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Expand Medicaid Reforms

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By JEB BUSH

Special to the Tribune

Published: November 29, 2008

In 2006, Florida launched the first substantial reform of Medicaid since the program was originated more than three decades ago. The goals of reform were to improve the quality of health care provided to 2.2 million poor, elderly and disabled citizens under the state-federal program and to control skyrocketing costs that threatened the sustainability of this important program.

The tenets of the reform are simple. New Medicaid is a patient-centered system that respects individual participants by empowering them to direct their own health care. It provides choices, promotes preventive care, reduces inefficiency and prevents fraud. Most importantly, the reform plan harnesses the power of the marketplace to foster innovation and spur competition, which improves the quality of care for our most vulnerable Floridians and drives down the costs to taxpayers who are paying the medical bills.

Questioning The Progress

Recently, a flawed study published in Health Affairs Web Exclusive and a misleading Tampa Tribune editorial questioned the progress made in the implementation of Florida's bold reform and the wisdom in continuing it.

Now expanded to five counties, 220,000 beneficiaries are currently participating in the pilot program. That's just 9 percent of the program's participation but more than the entire Medicaid enrollment in 12 states. Just 29 months in, Medicaid reform can claim significant successes.

Under reform, we get more for less. Without an increase in premiums, new services are now available to Medicaid recipients, including wellness checks, dental services and coverage for over-the-counter medications. The number of plans available has nearly doubled, with more than 80 percent of participants making their own informed decisions. The amount of the state's contribution reflects the medical needs of each consumer instead of a cumbersome, one-size-fits-all program that was too much for some patients and too little for others. To this end, the first-ever specialty plan will soon be available in one of the pilot counties - a plan specifically tailored to meet the health care needs of HIV/AIDS patients.

Why The Reforms Work

Critics cleverly use problems and popular complaints already inherent in today's health care system to discredit and undermine reform policies. First, government will always rely on private companies to ultimately deliver care to patients - the state is the payer, not the provider. We can always do a better job of rooting out fraud, waste and mismanagement, but a government takeover is not the answer, since government interference and mandates are what led to the problems we have today.

Second, managed health care companies make less under reform because they are no longer paid the same for healthy and chronically ill people. Providers are only paid for the services actually required by the individuals in the plan, not an expansive and expensive menu of services never utilized by healthy patients. This shifting of resources may explain why three organizations recently threatened to drop out of the pilot plan - a sign of success, not failure.

Third, with taxpayers footing the bill, it is impossible to insulate Medicaid - old or new - from downturns in the economy and subsequent revenue shortfalls and budget cuts. Reductions in Medicaid rates have nothing to do with reform. Rate reductions for the current fiscal year apply to all providers both in and out of the pilot communities.

Lastly, we can't pretend there is a one reform or solution that will deliver everything to everyone. Every health system imposes limits. The improvement in Medicaid reform is that financial incentives are given to managed care organizations to keep people healthy and make sick people better.

Old Program Was Costly

Without reform, Medicaid is unsustainable. In less than a decade, the traditional Medicaid program would consume nearly 60 percent of the state's budget - leaving little left for spending on education, infrastructure or public safety. Eventually, lawmakers would be forced to raise taxes or cut benefits for Florida's most vulnerable populations.

Even more troubling than the escalating, out-of-control costs are the limited access to and poor quality of care under the antiquated, bureaucratic system. Under old Medicaid, only half of children received annual wellness check-ups and just 16 percent went to the dentist for preventive dental care. Only 4 percent of women received mammograms compared with 42 percent of women with no insurance at all. No incentives were provided for preventive care and disease management, and more and more people visited Florida emergency rooms for routine care.

Last month, the Florida Agency for Healthcare Administration recommended expanding the pilot project to 20 more counties. Expanding reform based on solid policy with a commitment to perpetual improvement will ensure Florida can continue to provide quality health care to more than 2 million poor, disabled and elderly Floridians.

Ultimately, success will be determined by improving the quality of care for Medicaid consumers and preserving manageable costs for Florida taxpayers. Successful reform depends on bold ideas, thoughtfully debated, responsibly implemented and objectively evaluated. Gov. Crist and the Legislature should carry forward with Florida's landmark Medicaid reform.

Jeb Bush is former governor of Florida.

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