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Congress Opens 'Pandora's Box' Of Medicaid Managed Care

Proposal Allows States To Push Millions Into Managed Care Without Adequate Consumer Protections, Quality Standards, Federal Oversight

June 16, 1997

WASHINGTON, DC - Congressional proposals to shift control over the Medicaid program to the states and, thus, allow states to push millions of Medicaid beneficiaries into mandatory managed care, threatens the health care safety-net for over 37.5 million Americans. AIDS Action, the nation's foremost AIDS advocacy organization, today said Congress is opening a "Pandora's Box" that may exacerbate the access to care crisis already faced by thousands of people with AIDS by undermining the health care that Medicaid beneficiaries with AIDS now receive.

"Medicaid represents the only link to state-of-the-art care for over half of adults and 90 percent of children living with AIDS," said Christine Lubinski, AIDS Action's deputy executive director. "These sweeping changes - born out of blind faith in the managed care industry - jeopardize their health care by weakening consumer protections, quality standards, and the guarantee of due process. Congress is treading in dangerous waters."

In its mark-up of the House of Representatives' version of the Budget Reconciliation Bill, the House Commerce Committee moved last week to allow states to push Medicaid beneficiaries into managed care by eliminating the need for states to obtain a waiver of federal rules, or a Section 1915 B waiver, from the Secretary of Health and Human Services. Under current law, the Health Care Financing Administration (HCFA) reviews waiver requests, including the effect of the proposal on recipient access to services and the quality of services.

The waiver process has allowed consumers, including people with AIDS, and their advocates to participate in the process and ensure that the health care needs of Medicaid beneficiaries are met under the new system. In New York and Pennsylvania, for example, the collaborative process has yielded significant improvements in program design. In lieu of the high level of consumer involvement to date in the waiver process, the bill would require only that states have public notice and comment procedures.

Lubinski explained that Medicaid disabled populations, including people with AIDS, are especially vulnerable. She fears that under the current proposal, these populations are placed at greater risk, especially since most managed care plans have little experience with addressing the health care needs of disabled populations. Lubinski added that the federal government more than once has rejected state-initiated Medicaid managed care proposals because they did not demonstrate the ability and capacity to adequately treat disabled populations.

AIDS Action is pleased with the consumer protections which were added to the House Budget Reconciliation Bill last week - protections for consumers in enrollment and marketing, the "prudent lay-person standard" for the payment of emergency care claims, and the exemption of special needs children from mandatory enrollment in managed care. Lubinski said, however, that much more must be done. She expressed significant concern about the lack of consumer protections for disabled populations.

"What are people living with disabilities, including people with AIDS, to do if inadequate consumer protections allow a state to move them into a managed care plan that lacks the level of medical expertise needed to address complex diseases such as HIV? According to this bill, very little," Lubinski said.

Lubinski said the Senate has a unique opportunity to serve as an advocate for vulnerable Medicaid beneficiaries with special health care needs, including people with AIDS. She urged Senate adoption of the exemption of special needs children from mandatory enrollment in managed care and its expansion to include adults with special needs. Lubinski explained that much like special needs children, adults with HIV/AIDS require the same protections from a managed care system with little experience serving their needs. Lubinski also called on the Senate to ensure that disabled beneficiaries in managed care plans get the health care they need by adopting a provision which would allow disease specialists to serve as primary care providers, or "gatekeepers."

In a related matter, Lubinski said the final budget reconciliation bill must also reflect the bipartisan budget agreement which calls for the restoration of SSI and Medicaid benefits to legal immigrants in the country by August 22, 1996, who were then disabled or who might become disabled some time in the future. The House bill breaks the agreement by denying cash assistance and Medicaid benefits for any legal immigrant who experiences a disabling disease, including HIV disease, some time in the future.

AIDS Action is the nation's foremost AIDS advocacy organization, representing all Americans affected by HIV/AIDS and over 1,400 community-based organizations that serve them.

For more information, contact:

José Zuñiga
(202) 986-1300 Ext. 3042

AIDS Action Council
1875 Connecticut Avenue NW #700
Washington DC 20009
202-986-1300, extension 3053
202-986-1345 (fax)
202-332-9614 (tty)

This article was provided by AIDS Action Council.
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