Messing Up Medicaid in Ole Miss

Medicare is fairly easy to understand, if challenging to reform.  If you're over 65 or have some specific disability, bam, you'd got it, and you've got the same basic coverage no matter where you live.  Medicaid is infinitely harder to understand.  Most people think of it as "health care for the poor," but even that is not necessarily the case.  Every state makes us its own eligibility requirements and procedures - and a quick glance at how Medicaid works in Mississippi shows just how screwy those decisions can be.

Take the underlying assumption that Medicaid is "health care for the poor."  Not so in Mississippi, where you don't qualify for Medicaid if you're making 100% of the poverty line or below which in 2008 was $21,200 for a family of four.  You only qualify if you're a child whose family is under 100% of the poverty line, if you're over 65, disabled or blind - the minimum set of requirements under the legislation creating Medicaid back in the 1960s.  If your family is making $20,000 a year, the children qualify for coverage, but the parents explicitly qualify for nothing.  It's not like there isn't a need for the program, since Mississippi is ranked 50th among states in mean income by the 2000 Census (and 51st if you're counting D.C.).  And yet Mississippi since 2005 has actually made it harder to stay on Medicaid.  Under the guise of fighting fraud, the state legislature instituted the requirement that you could only re-apply for Medicaid and SCHIP coverage face-to-face, during normal business hours - because if there's one thing the working poor are known for, it's having flexible work schedules and reliable automobile transportation.  Mind you, this isn't preventing auto-enrollment - this is just ruling out applications by mail for re-enrollment.  As a direct result, Medicaid in Mississippi now has 53,000 fewer enrollees overall, and the number of uninsured children left out of Medicaid and SCHIP has jumped by 146,000.

Mississippi Gov. Haley Barbour has sworn to resist attempts to overturn this law with a measure of righteousness, proclaiming, "We have enacted reforms because we know it is wrong for a family to work hard at two or three jobs, to raise their kids and pay for their health care, and then have to turn around and pay extra taxes so others who are able to work and take care of themselves choose not to but instead get free health care at taxpayers' expense."  That may be true, but it seems equally wrong to deny children health care because their parents, who have already demonstrated a need for the program, haven't jumped through the correct yearly hoops, to say nothing about the backwards thinking that it's ok for parents under 100% of the poverty line to be denied care, so long as they're not blind or disabled.

Medicaid was always intended to be a federal-state partnership.  But it's time to reconsider how that partnership operates.  In the case of Mississippi, where a full 20% of the population including children is on Medicaid already, the reality is there's only so much the state can afford to do to expand and improve coverage (although not making it a hardship to be in the program in the first place would be a welcome start), especially when you consider rich states with a progressive tradition like New York, California and Massachusetts are also trying to figure out how they can spend less, often by covering fewer people and services.  Sen. Max Baucus in his white paper offers to make the Federal government the sugar daddy for an expansion to 100% of the Federal poverty line for all states, picking up some of the state tabs for their idiosyncratic "means testing" administrative costs (a leading factor in Medicaid's administrative costs being twice that of the national Medicare), and creating a trigger mechanism to automatically increase the Federal government's share of Medicaid when an economic downturn hits - like an automatic stimulus package.

That's a great start, but not sufficient.  Assumption of more of the costs for Medicaid by the federal government isn't enough to reform the system in a way that will lead to better quality or cost savings down the road.  Let's attach some strings to that money.  You want extra cash for "means testing," not a problem - but let's trim the heavy amounts of administrative waste and confusion for families who have recently moved by making the paperwork and the process simpler and uniform from sea to shining sea.  Want to fight fraud, we can help you - but let's make it a requirement that you first give the benefit of the doubt to high risk but cheap to cover populations like children.

The Federal government shouldn't just be the pocketbook - it should be the agent of change to build a stronger Medicaid, particularly in these troubled times.

(Photo credit:  Jim Frazier on Flickr.)