Medicaid cost sharing will be hot debate in Legislature

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Gov. Brian Sandoval's recommendation that Medicaid recipients share in the cost of care has been met with criticism from advocates for the poor, but the agency chief who oversees Nevada's complex social safety net programs says such requirements are not a new concept.“We already do cost sharing,” said Mike Willden, director of the Department of Health and Human Services. “Every state does some sharing.”But critics say while that may be true for some programs, requiring copayments from Nevada's poorest residents to receive care goes beyond acceptable boundaries.“This is a tax. It's a tax on poor people,” said Bob Fulkerson, executive director of Progressive Leadership Alliance of Nevada.Sandoval, a Republican, first mentioned cost sharing when he announced in December his decision to expand Medicaid eligibility as called for under the federal Affordable Care Act. Sandoval reiterated his stance in his State of the State address Wednesday night, saying, “I believe we must ask certain Medicaid patients to make a modest contribution toward the cost of their own care.”What constitutes a “modest” contribution has not been determined, though Sandoval has suggested it could be $1, maybe $5, to see a doctor.But Willden, speaking with The Associated Press, said cost sharing could take other forms, such as requiring some sort of payment for when a recipient seeks care at an emergency room for something that could have been treated by a primary care doctor.“We don't know exactly what our final rules will be,” Willden said. “We have not locked into how we're going to do that.”Willden said the goal is not to pad state coffers, though the governor's budget estimates cost sharing would save the state general fund about $700,000 in the 2015 fiscal year.“It's not really being built as a tool to save money,” Willden said, adding the concept is more about “personal responsibility.”“It's all about those kinds of principles, about how we get more personal responsibility and better health care outcomes,” Willden said.Fulkerson on Friday said that reasoning was “insulting” to poor people.“Absolutely, it's insulting because it insinuates they have no personal responsibility” and are to blame for being in poverty, he said.There's no evidence, said Jon Sasser, advocacy coordinator for Washoe Legal Services, “that low income people overuse medical services and need to pay a copayment to keep them from going to the doctor willy-nilly.”“What a copay does is discourage people from getting necessary medical care, then problems get worse,” he said. “The whole idea that people need skin in the game and their self-esteem would be increased, I think, is malarkey.”Willden noted that Medicaid patients in long-term care facilities are required to use all but $100 of their meager incomes, often Social Security checks, to help pay nursing home costs that run thousands of dollars per month. The state then pays the difference.“That's a form of cost sharing,” he said.He cited other examples, such as Nevada Checkup, an insurance program for children in households with incomes that slightly exceed Medicaid eligibility. Those families pay a quarterly premium between $25 and $80, depending on their income.Another, the Katie Beckett program, authorizes Medicaid coverage to severely disabled children younger than 18 so they can be cared for at home. “We allow parents with pretty high incomes, up to $100,000 sometimes, to share in the costs,” Willden said.But Sasser said those examples are not an accurate comparison to the overall Medicaid population.In nursing homes, he said, patients are receiving “all the basic necessities of life,” while Nevada Checkup families have higher incomes than Medicaid recipients. Under the federal health care law, Nevada has agreed to expand its eligibility to people with incomes up to 138 percent of the federal poverty level. For a family of four, that equates to $31,809.Nevada Checkup insures children through 18 years old who don't qualify for Medicaid; are otherwise uninsured; and whose family's gross annual income is up to 200 percent of federal poverty — $46,100 for a family of four.Willden said U.S. Health and Human Services Secretary Kathleen Sebelius issued new copay regulations in the past week. The state is reviewing those before recommending how cost sharing should be applied in Nevada.Whatever the outcome, Willden said it won't keep Medicaid patients from receiving necessary care.“We can never deny a Medicaid recipient access to medical care,” he said. The topic will be debated in the upcoming Nevada Legislature that begins Feb. 4.


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