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Article of Interest - Medicaid

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Bridges4Kids LogoState Violating Medicaid Laws
Illinois denies children equal access to care, judge says.
by Ameet Sachdev, Chicago Tribune, August 25, 2004
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Illinois' 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 constraints.

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 included.

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 lead-screening test.

- 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, lawyers said.

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 name."

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 recipients.

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 groups.

"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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