We need to prepare for post-Medicaid

I think most of us who have been paying attention would agree that Medicaid is in trouble. Like most programs that LBJ and friends started back in the 1960s it was done with the best of intentions and with the most simplistic, nai?ve understanding of human nature.

I remember in the late 1970s or early 1980s watching the demolition of a low income housing project that was built in the 1960s in St. Louis. One of the residents was there to watch and celebrate. She hated the place. She went on to describe how it had all started with so many promises. She was a young single mother who along with her child's father were poor and living with her mother. She was told that she would qualify to become a resident because of her circumstances and her income. From the beginning she noticed that everyone who lived in the projects were basically bound by the same eligibility requirements. Even from the beginning she never felt that everyone's circumstances were all the same but, in order to become a resident, you had to become like everyone else. "I knew from the start," she said "that this was kind of strange. They just assumed all poor people like to live together, I guess, and live together in huge numbers."

The rest of the story is a positive one, but one that took courage and determination. After several years in the projects this women told how she and her boyfriend married and moved out to make a better life for themselves. Mainly, she said, because we could have the freedom to determine what was best for us.I have thought about this story many times over the past 30 years and I have watched Idaho, like most states, struggle to do what is best for its citizens while always trying to comply with what the federal requirements are. Unfortunately, we have become so dependent on the promise and the money that goes with it that we have forgotten the feeling we once had that this whole thing doesn't feel right.

Well it isn't right and it is going to take courage and determination for our state to think about the unthinkable and opt out of Medicaid for some optional programs. We need to stop looking at federal Medicaid dollars as free money. It isn't free, but we have been conditioned to think it is. The states act as if they live in Albania and each month some rich cousin in America sends them a check. Well, the rich cousin in America is broke and pretty soon the check is going to stop coming.The fact is that without the federal eligibility requirements we are now bound by, the state would have much more flexibility to develop programs that can allow individuals and families to assist in their own care. The reality is that we need to start planning as a state to assume that federal Medicaid is not going to be there in its present form at least for those programs for some of the most needy. One indication things might be getting tighter is the fact that President Obama made a recess appointment this last summer of a Harvard professor named Don Berwick. Prof. Berwick is the new head of the centers of Medicare and Medicaid services. He is on the record stating "it is not whether or not we will ration care - the decision is whether we will ration with our eyes open." If that is not playing your hand I don't know what is.

The basic Medicaid eligibility requirements for all states deal mostly with poor families with children and the medically needy. The states are also given the choice of having optional services that they can use Medicaid to fund but have more flexibility in determining how the money can be spent. The same argument is often made when looking at using the block grant approach to funding for the states. The assumption is always that if Medicaid lets us have the money in a different form, we will be more likely to spend less. The fallacy is thinking that Medicaid will give us money with less requirements, and the so-called flexibility will actually translate into lower cost. Let's take the situation at Idaho State School and Hospital (ISSH) in Nampa, for instance. Built at the turn of the century as an institution for what then was referred to as "the insane and the handicapped," it at one time had a population of almost 1,000 people. In the 1960s a process of moving people out of institutions and into the community began and it coincided with the advent of Medicaid.

Over the last several decades Idaho has done a good job of transitioning people into communities and they have used Medicaid money to develop these community programs. We as a society no longer automatically put people in institutions, and getting someone into an institution is gladly very difficult. ISSH presently has a population of approximately 60 to 70 people mostly there because of behavior issues, those involved with the criminal justice system and the medically needy. The annual budget for ISSH is around $20 million annually. This works out to about $800 per day per individual. The budget for ISSH in the early 1970s when it had 600 people was around $22 million. Medicaid now pays 70 percent of the costs at ISSH.

The attitude on the part of most state legislatures is that since most of the costs are paid by the feds we don't need to address them. When Medicaid begins to shrink - and it will have to if it is to survive - these optional programs will be the first to go. The question Idaho and other states will have to ask is what to do with services in optional programs. These programs deal with the most needy and the most dependent who cannot live without some form of state support. We pay $800 per day for each person to be at ISSH. If we wanted to send them to Harvard with two full-time care givers getting $25 per hour, the cost would be about $600 a day and that difference alone would save us nearly $6 million. We pay this incredible amount in order to be funded by Medicaid and comply with all of the rules and regulations that we must adhere to maintain an institution. It doesn't matter if we have one or 600 - the costs remain the same. We pay millions in Medicaid match money in many cases to help maintain a system that is expensive and does not allow us to provide services in a way that are truly needed.

We have become so focused on feeding a system we have lost sight of the fact that we on the state and local level can perhaps do it better. Many of the optional programs have always been a process of trying to fit a square peg in a round hole. The present system of Disability services have always been about what Medicaid will pay for and not what is best practice and what are the best kinds of services. Medicaid services originally were for hospital-based services, but over the years - especially in the process of moving from institutional-based services to community services - the disabilities programs never were a comfortable fit. So over the course of time, the feds came up with the concept of waivers, or waving the original Medicaid rules to allow states to pay for different kinds of services.

These waiver programs have become a huge part of the growing cost of Medicaid. They have been some of the most innovative parts of Medicaid and have shown promise in having the potential of reducing costs. The downside is like the old saying, I have seen the enemy and it is me, and every where I go there I am. The rules are still dictated by what Medicaid needs and allows. We have developmental disabilities services across the state that provide treatment and therapy services year after year for a persons lifetime not because they need therapy and treatment but because that is the only way we can get Medicaid to pay for it. Do we need services for people with disabilities in the community? Yes we do. We need them in the community more that ever because we know that is the best place for people to live. The majority of people with disabilities no longer live in institutions and yet we have continued to provide expensive institutional like services in the community. Most of these prescriptive services are expensive and unnecessary but in true Medicaid fashion, exist not because they are truly needed but because that is the only way they can be paid for.

We need to start to look at ways to provide the best services that are needed, not just what services Medicaid will pay for. We already pay millions of dollars in the states for Medicaid in match money, and in many cases we are not getting what we need, but what the system wants.We have to start looking at ways to insure services for the most helpless in our state. We need to, at least, have some ideas of how we might provide them if and when Medicaid is no longer an option. We need to explore how and where are we going to spend money in a post Medicaid world. We are presently expending most of our energy and dollars feeding a system that is driven by political correctness, legal paranoia, and an increasingly shaky bureaucracy. This is why we need to start to explore the concept of opting out of Medicaid in some optional programs.

Keith Knight is a retired special education teacher who resides in Hayden.