By John Bouman, Sargent Shriver Center on Poverty Law
On June 17, Dr. Karin Rhodes and her colleague Joanna
Bisgaier of the University of Pennsylvania released a report on access to
subspecialty doctors by children covered by Medicaid in Cook County, Illinois.
The authors also published an article about the study underlying the report in
the New England Journal of Medicine.
Dr. Rhodes undertook and was paid for the study pursuant
to a contract with the Illinois Department of Healthcare and Family Services,
the state’s Medicaid agency. The study was part of the department’s compliance
with a 2005 consent decree in the case of Memisovski v. Maram, which followed a
2004 federal district court ruling that the state was not in compliance with
Medicaid Act requirements that children receive recommended levels of
preventive care and treatment of diagnosed conditions, and that they receive
care at least to the same extent as children covered by other forms of
insurance.
Following the consent decree in Memisovski, Illiniois has
undertaken very significant reforms of the primary and preventive care system
for children on Medicaid. It improved the rates paid for office visits to
primary care doctors and dentists, and it held the processing time for those
services to a reasonable level, even during the recession (when all other state
bills were being delayed for many months). It launched a statewide “medical
home” initiative designed to match children up with primary care doctors, which
has had considerable success. Other strategies to improve primary care have
been launched, and the overall effort continues.
The consent decree was less specific with respect to
access to specialty care to diagnose conditions or especially to treat
diagnosed conditions. It provided that the department undertake a study to
examine the extent of access problems, and it left the remedies for any such
problems to be determined after the study was completed. However, Illinois was
not idle on this front. It enacted a round of rate increases for some pediatric
specialists, and it included children in a disease management program for
people with chronic illness.
The study released last Friday, however, shows that there
is a very serious problem with access to specialty care for children covered by
Medicaid and other public insurance, particularly as compared to children
covered by other forms of insurance (mostly employer-based private insurance).
Using a “secret shopper” methodology, the investigators posed as parents
seeking care for a child, saying in one call that the child’s coverage was
Medicaid and in the next call that the same child’s coverage was Blue Cross
Blue Shield PPO (which dominates the market in Illinois). The Medicaid-covered
children had very significant disadvantages for almost all sub-specialties in
both the ability to get an appointment and in the waiting time for the
appointment if it was granted. The one exception was psychiatric care, where
there was a severe access problem regardless of type of insurance.
At the time of the original court order and consent
decree, Illinois authorities were dealing with an inherited problem resulting
from decades of underfunding and neglect of access issues in the state’s
Medicaid program. They have been working to comply with the decree and improve
the program, in spite of the grinding recession-driven budget crisis in the
state. Representatives of the children in the case look forward to working in
cooperation with state authorities to find and implement solutions to these
newly documented problems with specialty access.
Meanwhile, the study has resulted in media coverage, and
some commentators are attempting to use it to bolster current attempts by
conservatives to cut spending on Medicaid or relieve states of the duty to
comply with Medicaid’s federal rules guaranteeing children access to all needed
care. Medicaid is not “broke”; it is underfunded. The underfunding causes it to
fall short on its ability to deliver the kinds of quality health care that,
over the long term, would save money by supporting healthier people. And
Medicaid is not “broken”; it is falling short of its full potential. It
provides plenty of essential health care to millions of children, working
adults, people with disabilities and seniors. Cutting them off of Medicaid
would hurt them immeasurably. And starving the program of funds would only
exacerbate the problems with access and the efforts to expand the health care
workforce needed to provide adequate care to all beneficiaries. Just because
there are flaws in the program does not mean the program must end for millions
of beneficiaries. If we scrapped every governmental program that has flaws that
need fixing, where would the armed forces, roads, or schools be? Medicaid is
essential, but it can and should improve, especially on this issue of access to
needed care.