NURS 6050C: Policy and Advocacy for Improving Population Health

NURS 6050C: Policy and Advocacy for Improving Population Health

INITIAL POST

The Privatization of Medicaid in Community Mental Health

            I currently work for Hillcrest Family Services, a non-profit community-based organization which also provides many services including inpatient and outpatient mental health, primary care, a school for special needs children, adoption, and an HIV clinic are just some of the programs offered. Hillcrest Mental Health Center serves a vulnerable patient population, who are not only very ill but are also very poor. Approximately 85% of the patients who seek psychiatric services at our clinic have Medicaid. However, in 2015 the state of Iowa led by then Republican Governor Terry Branstad partially privatized Iowa’s Medicaid program through the implementation of managed care organizations (MCOs). The state of Iowa’s Department of Human Services (DHS) still provides Medicaid to a small portion of Iowans, on a limited basis. However, most Medicaid recipients receive services through one of three MCOs.

      According to the University of Washington School of Medicine (n.d.), “the overall aim of managed care is to place administrative control over cost of, quality of, or access to health care services in a specific population of covered enrollees” (University of Washington School of Medicine, n.d., para 2).  Working with the MCOs is a nightmare for patients who are frequently unable to see their established providers, or get coverage for medications that they have taken for years with good efficacy. Patients and providers are frustrated, overwhelmed, and trying to maneuver through the obstacle course of pitfalls used by managed care to earn profits at the expense the poorest, sickest, most vulnerable people in our society.

Costs Savings, Quality, and Accessibility

            The push for the privatization of Medicaid was primarily fueled by the promise of costs savings for the state. Leys and Rodriguez (2018) report that in 2015, Branstad predicted privatization would save taxpayers $232 million annually by 2018. However, a 2018 audit reveals the actual savings is only $141 million. Branstad and the Republicans further claimed that private companies would not only provide cost savings but, would also provide more effective and efficient healthcare to Iowa’s most vulnerable citizens (Leys & Rodriguez, 2018). The fallacy of this assertion is that healthcare is a service or commodity, rather than a fundamental human right.

MCOs are Missing the Mark

The cost of such a complicated program is not as simple as the auditor’s report reveals (Leys & Rodriguez, 2018). Clayworth (2018) contends that AmeriHealth Caritas, one of the three original MCOs dropped out of the state exchange. By their own account, AmeriHealth Caritas left Iowa with over $14 million in unpaid insurance claims (Clayworth, 2018). Unfortunately, the other MCOs have also failed to pay for services already rendered. Wong (2018) reports that Hillcrest Family Services has not been paid by any of the MCOs for services provided at the subacute psychiatric unit in over eight months. AmeriHealth Caritas left the exchange still owing the subacute unit over $800,000; but, subacute is just one of the programs offered by Hillcrest. All in all, each of the three MCOs currently owes Hillcrest six-figures (Wong, 2018). Hillcrest, my employer, had to take out a line of credit to make payroll in December of 2018. We are the only organization that provides psychiatric services to Medicaid patients in a 100-mile radius. If Hillcrest closes due to non-payment by the MCOs, the implications for the patients we serve will be devastating.

The Effects of Medicaid Privatization

    The adverse consequences of privatization in Iowa are not merely financial. Clayworth (2018a) reports that the MCOs have denied legitimate services to patients’ time and time again. One example includes the use of a specialty wheelchair to a 70-year-old woman suffering from severe cerebral palsy and a traumatic brain injury. And, a 6-year-old girl with muscular dystrophy was denied a wheelchair ramp that would allow her access to the family’s van even though the family raised over $ 11 thousand towards the cost. The MCO refused to pay the remaining $6 thousand, claiming the ramp was not medically necessary (Clayworth, 2018a).  “The denial of care for Medicaid services, especially those who had already been approved through the state, is an endemic problem in Iowa” (Clayworth, 2018a, para. 11).

            An investigation by The Des Moines Register found compelling evidence that the MCOs have denied in-home care services for disabled patients which had been routinely approved by Iowa DHS when ran the Medicaid program. Additionally, administrative judges have found that MCOs violated due process by failing to properly notify Medicaid recipients of reductions in care, and their rights to appeal unfavorable decisions. Moreover, when Medicaid recipients appeal unfavorable decisions and win, the MCOs are allowed re-evaluate the recipients’ medical needs status, and deny the same services within as little as 60 days. Should the same treatment be denied again, and it usually is, the appeals process starts all over (Clayworth, 2018a).

            The evidence shows that MCOs in Iowa have been a disaster for patients, providers, and have failed to save tax-payers money. The quality of care and patients’ ability to access care has declined since the privatization of the Medicaid program. Moreover, the rates of compliance violations have sky-rocketed with over 500 claims being substantiated (Clayworth, 2018a). If non-payment continues, I along with other nurses, providers, therapist and support staff may lose our jobs. Currently, our nurses spend hours each day on the phone and filling out endless complicated forms to help our patients get the medications they rely upon. The MCOs make our patients jump through hoop after hoop to get the medication that works. It seems that they are constantly changing the rules, or applying them differently depending on the situation. 

Public Policy Change

According to Milstead (2016), the Kingdon model refers to three categories of independent and interdependent variables, problem, policy, and politics. These variables must all align to produce the opportunity to successfully create policy changes. Medicaid privatization is already viewed as a problem in Iowa. Leys (2018) asserts that the majority of Iowans (48%) want DHS to take Medicaid back from the MCOs, while a small number (28%) continue to support privatization. The issue was debated contentiously during the gubernatorial election in 2018. Then-candidate, Kim Reynolds stepped in to negotiate payments from the MCOs to Hillcrest Mental Health clinic. A monumental 51% of citizens report they feel it is a problem that Governor Reynolds has failed to address the issues with the MCOs (Leys, 2108). 

Because Republicans control both chambers of Congress, and the governor’s office, the opportunity for policy change does not exist at the state level. Cox (2018) maintains that “Even a de-privatized Medicaid will have a big target on its back that says “welfare,” and will be chronically underfunded, leaving poor Iowans in perpetual uncertainty about their access to health care” (Cox, 2018, para. 18). However, the national push for Medicare for all is gaining momentum (Cox, 2018). The political variable is present within the federal government, and it coincides with the policy variable. While Republicans control the Senate and the executive branch, the house of representatives is dominated by Democrats. Moreover, it is promising that the Republicans were unable to repeal the Affordable Care Act within the last two years while they had control over all three branches of the federal government. Policymakers on both sides of the aisle are feeling pressure from their constituents to fix the broken healthcare system.

            The public policy solution comes through single price healthcare, putting a cap on insurance rates and pharmaceutical costs for consumers, and reimbursement rates to providers and facilities. When costs are controlled in the private market the same way they are in  Medicare and Medicaid, the fee for service model will be eliminated, and healthcare organizations will be incentivized to operate more efficiently. The single price healthcare solution allows both the private market and the Affordable Care Act to co-exist, which will please both republicans and democrats.

Additionally, taxes will not need to be increased to pay for healthcare because the free-market will compete, but in a controlled environment. Healthcare professionals and industry experts have been discussing and writing about single price healthcare for years, I have read numerous articles in publications such as The Journal of the American Medical Association, The Journal of Healthcare Finance, and Forbes Magazine. The lobbyist for organizations of healthcare professionals should push the idea to politicians, who will disseminate information to their constituents. Once the idea for single price healthcare ignites in the public sphere, all three variables in Kingdon’s model, problem, policy, and politics will align, and the opportunity for policy change will exist. 

References 

Clayworth, J. (2018, August 30). A private medicaid company that pulled out of Iowa has yet to pay thousands of medical bills. The Des Moines Register. Retrieved from https://www.desmoinesregister.com/story/news/investigations/2018/08/30/iowa-privatized-medicaid-company-amerihealth-caritas-thousands-unpaid-medical-bills-broadlawns/1137484002/

Clayworth, J. (2018a). Medicaid maze strands patients without care. Retrieved from http://features.desmoinesregister.com/news/medicaid-denials/

Cox, J. (2018, February 20). Democratic gubernatorial candidates should go back to the future. Retrieved from https://www.bleedingheartland.com/2018/02/19/democratic-gubernatorial-candidates-go-back-future/

Leys, T. (2018, September 26). Iowa poll: Share of Iowans who want to continue Medicaid privatization drops to 28 percent. The Des Moines Register. Retrieved from https://www.desmoinesregister.com/story/news/politics/iowa-poll/2018/09/26/iowa-medicaid-privatization-support-drops-28-percent-iowa-poll-governor-kim-reynolds/1408907002/

Leys, T., & Rodriguez, B. (2018, November 27). Audit: Privatized medicaid is saving Iowa millions of dollars. democrats aren’t convinced. The Des Moines Register. Retrieved from https://www.desmoinesregister.com/story/news/2018/11/26/iowa-state-auditor-mary-mosiman-estimates-privatized-medicaid-saves-iowa-126-million-rob-sand/2113135002/

Milstead, J. A. (2016). Health Policy and Politics a Nurse’s Guide(6th ed.). Burlington, MA: Jones & Bartlett Learning.

University of Washington School of Medicine. (n.d.). Ethics in medicine: Managed care. Retrieved from http://depts.washington.edu/bioethx/topics/manag.html

Wong, A. (2018, November 1). Hillcrest operating subacute unit while waiting on payments from Iowa Medicaid managed care organizations. Retrieved from https://www.kcrg.com/content/news/Hillcrest-operating-subacute-unit-while-waiting-on-payments-from-Iowa-Medicaid-managed-care-organizations-499349361.html