Asinof: The Political Choices of Health Care Facing Rhode Island

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If reporters were to ask politicians running for statewide office whether they saw the high number of Rhode Island residents – roughly some 275,000 – who are Medicaid members as a sign of economic strength or weakness, how do you think the politicians would answer? Good question.

Many, if not most, particularly those weighing in on the conservative side of the political seesaw, might predictably say that it is an economic weakness, something that has driven up the size of the state budget every year, something that needs to be contained, believing that Medicaid should have a target on its back in order to root out fraud and corruption in order to tame spending by the government. Sound familiar?

Some who lean even further to the right might also call for the imposition of work requirements, a strategy being pursued by a number of states, as a way to weed out and punish those who are labeled as being the “undeserving” poor. Efforts to do so in Kentucky were blocked last week by a federal district court judge.

Of course, removing “undeserving” adults from the Medicaid roles may score political points, but in terms of spending, it only promises to drive up costs for those denied access to care who then become dependent on un-reimbursed emergency room services. You can pay now, or you can pay double or triple the amount later.

Pay Now or Later

In contrast, those politicians weighing in on the progressive side of the political seesaw might see the high number of Rhode Islanders on Medicaid as a relative economic strength, pointing to the success of Rhode Island having one of the highest rates of health insurance coverage in the nation – more than 97 percent of residents are covered.

Progressive politicians might no doubt point to the incontrovertible facts detailed in 2018 Rhode Island Kids Count Factbook that those investments in health coverage through Medicaid and RIte Care for women and children have translated into better health outcomes and prevention efforts for children and families.

Is there any politician, regardless of their political stripe, who would argue publicly against investing in access to preventive health care for young mothers and newborns as the best prescription for healthier, future lives, improving educational achievement and economic attainment opportunities?

Medicaid as Strength

In that context, the call by many from the progressive side of the plate is to create a single-payer system, which some have dubbed Medicare for all.

What is often missing from the political arguments about Medicaid is a basic understanding of how Medicaid works and, for that matter, how the health care delivery system operates – what some have called not a system of care delivery but a system of wealth extraction.

In our current health care delivery system, more than 60 percent of the health care spend in the U.S. is driven by federal health insurance reimbursements through Medicare and Medicaid. Those numbers hold true for Rhode Island, according to a number of health care experts.

None of that money goes directly to Medicaid or Medicare members; it flows to hospitals, providers, insurers and pharmacies for services allegedly provided to patients. The discrepancies about what gets charged for an emergency room visit or an urgent care visit best exemplifies the disparities – and the lack of transparency – in our ever-escalating medical costs.

Just the Facts

The perverse corollary is that in Rhode Island, the health industry sector is an economic engine generating one-sixth of the state’s economic product, where hospitals are the leading private employer, where future job growth is tied to expansion of the nursing needs generated by the health industry sector, and where the academic medical research enterprise has emerged as the jewel in the crown of the state’s future innovation economy.

At the same time, expansion of integrated primary care, particularly for underserved populations, has been found to lower costs and boost wellness and prevention, particularly for women and children, through the existing network of community health centers and the development of patient-centered medical home practices.

The cost of care for chronic diseases – including heart disease, diabetes, obesity, high blood pressure and stroke – is one of the biggest drivers of increasing health care costs.

Imagine a long line of customers stretching for miles, approaching a cliff: you can invest in expensive clinical care once the customers have fallen off the cliff; you can practice triage for those closest to the cliff as a way of reducing short-term costs; or you can put resources into preventive care. Where do we invest our limited resources?

Short Term Pain vs. Long Term Gain

Another important factor to consider: roughly 80-85 percent of health outcomes are determined not by genetics or by care received in a hospital or a doctor’s office, but by factors in the community where people live. Translated, access to healthy affordable housing, good education, healthy foods and community supports are the basic ingredients to achieving better health outcomes. Achieving health equity in a community-based approach is a way to interrupt customers from joining those long lines approaching the cliff.

Did you know that there are currently nine health equity zones operating in Rhode Island? Which politician running for statewide office can name them? [Or, for that matter, which political reporter?]

There is no denying the fact that the state Medicaid budget in Rhode Island keeps growing – directly linked to ever-increasing medical costs and rising Medicaid enrollments.

Reinventing Medicaid

The major driver of this cost escalation is the cost of caring for chronic diseases and the demographics of skilled nursing care: as the state’s aging population gets older, and as chronic diseases, such as Alzheimer’s and Parkinson’s diseases, diabetes and heart disease, flower and peak, it often requires 24/7 care in a skilled nursing facility. Medicaid becomes the last resort after a person’s other financial resources have been exhausted.

The botched rollout of the $492 million Unified Health Infrastructure Project, or UHIP, which resulted in massive, continuing delays in the state certifying Medicaid eligibility for clients receiving long-term care, has severely damaged state’s long-term care infrastructure. In addition, the Deloitte-built software system has created glitches in determining who is eligible and who is no longer eligible for state-sponsored benefits. Advance payments made to nursing homes because of the failure of the state to make determinations of Medicaid eligibility within 90 days, the legal requirement, still need to be reconciled with the feds.

One of the tenets of the Reinventing Medicaid efforts led by Gov. Gina Raimondo and enacted into law in 2015 by the R.I. General Assembly was the desire “to rebalance the system away from high-cost settings” – which translated to reducing fees to skilled nursing facilities.

The 2015 law reduced the fee paid to nursing homes by 2 percent for 12 months, but when 2016 rolled around, legislative leaders and the Raimondo administration decided to keep the rate reduction in place after it was supposed to sunset. [That was the subject of a lawsuit, won by the nursing homes in R.I. Superior Court, which led to the embarrassment of the government attorney representing R.I. EOHHS failing to file an appeal in time.]

Keep Seniors in the Community

The desire to keep senior citizens in the community, allowing them to age in place, may make great emotional sense, but it remains unclear if it makes practical or economic sense.

In 2013, the Chafee administration launched the first phase of the Integrated Care Initiative, known as Rhody Health Options, with great optimism that cost savings could be achieved by reducing the number of dually eligible Medicaid patients in nursing homes and returning them to the community.

Neighborhood Health Plan of Rhode Island was chosen as the sole source contractor. Fast forward to 2018: the results proved to be abysmal, with few patients ever being returned to the community, despite the pledges that the program would pay for itself. The R.I. General Assembly, at the urging of R.I. EOHHS because of the lack of results, finally cut some $13 million in annual administrative fees being paid to Neighborhood.

The result is that Neighborhood has now withdrawn as the contractor for Rhody Health Options, but only after receiving tens of millions of dollars in administrative fees during the last five years for a program that produced negligible results. Where is the accountability?

If you think that the UHIP mess was bad, if you are just learning about the problems with the lack of results under Rhody Health Options, just wait until the next chapter hits the fan: the roll out of accountable entities for the managed Medicaid population, coming soon on Aug. 31. Buckle up.

 

Richard Asinof
Richard Asinof is an award-winning journalist who frequently writes about health, innovation, science, technology and community in Rhode Island. He is the founder and editor of ConvergenceRI, an online newsletter offering news and analysis at the convergence of health, science, technology and innovation in Rhode Island. He can be reached at RichardAsinof@gmail.com.
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