Violating Medicaid Laws
Illinois denies children equal access to care, judge says.
by Ameet Sachdev, Chicago Tribune, August 25, 2004
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health-care program for poor children violates federal law
because it fails to ensure that youngsters receive appropriate
preventative medicine, from immunizations to tests for lead in
their blood, a federal judge has ruled.
The decision is a significant victory for advocates of the poor
who have been fighting for more than a decade to force the state
to provide promised benefits for children under Medicaid, the
federal-state health program for low-income people.
About 600,000 of the roughly 800,000 Illinois children on
Medicaid live in Cook County. Now a judge will compel the state
to make improvements.
"The plaintiffs have met their burden of establishing that the
defendants have violated their rights by failing to provide them
with equal access to medical services," U.S. District Judge Joan
Lefkow wrote in her opinion released late Monday. "Plaintiffs
simply do not have access to medical services which is equal to
that of privately insured children."
Lawyers who brought the class-action suit on behalf of
low-income children in Cook County hailed the decision but
cautioned that much work lies ahead.
"It's a wonderful outcome, but when you get the ruling from the
court, you're really just getting started," said John Bouman,
director of advocacy at the Chicago-based Sargent Shriver
National Center for Poverty Law, who is co-counsel in the suit.
"Now the interpretation of the law is clear. What are we going
to do about it?"
The burden for reform will fall on Gov. Rod Blagojevich's
administration, although many of the problems have been
long-standing. The case was first brought in 1992 and was
postponed for seven years while previous administrations tried
to fix the Medicaid program.
Officials at the Illinois Department of Public Aid, which
administers the Medicaid program, declined to comment while they
review the ruling. But a spokesman said, "It's clear we share
the goals of the plaintiffs, which are to provide access to
quality health care at reasonable costs for all who need it."
It's too early to say what remedies will be proposed. But based
on the ruling, the state will have to address the fundamental
issue of Medicaid funding at a time of massive budget
Federal law requires that children covered by Medicaid receive
regular vision, dental and hearing screenings, along with
immunizations and other preventative medical services. The law
requires that at least 80 percent of Medicaid-eligible children
receive at least one service a year.
But Illinois has fallen well short of that goal, according to
evidence that lawyers for the children presented during the
four-week trial that started in May. That evidence was based on
nearly 3-year-old data, so any recent improvements would not be
An analysis of the state's Medicaid claims in Cook County from
July 1, 1998, to Dec. 31, 2001, showed:
- 43 percent of Medicaid-eligible infants hadn't received a
single medical exam, even though they should have received six
screenings during their first 11 months. Only 8.2 percent
received six exams.
- More than three-fourths of Medicaid children between the ages
of 11 months and 23 months did not receive a recommended blood
- 93.6 percent of those who should have received hearing exams
between 47 months and 59 months of age did not receive them.
Lawyers for the defendants--which included the Illinois
Department of Human Services--argued that the analysis
understates the actual level of medical services provided to
children. For example, there are a number of free services
provided by public-health clinics and school-based clinics,
The judge was not persuaded by the argument.
"For the defendants to argue that the number of services listed
above are provided somewhere by someone who does not bill the
[Department of Public Aid] is sheer fantasy," Lefkow wrote. "It
strains the imagination to believe that this many services are
provided for free by some provider the [department] cannot even
Medicaid reimbursement low
The lack of equal access to health care comes down to economics:
Doctors refuse to treat Medicaid patients because reimbursement
rates are too low, lawyers for the children argued. They
presented evidence that showed Medicaid rates are significantly
lower than private-insurance reimbursement rates and don't even
cover a physician's overhead costs. Doctors also testified
during the trial that the state often takes two to six months to
pay its bills, compared with a month for most private insurers.
The judge concurred that rates cannot be divorced from the issue
of equal access and found that the Medicaid payments are
"insufficient to entice" doctors to treat Medicaid patients.
The state did little to rebut the testimony about rates except
to say that it only establishes that physicians want more money,
according to the judge's ruling.
Lefkow also was swayed by the testimony of six Medicaid
recipients who expressed their frustration about everything from
finding doctors to having to wait in long lines for service.
For example, Elissa Bassler was referred by the Department of
Public Aid to eight doctors, none of whom would accept Medicaid.
Sara Mauk testified that one of the doctors her daughter saw
made Medicaid patients wait for an examination until the doctor
finished treating patients with private insurance. She also said
her children could be seen only on certain days of the week,
known as "Medicaid days" at the doctors' offices.
In addition to addressing reimbursement rates, the state will
have to look at ways to improve communication with Medicaid
Lefkow was persuaded by arguments that access to health care
also was hurt by the state's failure to adequately inform
Medicaid recipients about the availability of preventative
medical services. Written notices, for example, mentioned only
well-child examinations and omitted lead-blood screenings and
were haphazardly delivered.
Managed care isn't working
The court also ruled the class proved that the state's attempt
to improve access to health care by using managed-care
organizations isn't working. Currently, less than 15 percent of
Medicaid-eligible children receive care from managed-care
"We have as complete a victory as we possibly could have," said
Fred Cohen, one of the lead plaintiffs' trial lawyers, whose
firm Goldberg Kohn Bell Black Rosenbloom & Moritz is handling
the case free of charge. "Our strategy from the beginning was to
show that this is a systemic problem that is pervasive."
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