Medicaid Coverage Disappears For Poor Women

by Molly M. Ginty

(WE) NEW YORK -- Teresa Kai was in crisis. A 42-year-old single mother living in Pender, Neb., Kai relied on Medicaid, a government-funded health insurance program, to pay for medication for her four health conditions: diabetes, high blood pressure, clinical depression and asthma. In 2002, budget cuts forced Nebraska to eliminate Medicaid coverage for people like Kai: low-income adults who were granted coverage because they were caring for children under the age of 18 but who were not required to have this coverage under existing state and federal laws.

"My daughter was still covered under another government insurance program," says Kai. "But I no longer had any access to health care. Since I didn't have any savings, I wasn't able to buy private health insurance for myself. Since my medications cost half of what I earned as a part-time cook, I couldn't afford to pay for them out of pocket. Without my prescription drugs, I couldn't function at work and was in danger of loosing my job. The Medicaid cuts threatened not only my health, but my very livelihood."

In 2003, Kai sued the Nebraska Department of Health and Human Services and won a year's worth of Transitional Medicaid. Her court victory helped her and 10,700 other state residents affected by the cuts to gain 12 more months of additional coverage. But this fall, their Medicaid--and their health care options--will run out.

As state budget cuts whittle away at Medicaid coverage, more and more low-income women are losing the health care on which they have come to rely.

According to a new joint report by the Washington-based National Women's Law Center and the Portland-based Oregon Health and Science University, a growing number of states are requiring Medicaid recipients to pay for prescription drugs, doctor co-pays and other health services. States are also limiting Medicaid coverage for abortion and imposing enrollment caps that limit the number of residents who qualify for coverage.

"State policy makers' piecemeal approach to the Medicaid crisis has resulted in a complex and ineffective system," said Judy Waxman, the law center's vice president of health. "Lawmakers need to work together to solve this problem now."

The May 2004 joint report, called Making the Grade on Women's Health: A National and State-by-State Report Card, surveyed all 50 states and found that most of them are making cuts to Medicaid, a health insurance program that is jointly funded by state and federal governments. Medicaid covers 9 percent of all women and 30 percent of low-income women in the United States.

Ranking each state based on health benchmarks developed by the U.S. Department of Health and Human Services' Healthy People initiative, the report found that all of the states only met two policy goals related to Medicaid and women's health: providing coverage for breast cancer and cervical cancer patients.

The report found that, overall, there were some small improvements to Medicaid. Thirty-one states now cover the health care needs of all women who are pregnant (two more states than in the previous joint report, in 2001). Sixteen states have improved Medicaid enrollment by adopting a mail-in application. Thirteen states have created better linguistic access to Medicaid services for recipients who speak Spanish and other foreign languages.

While applauding these advances, the report also noted some troubling setbacks. In the past three years, 15 states have imposed new co-payments on Medicaid prescription drug coverage. Ten have added restrictions to abortion access and 33 cover abortions only in the case of rape, incest or a pregnancy that poses a health threat to a woman's life. Several states have also imposed enrollment caps on Medicaid.

In general, states cover 50 to 70 percent of their residents' Medicaid costs, while the federal government picks up the rest of the tab. As the economy worsens, cash-strapped states are being forced to cut back on the health services that they offer to needy residents.

"In part, these cutbacks are a matter of financing," says Alina Salganicoff, the director of Women's Health Policy for The Kaiser Family Foundation, a health care policy organization based in Menlo Park, Calif. "But they're also a matter of philosophy. In recent years, federal and state governments have become more conservative in their approach to helping low-income residents. More and more, we're seeing the belief that people shouldn't have open-ended entitlement."

Health advocates say recent policy changes will likely cause more Medicaid recipients to lose their coverage. The Medicare Prescription Drug Improvement and Modernization Act of 2003 will limit drug coverage for the poorest beneficiaries who also have Medicaid assistance now, thus forcing many of them to go without necessary medication. The Bush administration hopes to change Medicaid from an entitlement program (in which everyone who is eligible may be enrolled) to a block grant (which will limit funding and deny coverage to some who now qualify). Bush spokespeople could not be reached for further comment on the president's proposal.

If states continue imposing restrictions on Medicaid coverage, many low-income Americans could find themselves in Teresa Kai's position: unable to get health care because their jobs don't provide it and unable to afford it on their own. Currently, Medicaid is only available to people whose incomes are below 200 percent of the poverty level. Though poverty levels vary from state to state, the average poverty level for a family of three in the United States was $14,395 in 2003. This means that a family of three with an income above $28,790 would not likely qualify for Medicaid coverage. Struggling to make ends meet on such a low income, this family would probably not be able to afford private health insurance, which averages $9,000 per family per year in the United States.

Health Advocates Call on States to Save Medicaid In the joint the report, the agencies urged state and federal authorities to preserve Medicaid as an entitlement program instead of turning it into a block grant program. They also called on states to boost public outreach so all qualified women can enroll and to provide coverage for mammograms and HIV and AIDS medications.

Health policy analysts say states could make the most of the money they do have for Medicaid by funneling more funding into preventative care.

"Take the example of contraception," says Rachel Gold, the Director of Policy Analysis for The Alan Guttmacher Institute, a health policy organization based in New York City. "Even though they are dealing with budget crises, 18 states have recently extended Medicaid family planning services to 1.7 million low-income individuals who would not otherwise be eligible. These states realize it's more cost-effective to provide contraception to low-come women than it is to provide pregnancy-related services for unplanned children."

In the future, health advocates hope states will find other creative ways of lowering Medicaid expenses without cutting recipients from the rolls. "There are a lot of flaws with Medicaid, but it's a crucially important program," says Sagalnicoff. "If Medicaid goes away, there is literally no health care left for the low-income women who need it most."