Cutting MaineCare no way to ‘share the pain’

Less than a year ago, as Gov. Baldacci spoke about the promise of the Dirigo Health Plan and universal health care coverage, he advocated for increasing the investment in primary and preventive care services, increasing case management, and decreasing the cost shift that occurs in today’s health care economy. Sadly, the MaineCare cuts that he is putting in place as of Jan. 20 work against all three of these goals, and seriously undermine the ability of Dirigo Health to succeed.

These cuts to MaineCare – the broadest sweeping reductions to health benefits for the poor, elderly and disabled ever instituted in Maine by a governor without legislative approval – have been imposed under the banner of equitably sharing the pain of our state’s budget deficit.

What is equitable about asking a person who already struggles to get by on her SSI check of $574 a month to now meet higher co-payment demands across the board, reduce her access to primary care services, decrease her independence and quality of life, and highly increase her chances of a lengthy hospitalization and need for subsequent rehab services?

Sadder still is that these cuts set aside economic common sense in the name of “sharing the pain.” Based on the Medicaid formula for federal matching funds, chopping off $9.5 million in state spending on MaineCare eliminates $18 million in federal support for these same services. More damaging still is that artificially constraining demand for primary care and preventive services will only result in worse health outcomes and higher, more expensive rates of acute care and crisis services. The actual impact of the governor’s proposals to ration primary care and end case management support will prove to be many times greater than the short run gains he is banking on.

One such cut limits coverage for MaineCare members to just 10 visits a year to federally qualified health centers or rural health clinics in Maine. Let’s see how this applies:

Smith is a 73-year-old patient at a community health center, or FQHC. His diagnoses include depression, frequent dental infections, chronic sinusitis, and is a carrier with active Hepatitis C. Fortunately in 2003, his depression was brought under control as managed in concert with his primary care provider and medication oversight by a psychiatrist. Once unable to find a dentist, Mr. Smith was also able to get immediate care at his FQHC for oral infections that previously landed him in the hospitals’ emergency room. He also requires frequent monitoring of his Hepatitis C to assess his liver function and medication usage. In all, he totaled 19 visits to the health center in 2003. With visits now capped at ten, where does Gov. Baldacci draw the line for coverage of Mr. Smith? Should he not have coverage for his depression management? Oral health care? Hepatitis C monitoring?

Instead, the governor sends Smith scrambling to seek care elsewhere, leaving the FQHC as his medical home and the care team that worked with Smith on patient self-management and effective use of community resources. As primary care access points in medically underserved areas, FQHCs are often an hour away from the next closest available provider. Moreover, FQHCs are excellent providers of care and are driving down the total costs of health care in Maine.

This same story applies to more than 1,300 people in Maine who are to have more than 6,000 primary care visits at FQHCs denied in order for the state to save less than one-fifth of 1 percent of its current budget deficit.

According to the American College of Obstetricians and Gynecologists, a woman with a normal pregnancy needs at least 10-12 prenatal visits. This excludes the number of visits that occur on an emergent basis, or for intensive monitoring of patients who are past their due dates for fetal well-being testing. The cap also leaves no room for coverage of visits for oral health, podiatry, or any other primary care that the expectant woman may need.

Or take diabetes. A person with diabetes without any complications at all should be seen by a podiatrist at least six times a year. Given the frequent monitoring needs of blood sugar levels, eye and kidney function, and medication management, there is no room under the governor’s cap for poor health. If a foot ulcer occurs, the patient would need to be seen weekly for eight weeks to prevent infection and eventual amputation. Under the cap, coverage would end short of appropriate primary care and leave no room for other health needs such as for dental care, or for mental health. Instead these will be addressed more expensively in the emergency room or through hospitalizations that would have been prevented if it were not for the arbitrary restrictions on primary care.

The rationing of primary care will also stunt the quality improvements and health care savings that FQHCs have delivered to their communities. Within a year, Harrington Family Health Center dropped the inpatient admissions for mental illness among its patients by 91 percent through aggressive case management. Katahdin Valley Health Center’s disease management of diabetes saved health care purchasers $115,000 in avoided medical costs due to the decrease in strokes, heart attacks, and other averted outcomes. Both of these efforts require a higher volume of patient visits and both result in improved health outcomes at lower total cost to the purchasers of health care, including MaineCare. And both efforts would be gutted by capping MaineCare coverage and eliminating case management payments.

Together, rationing primary care and ending support for case management will cost the state’s community health centers $1.25 million in lost MaineCare funding. For most of these primary care access points, this will mean painful choices for communities in great need and the end of some types of services – podiatry, chiropractic, substance abuse treatment, even dental care. For those already experiencing deficits, this could mean the closure of access points that will leave gaping holes in the availability of services in rural Maine not just for those with MaineCare – but for all. For the state, it promises much greater health care expenses, larger deficits to fill in years to come, and a faltering foundation on which to base our launch of universal coverage through Dirigo.

Gov. Baldacci, Maine can do better.

Kevin Lewis is executive director of the Maine Primary Care Association whose members provide access to comprehensive primary care in the state’s medically underserved areas.