Unless Congress takes action to reimburse metropolitan counties for health care they are currently providing for free, America’s health care safety net will be in jeopardy, said members of NACo’s Large Urban County Caucus (LUCC), who met in Washington, D.C., Feb. 4–6.
“We are in a crisis situation and don’t have much time,” said Supervisor Don Stapley, Maricopa County, Ariz. and LUCC chairman. “If we don’t triage the patient soon, the patient may soon die.”
Faced with a sluggish economy and rising number of uninsured, metropolitan county leaders told congressional and White House officials that the nation’s health care safety net is falling apart.
“Budget cuts are putting incredible pressures on us,” said Commissioner Peter McLaughlin, Hennepin County, Minn. and LUCC vice chairman. “We run a darn good teaching hospital, but we are getting pressures that are adversely affecting us.”
Some of those pressures include the nation’s new bio-terrorism threats. If the smallpox virus were to hit our nation’s shores, Hennepin County’s teaching hospital, for example, would be prepared to receive some of the first of those exposed to the virus, McLaughlin said.
“If we don’t stay strong, we can’t be the homeland security partner that we are often touted as,” said McLaughlin. “We welcome our new assumed responsibilities, but they are coming at great costs to local health care providers.”
As bioterrorism becomes more and more of a threat, America’s metropolitan public health systems have been asked to enhance existing programs, create new programs and improve communications and operations.
During a White House meeting with Alan Gilbert, special assistant to the president for Domestic Policy; Ruben Barrales, deputy assistant to the president for Intergovernmental Affairs; and Eric Ciliberti, associate director for Intergovernmental Affairs, many LUCC members said the president’s new Medicaid reform proposal to increase funding is a good first step. However, some were understandably concerned that the recent proposal leans too heavily on states to manage vital programs.
The Administration’s proposal calls for a cash infusion into the Medicaid program of $3.25 billion beginning in FY04 and a total of $12.7 billion over the next seven years for states willing to accept certain federal requirements. This represents an increase in current federal Medicaid spending of 9 percent over that period. The proposal remains budget neutral by reducing federal funding in the last three years of the 10-year period.
For those states accepting the new federal offer, the current quarterly installment of four checks for the State Children’s Health Insurance Program (SCHIP), Medicaid, the Disproportionate Share Hospital program (DSH) and management expenses would be reduced to two checks, one for acute care and one for long-term care. Transferability of up to 10 percent from one program to another would be provided and a 15 percent deduction for management expenses would also be permitted.
States would be required to adhere to maintenance of effort (MOE) regarding mandatory coverage for mandatory populations. However, states accepting the Administration’s new proposal would receive new unparalleled flexibility.
Specifically, states would no longer have to seek prior federal approval in the form of a waiver to undertake efforts to expand benefits. Essentially, the proposal would provide states flexibility to tailor coverage for “non-mandatory” recipients and services as they see fit.
“I’m a solid Republican and I strongly support my president,” said Stapley. “But a proposal that hands money to states and not the provider [Maricopa County] is a very big mistake.” Stapley estimated that his county provides care to nearly two-thirds of Arizona’s population. “My county’s public health system is bleeding $70 million a year as the uninsured and illegal alien population grows,” said Stapley.
Barrales, a former San Mateo County, Calif. supervisor, said he completely understood Stapley and the others concern, so much so that he insisted before the meeting had ended that a second meeting be scheduled within weeks with LUCC leaders and the president’s key Medicaid policy advisors.
“I’ve been there. I know you are hurting,” Barrales told Stapley. “Your timing is perfect since we all are looking at the first draft (Medicaid reform). The president needs and wants your input and ideas on Medicaid reform and that is why we need to hear from you.”
During the two days of meetings, metropolitan elected leaders also expressed to key federal lawmakers their concern that most of the bloodletting is taking place in county public hospital emergency rooms.
“The national trend is to allow metropolitan counties to shoulder the burden of treating the uninsured, under-insured and illegal immigrants with little or no help from anyone,” Stapley said. “A sad reminder of this can be seen in emergency rooms that now serve as primary care facilities for many individuals.”
Some county officials say the challenges are compounded by an uncooperative Immigration and Naturalization Service (INS). “Counties take our responsibility seriously to provide emergency health care to our communities,” said Commissioner Susan Bronson, Pima County, Ariz. “But when the INS continues to shuttle illegal aliens to our hospitals without shouldering any of the financial responsibility, we’ve got a big problem.”
A survey conducted by NACo and released on Feb. 5, in time for the LUCC meeting, supports county officials’ concerns. When counties were asked to rank the services they provide that have experienced the greatest demand for uncompensated care in the last five years, nearly 50 percent ranked both treatment of routine health issues and prescription drugs within the top five services. One county official noted that more than three out of four emergency room visits was for non-emergency treatment.
In all their meetings, LUCC leaders strongly suggested that America’s public health care system could be stabilized immediately by supporting several key measures during the 108th Congress.
LUCC officials asked congressional leaders and the administration to support a temporary increase in the Federal Medical Assistance Percentage (FMAP) program as well as support the Medicaid Safety Hospital Improvement Act of 2003, extend modifications to the Disproportionate Share (DSH) allotments provided under Medicare, reimburse public county hospitals for emergency health services provided to undocumented aliens and clarify the 340B prescription drug discount program to include outpatient prescription drugs.
Someone who has certainly experienced first hand the challenges associated with catastrophic events, Montgomery County (Md.) Executive Doug Duncan, whose county borders Washington, D.C. (September 11, anthrax and last year’s sniper incident), asked during one of several meetings, “What good does it do us if something catastrophic happens and the current public health system can’t handle it? The answer is not much good.”
