WASHINGTON -- As part of its health-care plan, the Clinton administration is considering a proposal to dismantle the Medicaid program and integrate low-income people into the same networks of doctors, hospitals and private insurance companies that would serve more affluent people, administration officials say.
But poor people would probably receive medical and social services beyond the standard package of health benefits to be guaranteed to all Americans, the officials said. These might include additional dental care, transportation to a doctor's office and translation services for people who do not understand English. And the government would help pay the insurance premiums and other health costs of low-income people.
Confidential work papers from Hillary Rodham Clinton's Task Force on National Health Care Reform say that maintaining a separate Medicaid program "would perpetuate segregation of the poor in the health care system, with the associated adverse implications for access to and quality of care."
How to care for the nation's 35.7 million poor people is one of the most important moral, political and policy questions facing the administration as it drafts a legislative proposal for sweeping changes in the U.S. health-care system.
Drew E. Altman, president of the Henry J. Kaiser Family Foundation, which is sponsoring a major study of Medicaid, said: "There are really serious problems in putting Medicaid into the new system, but that's what we ought to do."
While no final decisions have been made, the shift of millions of people out of Medicaid and into the networks of doctors and hospitals would probably occur over several years.
Established in 1965 to finance health care for low-income people, Medicaid now provides care for more than 30 million people, including several million with incomes just over the official poverty level. It has become one of the fastest growing programs in the government. The federal government expects to spend nearly $80 billion on Medicaid in the current fiscal year, while the states plan to spend $60 billion, straining their ability to spend in other areas, such as education.
Throughout the work papers of the task force, it is assumed that Medicaid recipients "will be integrated fully or partially" into the new system, which the administration calls managed competition.
Under that system, huge consumer groups, known as health insurance purchasing cooperatives, would buy health care from large networks of doctors and hospitals. Advocates of this proposal say the buyers will command so much economic power in the medical marketplace that they can get high-quality care at reasonable prices.
But many people, in and out of the government, question whether the differing needs of poor people and the middle class can be adequately addressed within the same networks of doctors, hospitals and insurance companies. Doctors say poor people are more likely to have special health needs and problems, ranging from AIDS to drug abuse, tuberculosis, diabetes, high blood pressure and birth defects.
In most states, Medicaid recipients can now generally go to any doctor or hospital that will accept them. The doctors and hospitals are typically paid for each service or procedure they perform. But many doctors take limited numbers of Medicaid patients, and some doctors and private hospitals do not take any.
Under Mr. Clinton's plan, more people would be enrolled in health maintenance organizations and similar groups. Government agencies and employers would pay a fixed amount, set in advance, for each patient. Rather than having unlimited freedom to use any doctor or hospital, consumers might have to go through one doctor, a "case manager," who would approve their use of specialists and hospitals.