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Attending to Medicaid

Published online by Cambridge University Press:  01 January 2021

Cindy Mann  and
Tim Westmoreland
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Extract

[P]layers line up in a long line and hold hands. The player at the front of the line is the ‘head’ and the player at the end of the line is the ‘tail’.… The game begins when the head begins to run wildly in any direction, making sharp turns and quick double-backs.… The force created by the twists and turns will often send the tail of the whip flying.… It may be best for the tail to hold on with both hands to keep from flying off the end. Sometimes, however, the tail will go flying no matter how hard they hold on ... Be prepared to get dirty if you play this game!

--"Crack the Whip: Party Game Central

If the evolution of American health policy (in both its purposeful and its accidental forms) is compared to the children’s game of Crack the Whip, then there is no question that the Medicaid program is the tail of the line. When those at the head of the line (e.g., employer-based insurance, Medicare, managed care plans, and pharmaceutical companies) start to move. Medicaid receives whatever shocks and unintended consequences result, and when the line “begins to run wildly in any direction,” it receives them faster and harder than the players at the center.

Shocks also come from other sources. When the economy slumps, an epidemic arises, or a path in another part of the system becomes a cul-de-sac, new twists and turns occur, with Medicaid absorbing much of the change.

Type
Symposium
Information
Journal of Law, Medicine & Ethics , Volume 32 , Issue 3 , Fall 2004 , pp. 416 - 425
Copyright
Copyright © American Society of Law, Medicine and Ethics 2004

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States should, of course, be permitted to adopt procedures that assure program integrity. States have generally found that streamlined processes do not interfere with states’ ability to take a variety of measures (including data matches, using information from other state programs, and random audits) to assure that people who are enrolled are eligible for the program. Cohen-Ross, D. and Cox, L., “Preserving Recent Progress in Health Coverage for Children and Families: New Tensions Emerge,” Kaiser Commission on Medicaid and the Uninsured Washington, D.C.: Kaiser Family Foundation, 2003).Google Scholar
Research has repeatedly shown that premiums and cost sharing, if set too high, will deter low-income people from enrolling in coverage and accessing necessary care; See, Hudman, J. and O’Malley, M., “Health Insurance Premiums and Cost-Sharing: Findings from the Research on Low-Income Populations,” Kaiser Commission on Medicaid and the Uninsured Washington, D.C.: Kaiser Family Foundation, 2003); Ku, L., Charging the Poor More for Health Care: Cost-Sharing in Medicaid, (Washington, D.C.: Center on Budget and Policy Priorities, 2003); Tamblyn, R., et.al., “Adverse Events Associated with Prescription Drug Cost-Sharing among Poor and Elderly Persons,” Journal of the American Medical Association 285, no. 4 (2001): 421–429; HRSA State Planning Grant Consultant Team, Income Adequacy and Affordability of Health Insurance in Washington State (University of Washington Health Policy Analysis Program, Rutgers University Center for State Health Policy, RAND, William M. Mercer, Inc., The Foundation for Health Care Quality, 2002). The recent experience in Oregon where more than half of the poor adults who were subject to premiums dropped out of the program shows that even relatively modest premiums (in this case, premiums ranged from six dollars to twenty a month) can be too high for poor people; McConnell, J. and Wallace, N., Impact of Premium Changes in the Oregon Health Plan (February 2004), Oregon Health Research & Evaluation Collaborative, at <http://www.ohpr.state.or.us/OHREC%20welcome2_files/Reports%20and%20Briefs/Impacts%20of%20Premiums%20-%20FINAL.pdf> (last visited July 1, 2004).Google Scholar
For the list of HHS waiver initiatives, see supra note 59. For a description of the new Health Insurance Flexibility and Accountability waiver initiative and some of the implications of the new waivers, see Mann, C., “The New Medicaid and SCHIP Waiver Initiatives,” Kaiser Commission on Medicaid and the Uninsured Washington, D.C.: Kaiser Family Foundation, 2002); Mann, C., Artiga, S. and Guyer, J., “Assessing the Role of Waivers in Providing New Coverage,” Kaiser Commission on Medicaid and the Uninsured (Washington, D.C.: Kaiser Family Foundation, 2003); Artiga, S. Guyer, J. and Mann, C., supra note 63; and other waiver reports and fact sheets prepared by and for the Kaiser Commission on Medicaid and the Uninsured, at <http://www.kff.org/medicaid/waivers.cfm> (last visited June 24, 2004).Google Scholar
Guyer, J., “The Financing of Pharmacy Plus Waivers: Implications for Seniors on Medicaid of Global Funding Caps,” Kaiser Commission on Medicaid and the Uninsured Washington, D.C.: Kaiser Family Foundation, 2003).Google Scholar
Recently the far-reaching nature of waiver activity has attracted critical attention from the Congress as well. See, Letter from Senators Charles Grassley and Max Baucus to CMS Director Mark McClellan, June 16, 2004.Google Scholar