BELLEVILLE, Ill. — Across the nation, state governments spend nearly as much money on health insurance for the poor as they do on public schools--more than on welfare, prisons and roads combined. And the tab keeps rising, fast.
Their budgets squeezed tight by recession, lawmakers in state after state have had enough. They are moving to cut some people off Medicaid insurance and to trim benefits for those who remain.
Federal law requires states to provide basic health coverage for poor kids, pregnant women and the most desperately needy disabled adults. But most legislatures have expanded Medicaid far beyond those core groups, reaching to cover low-income working families and people with extraordinary medical bills, such as AIDS patients or transplant recipients.
Some states, California among them, still are looking to broaden Medicaid's reach. But many others are frantic to scale back a program that eats up close to 20% of state spending. At their annual meeting last week, the nation's governors were unanimous in declaring Medicaid's cost the most urgent crisis they face. Just how grave the problem is became clear Friday, when Mississippi's Medicaid program went broke. Lawmakers there were unable to come up with the money to pay for medical care for the poor.
Patients "are calling me asking, are they going to be able to see their doctor? Are they going to get their prescriptions filled? Unfortunately, the only answer to those questions is, 'I hope so.' There is no guarantee," said Rica Lewis-Payton, director of Mississippi Medicaid.
Added Dennis Braddock, who directs Washington state's program: "There needs to be a total rethinking of Medicaid and who it's intended to serve."
The rethinking has begun.
In Vermont, low-income senior citizens soon may have to buy dentures on their own or go without. In North Carolina, Medicaid no longer will cover infant circumcision. In Washington, 150,000 children may lose health insurance altogether. And in Utah, families with annual incomes as low as $7,500 will have to pay a few dollars for each doctor's visit, up to $500 a year.
In Florida, disabled construction worker Oliver Hill Sr. faces the prospect of trying to pay for his own eyeglasses for the first time since he went on Medicaid. The 59-year-old knows he won't be able to do it. With the special lenses he needs to shield his glare-sensitive eyes, glasses cost more than $200. "By the end of the month, I don't even have enough for a $2 co-pay for my doctor," he said.
In Illinois, Republican Gov. George Ryan is taking a different tack: Instead of cutting benefits, he has told medical providers that the state will pay them less for treating the indigent.
The prospect does not so much enrage nursing home owner Steven Wolf as it leaves him speechless. Already, he says, he is losing more than $20 a day on each of the 115 or so Medicaid patients at his Calvin Johnson Care Center--a worn but cheery nursing home in Belleville, a blue-collar suburb of St. Louis.
The medical staff and the housekeepers, the liver lunches and the scrambled eggs on request, the balloon volleyball games, the pet therapy, the concerts of patriotic music--it all costs him close to $107 per patient per day. Medicaid pays him $86. And the governor has proposed slashing that by nearly 9%.
"I don't think it's possible," Wolf said.
His words echo in state after state, as advocates for low-income patients look at proposed cuts with horror.
Missouri Gov. Bob Holden, a Democrat, wants to eliminate in-home services for 9,000 disabled residents who need help bathing and eating but who prefer to live on their own rather than in an institution.
Florida Gov. Jeb Bush, a Republican, wants adults with catastrophic illnesses to pay their own medical bills until they have sunk into extreme poverty. His plan would leave a single adult with less than $180 a month for rent, food and other living expenses.
"It's just impossible," concludes Anne Swerlick, an attorney at Florida Legal Services, which works on behalf of low-income people.
But state lawmakers and Medicaid administrators throw the same phrase right back at their critics. It's not possible, they say, for Medicaid to do so much for so many. Not if there is to be money left over to improve schools and fix highways and protect children from abuse, to lower taxes and build parks. Not in this economy.
Look at the numbers in Illinois: When planning for this year's budget began, state analysts expected $900 million in revenue growth. Then came Sept. 11. Tourism plunged; the economy tanked. The new growth estimate: $250 million.
To cover the gap, Ryan has proposed cutting 3,800 state jobs, closing two prisons and cutting a variety of services. Medicaid was hit especially hard. In an emergency measure last fall, Ryan cut the fees hospitals collect for treating Medicaid patients by 13%. His new budget proposes another 13% cut in hospital fees--plus deep reductions for other health-care providers.