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Critics: Health Care Changes Would Burden State's Poor

Budget Crisis

ARIELLE LEVIN BECKER

February 17, 2009

If you think your budget is tight, try Maria Gonzalez's.

With the money she earns from working two part-time jobs — less than $20,000 a year — the Meriden woman supports herself and a teenage daughter, and helps out her 23-year-old son, who was injured in Iraq. She has her own health problems — diabetes and fibromyalgia — and takes at least eight medications.

Gonzalez is barely above the poverty level. But under Gov. M. Jodi Rell's proposed budget, she would have to start scrounging up the money to pay premiums and co-payments to keep her health coverage under the state's HUSKY A program.

Or, more likely, she'd go without.

"I guess I just won't be able to get [my medication]," she said. "That's going to be horrible, because that's putting my health in jeopardy."

Gonzalez, other Medicaid recipients and health care advocates are livid at changes Rell has proposed, which include implementing premiums and co-payments for many HUSKY recipients and other cuts in coverage and services for state health insurance programs. They say Rell's plan unfairly burdens some of Connecticut's poorest residents, while asking little of the wealthy.

State officials point to Connecticut's budget crisis and say that Rell's proposal still includes funding for an anticipated increase in people relying on state health insurance programs without cutting back on most eligibility standards. They note that 44 other states already require Medicaid recipients to make co-payments and that many of the changes mirror policies in other states.

But critics say the changes are bad policy, for both health and financial reasons.

They cite studies indicating that even modest co-pays or premiums can cause a significant drop in low-income residents' access to health care, and warn that the changes will result in poor people either dropping medical coverage or waiting until they are sicker to see doctors, potentially forcing the state to face even higher medical costs in the end.

"For very low income people, it starts becoming a choice of things like food and medication," said Sheldon Toubman, an attorney for the New Haven Legal Assistance Association. "The consequence of that, if they forgo treatment, is that a significant number of those people are going to end up in emergency rooms, and then you've blown many, many years worth of savings."

Dropping Out

The changes include requiring most HUSKY A recipients to pay premiums for the first time if they fit certain income levels — for a family of three, between $18,310 and $33,873 a year. State officials estimate doing so would save $18.1 million over two years.

Most Medicaid recipients who are above the poverty level also would be charged co-payments of between $0.50 and $5.70. Budget figures project a $19 million state savings over two years.

Other changes include eliminating all but emergency dental coverage for adults in Medicaid and state-administered general assistance (a two-year savings of $50.7 million), no longer providing non-emergency medical assistance to legal immigrant noncitizens who have been in the U.S. fewer than five years (a $48.1 million two-year savings that would cut 6,000 people from state programs) and increasing eligibility requirements and reducing coverage for prescription drug programs.

Jeffrey Beckham, a spokesman for the state Office of Policy and Management, said the changes are consistent with what other states do and that most would only affect adults above a certain income level. Connecticut is one of just a handful of states that offer some of the services affected by the changes, he said.

"Connecticut's got a pretty generous social welfare net," he said.

Because social services represent more than a quarter of the state budget, Beckham said, they were a logical place to look for savings. The federal government reimburses Connecticut for a portion of the money it spends on Medicaid, but the state must budget all the money up front.

Study Results

Research suggests that similar changes in other places have led to fewer people receiving medical coverage.

In 2003, changes to Oregon's Medicaid programs required many recipients there to pay co-payments and increased premiums, and those who did not pay premiums lost coverage. Unlike Connecticut's proposal, those affected included residents below the poverty line.

Within a year, 44 percent of the affected recipients lost their health coverage and were significantly more likely than those still covered to report unmet health care and medication needs, according to a report prepared for the Oregon state government.

A study of similar changes in Quebec found that emergency room visits, hospitalizations, nursing home admissions and deaths increased among low-income elderly people and welfare recipients who were required to begin paying a portion of their medical expenses.

The study, published in the Journal of the American Medical Association in 2001, found that once the changes were implemented, the number of medications those residents used per day dropped significantly, and that those who cut their use of "essential" drugs had a significantly higher rate of serious medical problems.

Co-payments of a few dollars, like the ones contemplated under Rell's budget, may be small when compared with those charged in many private insurance plans. But that's the kind of money Waterbury resident Jennifer Detzer struggles with — the $4.50 she spends in bus fare each week for her autistic, 10-year-old son to get to therapy that helps him with coping skills; or the $2 a week she pays for him to be in Cub Scouts, which helps with his social skills.

Detzer is on disability and takes four medications. Medicaid pays for them now, but she's not sure where she would find the money for co-payments, even if her prescription drug costs are capped at $20 a month under Rell's proposal. "It's hard enough just getting by with regular things," she said.

Those kinds of challenges could lead people to put off doctor visits if they can't afford a co-payment, said Ellen Andrews, executive director of the Connecticut Health Policy Project. "There are a lot of times my clients just won't go if they don't have the $10, or the $20," she said.

Several lawmakers also have criticized the idea of raising costs for poor residents and questioned the effects of the changes.

State House Speaker Christopher G. Donovan, who will have a key role in budget decisions, said he was concerned that the Medicaid changes would backfire, leading people to forgo care and costing the system more in the end. He also questioned the premise of trying to solve the budget gap with money from poor people. "This proposal would say ... 'When you're down and out, we're going to make it a little harder for you,' " said Donovan, a Democrat from Meriden. "Right now, we need to assure people we're there for them."