Don't rush into risky Medicaid change

Dec 4, 2005

Dan Gelber

Orlando Sentinel


The Florida Legislature is on the brink of radically altering the way health care is delivered to hundreds of thousand of our most vulnerable residents, specifically children, lower-income seniors and the blind and disabled.

In its simplest terms, this experiment will transfer Florida's Medicaid recipients over to HMOs and other managed-care entities with the hope that "market forces" will improve care and reduce costs. And instead of guaranteeing robust access to health care, the state will simply pay a premium per person and give HMOs wide latitude in determining what benefits they will provide.

Gov. Jeb Bush's theory—wholly untested anywhere in the nation—is that HMOs will offer plans that are suited to certain recipients, try to keep Medicaid recipients healthy and, thereby, reduce costs.

But there are many doubts about the outcome of this experiment, which is why advocacy groups like AARP, the Florida Pediatric Society and more than 84 statewide organizations concerned with the impact on persons with disabilities have already formally opposed the plan. I share the advocacy groups' concerns, because a failed experiment will not only be more costly, but also could result in substandard health care for our most frail residents. At the very lease, the Legislature should heed the warning signs below.

Go Slow. Under the Legislature's plan, if approved, this experiment was to be rolled out as a pilot project in Broward and Duval counties only. However, the governor now seems intent on pushing the plan forward statewide without any testing or phase-in. This is a very risky proposition that could have devastating repercussions. Under no circumstances should the Legislature allow this experiment to go statewide without at least three complete years of operation as a pilot program. And even then, only after the Legislature evaluates its performance should the Legislature consider authorizing an expansion.

Caution: Gaps in the Road. The governor's proposal will allow private companies the ability to set health plan that have varying levels of benefits presumably tailored to what certain clients will need. For instance, an HIV-positive patient might choose a plan with generous prescription-drug coverage but less coverage for physical therapy or surgery.

While this flexibility will certainly allow managed-care companies to control their costs, it increases to likelihood that low-income children, seniors and the disabled will find themselves without access to health care due to incomplete benefit packages. So what happens to Floridians who will need an unexpected surgical procedure or more of a given service than their health plan offers? What about people who need more drugs, another physician visit, or another round of physical therapy.

The answer presumably is they got without care or, if their illness is life-threatening, end up in a hospital emergency room. Because Medicaid recipients lack the means to pay for any significant health care, the Legislature should not put them at risk without establishing adequate minimum benefits and a mechanism to provide for gaps in coverage.

Warning: Bottom Feeders Ahead. In order to work, the governor's plan must attract private health plans to serve Floridians in this new Medicaid managed-care community. The problems is that the last time the state implemented Medicaid managed care (in the early 1990s_, the lure of easy money attracted an array of bad actors looking for a quick buck and unconcerned about patient care. The state had to close several health plans, impose sanctions and drastically raise the bar to assure that all plans met stringent quality standards that protected their patients.

Today, health plans are regulated by two state agencies, are frequently inspected and are held to higher quality measures and accountability standards. It is essential that the Legislature keep these safeguards in mind and not sacrifice quality in order to foster competition. Any new health plans trying to enter the marketplace must be held to at least these same time-tested regulatory standards.

While I belief the Governor's plan was more designed to cut costs than to improve health care, rushing to implement a risk, untested health care system may accomplish neither.




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