Political analysts predicted it would happen, and it did. In an environment of tight budgets, tax cuts and lingering economic uncertainty, health care policies grew out of budget and appropriations bills, not from health or social services proposals.
The result: Thirteen states have proposed new taxes, fees or assessments on health care professionals or services; 18 considered freezing or reducing eligibility for health services programs, according to the 2005 State Health Care Priorities Survey Report published by the Health Policy Tracking Service. Others have added patient copayments.
The fallout: Physicians will be faced with deciding whether they should refer their Medicaid patients to other health professionals or accept less income from Medicaid.
This year, Tennessee led the way in grappling with Medicaid issues. In January, Democratic Gov. Phil Bredesen proposed a plan that would cut 323,000 people from TennCare, the state's Medicaid program, and implement coverage restrictions on another 396,000 adult beneficiaries who remain in the program.
In April, the governor revised his proposal, reinstating coverage for 97,000 people whose medical bills would bankrupt them without Medicaid. The new plan came with caveats: Physicians would be required to get government permission to prescribe medications not on the state's preferred-drug list; TennCare would pay for only five prescriptions per month, including no more than two brand-name drugs; and the state would be given final authority to determine medical necessity of services.
In May, Missouri Republican Gov. Matt Blunt signed legislation eliminating almost 92,000 Medicaid beneficiaries from the rolls. The new law cuts 68,219 people by setting income eligibility for parents at 23 percent of the federal poverty level, or $308 a month for a single parent with two children, and removes 23,625 elderly or disabled beneficiaries from the rolls by reducing eligibility from 100 percent of federal poverty level to 85 percent. It also implements copayments of between 1 percent and 5 percent of the beneficiary's family income.
"In addition, the act provides that a health care provider may not refuse to provide a service if a recipient is unable to pay a required fee," the Health Policy Tracking Service said in its May 9 Medicaid spotlight report. With approval from the Missouri Department of Social Services, the physician can "terminate future services to an individual with an unclaimed debt, so long as it is the provider's routine business practice to do so and the provider gives advance notice to the individual and reasonable opportunity for payment."
State efforts to contain Medicaid costs have pushed physicians into an untenable position, say analysts. For example, increasing copayments for office visits -- an apparently innocuous attempt to ask Medicaid beneficiaries to take more responsibility for their care -- transforms the doctor from a healer to a collections agent, said Ray Saputelli C.A.E., chapter executive for the New Jersey AFP.
Saputelli points to a New Jersey proposal that, if passed, would require patients to make a $3 copayment physicians' offices would be required to collect. Many physicians call such an approach a back-door tax on Medicaid providers, said Saputelli.
"If you ask a patient who's already on Medicaid to bring in more dollars, there's a good chance they will go and not pay, or worse, not reach out for necessary medical care, which puts the doctor on the spot of having to collect" from the poor, he said. "Family physicians will often either not collect the copayment or spend more than $3 to do so.
"The state is trying to balance its budget on the backs of physicians and making the physician the bad guys," he continued. "We believe physicians who see Medicaid patients already subsidize that relationship. This $3 copayment is enough of an issue that many may opt out of Medicaid."
Moreover, future Medicaid programs may look even more different. Some states, such as Missouri, are establishing commissions to review their states' Medicaid programs and either remodel them or put new systems in place.
