Topeka Capital-Journal, October 21, 2007: Medicaid A crisis in care

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By Jan Biles & Dave Ranney

The Capital-Journal & KHI News Service

Published Sunday, October 21, 2007

Bodi Baker lost her food-service job last month. She was fired.

“I can’t really blame them,” she said. “I’d had to be off so much because of my kids.”

A 26-year-old single mother, Baker has two daughters, ages 3 and 6, with special health care needs that at times must take precedence over a job.

“Both my daughters have asthma really bad,” she said. “My oldest was born premature, and my youngest has what’s called Erb’s Palsy. She can’t use one of her arms her right one for a lot of things. She has to have physical therapy once a month at Children’s Mercy (in Kansas City, Mo.). She got stuck in the birth canal when she was born.”

Baker, who moved to Topeka from Iola about four years ago, figures she missed about 20 days of work between February and September dealing with medical emergencies.

“That doesn’t include the time I had to take off for doctor’s appointments that were scheduled ahead of time,” she said. “We go to the emergency room once every couple of months. My youngest daughter’s asthma acts up when it’s cold, and my oldest daughter’s acts up when it’s hot. It gets to where she can’t breathe.”

Baker’s former husband’s health insurance covers some of the girls’ medical bills. Medicaid makes up the difference. Baker said she is only able to receive Medicaid benefits when she isn’t working.

“I don’t know what I’d do if they (the children) weren’t on Medicaid,” she said. “I don’t know where I’d find the money for their medications. We’d be worse off than we are now.”

Baker and her children are among the estimated 276,640 Kansans about 10 percent of the state’s population in 2006 whose health care needs are covered by Medicaid.

The assistance program provides health care coverage to low-income children and some of their parents, certain pregnant women, low-income seniors and certain individuals with disabilities.

The Medicaid program in Kansas cost $2.2 billion in 2006. The federal government pays 60 percent of the cost, while the state pays 40 percent.

Medicaid, like other government-funded health care programs, is under the gun a target for lawmakers and policy-making officials looking for ways to trim budgets at both the state and federal levels.

As the fate of the State Children’s Health Insurance Program is hotly debated in Washington, the Kansas Health Policy Authority, which oversees the state’s Medicaid program, is scheduled to go before Gov. Kathleen Sebelius and the Legislature on Nov. 1 to present its recommendations for health care reform.

‘Just common sense’

While politicians debate who should or shouldn’t receive health care assistance, it isn’t unusual to see Jennine Marrone in her office after 5 p.m. making phone calls to pregnant women and low-income parents of children who have appointments at the Community Health Center of Southeast Kansas in Pittsburg.

Marrone’s job as a part-time eligibility assistant coordinator is to find out if patients have medical insurance and to help complete the required documentation and paperwork to obtain health care coverage through Medicaid or SCHIP.

“Jennine talks to about 120 people a month by phone or person,” said Jason Wesco, chief operations officer at the health center. “In the first two months (she was here), 40 children and pregnant women got signed up.”

Wesco said the health center sees 30 to 40 children each day at the clinic, and three to four of those kids are uninsured.

About 94 percent of the patients seen at the clinic are under the 200 percent federal poverty level an annual income of $36,000 for a family of four and qualify for Medicaid or HealthWave, which includes both Medicaid and SCHIP.

“So we shouldn’t really have any children who are uninsured,” Wesco said.

That is the crux of a $41,000 grant the health clinic recently received from United Methodist Health Ministry for a project called Canvassing for Kids. The goal of the grant is to reach more than 1,000 uninsured children ages birth to 5 in Crawford, Cherokee and Bourbon counties to help them access medical, dental, and mental health services and establish a “medical home” for preventative and acute care.

“This was not so innovative. It’s just common sense,” said Krista Postai, chief executive officer of the health center.

About 20 percent to 25 percent of the children in those three counties are living in families whose income is at the 100 percent of the federal poverty level or below, according to U.S. Census records.

An average of 140,000 low-income children were enrolled in Medicaid in fiscal year 2006.

But Marcia Nielsen, executive director of the Kansas Health Policy Authority, said only 80 percent of the children eligible for Medicaid in Kansas participate. That leaves 20 percent, or about 35,000 children, uninsured.

“There’s an enormous amount of kids who are eligible and are not enrolled,” said Corrie Edwards, executive director of the Kansas Health Consumer Coalition in Topeka. “In our minds, it’s too much. Everybody who is eligible should be enrolled.”

Signing up

The number of uninsured children in Kansas continues to increase. And despite voiced concern from policymakers, Wesco said little has happened to make the situation better. In fact, he says, the system has become worse.

Since the July 1, 2006, implementation of citizenship documentation requirements for Medicaid and HealthWave, the Community Health Center in Pittsburg has seen a 96 percent increase in the number of uninsured children it serves, from 198 to 390.

In the past year, the clinic has provided $73,995 in uncompensated care to uninsured children who are, in most cases, eligible for public insurance programs. That amount represents a 125 percent increase over the 12-month period preceding the change.

KHPA officials have said at least 20,000 children who had Medicaid benefits have lost coverage as a result of the citizenship documentation change, which was designed to eliminate undocumented immigrants from receiving benefits.

One aspect of the Canvassing for Kids project is to get these once-Medicaid-eligible kids back on the rolls, Wesco said.

“It shouldn’t be this hard,” he said. “We shouldn’t have to have people here like Jennine to do this.”

Wesco said even he is intimidated by the 10-page public assistance package that Medicaid applicants must complete. Required documentation includes utility bills; child care bills and receipts; proof of income, such as stubs, earnings statements, rental property or sales contracts; life insurance, burial plans and health insurance policies; vehicle titles and registration; rent receipts or mortgage payments, including insurance and property taxes; federal income tax returns if self-employed; proof of medical expenses if elderly or disabled, including medications, doctor bills, hospital bills and insurance premiums; proof of high school graduation or GED; and bank statements for checking and savings accounts.

And that is just part of the information applicants are to bring to the table.

“It’s not unreasonable to me to think it’s designed to keep people off assistance,” Wesco said. “You can buy a house with less paperwork.”

Just because the application has been completed and mailed doesn’t mean the Kansas Family Medical Clearinghouse received the form or processed it in a timely fashion, Marrone said.

When she has called the clearinghouse in Topeka to check on the progress of applications, she has been told at least a dozen times that the forms weren’t on file.

“We’ve had to start over with a lot of people,” she said.

Nielsen said she saw “how onerous the paperwork burden was” when the new federal requirement was implemented and unprocessed applications and reviews piled up at the clearinghouse.

In February, 15,000 applications and reviews were waiting to be processed. From February through Sept. 26, an additional 75,016 requests for medical assistance were received.

Additional funds allocated to KHPA by the Legislature were used to bring 13 contract staff members and four state staff members on board by the first week of July to help reduce the backlog, said Megan Ingmire, KHPA spokeswoman.

The backlog had been reduced to 6,399 applications and reviews, and Nielsen said she expects the clearinghouse to be caught up by January.

But what happened to those people who were once eligible for Medicaid benefits the ones who weren’t undocumented immigrants?

“No one wants to ask the question about what happened to the people who went off the system,” said Bob Harder, former secretary of the Kansas Department of Social and Rehabilitation Services.

The answer is clear: More people are seeking health care at community health centers and emergency rooms and often put off treatment until they are much sicker.

But the real irony of the Medicaid system is qualifying for the program doesn’t mean one is going to get health care.

Many doctors, dentists and other health care providers are limiting the number of Medicaid patients they see or not seeing them at all because they are reimbursed only a portion of the cost of services.

“If you see Medicaid patients, you’re actually paying to see them,” said Dr. Dennis Cooley, of Pediatric Associates of Topeka.

Reform on the way?

Nielsen said KHPA is couching its Nov. 1 recommendations to the governor and Legislature in a three-prong framework:

• Promote personal responsibility by embracing healthy behavior and contributing to the cost of health insurance.

• Pay for prevention and a primary care medical home to improve health outcomes, coordinate care and drive down health care costs.

• Provide and protect affordable health insurance for all Kansans to ensure appropriate access to health care.

“We will have several sets of proposals for the Legislature,” she said.

Of course, those recommendations will be scrutinized by legislators, health care providers, consumers and other interested parties based on whether they align with their desired outcomes.

Take the much-talked-about premium assistance program.

While House Speaker Melvin Neufeld, R-Ingalls, pushes the program, Wesco said it is “ridiculous.”

“Premium assistance equates insurance products with access,” Wesco said. “You can have insurance and not have access.”

Cooley, the Topeka physician, said he would like to see Medicaid rates parallel those of Medicare. Otherwise, he said so many options and plans are being talked about that he isn’t “sure what’s best for this country.”

His diagnosis, “I think we have a health care system that is really sick.”

Harder and Donna Whiteman, of Topeka, another former SRS secretary, said the state’s leaders have broken a promise made to its residents.

“When I was with SRS, I felt like we had a moral obligation and contract with the poor, needy and disabled and aged to ensure medical services as best we could,” Harder said. “We shouldn’t have insurance companies profiting over the illness of people, profiting on people who have misfortune that is out of their control. In terms of the poor, needy and voiceless, I think the social safety net is now in tatters.”

Gregory Schneider, a senior fellow at the Flint Hills Center for Public Policy in Emporia, anticipates a “healthy debate” about health care reform during the next legislative session.

“The health care moment has arrived in American politics,” he said.

But Schneider is skeptical that any action will be taken because it is a presidential election year. Discussions and hearings on health care will be wrapped in “wait and see what happens” at the national level, he said.

A year ago, Schneider was excited because legislators were discussing the issues, SB 11 had passed and the KHPA had begun meeting to hash out solutions. Reforms were surely on the horizon, he thought.

“But now,” he said, “I’m not so sure.”

Jan Biles can be reached at (785) 295-1292 or Dave Ranney, a staff writer for Kansas Health Institute News Service, can be reached at or (785) 233-5443, ext. 128.

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