Governor George Pataki’s proposed budget for health care is a devastating package that is especially cruel and insensitive to working people and their families and takes funds away from patient care. It would cut health care spending in the state by more than $1.45 billion, including direct cuts to Medicaid and increased taxes on nursing homes, hospitals, and home care agencies. The New York City health care system alone would lose over $875 million.
Many think of Medicaid as a program for poor adults. But 70 percent of Medicaid spending pays for care for the elderly and disabled, and half of the rest is for children. Medicaid reimbursements keep our hospitals, nursing homes, home care agencies, and community health centers afloat.
In previous budgets, the governor mainly tried to cut funding to health care providers, making it harder for them to serve all of us. But this year, his cuts would take coverage and services away from hundreds of thousands of less politically powerful people -- working people, the elderly and disabled adults.
TARGETTING LOW-WAGE WORKERS
Family Health Plus, the Medicaid expansion that covers low-income working adults (e.g. a family of three with a gross income under $23,000 a year) , is targeted for cuts. Governor Pataki proposes that anyone who works for a company with more than 50 employees, or who has had health coverage within the last 12 months, would be ineligible for Family Health Plus. So, an under-paid Wal-Mart worker who cannot afford health benefits would be barred.
The administration says it is doing this because large companies should provide coverage for their workers. And they should. But why penalize the workers? Does the governor think that people with low-wage jobs at big companies have the leverage to make their employers provide affordable coverage?
The budget would require people covered by Family Health Plus to pay part of the cost for doctor visits, hospital stays and even ambulance services, increasing costs for taxpaying New Yorkers who are barely above poverty. And people on Family Health Plus would no longer be covered for going to the eye doctor or dentist.
HARDER TO GET LONG-TERM CARE
The budget would make it harder for senior citizens to qualify for Medicaid coverage for long-term care (nursing home or home care). People needing such care must spend any assets they have above a certain amount on their care before Medicaid steps in. If the person transferred assets to someone else (e.g. a family member) before applying, Medicaid counts the value of those assets as if the person still had them for three years after the transfer. The governor would extend the look-back to five years back from the date of application (not the date when the asset had been transferred). So, if an elderly person pays for a grandchild’s college education and four years later goes into a nursing home this year, the governor would deny that person Medicaid for five years.
Supposedly this would keep people who can afford their own care from taking advantage of Medicaid. Actually, it would require people of modest means to impoverish themselves to pay for care or would pressure family members to give up their careers to care for an elderly relative. People who can afford lawyers can use trusts and other arrangements to get around these proposals.
It is ironic. If you are very wealthy and die, Republicans want you to be able to leave your entire fortune to your family without any estate tax. But if you are middle class and frail, they want you to spend your life savings on health care, leaving you with little or nothing to pass on to your family.
COST OVER QUALITY IN DRUGS
The governor is in the right ballpark in proposing a preferred drug list for Medicaid. The only Medicaid providers whose rates of payment are virtually unregulated by New York’s Medicaid program are the drug companies. Now, the governor has proposed a preferred drug list for Medicaid. A preferred drug list/prior authorization program – if done right – can dramatically reduce what we pay to drug companies. It can encourage doctors to focus on effectiveness and cost, without restricting their patients’ access to needed drugs. But the Pataki proposal gives too much weight to cost rather than quality in determining what drugs would go on the preferred list and would allow state bureaucrats to override a physician’s judgment on what drug to prescribe a patient. In upcoming budget talks, the Assembly will work to negotiate a good system.
RED TAPE
The budget refers vaguely to promoting "case management" of "high-cost cases." Effective management can mean better care and lower cost, but it can only be done if a patient is covered by a plan over an extended period of time. Today, people are constantly dropped from Medicaid only to re-enroll months later, because of outdated bureaucratic requirements. The Assembly has fought to cut red tape to promote stable coverage and better management of care. The governor opposes these reforms.
THE CALIFORNIA QUESTION
People often, for example, ask why New York spends so much more than California per Medicaid recipient. The implication is that we must be spending money we don’t need to. But there are good and important reasons for the difference.
For one, New York has shifted most of its mental health spending into Medicaid. We are smart to do that, because the federal government helps us pay for Medicaid. California does not do that, so its state and local governments end up paying the whole bill.
We provide good care for elderly and disabled patients, including much more home health care than California. If we did not, many New Yorkers would receive no care, become impoverished paying for care, or their family members would have to disrupt careers to care for them.
New York’s payments to hospitals, nursing homes, home care agencies, and health centers are more closely related to the real cost of providing care than California. That supports the health care system that we all depend on. If funding is cut -– whether by Medicaid cuts or more patients being uninsured –- then staffs will be reduced and services stretched thinner. Even the wealthiest patient will get poorer quality care, and lives will be in jeopardy.
California’s Medicaid program is actually one of the worst in the country –- spending less per recipient than any state, including Mississippi. New York’s Medicaid spending is not much different from neighboring states like Connecticut, New Jersey and Massachusetts.
In health care, as in education and other human services, cutting is not reform. The real solution to the inefficiencies and inequities in health care and health care financing is to move toward universal coverage with broad-based public financing. Governor Pataki’s proposed budget is a major step in the opposite direction.
Richard Gottfried is a member of the New York State Assembly. A Democrat from Manhattan, he is chair of the Assembly’s Committee on Health.
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Injuries to children from lead paint cause irreparable harm - brain damage that is irreversible, nervous system disorders, delays in development, and many other permanent conditions. Lead poisoning robs vulnerable children of the potential to become all they might be, and particularly afflicts children of color, who represent nearly 95 percent of the victims in New York City, according to a report (in pdf format) by the Department of Health and Mental Hygiene.
A new law, which the New York City Council is expected to enact this week, is the product of many lessons learned in the struggle against pediatric lead poisoning in the decades since the city first banned lead paint in 1960. Yet when the council members vote, it will be in defiance of Mayor Michael Bloomberg, who vetoed the bill (in pdf format) in December. He was wrong to do so.
"Childhood lead poisoning remains a significant public health problem in New York City," according to the New York City Department of Housing Preservation and Development(in pdf format) "Over the last five years, more than 35,000 NYC children have been newly identified as having elevated blood lead levels." In fact, the numbers may be far higher, since less than a third of children are actually tested, according to the Health Department (in pdf format).
According to studies(in pdf format) by Dr. Philip Landrigan of Mt. Sinai Medical Center, the social costs of childhood lead poisoning in New York City alone are in excess of $1.27 billion a year.
The history of efforts to combat this problem is long and convoluted, some of it detailed online by the New York City Coalition to End Lead Poisoning . In 1982, the city passed Local Law 1, which required the abatement of all lead paint, in any condition, in homes where young children reside. While many experts believe that full abatement is, in the long term, the best way to prevent lead poisoning, and in the long run more cost-effective, there were concerns about the immediate costs of such an effort.
The 1982 law was replaced by Local Law 38 in 1999. That law was criticized by virtually every expert in the field as far too constrained, limiting landlord responsibilities only to peeling paint, and leaving out lead dust and the conditions that cause lead dust.
Indeed, the failure of the law to consider lead dust was a key reason why the state’s highest court, the New York Court of Appeals, last year struck down Local Law 38, after declaring that the "numbers of New York City children with elevated blood lead levels remain alarmingly high."
The high court's decision gave new impetus for the City Council to re-examine the current lead poisoning prevention policies, and on December 15, 2003, by a vote of 44 to 5, the council passed a new lead poisoning prevention bill, Intro 101A. The mayor vetoed it later that month.
The new bill represents, in significant part, an attempt to find a middle ground between the 1982 law (which is the law under which the city began operating again starting last year ) and the now nullified 1999 law.
The overall approach of the new bill is to recognize that if landlords are going to be permitted to leave lead paint in place, they must be proactive in assuring that the lead remains in a condition that is not immediately hazardous to the occupants. Thus, while the new law will not require the 1982 law’s full abatement, it will continue the mandate that owners maintain a safe dwelling at all times, using their knowledge of the particular characteristics of the buildings they manage. And more specifically, it requires that work involving repairs or disturbance of lead paint always be done by properly trained personnel using safe work practices. They must be particularly mindful of lead dust, which is so highly toxic that a particle less than the size of a grain of coffee sweetener is sufficient to inflict brain damage on a child.
Under the new law, landlords will be required to actively ascertain whether children under the age of seven reside in multiple dwellings units (as under the window guard law) and if so, must inspect those units at least once a year (and more often if necessary) for lead hazards, and promptly and safely correct them. Lead hazards can include not just peeling paint, but also "friction surfaces" (painted surfaces that bind and rub), "impact surfaces" (painted surfaces that get damaged by banging), and "chewable surfaces" (those that teething infants are mouthing). Lead dust is also a defined hazard, and peeling lead paint in common areas must also be corrected.
The arguments of the mayor and other opponents of the bill, such as Julia Vitullo-Martin of the Manhattan Institute writing in Gotham Gazette in December, seem to be based on misstatements of the plain language of the law, as well as wholly unsubstantiated scaremongering. We have written a detailed point-by-point response to Vitullo-Martin’s article, and a response to the mayor's veto. In general, they are claiming that requiring landlords to maintain their rental properties so as not to be hazardous to the occupants will result in buildings that become poorly maintained or even abandoned. This is Alice-in-Wonderland reasoning -- requiring something to be safe will make it unsafe -- and is reminiscent of arguments undoubtedly made at every juncture in the history of housing reform in New York, going back to the requirement of indoor plumbing and adequate air and light when the tenement laws were reformed a century ago. As in the past, these will prove to be unfounded.
Equally unfounded are assertions that the bill will make conscientious, responsible owners liable. The problem has never been conscientious owners -- by definition they don't poison children, and one can't be held liable unless there is a victim. While the number of children lead-poisoned each year remains shockingly high, it is still a relatively small percentage of the potential threat; the city estimates there are 300,000 apartments with both some lead painted surfaces and young children in residence. Thus, it is readily apparent that most landlords already are capable and diligent in keeping their buildings in safe repair, and careful, responsible property owners should have no reason to fear the new law. The problem, rather, is the reckless or negligent landlords who cause great injury to our children, and who should continue to be accountable for the consequences. What possible social policy is advanced by changing ours law to immunize them?
It is national policy(in pdf format) that childhood lead poisoning be eliminated by 2010. Given that New York City was one of the first jurisdictions in the nation to ban lead paint, New Yorkers should be seeking to achieve that goal even earlier. Intro 101A is a major step in that direction.
--Matthew Chachère and Andrea Rodriguez are staff attorneys at Northern Manhattan Improvement Corp. Legal Services, which represented the plaintiffs in the lawsuit that overturned Local Law 38 of 1999 (NYCCELP v. Vallone).
President George W. Bush signed into law in December, 2003 the most sweeping changes to Medicare since the 1965 creation of the federal health insurance program for people over 65 (as well as some disabled persons under 65). The most significant - and controversial - element of the new law is the addition to Medicare of prescription drug coverage.
The $400 billion Medicare Prescription Drug Modernization Act has generated bitter conflict throughout its progress into law, with supporters claiming it will greatly help the 40 million seniors on Medicare to pay for the medications many of them rely on, and critics fearing that the plan will mainly benefit the drug companies and the private insurers and plans that will deliver the Medicare benefit. They even suggest that it is a first step towards the dismantling of Medicare. The bill squeaked through Congress by the narrowest of margins - according to a CNN.com report, in the House of Representatives the vote was running against the bill 218 to 216 until Bush himself made a series of last-minute telephone appeals to members, and slid to victory with 220 for and 215 against.
Now that the bill is law, health care experts and advocates for the elderly seem as divided as ever about whether it will benefit or hurt most present and future Medicare recipients. Indeed, with provisions having been added to and removed from the bill until the last possible moment, and many of them discreetly buried in the nearly 700 pages of drug-plan legislation, both the analysts and those charged with implementing the plan are still figuring out exactly what the law says. Answers to these questions are likely to be slow in coming, since most of the new legislation's provisions will not take effect immediately -- the drug plan, for instance, not until 2006. (Starting this spring, however, Medicare enrollees will be able to purchase prescription-drug discount cards for $30 or less that are expected to save them 10 to 25 percent.)
"The short-term impact in New York is not likely to be dramatic," says James R. Tallon, president of the United Hospital Fund, a federated charity (the nation's oldest) that researches and analyzes health care issues in New York City and issues public-health grants. "There will be some benefit to the hospitals, especially rural hospitals, like those upstate. They used to be reimbursed less than urban hospitals, on the assumption that their costs were lower; now much of that gap has been closed. Hospitals in New York City probably won't be affected that much."
"Over the long term, we're just not sure what will happen," he says.
PRESCRIPTION DRUG COVERAGE
For those Medicare recipients who currently have no prescription drug coverage at all, something is clearly better than nothing. Some aspects of the new prescription drug provisions do look good on paper, at least for those seniors with especially high drug costs and/or very low incomes. The benefit will cover 95 percent of the cost of drugs for people with $5,100 or more in drug costs. And for the 11 million or so Medicare recipients whose income is less than about $13,000 for individuals (or $17,500 for couples), it will pay almost the full cost of prescription drugs, with no premiums or deductibles. Those with incomes no more than 50 percent above the federal poverty level will pay sliding-scale premiums and a modest deductible of $50.
However, the benefit is stingier for seniors who do not fall into the above categories. These seniors must pay the first $250 of their drug costs out of pocket. Medicare would then pay 75 percent of costs up to a limit of $2,250. At that point payments would stop altogether until/unless the beneficiary's costs reach the $5,100 mark, and the 95-percent coverage kicks in. Enrollees will still be required to pay their premiums, estimated at about $35 a month, throughout this $2,850 gap in coverage.
Groups such as the National Committee to Preserve Social Security and Medicare and the Medicare Rights Center and public officials such as Senator Hillary Clinton, have expressed serious concern that the new law does not allow the government to negotiate drug prices with the drug companies, even though it does so for other health care programs like the Veterans Administration's, and such negotiations have been vital in keeping costs down. Spending on prescription drugs in the U.S. has been increasing by over 15 percent annually for several years; critics of the Medicare plan say that with no price controls, by 2006 and beyond seniors will be spending more with the insurance than they do now without it.
NEW CAP ON CONTRIBUTIONS
The new law also allows the government for the first time to cap its general contribution to Medicare. And the $400 billion in federal funds set aside for the Medicare changes over the next ten years will not all go to pay seniors' drug costs; a quarter of it is earmarked for subsidies to private enterprises like the HMOs, PPOs, and other private providers who will administer the drug coverage, and to the companies that will be needed to perform the complex task of coordinating benefits. With costs escalating and the federal contribution capped, the result might well be higher premiums and the shifting of other costs to Medicare enrollees.
"I'm skeptical about these so-called market-driven initiatives," says James Tallon. "The administration used phrases like offering seniors more 'choice' and 'flexibility' in choosing providers, but these words really are euphemisms for cost-sharing. One thing we do know is that the private health care market has higher administrative costs than the federal programs, and its reflexive strategy tends to be to pass on the higher costs to the insured."
"When costs go up, and costs are going to go up, the seniors and the disabled are going to pay for it," says Judy Wessler, director of the Commission on the Public's Health Systems, a New York nonprofit that advocates for affordable health care for all residents. "And the legislation leaves very clear holes, holes that people will fall through. A lot of these holes came out only after the bill was passed. Lots of things have come out since that raise red flags and concerns. The law is very problematic, and a big disappointment to those of us who have been waiting so long for Medicare drug benefits."
BENEFITING OR HURTING NEW YORKERS?
It remains far from clear whether the new plan will end up, on balance, benefiting or hurting the 2.7 million current Medicare recipients in New York State.
"One big question, especially for low-income people, is how the new plan is going to be administered, and how confusing the new options and changes will be," says Tallon. "One of the things we have learned, historically, is that the implementation of a new program this big typically involves complexities that far exceed anything the legislators foresaw. These added complexities are a big problem for people. They are confusing even to health care administrators. If English is not your native language, or you're not skilled at dealing with bureaucracies, you can get completely lost in the shuffle.
"Another big issue is, how is this bill going to connect to existing programs like EPIC [Elderly Pharmaceutical Insurance Coverage], New York's state-run pharmaceutical assistance program, and Medicaid and private retiree programs?"
Tallon is not alone in his concern; many of the plan's opponents and critics predict that seniors will actually end up paying more for prescription drugs when that part of the law goes into effect, particularly if the new Medicare coverage means they lose their eligibility for other, more generous prescription-drug plans such as state-run pharmaceutical-assistance programs or an employer's retiree plan.
New York State's Elderly Pharmaceutical Insurance Coverage program (EPIC), for example, currently provides prescription drug benefits at very low cost to about 320,000 seniors. Notably, the program's eligibility requirements are much less stringent than those set by the new Medicare plan for full coverage of drug costs. For seniors with individual incomes under $20,000 (or married seniors with total income under $26,000), the state program's fees are also generally much lower than the premiums for the Medicare drug plan. A senior with an income of $14,000 who is enrolled in the state program pays an annual fee of $60; a senior with the same income would pay premiums totaling $420 a year for the Medicare plan. EPIC covers almost all prescription drugs, which will almost certainly not be the case with Medicare benefits delivered by a myriad private providers. It imposes no deductible for individuals with incomes under $20,000 or couples with incomes under $26,000.
A Jan. 4 New York Times article reports that both Democrat and Republican state legislators are worried that coordinating the two programs will be extremely complicated and confusing to seniors eligible for both, and some fear that the Medicare plan will provide an excuse for greatly diminishing or eliminating the state program.
Also, under the new law, the 219,000 low-income seniors in New York who qualify for both Medicare and Medicaid will lose their eligibility for the Medicaid prescription coverage and be covered only by the Medicare plan. Whether the forced change from the Medicaid to the Medicare drug plan will benefit or hurt them depends, like so much else, on how the Medicare provisions play out; something which will remain unknown at least until 2006, and probably a good while longer.
Sue Wilson is a journalist who writes frequently on health and science topics for such outlets as the New York Times, WNET, and UNICEF.