OCTOBER 28, 2005 -- Members of the Bush administration's Medicaid advisory panel began grappling this week with the enormity of their challenge: Give expert advice on controlling the program's costs but also determine how to help the growing number of uninsured.
Democrats contend the panel is no more than a "sham" commission controlled by people hostile to Medicaid. But during a two-day meeting in Washington this week, members of the panel displayed the kind of concentration, curiosity, and passion that suggested their concern about the stakes involved.
Focus too narrowly on dollars and commissioners risk adding unnecessarily to the suffering of some, if not many, people. Pretend dollars aren't an issue and they risk having states not amenable to tax hikes forced to cope with fast-rising Medicaid costs by dropping large numbers of people from the program.
But whether the panel is up to the job is an open question. Its level of Medicaid expertise is uneven and it will meet only about a half dozen times before filing its recommendations, which are due December 31, 2006.
Time Bind
The Medicaid Commission, appointed in July, has shifted its attention from making recommendations on short term changes to the program to developing recommendations for longer term changes.
At their meeting Wednesday and Thursday, members repeatedly expressed concern about the limited meeting time and with the need to master a complex program that includes more than two dozen eligibility categories.
One commissioner said the topic of which populations should be covered in Medicaid deserves a full two-day meeting in December. But Commission Chairman Don Sundquist, former governor of Tennessee, said the commission can't find the time to meet then.
Sundquist added the panel is limited by law to six meetings a year and suggested dealing with the time crunch by adding a third day to two-day meetings and by having more working lunches.
Carol Berkowitz, president of the American Academy of Pediatrics, said working groups should be organized on specific topics to build expertise. But Sundquist said it's hard to define what the work groups should cover and urged a delay in deciding whether to proceed in that manner.
"We need to look at some pretty big solutions," observed commissioner Bill Shiebler, former president of Deutsche Bank. "We don't just owe something to recipients of Medicaid," but also to "kids and schoolteachers," he said, referring to the impact of rising Medicaid outlays on state spending on education. Shiebler expressed skepticism that such challenges could be handled by meeting every other month.
Learning Curve
While panel members aren't strangers to health care, Medicaid is a world unto itself. To develop a common base of current knowledge about the program, former New Mexico Medicaid Director Charles Milligan led the commission through a series of learning "modules" over much of the two days, ranging from "Medicaid Eligible Populations" to "IT, Fraud and Abuse, and Financing."
Asked his assessment of the members' knowledge of Medicaid, Milligan said commissioners began with "varied levels of knowledge, but they're ramping up very quickly." One of the goals of the organizers of the commission was to include "thoughtful outsiders," he said. "Individuals who put the commission together wanted to make sure that the membership included people who would bring in fresh thinking." Members include insurance, hospital, and drug store executives, as well as analysts who focus broadly on health care rather than specifically on Medicaid.
Findings a Foregone Conclusion?
The questioning of Milligan was sharp and detailed and interspersed with commentary that reflected a range of opinion on long term changes. Shiebler declared the $11 billion in Medicaid cuts advocated by the commission this summer was not enough.
Noting projections that the cuts would only shave the projected yearly percentage increase in Medicaid spending from 7.4 to 7.2, Shiebler said that level of growth simply could not continue. Quoting the late economist Herbert Stein, Shiebler said, "'All unsustainable trends stop.' It's going to stop one way or another. We want to bring this in for a soft landing."
Berkowitz, on the other hand, emphasized wider coverage. She termed the lack of coverage in the United States "a disgrace" and called for a plan that would "make sure that everyone who needs coverage has coverage."
The varied opinions on display suggested the possibility the commission may not be the "sham" its critics say it is. Liberals have suggested that a recommendation to dismantle much of the Medicaid entitlement is a foregone conclusion because of the commission's administration-appointed membership.
But one liberal analyst noted Republicans are often "shocked" to learn what Medicaid doesn't cover, including childless adults with incomes well below the poverty level. "In Republican states they've had commissions that say we need to do more, not less" in Medicaid, he said.
But the same analyst added that the commissioners who appeared friendlier to Medicaid in its current form were non-voting members. And the appointments of two more voting members announced Oct. 21—Florida Governor Jeb Bush and West Virginia Governor Joe Manchin—add to the voices on the commission arguing that the Medicaid status quo cannot continue.