Medicaid revamp

By Edgar Simpson

Few issues reveal the souls of those in power more than the fate of Medicaid, a monstrous but necessary program begun in the fervor of the 1960s and the push for the Great Society.

As with most government programs, it began with the best of intentions, serving as a safety net for those whose only hope rested with the goodness of others. Since then, it has become entwined in the universally renounced welfare system and the ongoing struggle on how to define a hand-out versus a hand-up.

Missouri Gov. Matt Blunt, a Republican, cut Medicaid a little more than a year ago, through lowering the income ceiling for eligibility and cutting some direct services. At the time, the Department of Health and Human Services concluded the changes would kick about 90,000 Missourians off the assistance program.

The legislation that enacted the cuts included a mandate to kill Medicaid in 2008 unless the program was reauthorized. It is a remarkable strategy. No one seriously considered ending Missouri Medicaid, but the law does ensure a massive battle this legislative season on how to redraw it.

A task force appointed by Blunt has released a report, the health-care version of the Iraq Study Commission, that will no doubt form the basis of debate. The report contains 14 "transformation" recommendations.

Many are procedural, but taken together would fundamentally alter the way services are delivered. The plan contemplates changing the focus of Medicaid from treating illness and disability to promoting "healthy behavior."

Those receiving assistance would receive points by "taking part in an approved list of healthy behaviors" that could then be used to, essentially, buy Medicaid services, which would be renamed Mo HealthNet and Mo HealthNet Plus.

The Democrats have responded to the report with some amount of horror. They are now estimating that 177,000 fewer residents, including 70,000 children, are being served by Medicaid, nearly twice the number of the initial guess.

They are proposing no radical reform, but rather a restoration and extension of Medicaid services. Their plan "recognizes that access to basic health care is a right, not a reward for healthy living," the Democrats said in a statement issued late last week.

"The primary goal of any changes to the state health-care system must be a responsible expansion of coverage to those who need it the most," state Rep. Judy Baker, D-Columbia, said in the statement. "By following these simple principles, we can craft a health-care delivery system that serves Missourians' needs."

While the two plans are fundamentally different in philosophy, they do agree on some basic things.

Democrats would address prevention through establishing a state surgeon general "to promote policies that encourage healthier living and prevent the spread of disease."

Both plans also recognized the need for wider private health insurance coverage. The Democrats would achieve this by refusing tax breaks to companies with more than 500 employees that do not offer health-care coverage to their workers. (That is directly aimed at Wal-Mart.) The Republicans, ironically, would do this through offering tax breaks to small businesses that offer health insurance and expanding Medicaid services to more children.

The governor's plan, overall, contemplates tap-dancing through a minefield of social issues. Is it possible to force Medicaid recipients to, for example, give up smoking? If a single mother of two falls into the Medicaid net through an addiction to meth, would she or her children be denied some services if she can't kick the habit?

Who determines when someone has given up smoking or drinking or using drugs? Who determines whether the children in the care of someone indulging in "unhealthy behavior" should be treated differently than those in the care of someone who doesn't?

The Democrats have not chosen a minefield, but rather a polka around a single high explosive. By failing to address the core issue -- controlling the cost of Medicaid -- they have given the Republican-controlled legislature ample reason to reject all of their ideas.

Blunt went too far in 2005, and he knows he must address this if he hopes to continue on in politics. Too many Missourians are suffering, and most of those who aren't know or know of somebody who is. They need help, and it is right and proper that the state step in through established help programs.

But Blunt also is right that the rapid expansion of Medicaid had to be curtailed. In the 2006 fiscal year, Medicaid made up more than $5.2 billion of the state's budget.

There must be some balance between the task force recommendation that government get into the behavior-control business and the Democrats' everybody-is-welcome philosophy.

Money can be found by cutting waste and fraud, upwards of $700 million by the GOP count and $500 million by the Democratic estimate. So do that.

Children should be first and the Medicaid guidelines for families with kids should be moved back to 300 percent of the federal poverty guideline. This will cover most of the 70,000 children tossed with the 2005 cuts.

The Medicaid program covers those among us who need help, and represents the core values of our government. We are not miserly as a people, or cold-hearted, and wherever the legislature lands, it should reflect those basic Missouri instincts of neighborliness and love for our fellows.

The Medicaid debate is an opportunity to put those values into concrete action, and lawmakers should not be dissuaded or distracted by bureaucratic mumbo-jumbo or disproved social modification theories.

Edgar Simpson is editor of The Joplin (Mo.) Globe. E-mail: esimpson@joplinglobe.com.<I>