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No easy answers for health care coverage

State House hopefuls offer bevy of solutions, from fighting fraud to mandatory co-pays.
Sunday, October 22, 2006 | 12:00 a.m. CDT; updated 9:48 p.m. CDT, Saturday, July 12, 2008

With Missouri’s Medicaid program scheduled to end in 2008, health care issues have become central to the campaigns for seats in the Missouri House of Representatives.

Candidates said they recognize a need for changes to health care that will address the needs of those with little or no health insurance. Many said the legislature also must find a way to eliminate fraud in the system.

Democrats Paul Quinn, Skip Elkin, Jeff Harris and Jim Ritter, running in the 9th, 21st, 23rd and 24th districts, respectively, emphasize attacking fraud. Harris and Ritter estimate it could be costing the state as much as $500 million a year.

Harris said eliminating that cost could produce the resources necessary to provide care for those who lost coverage to Medicaid cuts approved by the legislature in 2005. Ritter said any serious effort to eliminate fraud must be comprehensive. It’s not enough, he said, to simply ensure that everyone enrolled in the Medicaid program is qualified.

“This involves recipients, hospitals, nursing homes, physicians, in-home care services, equipment providers and others,” Ritter said. “While the vast majority do not abuse Medicaid, those who do cost the state millions of dollars and drive up the cost of health care.”

Ritter’s opponent, 24th District Republican incumbent Ed Robb, said the legislature must be careful about crafting a fraud bill.

“It’d be easy to craft a plan that would be opposed vehemently by many physicians,” Robb said. “If that occurs and they drop out, you’ve shot yourself in the foot.”

Robb added that the legislature also must avoid creating a fraud bill that benefits lawyers by creating incentives for frivolous lawsuits.

Patrick Crabtree, the Republican running against Harris in the 23rd District, called the Democrats’ estimate of $500 million worth of Medicaid fraud a “crock.” If the estimate is accurate, Crabtree said, State Auditor Claire McCaskill should be impeached.

“Having fraud in 8 percent of our budget is just insane,” Crabtree said.

Robb defends the Medicaid cuts of 2005, which took almost 100,000 Missourians off the program. He noted that Medicaid had become a much larger expense than intended, doubling in size over the past decade until it provided for one in five Missouri residents. Fully funding the program, he said, would have required a $1 billion tax increase.

The legislature should have acted sooner so that the cuts wouldn’t have been so deep, but something had to be done, Robb said.

“There’s only so many dollars available,” he said.

Ninth District Republican candidate Kathyrne Harper agreed with Robb that Medicaid simply got out of control.

“(It) was designed for a stream or a trickle, and what happened was a flood,” she said. “It was designed to help people that had nowhere else to go, and instead it became something that many people in our state needed because there wasn’t enough health insurance available.”

Ritter, however, criticized the legislature for abruptly cutting people from the program without considering their needs — especially those of seniors and people with disabilities.

“I can certainly understand there are some people on Medicaid that shouldn’t be there, and they need to be cut out, but not with a meat cleaver,” Ritter said. He argued taxpayers saved nothing from the cuts because those who have health insurance end up absorbing the costs of those who lack insurance but seek emergency room care when they’re sick or injured.

Quinn said the legislature should have attacked provider fraud before making deep cuts.

“They made cuts and then, after that, decided to go back and see what they did wrong,” Quinn said. “Well, that’s wrong.”

Harris, the House minority leader, was so opposed to the Medicaid cuts that he voted for cuts in heath insurance for legislators.

“You’ve got to lead by example,” said Harris. Supporters of the cuts, he said, “didn’t practice what they preach.”

Elkin said the legislature simply dropped the ball. He thinks the legislature should immediately reinstate benefits for those who were cut, then attack fraud and waste.

“We can’t revamp the system by 2008,” Elkin said. “It was shortsighted to think it could be. Ultimately, people are being hurt.”

Quinn said he has no specific plans for Medicaid but said developing a new program must be a priority. Harper said she hopes the legislature can push political disagreement aside to craft a new program and said her experience as a certified public accountant will help.

Both Ritter and Robb see opportunity in the need to create a new program.

“The old Medicaid is a really bad program; no one would voluntarily sign up,” Robb said. “We need a program that takes care of the needs of the citizens and one we can afford.”

“I understand the devil is in the details,” Ritter said, “and there’s a lot of work to be done, but we need ... a plan that legitimately serves people’s needs.”

Robb offers more specifics than the other candidates. He said any new plan should contain three key elements.

First, every person enrolled in the program should be assigned a primary care physician.

“That gives them a contact point, someone who can advise them on lifestyle changes, who will reduce the need for medical assistance,” Robb said. “It’s someone they can call on if they have a problem, as opposed to using emergency resources.”

Second, Robb wants to emphasize preventive care and strategies to ensure that seniors and people with disabilities can continue living independently as long as possible.

Third, he wants to eliminate incentives for people to stay on Medicaid. Under the current program, participants’ benefits are abruptly cut off when they reach a certain income level. Robb would rather phase people out as they gradually pay larger shares of their costs.

“We need to have incentives in the system that not only provide a reason for people to change their lifestyle but incentives for people to avail themselves of services in a manner that’s reasonable,” he said. “It’s very tricky to do this right.”

Crabtree also proposes a greater emphasis on preventive medicine and said a mandatory Medicaid co-pay of $10 would help curb abuse.

“We need it so that people have to pay something out of their pocket ... so that they will say, ‘Do I really need to go to the doctor?’” he said.

Both Robb and Ritter also suggest that the legislature review the feasibility of mandatory health insurance.

“We need to explore health insurance programs that have been instituted in other states and develop one that is appropriate and unique to the needs of Missourians,” Ritter said.

“I can’t imagine a major downside” to mandatory insurance, Robb said. “But we’ll look at Massachusetts (one of two states with such a requirement) and find out for sure. It will receive very serious discussion, no doubt about it.”

Several candidates said the General Assembly should find ways to work with employers to make health insurance more affordable. Ritter said the legislature should make it easier for small-business owners to create employee health insurance pools. Republican Steve Hobbs, Elkin’s opponent, said he also likes that idea. Harper supports tax credits for small businesses that offer health insurance to their employees. Harris said a good first step would be to require Medicaid recipients to identify employers on their applications so the state can discern which sectors lack coverage.

Hobbs said his No. 1 priority if re-elected will be to provide better health-care access for rural Missourians. His proposal, the Rural Missouri Health Care Access Initiative, would give 50 percent tax credits to private entities that donate money to financially strapped medical clinics and have the state match those donations dollar for dollar.

“We need to provide people with a medical home,” Hobbs said.

Missourian reporters Elizabeth Kusta, Charles Berman, Matthew Haag and Kate Cerve contributed to this report.


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