A look below the surface

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Details about health care for the most vulnerable

By Merilee Dannemann

What are we going to do about this health care system? Or this polyglot of programs we have instead of a system?
That’s one of America’s big questions, of course.
At the recent Domenici Institute conference in Las Cruces, Dr. Mario Molina of Molina Healthcare presented some sobering statistics that add focus to the issue.
Molina talked about a category of people called “dual eligibles.”
We have heard that people in their last months of life are the most expensive patients. Dual eligibles are next.
Dual eligibles are people enrolled in both Medicare and Medicaid.
They qualify for Medicare either by age or due to a qualifying disability and for Medicaid because of low income.
And they cost a lot of money. Some numbers from Molina’s presentation:
As of 2009, the U.S. population was about 309 million.
The total enrolled in Medicaid was about 58 million, close to 19 percent of the population.
Fifty percent of Medicaid enrollees are children, 10 percent are disabled adults, 15 percent are elderly adults, and 25 percent are other adults.
Medicaid spending has been growing under Republican and Democratic administrations, as measured both in costs and the number of enrollees. The curves on the graph are especially steep during the George W. Bush administration, and projections for the future continue pointing upward to $1 trillion spending estimated in 2019, based on additional coverage under Obama health care reform.
States bear a large part of this expense. In 2010, Medicaid expenses were the single largest portion of state spending, about 22 percent of all state expenditures. (New Mexico is an exception because we fund education at the state level.)
In 2009, total spending on dual eligibles was $321 billion.  
Duals make up 15 percent of the Medicaid population, but account for 40 percent of Medicaid spending.
Nearly half of Medicaid and one quarter of Medicare spending, roughly $300 billion combined, is driven by 8.7 million duals. Most of them — 87 percent – have one or more chronic conditions. (Chronic equals expensive.)
Medicaid-Medicare spending for duals averages $20,000 per person per year, five times greater than other Medicare beneficiaries.
We have heard about these people: the ones who don’t keep their appointments but turn up in emergency rooms, costing way more money.
According to Molina, that’s not due to irresponsibility but results from no reliable transportation and other issues related to their lack of resources.
So too, their chronic conditions may be made worse by poverty – limited access to good food, for example.
They don’t take their medications, sometimes because they can’t get to a pharmacy, sometimes because they can’t read and don’t understand the instructions.
Molina makes a powerful argument for an orderly managed-care system for this population.
Features like coordinated transportation and on-site pharmacies would make their lives easier.
Overall, he says managed care would save an estimated $2 trillion over a decade.
I remember when New Mexico’s Legislature divided the general fund into roughly 50 percent for public schools, 17 percent for higher education, and the rest for general government.
The arguments were over a few percentage points. Then Medicaid came along and changed everything.
But as we see, everything is related to everything else:
This expensive, inefficiently delivered health care is provided to people who don’t have what the rest us have that helps us  take care of our health – decent housing, food, sanitation, education, transportation.
If you ever think your life is out of control, these folks are much worse off.
The deeper question is what we really expect of our health care system, what we are willing to pay for, and how that relates to a larger social safety net.
We don’t know or even talk about the answers. Maybe that’s one underlying reason we still have a mess of programs instead of a health care system.

Merilee Dannemann
© New Mexico
News Service 2011