Citiwire.net

For Release Saturday, December 26, 2009
Citiwire.net

The best news about the health care legislation now on the brink of congressional approval is that the United States will be making an historic move toward providing care for all Americans at reasonable costs. Some 30 million more Americans will be covered–moving us, finally, toward the universal coverage standards long observed by all other industrialized democracies.

But–when President Obama signs the legislation, this will be a Christmas present very much in need of assembling. The added millions of insurance recipients will provide one of the most daunting management and public administration challenges we’ve ever faced. This is bigger than welfare reform, education reform, even homeland security.

Why? Topping the list, in my judgment, is changing the Medicaid system which is now the largest insurer in our nation. It provides–in combination with the Children’s Health Insurance Program (CHIP)–coverage to 60 million Americans. The Congressional Budget Office projects that 11 million of the newly insured Americans will become enrolled in Medicaid by 2019. Estimates are that, through this reform, approximately 25 percent of the entire U.S. population will be enrolled in Medicaid for at least some of 2019. What was originally conceived as a “welfare” program for the poor will be transformed into a mainstream health insurance program, without stigma and, hopefully, with credibility for providing access to quality care that is affordable.

But getting there from here will require overcoming major obstacles. For starters, today only about half of this nation’s physicians even accept new Medicaid patients. Stigma, low payment rates and slow payment procedures are part of this problem. Given our nation’s pattern of residential segregation based on income and race, most Medicaid recipients live in medically underserved communities where there are simply too few health care providers to assure timely, quality care. The health care workforce will have to be increased and be diversified. This should be good news for many local economies.

If the final bill does expand Medicaid eligibility to 133 percent or 150 percent of the federal poverty level by 2013 as projected, there is still a window of time to begin to address these pressing workforce issues before millions more uninsured adults (without children), and low income working families will need to be enrolled in this state/federally financed program.

There is, of course, something inherently right about expanding Medicaid. It is our nation’s most compassionate insurer, having evolved now to cover not only vulnerable low income mothers and children, but the blind, aged and persons with disabilities, as well as those who experience disasters, like hurricanes, or temporary unemployment. It also pays for health care for those whose incomes and medical conditions combine to necessitate long term care.

But–some Medicaid directors are already panicked by the very thought of the pending enrollment expansion. And for good reason. States have faced a decade of budget constraints and, most recently, dramatic recession-generated deficits. Although some relief came this year from the re-authorization of the CHIP in 2009 and from funds in the American Recovery and Reinvestment Act, this fiscal relief is scheduled to wane in 2010, leaving many states’ Medicaid budgets facing serious shortfalls.

Already, states such as Massachusetts and California are on life support when it comes to meeting escalating health care needs for low income families in the face of declining revenues. Cash strapped state Medicaid budgets translate into reduced services for vulnerable families. Mental health care, coverage for some prescription medications and dental health care access are often sacrificed.

All this means Congress will have to assure long term, robust federal support for the proposed Medicaid expansion. And even then, implementation will require applying critical lessons about government reinvention from past, sometimes unrelated efforts at transforming our public systems.

Here are some of the lessons we should have learned, and will now need to apply:

• Allow ample time for planning and designing regulations and assure early citizen engagement that reflects the income and diversity of the communities that will be affected by the reform.
• Identify and remove bureaucratic obstacles to creating the required technical and human infrastructure for effective program implementation. This may mean streamlining procurement and hiring processes.
• Use contemporary tools of engagement, such as social media and marketing to manage perceptions and expectations of the process and to provide timely feedback.
• Provide incentives for innovative approaches to outreach, management and performance improvement. Disseminate news about new strategies and support innovators.
• Build in the capacity for real time monitoring, data analysis and integration, to enable data-driven decisions and responses.

Bottom line: the new legislation’s breakthrough era for health care access in America will require unprecedented collaboration involving government, nonprofit and private agencies. Rough spots are surely ahead. But, like proud parents on Christmas morning, we, as a nation must be up to the task of putting this “present” together and witnessing the joy of those that will most assuredly benefit.

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