. Once a patient is reported, the program can monitor his or her progress. If treatment is stopped too early, the local health department now has the means to get them back into treatment.
• Detention.
Using New York City’s updated laws on detention of TB patients, the California Department of Health Services created a step-wise progression of legal orders, beginning with the least restrictive and expensive practice, such as court-ordered DOT. By adding a civil process to what had only been a criminal process for detention, the state depended on the CDC’s legal frameworks for TB control published two years ago in the Morbidity and Mortality Weekly Report.1
"We now have statutes that are modern and strike a good balance between health officer authority and a TB patient’s legal rights for due process," Royce explains.
The governor’s budget for 1997-1998 includes funds to create secure treatment facilities for noncompliant patients as an alternative to jails.
"We don’t have facilities where health officers can order detention using the civil process, and, happily, there are funds in the governor’s budget to address this," she adds.
Reference
1. Centers for Disease Control and Prevention. Tuberculosis control laws United States, 1993. MMWR 1993; 42(No. RR-7).
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content