Medicaid revolving door frustrates many in Md.

Assistance: For Maryland's sick poor, help is there in the form of Medicaid, but many aren't poor enough to qualify, or their high medical bills just aren't high enough.

September 01, 2002|By William Salganik | William Salganik,SUN STAFF

On a waiting list for a heart transplant, Sanusi Cole wishes he had more medical bills. If he had enough -- more than $6,000 worth -- he'd be eligible for the state's Medicaid program.

His cardiologist has assured him that he'll get the transplant when his turn comes, regardless of his insurance status. Meanwhile, he's been on an insurance merry-go-round. Sometimes he's covered, sometimes he's not.

He got a Medicaid card in mid-August, and for the first time in months he was able to obtain most of his expensive heart, liver and kidney medications. The coverage, however, was good only until the end of August. Now he will have to do without, again.

"They said without medication, you could be very sick and even die," Cole, 38, fretted.

When he doesn't get his liver and anemia medications, he said, "I feel tired and sleepy all the time. My blood pressure is so low that the last time a nurse checked me, she called in another nurse to make sure she did the right thing."

Is he in jeopardy? "Sure, he is," said Dr. Thomas Traill, a professor of cardiovascular medicine at the Johns Hopkins School of Medicine who treats him. "He's skimping on his medicines, and I don't know which medicines he's skimping on."

Cole, who lives in Rosedale with his wife and four children, worked until a year ago as a toll collector at the Fort McHenry Tunnel. Now, he collects $792 a month in disability payments. His wife makes $200 a week as an aide in a nursing home.

At about $1,600 a month, their income is well below the $2,022 federal poverty level for a family of six. But for Cole to get full Medicaid coverage, his family income would have to be below $573 a month -- 28 percent of the federal poverty level.

Under the "spend-down" rules of the state's Health Department, however, Cole qualifies as "medically needy" only when his medical bills hit a certain threshold (based on his income and family size) during a six-month period. Then, he gets coverage for the rest of the six months.

Cole is one of thousands of Marylanders caught in the state Medicaid program's revolving door. Like him, they have poverty-level incomes and disabling chronic medical problems.

They are poor, but not poor enough. They have medical bills that are high, but often not high enough. They are insured some months, but uninsured others.

Ronald Campbell, 50, of East Baltimore receives $919 a month in disability payments. To qualify for Medicaid from a one-person household, he'd have to be getting less than $350.

"I'm too rich to be poor," he said.

He estimates that he has been on and off Medicaid 10 times since the mid-1990s, when he became disabled and stopped working as a machinist.

Campbell ran up more than $3,000 in bills this spring and summer, qualifying for Medicaid, but he has been waiting for more than two months for the paperwork to be completed so his coverage can resume. Meanwhile, he's holding 13 prescriptions that he's waiting to get filled.

"I'm getting sicker and sicker by the day," he said. "My diabetes is getting worse. My blood pressure is getting worse. My pain is getting worse."

And when his coverage does come through, "I'll be on Medicaid until November. The first of December, I got to start this mess all over again."

The revolving-door coverage for chronically ill patients is "ridiculous but true," said Laurie Norris, a staff attorney for the Public Justice Center.

And it does have an impact on health.

"You lose the whole effect of having continuity of care for people with chronic conditions," said Dr. Thomas O'Toole, assistant professor of medicine at the Johns Hopkins School of Medicine. "We end up looking more like a MASH unit than a comprehensive-care setting."

As of March, the most recent month for which figures are available, about 1,300 Maryland adults had joined the Medicaid rolls because they had met spend-down requirements, the state Health Department said.

Probably two or three times as many revolve on and off coverage in the course of a year as they meet (or don't) the spend-down number, estimates John Folkemer, executive director of the Health Department's office of planning, development and finance.

Dollar limits unchanged

Folkemer said the dollar limits on adult coverage -- allowing full-time Medicaid membership without spend-down -- haven't changed in at least a decade.

Debbie I. Chang, the deputy health secretary who oversees Medicaid, said, "Basically, it's a program for children and people over 65." She said the Health Department has the authority, in theory, to change the eligibility levels but needs budget authority to do so.

The state legislature has provided funds over the past four years to expand children's coverage to 300 percent of the poverty level -- $4,527 a month for a family of four -- and added about 150,000 children to the rolls. It has not expanded adult eligibility.

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