Access a Main Nursing Concern as States Cut Medicaid Budgets
By John Leighty
March 28, 2005
Carmen Eucker, RN, CDE, takes a hands-on approach in helping low-income people with chronic conditions, often driving 250 miles along the Washington state coast to provide resources, ranging from medical supplies to transportation, heat, and even food.
As one of 22 nurses in Washington state involved in a Medicaid-funded disease management program, Eucker enjoys the challenge of trying to bring healthier outcomes to clients suffering from heart failure, chronic obstructive pulmonary disease, coronary artery disease, asthma, and diabetes.
At Ketchikan General Hospital in southeast Alaska, low-income patients with medical problems like appendicitis or bowel obstruction often arrive by boat or plane from remote communities, and are taken home the same way, the expenses covered by Medicaid travel vouchers.
For nurses who provide a wide spectrum of care for some 52 million Americans covered by Medicaid — half of them children — changes are in the wind as many states begin cutting back in the $300 billion program for the needy. With President George Bush committed to cutting Medicaid's budget by $60 billion over the next 10 years, states are looking at ways to reduce the increasing cost of their share of the program that also serves people with disabilities, the elderly, pregnant women, and low-income parents.
In mid-March, meanwhile, the U.S. Senate made $14 billion in Medicaid cuts over five years in its 2006 budget resolution and formed a bipartisan commission to explore long-term changes to the program, an action supported by the American Nurses Association. The House narrowly voted to cut $20 billion from Medicare without making specific proposals, although Bush’s budget calls for reducing mental health services.
In Washington state, mental health programs have already been cut to help ease a projected $2.2 billion budget deficit, and further cuts in Medicaid mental health coverage could be disastrous, says Donna Poole, RN, MSN, a nurse practitioner at the Kitsap County community health clinic in Bremerton. As of July 1, the only reimbursements at the clinic will be for Medicaid-eligible patients because of the state’s cutting $82 million from its mental health programs, she says.
“I know the state’s short of money,” says Poole, “but if we cut back on mental health, we’ll only wind up spending more on people who will end up in jail or in emergency rooms.”
In Alaska, Rebecca Bolling, RN, BSN, says the state attracts a lot of people who like to live in remote areas or on one of the many islands along the peninsula. Cutbacks to the state’s $1 billion Medicaid budget could threaten access to care for some 130,000 recipients by reducing travel funds, she says.
“With reductions in Medicaid, I’m really concerned about the access problem, particularly for the younger population,” says Bolling, discharge planning care coordinator for the hospital and president of the Alaska Nurses Association. “The more strict Medicaid gets, the harder it will be for patients to get in and out — and it’s tightening up already.”
She says a 12-year-old boy was recently brought in for treatment whose only access was by air. “We serve eight to 10 communities that have airplane or ferry access only. They fly in for surgery and fly home the same day. It’s a little crazy, but that’s what they do.”
One of Bolling’s hospital duties is hooking senior citizens up with in-home support services paid for by Medicaid. These services — cleaning, meal preparation, help with bathing — supplement home health care provided by Medicare and help the frail elderly remain independent and in familiar surroundings. Without Medicaid funding, many of these seniors could wind up in assisted living centers that aren’t as therapeutic as the home setting, says Bolling.
A certified diabetes educator, Eucker typically has 100 to 125 clients in various stages of managing their conditions, and she does an initial assessment of each one in their home. She prioritizes their needs and helps them establish goals for improving their health.
“My biggest focus is enabling them to be proactive and have healthier outcomes,” says Eucker. “I open communications so they realize somebody really cares.”
For example, Eucker recently accompanied a woman for a physician visit because the client felt uncomfortable and hadn’t followed a care plan in the past. “I helped her set goals for herself and to be more compliant with what the physician asked her to do,” she says. “In this case, it was simple — getting her the right diabetes supplies to make procedures less uncomfortable.”
Eucker worked for 20 years at Grays Harbor Community Hospital in Aberdeen, Wash., before joining Specialty Disease Management, a Jacksonville, Fla., firm that supplies nursing teams for Medicaid programs in Colorado, Montana, Oregon, Texas, and Mississippi.
The Florida company was launched in 1999 with a successful HIV case management program for the state that demonstrated savings, piquing the interest of other states, says Judy White, RN, vice president of health operations.
White says she expects the service to grow because even with Medicaid cuts, the nursing teams’ approach to chronic care — which includes 24/7 phone triage service — improves patient outcomes and saves health care dollars. For one thing, stabilizing and enhancing a patient’s physical and mental health results in fewer trips to the ED.
“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.”
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.
John Leighty is a freelance writer .