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By contrast, smaller public coverage programs (for example, separate, non-Medicaid, SCHIP programs) and other public programs that help pay for medical services (such as the Ryan White program, the Maternal and Child Health block grant program, and various pharmacy benefit programs) do not extend a legal entitlement to coverage. Smith, B. and Rosenbaum, S., State SCHIP Design and the Right to Coverage, Center for Health Services Research (Washington, D.C.: George Washington University, 2001). As a result, the number of people provided services under these programs can be capped, waiting lists can be formed, and enrollment can be closed for budget or other reasons.Google Scholar

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For example, federal program data show that there were 13 million beneficiaries in 1968; program data for 2001 show enrollment above 47 million. The Congressional Budget Office projects that enrollment will reach 52.4 million in 2004. Health Care Financing Administration (HCFA) data for 1968 provided by the Kaiser Commission on Medicaid and the Uninsured; 2001 data from Georgetown University Health Policy Institute’s analysis of the 2001 Medicaid Statistical Information System (MSIS) data; 2004 data from Congressional Budget Office’s March 2004 Medicaid Baseline.Google Scholar

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This imbalance is mirrored at the Federal level in the consideration of legislation to require States to offer home- and community-based care. The Medicaid Community-based Attendant Services and Support Act (Mi-CASSA) has been introduced and re-introduced in the Congress for many years, but its consideration has been haunted by cost-estimates that are predicated on an assumption that more people would use such care than use institutional services. See Glazier, R., “The Re-invention of Personal Assistance Services,” Disability Studies Quarterly 21, no. 2 (2001), available at <http://63.240.118.142/_articles_html/2001/Spring/dsq_2001_Spring_12.html> (last visited July 1, 2004).CrossRefGoogle Scholar

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For example, in 1997, federal law was amended to provide states more authority to set rates for institutional providers (nursing homes and hospitals) and to require Medicaid beneficiaries, under certain conditions, to enroll in managed care. In that same year, states were allowed new options to presumptively enroll children in Medicaid and to keep children enrolled for up to twelve months regardless of changes in financial circumstances; See Yellowbook, supra note 3.Google Scholar

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For example, Oregon, has adopted a series of very deep reductions in coverage; it eliminated the portion of its program that covered people impoverished by their medical expenses and instituted new premium policies for poor adults that have caused about half of those adults to drop out of the program, See Oregon Health Research & Evaluation Collaborative Website, at <http://www.ohpr.state.or.us/OHREC%20welcome2.htm> (last visited June 24, 2004). Several states, including Florida and California, are considering major waiver initiatives that could affect the entitlement, benefits, cost-sharing and financing for everyone covered under their Medicaid programs. Ulferts, A. “Bush Strives to Rein in Medicaid,” St. Petersburg Times, February 22, 2004; Ulferts, A., “Medicaid Records Hard to Come By,” St. Petersburg Times, March 31, 2004; For California, see Medi-Cal Redesign Website, at <http://www.medi-calredesign.org/overview.aspx> (last visited June 24, 2004).+(last+visited+June+24,+2004).+Several+states,+including+Florida+and+California,+are+considering+major+waiver+initiatives+that+could+affect+the+entitlement,+benefits,+cost-sharing+and+financing+for+everyone+covered+under+their+Medicaid+programs.+Ulferts,+A.+“Bush+Strives+to+Rein+in+Medicaid,”+St.+Petersburg+Times,+February+22,+2004;+Ulferts,+A.,+“Medicaid+Records+Hard+to+Come+By,”+St.+Petersburg+Times,+March+31,+2004;+For+California,+see+Medi-Cal+Redesign+Website,+at++(last+visited+June+24,+2004).>Google Scholar

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Tax credits have been advanced as one possible way to help low-income people afford private coverage, and refundable tax credits have been proposed as a way to extend this subsidy to the millions of Americans whose incomes are too low to owe income tax (or to owe an amount of tax that would exceed the potential subsidy amount). A number of structural issues would have to be resolved for a refundable tax credit system to work well as a way to finance health insurance for low-income people; see Blumberg, L., Health Insurance Tax Credits: Potential for Expanding Coverage (Washington, D.C.: The Urban Institute, 2001). To date, the refundable tax credit created under the recent Trade Act has had limited take up, in part due these structural problems; as of the end of 2003, only about 3.6 percent of the workers who were potentially eligible had enrolled in the advance credit. Dorn, S. and Kutyla, T., “Issue Brief: Health Coverage Tax Credits Under the Trade Act of 2002,” Commonwealth Fund 721 (2004): 3; see also, Pear, R., “Sluggish Start for Offer of Tax Credit for Insurance,” New York Times, January 25, 2004.Google Scholar

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Some new tools could help states contain Medicaid costs without compromising the quality of care; for example, disclosure to state Medicaid agencies of drug pricing that would allow states to improve their ability to set drug prices. Some changes would need to occur within the Medicaid program while other measures go beyond Medicaid and would help Medicaid as well as other payers contain costs.Google Scholar

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“Churning” refers to loss of coverage, often due to administrative requirements, followed by re-enrollment in the program. This not only disrupts coverage and care, but also results in added costs. Fairbrother, G. Park, H.L. and Haidery, A., Policies and Practices That Lead to Short Tenures in Medicaid Managed Care, Draft, (Princeton, NJ: Center for Health Care Strategies, 2003); Short, P.F. Graefe, D.R., and Schoen, C., “Churn, Churn, Churn: How Instability of Health Insurance Shapes America’s Uninsured Problem,” Commonwealth Fund 688 (2003): 9–10.Google Scholar

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