Today, Illinois Governor Pat Quinn signed into law S.B. 2840, which carves $1.6 billion out of the Medicaid program, claiming that it represents a bold plan to save Medicaid. Since the new law cuts the program so deeply and in so many different ways, it is legitimate to ask if these cuts really do improve the program, in terms of policy and long-term financial sustainability, or if they are actually merely expedient and short-sighted. To answer this question, we need to step back and really think about what makes effective and efficient health care policy. It’s a difficult question, and we’ve heard a lot of different answers, but I think we can boil it down to some broad categories.
- Good health care policy obviously needs to be focused on providing the best outcomes possible immediately and later. Preventive services are key for this kind of health care; for example, check out the U.S. Preventive Service Task Force’s recommendations of effective and recommended services for adults. But not all procedures are necessary; some may not have any effect or even be harmful. For example, this year the U.S. Preventative Service Task Force issued advice counseling healthy women to undergo Pap tests only every three years instead of yearly. A representative for the task force noted, “We achieve essentially the same effectiveness in the reduction of cancer deaths, but we reduce potential harm of false positive tests […] It’s a win-win […].” We can prevent big problems from occurring tomorrow if we take some reasonable, manageable steps today. Preventing those big problems (obesity, heart disease, diabetes, etc.) can also save big money, in addition to improving people’s quality of life.
- Good health care policy also takes care of the whole person, from head to toe. The Medicaid program contains “optional” categories that states don’t have to cover, like prescription drug coverage and adult dental care, but are these categories really optional? At first glance, dental care might seem like an oft-dreaded luxury, but it is critical to good overall health. Cavities and gum disease contribute to wide-ranging health issues including low birthweights, coronary heart disease, strokes, and even cancer. As states cut dental coverage, more people are turning to emergency rooms to take care of dental issues (hospital coverage is a mandatory Medicaid category), but that’s a terribly inefficient way to deal with the problem. Emergency rooms usually don’t have a dentist on staff, so all they can do is prescribe pain medications or antibiotics, not treat the root of the problem. The problem is similar with prescription drugs—if people cannot afford their medications, they usually need other medical intervention. Treating people holistically, instead of with a narrow focus on certain aspects, is cost-effective and health-effective.
- Good health care policy needs to be fiscally sound not just now, but in the future, too. We don’t want penny-wise cuts today that are pound-foolish down the line, since Illinois will pay for pieces of the Medicaid program that are mandatory, like emergency room visits and hospital coverage. While some services, like prescription drugs and adult dental care are technically optional, dropping this coverage may cause higher utilization of the mandatory categories, resulting in unforeseen high costs.
Senate Bill 2840 makes dramatic cuts to the Medicaid program. Some of them are consistent with the above hallmarks of good policy, but more of them simply don’t make for good health care.
So let’s start on a positive note—some of the bill’s provisions are solid choices that will save money and improve the health of our Medicaid system and our people. For example, one section of the bill deals with increasing the state’s ability to ferret out fraud in the program. There will be increased effort to make sure only eligible people receive Medicaid, including electronically examining residency and income to verify that they meet program requirements. It is estimated that this increased effort will save the state $350 million. We are strongly behind the effort to make sure that Illinois Medicaid uses its resources wisely by only enrolling those eligible for the program and reimbursing vendors fairly. However, it’s worth noting that the intent of the law appears to be that the state use a private company to provide computerized eligibility verifications. This bears close watching because, in the past, private companies have been guilty of inaccurate and profit-motivated caseload reduction. The determinations need to be accurate and procedurally fair. The law also contains welcome measures for finding and preventing fraud on the vendor side of the equation.
Another provision we’re wholeheartedly behind ensures that Medicaid will no longer pay for medically unnecessary, or elective, cesarean births. A cesarean birth is a major abdominal surgery and comes with all of the risks associated with other common surgeries, including adverse reactions to medications and increased risk of infection. Babies born by c-section have, on average, more difficulty breathing after birth and have lower Apgar scores. Mothers have a longer recovery time and a higher risk of complications from c-sections than from vaginal births. Of course, some situations call for a cesarean section—medically necessary c-sections will still be covered under Medicaid, but elective c-sections will be covered only at the vaginal birth rate. This should cut down on the numbers of elective c-sections, saving money and improving health outcomes at the same time!
However, there are other cuts in S.B. 2840 that are clearly not good policy and not fiscally sound, or that depend heavily on implementation decisions before they can be judged one way or the other. Among these, the law slashes the Illinois Cares Rx program, the FamilyCare program, and dental coverage for adults, and it applies utilization controls on many services, including especially prescriptions. We’ve already written a blog about the cuts to the Illinois Cares Rx program and you can find that here. Of course, S.B. 2840 wasn’t the only health care related bill this session. There were also changes in the laws regarding hospital charity care obligations and the expansion of Cook County’s Medicaid system. We’re planning blogs on these and other provisions of the law to explain them and examine how they fall short or could be implemented without measuring up to good policy, so please keep us bookmarked and return for an update.