Medi-Cal reform a tall order with federal cuts looming

When she lived at home in Half Moon Bay before her parents died, Stephanie Hill would do the family's grocery shopping by herself. She'd zip to the store in her motorized wheelchair, pick items off the shelves, and carry the bags back to the house. And when she needed to go to the doctor, she often could go alone. Hill managed all of that even though she was born with cerebral palsy and can't get herself out of bed, walk or dress herself. But when her father became ill and died of colon cancer four years ago, her independence ended.

Though Hill is only 41, the state placed her in a nursing home where most of the residents are elderly. It was the only option readily available under Medi-Cal, the state's version of the federal Medicaid health plan that covers the severely disabled, the aged and the needy.

The woman who once kept her own schedule with the help of family members must sometimes wait hours even to be taken to the bathroom. "I'm stuck," she said.

Hill's situation is just one example of how Medi-Cal's tangled bureaucracy and complex rules often work against the people it is designed to serve.

Since he took office, Gov. Arnold Schwarzenegger has pledged to make the 40-year-old program work better and cost less.

The governor, facing a $7 billion state deficit, is poised to unveil his Medi-Cal overhaul in January as part of next year's spending plan.

Medi-Cal is the state's largest and most expensive social safety net, covering one in six Californians and one in four of the state's children at an annual cost of $33 billion. Although the state splits the cost with the federal government, the contribution amounts to 15 percent of the state budget.

Medi-Cal spending has almost doubled in the past seven years, driven by increasing prescription drug prices and growing enrollment. But at the same time, California still spends less per person on Medicaid than most other states, and state officials concede there is little waste.

--snip-

The U.S. Supreme Court, in its 1999 Olmstead vs. L.C. decision, ruled it was discriminatory to keep people with disabilities, like Hill, in institutions when they were capable of living at home.

If your up on Medi-Cal, I'd appreciate a chance to ask a few questions. You can Freepmail me if you'd like.

As for Olmstead, it's important to note that Olmstead shouldn't cost states anything for two reasons. First, we has a belief that community care is cheaper that residential health care. That's not an absolute, but it's a given in any discussion, at least in New York. The big reason is that the Court said that state's didn't have to change any of their rules. It only said that people who could be cared less expensively in less restrictive settings should be allowed to live in those settings, if the state had a program for them. The advocates have taken this case to mean that states must start deinstitutionalizing every disabled person who wants to live on their own, regardless of the cost. The case really had to do with some arbitrary refusals to discharge people, but advocates have convinced policy makers, who can't be bothered to read the case, that the Supreme Court has ordered them to something that it hasn't done.

OK, since The Mayor wants in too, I'll just throw a few things out there. First, in New York, prescription drugs are the biggest growth item. In 1999, New York opened eligibility up to more low income families though its Family Health Plus program. In the last two years or so, the Counties have be screaming about the cost of Medicaid, and specifically, this expansion. They claimed that it was a major cost factor, and was driving real property tax increases. This year, the State assumed the entire non-federal cost of Family Health Plus, and the counties turned around and said, "it's just a drop in the bucket". The big cost is drugs. I'm not sure which ones. I've heard lay people guess that its "lifestyle drugs" like viagra, but I doubt that. The new heart drugs and cancer drugs are very expensive, Epoetin is a big cost drug under one of the State's other programs, and it probably is under Medicaid as well.

Anyway, I've got two big questions. First, any idea what the state and county cost is of California's public hospital and clinic system, and whether that cost is included in the Medicaid spending totals? Second, I understand that instead of setting Medicaid rates and allowing any provider to enroll as a Medicaid provider, California bids out for contracts with providers. Any idea how reimbursement compares with other states? California does this cheaper than most other States.

Your enrollment rate, if it is about 1/6th, is similar to New York's. So, either provider fees are lower (how do docs stay in business), service utilization is lower (are people healthier), you pay for it outside of Medicaid (like through the County Medical Centers); or there is just simply less money wasted (where does our go?). I think we'd appreciate any thoughts you might have,

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