Uninsured Need Not Be

Red tape blamed for gap in rolls

 

 

Reprinted from the Poughkeepsie Journal   

Sunday, September 7, 2003

By Mary Beth Pfeiffer


Just after the Sept. 11, 2001, terrorist attacks, the state did what only a disaster could prompt: It began providing same-day medical coverage to uninsured people who simply filled out a one-page form attesting to their need. Anyone suspected of fraud would be rooted out later.

In four months, 10 times as many uninsured people were covered than usual. In one group of 75,000 patients seen at New York City clinics were 256 women discovered to have cervical or uterine cancer. Several hundred more were treated for other cancers, and 2,500 were hospitalized. The program, set up to address an anticipated demand for health care, was considered a smashing success.

Then things went back to normal. And it took four months to get coverage for 1,600 adults in a group of 10,000 applications taken by the city's Health and Hospitals Corp.

To advocates of the great masses of New Yorkers without health insurance, the experience demonstrates two things: Money and lives are saved when coverage is easy to get. And red tape keeps many low-income people off the rolls of state programs.

"They make promises. Then they put administrative criteria in the way. It's almost purposeful," said Anne Kauffman Nolon, chief executive officer of Hudson River Community Health, a network of clinics that serve the poor and uninsured.

State officials say their intent isn't to keep rolls down but to protect state coffers: "We have a responsibility to the taxpayers of the State of New York that we are providing health care to people who are eligible," said Robert Hinckley, Gov. George Pataki's senior deputy secretary for health and human services.

Efforts to close gap
New York has 2.9 million uninsured residents, who last year cost hospitals $1.7 billion in so-called uncompensated care. Yet an estimated 1.3 million of the state's uninsured are eligible for coverage under existing programs -enough to close the ranks of the uninsured by an astounding 44 percent.
While state officials boast of efforts to close that gap, a review of programs for the uninsured shows they have been slow to implement, poorly designed, and, most critically, beset with paperwork requirements that test the mettle of even the neediest. These requirements have spawned an expensive army of bureaucrats-in government, insurance companies, hospitals and clinics-who many say divert medical dollars away from care.

Allyson Gavigan, a single mother, was twice rejected for Family Health Plus, a government health insurance program for working adults, although she was clearly eligible. Finally, after five months, three applications and help from knowledgeable co-workers at the YWCA in Kingston, Gavigan, 32, was insured.
"I would've thought, I can't get insurance, and I would've left it at that," she said. That is a course other eligible people often take, system critics say. Now pregnant with twins, the High Falls resident has already started filling out insurance applications for her babies.

New York's patchwork of programs for the uninsured is a maze that only those with fortitude, patience, time and cunning can get through. And, unlike Gavigan, many simply cannot.
Consider:

 Four in 10 children are dropped from Child Health Plus, a program to cover working-class children, at annual re-enrollment, according to a study by the United Hospital Fund. The vast majority of children are still eligible for coverage but their parents fail to negotiate the paperwork requirements, another study found.
 

New York is just one of four states that requires a face-to-face interview to enroll in Child Health Plus or Medicaid, the government insurance program for poor children; it is one of five that requires proof of address and one of three that requires proof of age, according to a new study for the Kaiser Family Foundation on Health. In one New York City survey, almost half of Medicaid applicants had problems with paperwork, with a third returning to Medicaid offices two, three-even eight times.
 

So cumbersome is the process to get Family Health Plus that just one in 10 New York City residents was signed up within the 45-day requirement set by law, according to a study by the Coalition of Pre-Paid Health Plans. If applicants get sick during that time, they aren't covered.
 

Beyond this are the strictures of eligibility: A single adult working full time at a minimum-wage job won't qualify for Family Health Plus because he or she makes too much.

Pamela Goldman, 46, works full-time at the Highland Burger King and has no health insurance for herself, her boyfriend or their children, who are 10 and 12 years old. Health care consists of crisis-driven emergency room visits; the last cost $200 for an earache.

"Don't give it to me," she said of health insurance, "give it to the kids."

Great promise at first
In December 1999, Pataki and legislative leaders announced "historic" legislation that would cover one million people and establish two programs for low-income adults and people working for small businesses. At the same time, cigarette taxes were doubled to pay for the initiative-and have since raised $1.9 billion.
"Up to a million New Yorkers…will now get the health insurance they need," Pataki said. It was a figure also used by Assembly Speaker Sheldon Silver, D-Manhattan.

Today, just 300,000 people receive coverage under the two new programs announced that day-Family Health Plus, which serves low-income working adults, and Healthy New York, designed to cover employees of small businesses and those without insurance.
At the same time, just $167 million of $475 million projected for those programs-a third of the total-has been spent, according to budget figures.

"I think it's outrageous that we've got programs to cover low-income working New Yorkers, we've got money in the bank to pay for that coverage, but we're not letting them get the coverage," said Assemblyman Richard Gottfried, a Manhattan Democrat who chairs the Assembly Health Committee. "I don't think the Pataki administration has the necessary commitment to the programs."
Silver's office said Gottfried spoke for him.

Pataki administration officials believe such criticism is unreasonable. They say progress was set back by the events of Sept. 11, which destroyed a key state computer system-a factor critics acknowledge-and was further hampered because the Clinton administration held up federal approval for almost two years, a scenario critics dispute.

But while acknowledging money went unspent, state officials also say they never promised to cover one million people.

"The statement was one million people are eligible for these programs," Hinckley said of the 1999 pronouncement. Perhaps 600,000 additional people have been insured if those signed up in the special post-9/11 period are counted, he said.

"The fact that we have the largest programs of their kind in the country attests to the fact that our purposes are to provide care for as many eligible people as possible," Hinckley said. He called Family Health Plus "nothing but a success story," whose rolls are growing by the thousands each month.
New York is ahead of the nation in providing health care for low-wage and poor residents. It is among 13 states listed by the nonprofit Urban Institute as "innovators" for going   "significantly beyond required minimums" in covering uninsured children and adults.

But offering coverage isn't the same as providing it, contend providers, researchers and reform advocates who say barriers to health care for eligible residents go well beyond the start-up problems of Family Health Plus.

The process "reflects the legacy of a welfare system that was designed to discourage participation by creating barriers to enrollment," concluded the city study, prepared by the New York State Coalition of Prepaid Health Services Plans.

"It's a very complex, multi-layered system," agreed Beth Osthimer, senior health policy associate for the Children's Defense Fund, which has lobbied to simplify the system. "There are real costs to all these barriers," including, she said, the high cost of delayed care.

Pataki's spokesman demurs: "If it was so hard to enroll and stay enrolled, why would we have the largest program in the country?" Hinckley asked. Officials note the state spends $20 million annually on a program to help people sign up for subsidized medical coverage-which many say has helped boost enrollments but is another symptom of the difficulty in negotiating the system.

Healthy New York falters
To critics, it isn't who's in the programs but who isn't. A study by the United Hospital Fund concluded 410,000 children are eligible for Medicaid and Child Health Plus coverage but aren't getting it, along with 870,000 adults who are eligible for Medicaid or Family Health Plus.

That does not count the 1.7 million people that a state-sponsored study says are eligible for Healthy New York, the highly touted small-business insurance program, which now has a paltry 28,000 participants. The program was far too expensive and offered too little coverage; premiums were reduced last spring by an average 17 percent.

"We now think Healthy New York is going to take off," Hinckley said-but critics think the benefit package is still too limited.

Marco Incorvaia, owner of The Daily Grind'er, a sandwich shop on Main Street in the City of Poughkeepsie, checked out Healthy New York but concluded: "It wasn't worth it"-as have 85 percent of people calling a state hot line. Instead, he pays $600 a month for his own family's plan, which has a $2,500 hospital deductible and no prescription drug coverage.

Bills like that are what keep many New Yorkers uninsured, including Ron Greene of the Town of LaGrange, a former IBMer who is a computer consultant. "It's really money I don't have," said Greene, who avoids going to the doctor.

More than 15.5 percent of the state's population was without health insurance in 2001, up from 15.2 percent a year earlier. Nationally, the figure is 14.5 percent. To curb the problem, the state launched Child Health Plus for children not covered by Medicaid eight years before the federal government set up a nationwide program. Child Health Plus now covers 400,000 New York children and costs parents just $9 a month at the lowest end of a sliding scale of income-based fees.

Sherry Crescini, a single mother of two, earns about $20,000 a year as a bookkeeper and receives CHP for her children, Cameron, 1, and Bethany, 6. "Child Health Plus is really a savior," the Kingston resident said. "I couldn't afford a family plan through my job. It was prohibitive."

Crescini and others agree getting and keeping government-subsidized coverage isn't easy. She and others told of not being alerted when coverage was about to lapse, being denied coverage inexplicably, losing coverage because one document was out of order, or, in Santana Pearson's case, going to the doctor only to learn her Medicaid coverage was terminated.

To reapply, said Pearson, 19, a Poughkeepsie mother of two, "I'll be missing a day of work that I can't afford to miss."

Reams of paperwork
Robert Allers, Dutchess County commissioner of social services, acknowledges Medicaid applicants who come to his office are told: "Prepare to spend the day." This though Allers' office is considered by local advocates to be as efficient as possible within a document-hungry system.

Applying for Medicaid-and variously for Child or Family Health Plus-requires a laundry list of paper: proof of identity, residency, income, and assets, and, if applicable, child support, health insurance, veterans or other benefits and child-care costs. The application form is six pages long.

Reformers advocate waiving many of these requirements, since just one-proof of immigration status for non-citizens-is required by federal law. At least 10 other states verify income through wage-reporting databases, considered a big breakthrough.

But Allers understands the need for documentation.

"Right now Medicaid costs are killing the counties," he said, noting Dutchess pays $42.5 million annually for the program. "If you simplify (the process) you're going to have to be prepared to pay."
Indeed, an additional million people on the state's rolls would raise costs considerably. Currently, 4.2 million New Yorkers receive Medicaid, Child Health Plus or Family Health Plus at a cost of more than $13 billion a year. Many think the bureaucratic hurdles aren't primarily to deter fraud.
"Isn't the reason really just to save money because you want to discourage people from getting coverage?" said Richard Kirsch, executive director of Citizen Action.

"The way to keep the numbers down," agreed Judy Wessler, director of the nonprofit Commission on the Public's Health System, "is to make it very difficult for people to get on and stay on."
In the latest budget process, the Pataki administration tried to roll back a measure meant to make it somewhat easier to apply for Medicaid; it would allow applicants to "self-attest" to their assets rather than produce bank statements and such, and it was to take effect April 1. (The attempt, along with other cuts to Medicaid and Family Health Plus, failed but the measure still hasn't taken effect. Many believe the assets limit-$5,700 for a family of four-discourages people from saving and should be eliminated.)
Administration officials say they sought the delay because state computers hadn't been updated in time. "No savings were attributed to this change," Budget Division spokesman Andrew Rush said.
But, reformers say, the state does save money with such measures, which are particularly challenging to poor, uneducated people and those who don't speak English.

"There is a fundamental mismatch between the reality of applicants' lives and the requirements of the enrollment process," Kate Lawler, director of health-care access for the Children's Aid Society in New York, told a legislative hearing in January.

"It is difficult enough for a healthy individual to obtain all the necessary documents, much less an individual with a serious illness," testified Rina Kitazawa of the organization Cancer Care.
Bureaucrats argue that they have streamlined the system by using pre-printed mail-in renewal forms that are sent to clients and by no longer requiring a social security card and income or residency proof for renewing coverage in certain programs.

All this, said Robert Kenny, a spokesman for the state Health Department, "while also protecting the integrity of the Medicaid system and hard-earned taxpayer dollars."
Paying a price for uninsured

To advocates for reform, the question is what the system is protecting taxpayers from -and at what price. The cost of the uninsured is huge, as is the cost of the bureaucracy that reviews who is and isn't eligible for entry.

Having health insurance reduces overall mortality by up to 25 percent and makes people more productive and, consequently, better off financially, according to a review of scientific research published last spring in the journal Medical Care Research and Review. "The uninsured receive fewer diagnostic and preventive services, tend to be more severely ill when diagnosed and receive less therapeutic care," the study concluded.

"There is no question there is substantial value from improved health," said the author, Jack Hadley, a researcher at the Urban Institute, a public policy think tank, in terms of longer life, more education and more work. The potential worth of insuring all Americans was estimated at $65 to $130 billion annually in a June report by the Institute of Medicine.

Additionally, hospitals pay dearly when an uninsured person reports to the emergency room. The state paid $847 million to hospitals statewide in 2002 to cover some of the cost of indigent care; this included $9.8 million to six Dutchess and Ulster facilities. Nationally, $35 billion was spent on uncompensated care in 2001.

"It is going to get much worse," predicted Robert Savage, president of St. Francis Hospital in the Town of Poughkeepsie.

Beyond this, is the cost of the bureaucracy that assures eligibility: "It's costly, surprisingly costly," said Gerry Fairbrother, a senior scientist at the New York Academy of Medicine, who is in the final stages of studying those costs in New York.

In Dutchess, 16 caseworkers process Medicaid applications, each handling an average 425 cases and calculating which of nine different eligibility categories to put clients into. That doesn't count the $200,000 contract awarded to a local agency to help feed people into that system under the state's $20 million "facilitated enrollment" program.

Nor does it include the money spent by managed-care insurers that coordinate care; they spend $70 in staff costs alone to recertify every Child Health Plus enrollee, according to a new Commonwealth Fund report.

"I'm an employment mill," said Georganne Chapin, president of the nonprofit HealthSource/Hudson Health Plan, who voiced frustration over the hours spent by caseworkers to keep people covered. "We have a bunch of politically sound-bite worthy programs that are very, very difficult for people to get into."
Fraud discounted Reform advocates acknowledge Medicaid fraud potential at the provider level-for example, in well-known nursing home scandals. But there is little evidence of it among consumers, nor is there research on the role of red tape.

"We've become so fraud fearful that we've put in all these barriers to coverage that keep people from getting the coverage they need," said Patricia Boozang, senior health analyst for Manatt, Phelps, Phillips, a health policy research organization. She and others said states that have relaxed requirements haven't seen increases in fraud.

State officials see things differently and are studying the post-9/11 program to see if they made it, perhaps, a bit too easy to get coverage.
"We're looking at how much fraud, waste and abuse was inherent in that program," said Hinckley, the Pataki spokesman. He said he would not speculate on its extent.

The uninsured, meantime, try to cope.
William Wheeler, a 37-year-old Poughkeepsie resident, had a heart attack last year but can't afford his prescribed heart or blood pressure medicine. He hopes to get Medicaid.

"We try to fight the system," said Wheeler, who is unemployed, "but nobody listens."