By James Frogue
Former Florida Governor Jeb Bush led the most ambitious and significant reform to Medicaid in the country. Since he completed his term one year ago the bureaucracy and special interests are strangling it.
In early 2005, Jeb Bush unveiled his vision for a new Medicaid. The original outline would have allowed all people on Medicaid, regardless of their health status, to choose from competing private plans, each tailored to an individual's health needs. For the first time, they could change plans if unsatisfied. People who engaged in preventive screenings, necessary check-ups, and prescribed treatment regimens could earn credits to cover the cost of other health care services. They would be healthier and richer.
The old Medicaid system had been a demonstrable failure in both health outcomes and cost. Dubbed "pay and chase" by those in the know, its incentives encouraged outright fraud and uncoordinated, substandard, unnecessarily expensive care for patients. Only half of children got well child check-ups, 16 percent received preventive dental screenings, and a mere 4 percent of women got mammograms.
Old Medicaid also was on a path to gobble up over 50 percent of Florida's budget by 2015, up from 10 percent in 1995 and 25 percent in 2005. Responsible Floridians acknowledged that this spending trajectory posed a mortal threat to funding for education, highways, law enforcement, and environmental protection.
People began enrolling in new Medicaid in the summer of 2006. Each beneficiary would get a risk-adjusted monthly sum based on claims history and an initial health screening. People with multiple chronic conditions would get more money than a healthy young person. Patients could then shop for plans with help from unbiased counselors who spoke English, Spanish and Haitian-Creole.
Today there are over 200,000 people enrolled in 16 private sector plans in Broward County, 7 in Duval, and 2 each in the smaller counties of Clay, Nassau, and Baker. These at-risk plans have a strong financial incentive to quickly get each new member in for a thorough check-up because they will be on the hook later for avoidable high-cost encounters. Plans also have the incentive to offer expanded benefits in order to attract customers. Incidentally, there were zero formal grievances reported by HMOs in the most recent reporting quarter.
Among the innovative features of new Medicaid is that individuals can earn credits for healthy behaviors such as getting mammograms, pap smears, colorectal screenings, and bringing children in for appropriate screenings. Thus far, 110,000 beneficiaries have earned over $7 million that can be used to pay for health care expenses not covered by Medicaid. Individuals have access to that money for up to three years after leaving Medicaid to help with the transition.
Back in 2005, opponents of new Medicaid "had no alternative," according to Jeb Bush. They still don't. But their influence is growing. The confluence of unscientific studies and sclerotic state bureaucracies is combining to overwhelm the reform.
For example, the Jesse Ball DuPont Fund has published four anecdote-laden, scientifically questionable papers pronouncing reform a failure. In one "study" they used opinion data from 186 physicians in Broward and Duval counties who chose to respond to their survey to claim that physician participation in the reform counties is declining. But their own footnote admits this was an 8 percent response rate and, "the survey findings should not be considered generalizable."
By contrast, state data on Duval County reports that the number of dermatologists has doubled and number of orthopedists is up since enactment of Medicaid reform which requires networks to provide greater access to specialists.
In another study, the DuPont Fund criticized the availability of 50 prescription drugs, chosen by sales volume and not clinical efficacy, while admitting that any restriction can be overridden by a physician's request. Of course they fail to offer an alternative.
A legitimate academic analysis of Medicaid reform will be released later this spring by Dr. Paul Duncan at the University of Florida. Decision-makers should pay this study more heed.
Instead, officials in Florida's new administration have announced that they will not be recommending expansion of the pilot and have not indicated any plan to meet the statutory requirement to expand statewide by 2011.
The suffocation of Jeb Bush's reforms can still be reversed. But the last 12 months has been a case study in how defenders of a failed status quo, despite having no constructive alternative, can conspire to thwart real change. Sadly, the consequences may be that the great strides made during Governor Bush's tenure will disappear, along with the promise of better health at lower cost for the people of Florida.
James Frogue is Director of the Medicaid Transformation Project at former Speaker of the House Newt Gingrich's Center for Health Transformation (www.healthtransformation.net)