Medicaid is huge.
It costs the state more than education, and it covers more people than Medicare.
Its size might be matched only by its complexity.
And it’s often confused with Medicare, probably because the two sound so similar.
But they are two totally distinct health insurance programs.
Medicare is for old people, and Medicaid is for poor people.
Many of those on Medicaid may be old, or disabled, or mentally ill.
But the vast majority of them are poor moms and kids, many of them in situations similar to Tatiana Gagnon and her two month old daughter.
Gagnon: I’m 20 years old. I got pregnant when I was 19 and I had her. And I new that it was going to be expensive and stuff and I didn’t have any kind of insurance. So I was just kinda doing it on my own.
But it soon became clear that she could not do it on her own.
Gagnon walked into the Sea Coast Families First Clinic, and the staff quickly got her signed up for Medicaid.
Gagnon: I had to have a C-section with her so it was definitely expensive. Basically I just filed out information for it and in like a few weeks I got a card and it covers it takes care of all my medical bills and everything. I mean having a baby is not cheap.
Medicaid not only paid for her cesarian section, it covered her prenatal visits and she now receives home visits from a social worker teaching her how to be a better parent.
Although Gagnon’s coverage will eventually run out, her daughter will continue to receive health insurance through another part of Medicaid, the Healthy Kids program.
One out of five children under 9 are enrolled in Healthy Kids.
The program offers doctors visits, preventative care like immunizations, even eye glasses and dental work.
All this equates to considerable coverage, yet mothers and children are actually the least expensive to insure.
They make up over 70 percent of people on Medicaid, but they account for only 20 percent of the program’s total price tag.
The biggest chunk of Medicaid spending—about 80 percent—goes to the relatively few people who receive long term care.
In general, long term care breaks down into two groups, seniors in nursing homes and the developmentally or physically disabled.
At the Merrimack County Nursing Home, almost all of the patients are on Medicaid.
Clinical director Lori Brown says most of them have dementia and require a lot of help.
Brown: There’s 68 patients on this floor and they all require two people to assist them in all their levels of care. A lot of them need help feeding, dressing, bathing, walking, communicating in general.
Some patients do not receive Medicaid immediately when they come to Merrimack, but must go through what is called a spend down period first.
Brown: People may go into a nursing home with funds in the beginning. They may have a certain amount in a savings or retirement fund of something like that that they can use. But usually that is gone in the first 6 months, at least at this nursing home.
The other group in long term care includes those who are severely disabled.
Beyond paying for people in long term care to live in institutions, Medicaid pays for many of them to live in private homes.
Warren is 48 years old.
He has substantial developmental disabilities and cannot speak.
For the past seven years he has lived with Kelly, who provides 24 hour care for him in her tidy Nashua home.
Kelly: When he came to live with me he had Parkinsonian like syndrome, which is basically like having Parkinson’s disease. So he lives with that on a daily basis. He has a seizure disorder, which has been managed by medication, and he also has dysphasia which we just found out a few years ago. He’s no longer able to have anything by mouth.
Warren relies on Kelly for everything: dressing, showering, eating, and walking.
Medicaid pays for his doctor visits, his prescription drugs, and Kelly’s salary.
With it she’s been able to buy a house and stay home with her two kids, five dogs, and two cats.
It’s a busy house and Warren demands a lot of attention, tugging on Kelly’s shirt and holding her hand as she talks.
Kelly: You know he’s kind of come into the family like my kids treat him like an uncle. So I guess it’s been a short seven years with him.
An important part of Medicaid is that only some of the services—like hospital stays and nursing home care—are required by federal law.
One of the larger optional programs is mental health treatment.
Alan Moses is senior vice President of Riverbend Community Mental Health Center in Concord.
Riverbend treats the gamut of mental health issues, from severe schizophrenia to drug addiction to children going through family problems.
Moses says Riverbend sees about 2500 Medicaid patients each year.
Moses: However, even though that number only represents about 30 percent of our clientele, almost 70 percent of our dollars come from Medicaid. So it’s a large percentage of our budget. And it says that that indigent population with Medicaid are the folks that typically have a lot of needs.
According to the state Medicaid Director Steve Norton, optional services make up over a third of Medicaid spending.
But spending money up front for optional services may save the state dollars later on.
For example, Medicaid offers an extremely expensive prescription drug plan.
Norton: The pharmaceutical benefit is not mandated by the federal government, but we have chosen to participate as a state because it makes sense from a cost perspective. Generally, providing people with appropriate pharmaceuticals is both a humane thing to do and it ensures people stay out of the hospital.
Hospital stays are the most expensive medical service, and the state must pay for the cost, or rather, for half of it.
For all services, optional or not, the Medicaid bill is split 50-50 by the state and federal governments.
Norton says this partnership is being strained.
Norton: As the federal government has tightened their grip on those expenditures there’s a trickle down effect. And that trickle down effect is going to be felt in New Hampshire as it’s being felt in every other state at a more acute level now than certainly I’ve experienced in my tenure history with the Medicaid program.
A proposal from Health and Human Services is to change the way services are provided, particularly in Healthy Kids and in long term care.
But Franklin Pierce Law Professor Tom Bunnell says such changes are a way to balance the budget on the backs of New Hampshire’s must vulnerable residents.
Bunnell: There’s an overall budget and revenue question that’s driving all this. Nobody’s saying that Medicaid needs to change because it’s an ineffective program. It’s an effective program. They’re not saying it needs to change because it doesn’t meet people’s needs. People who are vulnerable’s needs. It does do that. They’re saying that it needs to change because of the projected costs that are associated with it.
Costs are expected to rise to 2 billion dollars by 2015.
What makes it such a challenge to wrangle with how Medicaid works is that so many people rely on the program today.
And those numbers are only going to grow.
For NHPR News, this is Kerry Grens.
