Patti Cullen's Blog

Reform 3.0: Add issues like Emergency Medical Assistance to the list

by Patti on Thursday, January 26, 2012 9:48 AM

The 2012 Legislative Session began this week, with a few key bipartisan themes: jobs and reform. Yup, it is tough to argue with creating more jobs, sustaining current jobs, and “doing things smarter.” So let’s talk about the call for reform. Certainly this is not the first time either the administration or one political party or another tooted the reform horn. Some of the concepts on the Republican’s Reform 2.0 list ( are great ideas — especially the one we forwarded to them on conversion of life insurance policies to pay for long-term care services! Most of the list is either “low hanging fruit” or concepts, rather than true reform plans.

When I think of reform I think of really changing up some long-standing ways of doing things in this state.

Take the current crisis for the 2,000+ individuals who were receiving medical and long-term care services under the Emergency Medical Assistance (EMA) program due to their immigration status. That program was gutted effective January 1, 2012. It is a crisis for the individuals who aren’t receiving their therapies or their medication or chemotherapy; it is a crisis for their families (if they are lucky enough to have family here); it is a crisis for those who are providing services without knowing if payment will ever come; and it is a crisis for a few large counties who have no placement options for these individuals outside of the very expensive hospital setting. It isn’t a crisis for policymakers who passed a change in the law during last summer’s “cone of silence” negotiations — nobody seems to be taking credit for the repercussions. But there are repercussions, and not just to the families involved. If this was an item that was placed on the “reform grid” — and I argue it should be — there are better ways to address the perceived problem of a growing budget.

First, understand who this program was really serving. From the undocumented son of a U.S. citizen permanently paralyzed from an accident residing in a nursing facility to a young child of an undocumented mother who is receiving chemotherapy for cancer — these people have individual stories … each and every one of them. Since most of them are appealing their denial of EMA, now administrative judges will hear these stories.

The first cost of this policy/payment change: court costs for the appeals.

Second, understand that the fiscal notes that drove this policy/payment change are general numbers, not specific to the programs and services that are being impacted. As a result, it is nearly impossible to determine how much it would “cost” to add back in any particular service that was removed, whether home care or nursing facility or clinic services or medications. The fiscal implications should be drilled down so there can be true cost comparisons.

Third, we believe the practical implications of this policy change are dramatic increases in the use of more costly services. Since the only sites where services will be paid for are the emergency room and inpatient hospital setting, guess where everyone is? That’s right, the absolutely highest cost setting. A few weeks ago a report came out in the New York Times about this same population and the impact of a similar policy — individuals living in hospitals at a cost of millions of dollars each year. The budget line item for EMA may look better moving ahead, but drill down on the costs to health systems and hospitals whose beds will be filling up with individuals who could easily be served in other settings at a fraction of the cost.

The second cost of this policy/payment change: huge uncompensated debt for hospitals.

How should the state address this issue in a reform-like method? First, those currently receiving services should be allowed to continue. Why would we stop chemotherapy treatments if they save a kid’s life? Or why take away the psychotropic medications that are stabilizing someone’s behavior, keeping all of us safe?? Or discharge the nursing home resident to the emergency room?? Then we should figure out how to prospectively stem the growth in this program. Meet with federal and state immigration officials first. Where are these folks coming from and why are they undocumented? Move upstream before individuals who lack the citizenship papers become ill or injured. Let’s figure out how we can streamline document processing. (Some of these folks are in the category of undocumented because something happened to them (accident/illness) before they could complete the paperwork.)

In my mind, reform is looking at a problem as an opportunity to change systems and approaches. Add this one to the list.

Copyright ©2012 Patti


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