Medicaid exceptions: Life-sustaining care is not optional in Missouri

Changes to the Medicaid system have been portrayed by many as extraordinary, but thoughtful consideration must be given to the fact that reform was essential to ensure the program's solvency.

Unfortunately, the details of these changes and the policies of the Department of Social Services have often been misrepresented. One of the most misunderstood changes involves the idea that some medical services are optional.

In explaining the tough decisions made to curb soaring Medicaid costs, a distinction has been made between services that are required by the federal government and those that are not. To participate in Medicaid, states must agree to provide mandatory services as defined by the federal Centers for Medicare and Medicaid Services. States may also opt to provide other non-mandatory services.

When fiscal times were good, Missouri opted to provide a wide array of these services. When the state could no longer pay the bills to support its Medicaid system, significant changes had to be made. Rather than cut thousands more people off Medicaid, policymakers determined that a combination of roll reduction, service reduction and cost sharing would stabilize the program.

Mandatory services were not eligible for reduction. Since the provision of durable medical equipment is not mandatory under federal law, some reductions were made in this area to reduce program costs.

For example, feeding tubes fall under the category of durable medical equipment and this is one of the recently reduced services.

However, since 1992, Missouri Medicaid has had -- and will continue to have -- provisions for physicians to request exceptions when services are needed to sustain life or prevent a higher level of care. There is no change in this process. If a feeding tube or another critical service is a medical necessity, a patient's physician can request an exception, submit the appropriate documentation, and it will be supplied.

Reform has not removed the safeguards in place to ensure that life-sustaining services are available.

I congratulate Department of Social Services employees and our partners for maximizing federal matching dollars for Medicaid, instituting managed care, designing innovative ways to control pharmacy costs and developing new ways to save money through chronic disease management.

We are aggressively addressing waste, fraud and abuse, yet costs cannot be contained without some reduction in program size and coverage. While cost sharing and reductions in service have been difficult, removing thousands more from the rolls would be significantly more difficult.

Faced with an unprecedented $1.1 billion dollar shortfall and a clear mandate not to raise taxes, policymakers were left with a thankless and unpopular choice: reduce spending.

To reduce Medicaid spending significantly without some impact on coverage for the elderly and disabled is not viable. Expenditures for these populations account for nearly 70 percent of the Medicaid budget.

Access to quality, affordable health care for our citizens is one of this nation's most complex and urgent social problems. We are working diligently to face the problem in Missouri and create a program that will serve our citizens well into the future.

And, now, for the bottom line: The equipment and services required to sustain life are not optional. They are exceptional. The long-standing process for these exceptions remains in effect.

Gary Sherman is the director of the Missouri Department of Social Services in Jefferson City, Mo.