America's public health safety net is under assault, said Sen. Hillary
Rodham Clinton (D-N.Y.). Keynoting a conference sponsored by Families USA in
Washington, D.C., in January, Clinton sounded a chord that would reverberate
throughout the meeting—a combination of grim foreboding about the
intentions of a second-term Bush administration toward the public health
systems that have been the legacy of the liberal Democratic establishment and
a defiant resolve to protect those systems against Republican efforts to
privatize and downsize.
"These are perilous times for America's health care
infrastructure," the former first lady told a crowded ballroom at
Washington's Mayflower Hotel. "We are about to experience one of the
most aggressive assaults on the structure and funding of public health
programs in our history."
Clinton focused especially on administration proposals to cap Medicaid
funding through block grants to states—effectively overturning the
system of matching funding that has been in place since the program began 40
years ago—and the new prescription drug benefit under the Medicare
Modernization Act (see page
Famlies USA, calling itself "the voice for health care
consumers," is a network of grass-roots advocacy groups that champion
public funding for Medicare, Medicaid, and the State Children's Health
Insurance Program, as well as such issues as minority health, access to
prescription drugs for the elderly, and relief of medical debt incurred by
individuals with and without insurance.
Echoing many others at the conference, Clinton said the new Medicare drug
benefit is rife with potential pitfalls and complications that could leave
some beneficiaries with much higher costs and a far less generous benefit than
has been touted.
She especially highlighted the subgroup known as "dual
eligibles," who qualify for both Medicaid and Medicare; when the new
Medicare drug benefit is initiated in January 2006, the Medicaid drug benefit
for those who are dually eligible will end, and the transition from one
program to the other is expected to be fraught with problems and
"If the transition from Medicaid to Medicare doesn't go smoothly, if
[there are] implementation problems that are just bound to occur when the
Medicare prescription drug benefit takes place, and if some of the problems
embedded in the prescription drug benefit come to pass, these individuals
could be left with no or inadequate coverage," Clinton said.
Clinton noted that most seniors in the Medicare program will have six
months to enroll in a prescription drug plan. The plans will be announced
October 13, and enrollment will begin November 15. Those who are dually
eligible have far less time to make a selection, however. They must be
enrolled in one of the new plans by January 1, 2006, since their Medicaid
coverage ends on December 31.
In response to this problem, the Centers for Medicare and Medicaid Services
(CMS) said it will automatically enroll dual eligibles into a prescription
drug plan. But that could create problems, Clinton said.
"When seniors are randomly enrolled in a drug plan, there is no
guarantee that the plan chosen is the one that will fit their specific
prescription drug needs," she said. "And, remember, we are talking
about a population that is juggling multiple chronic conditions and multiple
"If seniors are placed in a plan that is not a good fit, it is going
to require a lot of paperwork and research to find the right plan, assuming
it's in the right region where they live and that they can even get into the
plan," Clinton continued. "Can we really place that burden on our
already overburdened caregivers or medical professionals? Are we going to turn
doctors and RNs and nursing home administrators into government bureaucrats,
going through all the plans and trying to find the one that will fit the
person in need of continuity?
"I also think there will likely not be enough targeted public
education to help the dual eligibles with this transition process."
Even beyond the likely problems associated with dual eligibles, the new
prescription drug benefit received a thumbs-down review from Clinton—who
voted against the measure—and from many others at the Families USA
A principal complaint throughout the conference was the enormous complexity
of the benefit, with multiple plans expected to offer different formularies at
varying costs. "Just because a drug is on the formulary at the beginning
of the year doesn't even mean it stays on the plan for all of the year, or
that it's on the plan next year, or that the plan you signed up for is
available [the next year]," Clinton said.
"If this is confusing for you, imagine what it would be like for
people in their 80s or 90s, or a person with a disability, or a middle- or
low-income family trying to keep a loved one at home to walk through all of
this and make sense of it," she said. "We have larded in so much
extra cost into this drug benefit instead of providing a straight benefit at
the lowest possible cost to cover the maximum number of seniors.
"I think there is about $150 billion going to insurance companies and
related entities to provide this service," Clinton said.
But it was looming cuts to the Medicaid program, and especially
administration proposals for replacing federal matching funds with block
grants, that elicited the greatest foreboding among participants at the
conference, along with a sense of an impending showdown that would engage
fundamental values about how the nation intends to care for its poor.
One plenary at the conference that was closed to the press—a
strategy-making session to help grass-roots organizations in states challenged
by Medicaid cuts—was called "The Mother of all Medicaid
"Block grants are a bad idea from nearly every angle," Clinton
said. "Currently, the federal government and the states share the risks
of greater-than-anticipated increases in Medicaid enrollment and costs... so
federal payments rise as a state's costs increase. A block grant would end
this federal commitment by providing states with a fixed amount of Medicaid
funding each year without regard to the state's costs or enrollment
"This would freeze Medicaid programs over time and erode quality and
access, and states would have limited capacity to incorporate advances in
medical treatment and other proven remedies and interventions into their
programs due to cost," Clinton said. ▪