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Forget about health care legislation. If you want to ensure patients' access to care and your own reimbursement for providing that care, follow the money.
That was the advice from political observers who predicted "an unbelievably challenging year" for health care policy. Family physicians can achieve their political goals, but only if they keep their eyes on state and federal budget legislation, Victoria Wachino, health policy director for the Washington-based Center for Budget and Policy Alternatives, said during the AAFP State Legislative Conference here Nov. 5 - 6.
"The number of poor in America is increasing rapidly, more rapidly than any time in the recent past," said Wachino. A family of three earning $15,670 a year live in poverty, according to current federal guidelines, "and the number of children in extreme poverty, which is 50 percent of the poverty level, is rising very rapidly," she said.
Medicaid, the assumed safety net, has begun to fray under states' budgetary stress. And the current federal deficit, coupled with tax cuts and growing demand from an aging and uninsured population, is likely to shred that net a bit more, according to Wachino.
"We're going to have deficits for years to come," she said. "What does that mean to access to care? It means just about everything."
Dual budgetary stresses mean "you're going to have to be playing tennis on a lot of different courts -- on the state level and on the federal level," she said. "You're going to need to be extremely, actively involved in the federal budget process. Watch the budget legislation; it's not going to be framed as health care legislation. But it's going to have a big impact on health care."
Family physicians' patients stand to win or lose in the budget process. About 77 percent of active FPs take Medicaid patients, according to the 2004 AAFP Practice Profile survey.
Medicaid costs rank second in state expenditures, making them a target for cutbacks when states are under pressure, said another conference speaker, Barbara Lyons, vice president and deputy director of the Kaiser Commission on Medicaid and the Uninsured. Already, states have moved to aggressively limit their Medicaid outlays. Since 2000, states have sought waivers to Medicaid regulations in order to reduce benefits or shift costs to beneficiaries. Nearly half the states have implemented higher costs and procedural barriers to Medicaid eligibility, said Lyons.
At the federal level, Congress will consider ways to stem the cost increases, said Wachino. Rep. Joe Barton, R-Texas, has announced his intention to introduce what Wachino called a "significant federal Medicaid reform bill, most likely incorporating Medicaid block grants," during the 109th Congress. Other members of the House have broached the topic of capping Medicaid entitlement spending, she added. A final option is reconciliation, a legislative process that is difficult to track because it sets across-the-board deficit reduction targets over multiple years.
Tom Banning, director of legislative and public affairs for the Texas AFP, agreed with Wachino's belt-tightening forecast. "Congress wants fiscal accountability, and if that means redoing the whole system, then (their attitude is) so be it," he told conference participants.
To reach writer Leslie Champlin, e-mail lchampli@aafp.org
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Copyright © 2004 by American Academy of Family Physicians.