As Congress continues to debate how best to cover the nation's uninsured population, the role of Medicaid, the state-federal health program for the poor and disabled, has become a hot topic. Any overhaul legislation is expected to include a significant Medicaid expansion, and while lawmakers in Washington say they'll pick up the tab -- at least for some period of time -- time, cash-strapped states are worried they'll wind up footing part of the bill.
To get a view from the states, KHN's Jaclyn Schiff talked to Alabama Medicaid Commissioner Carol Steckel. Steckel, who first held the position from 1988 to 1992 and then returned to it in 2003, also chairs the National Association of State Medicaid Directors' executive committee. Alabama, which has narrow Medicaid eligibility rules that are focused mainly on covering children and pregnant women, has, like other states, been struggling with severe financial problems. Steckel says she has "some very mixed opinions" about the Medicaid-expansion proposals currently being discussed in Washington –- both in terms of how they should be paid for and how they should be implemented.
Q: How do you see Medicaid fitting into the overall effort to revamp the national health system?
A: Here in Alabama and in every other state, we run very effective, efficient programs with the resources given to us. I think you are seeing in almost every proposal [expansions] of Medicaid, particularly for childless adults, but also for children and pregnant women. Now that brings with it some significant issues. … What do you do to those states that have already expanded over or above the [eligibility being discussed]? How do you reward those states for going ahead and making that investment? [And for] states like Alabama, [which can only pay for current enrollees with the help of the government stimulus that expires in 2011], how do you afford the expansions they are proposing?
Q: How are you hoping things play out? It sounds like you have some concerns.
A: I do. Again, speaking on behalf of Alabama Medicaid, our number one concern is how can the state afford [the plans currently on the table]. … We were able to price out what it would cost our state just to [expand eligibility] to 100 percent of the federal poverty level for childless adults, and that's $200 million [annually]. Then, if we [increase provider payments] to 100 percent of the Medicare payment rate, that's another $270 million. Well, you're talking about $470 million. Even if the federal government pays 70 percent of it, with these economic times, it is impossible for this state to pick up that kind of cost. Some of the proposals have a phase in over five years, but you're still talking about cliffs at the end of that five-year period. How do you deal with a state that has a low per capita income [rate] and a significant population under the poverty level?
Q: What do you think is the best way for Congress to deal with these issues in the context of the current health care proposals?
A: Well I think… they need to let the states determine how [to] manage the program, and how to provide for their citizens, and not have a lot of heavy intrusion from the federal government. Now I understand the desire to have absolutely everyone covered with insurance. But it has to be a balance between the public and private sector. It has to be a relationship between the employers, employees and the uninsured, and there has to be a significant component of personal responsibility. But what works in Alabama may not work in New Jersey. And a per capita income of $30,000 in Alabama is extremely different than $30,000 in New Jersey. So, to come in and just do across-the-board minimums or maximums -- I don't think this is a very good way to do it.
Q: How has the economic downturn affected Medicaid in Alabama?
A: We are seeing an increase in the number of eligible [citizens] of about 5,000 per month. Most of those are children because we have very limited eligibility. We don't cover a lot of childless adults unless they are categorically eligible [meaning they qualify because they are disabled, for example]. But we are seeing a significant number of children come onto our rolls. Our unemployment rate [just] went up to 10 percent, [and] it's not unexpected that when adults lose their jobs, they're going to look to Medicaid for their children’s health insurance.
Q: This year, Alabama put more state funding towards its Medicaid program. How were you able to increase the state's contribution despite the recession?
A: Well, if you were to talk to the governor and to the legislature, both of whom support the Medicaid program, the way they were able to do it is at the price of other state agencies. That meant agencies like the departments of public health, mental health, public safety, corrections… all of those agencies, didn't get fully funded [and] are having to make some pretty horrific decisions. The other thing that saved us this year, and saved a lot of other states, is the stimulus funding. We would not have been able to make it through without the stimulus funding.
Q: What are some of the program areas that need improvement in Alabama? Coverage expansion? Reimbursement? Participation of certain providers?
A: We're not in a position where we can consider either reimbursement increases or coverage expansion. We just don't have the resources. But we're constantly looking at the design of the program. One of the things I am very proud of is that this agency has always looked at how do we become patient-centered, and how do we best design the program to be the most effective?
For instance, we have a Patient First program in which all of the Medicaid recipients are locked into a primary care provider. We basically share the savings with that primary care provider based on some criteria… [such as] the reduction in the non-emergency use of the emergency room or the use of generic medications. Not only is that good for all of us because we do save money, but the quality of care improves. And then, you add on top of it our Together for Quality initiative, which is our electronic health record/electronic clinical support tool. It includes a case management component. … You've got all of that going on… to give those primary care providers the tools and the information they need about their patients to make more informed, better decisions about that patient.