What Medicaid covers

State Medicaid programs must cover — Inpatient and outpatient hospital services Physician, midwife, and nurse practitioner services Lab and x-ray services Nursing home and home health care for individuals age 21 years and older Early and periodic screening, diagnosis, and treatment (EPSDT) for children under age 21 Family planning services and supplies Rural health clinic/federally qualified health center services States can offer optional services with matching federal funds. These may include prescription drugs, prosthetic devices, hearing aids, dental care, and intermediate care facilities for the mentally retarded. Source: Kaiser Family Foundation. Medicaid and the Uninsured: Assessing the Role of Recent Waivers in Providing New Coverage. December 2003.

“We’re strong believers in building personal relationships, establishing trust, and working with patients to empower them with information and link them with appropriate care providers and medical regimens,” says White. “We look at it as a quality approach that translates into cost savings.”

States are cutting back on Medicaid spending not only because of lower payments from the federal government, but because the program averages 22% of the average state budget due to the rising cost of care and increased participation. According to a study by the Kaiser Family Foundation, Medicaid pays for 40% of all live births, covers benefits for one out of every four children, and shells out 70% of the cost of nursing home care for the elderly.

At San Joaquin Community Hospital in Central California, more than 90% of births are covered by California’s version of Medicaid, called Medi-Cal, says Margo Praus, RN. A neonatal nurse who does discharge planning and utilization review in pediatrics, Praus says that nearly all children treated at the hospital are also covered by Medi-Cal. And anytime a pregnant woman shows up, she’s admitted.

“Any pregnant mom is presumed to be covered or eligible for coverage,” says Praus. She doesn’t see any drastic changes in coverage for expectant mothers or children under Medi-Cal reform.

Gov. Arnold Schwarzenegger’s proposal to overhaul Medi-Cal to save some $142 million over the next five years hangs on getting recipients into managed care and charging premiums of $4 per month per child and $10 per month per covered adult — capped at $27 a month for a family — for beneficiaries earning more than the federal poverty level. If implemented, the premiums would affect about 550,000 Californians, including 460,000 children.

The most dramatic changes are coming in Tennessee, where the once generous TennCare program is planning to limit eligibility and cut benefits because of fiscal losses, which could result in 323,000 adults’ losing medical coverage. Other states are proposing dramatic changes in their Medicaid programs. Florida is weighing flexible spending accounts, and South Carolina is considering covering catastrophic health care costs and giving recipients a debit card with a limited amount to cover other expenses.

In Pennsylvania, “Call To Action” was put out by a consortium of nursing organizations that say advance practice nurses — especially nurse practitioners and midwives — can be better used to provide quality care to underserved areas, thereby reducing medical costs.

“As much as 80% of adult primary care services and 90% of pediatric primary care services can be performed by advanced practice nurses — offering an untapped resource for the entire state to increase access to care for patients,” says Michele Campbell, RN, MSN, executive administrator for the Pennsylvania State Nurses Association.

Tine Hansen-Turton, executive director of the National Nursing Centers Consortium, says Medicaid cuts jeopardize 25 health centers across the country managed by nurse practitioners. In Nashville, 90% of patients at a health center are covered by Medicaid, but TennCare cutbacks could drop that number to between 50% and 55%, with a big jump in uninsured.

“Right now, our national uninsured rate is 46%, and our Medicaid rate is 37%, but with the large proposed Medicaid cuts, our health centers could face an uninsured rate of between 60% and 70% — which could put them at risk, as they won’t be able to sustain themselves,” says Hansen-Turton. “This would mean that thousands of people would have nowhere else to go and seek care at emergency rooms rather than in community-based nurse-managed health care settings.”

Suzanne Phillips, RN, MSN, a family nurse practitioner in a private practice in Irvine, Calif., says she’s provided care for a wide range of Medi-Cal–covered and uninsured walk-ins at a community clinic in Laguna Beach. A lot of emphasis was on preventive medicine — immunizations and checkups — but there was an HIV program and a large number of people showing up with diabetes.

Medi-Cal reform, she says, should fairly compensate both rural and urban clinics that rely on nursing skills as a cost-effective way of keeping people healthier and out of hospitals.

“The point,” says Phillips, “is to improve access for the underserved and not close down programs where nurse practitioners are providing care.”

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John Leighty is a freelance writer .