David Harlow

The Bush administration’s emphasis on personal responsibility for health care decisions and costs seems to have reached new heights (or depths, depending on one’s perspective) in its super-swift approval, in May, of West Virginia’s Medicaid state plan amendments. The plan (as described here, in a state powerpoint presentation and here, in a link-rich post on West Virginian Bob Coffield’s Health Care Law Blog) cuts back entitlements per the DRA, but also creates a package of enhanced benefits, available to beneficiaries who sign and adhere to a new membership agreement.  The enhanced benefits include things like mental health services, diabetes care and more than four prescriptions per month.  This agreement, per the state, "emphasizes personal empowerment and responsibility." The Center on Budget and Policy Priorities explains the member agreement as follows:

All children and parents affected by the plan will receive the new basic benefit package until they (or their parents on behalf of the children) sign a “Medicaid Member Agreement” entitling them to an enhanced benefit package.  The agreement must be signed at the office or clinic of the beneficiary’s health-care provider.  In the agreement, the beneficiary agrees to “do my best to stay healthy,” to “go to health improvement programs as directed by my medical home [health care provider],” and “to go to my medical home when I am sick.”

According to West Virginia’s state plan amendment, when a beneficiary “does not fulfill the responsibilities” listed in the agreement, his or her Medicaid coverage will revert to the basic benefit package. 

Health care providers will be expected to monitor and report on their patients’ compliance with their member agreements.

The CBPP’s analysis goes on to detail why the plan will neither reduce costs (it’s targeted at populations which consume a realtively small portion of Medicaid services) or improve health status (the theoretical underpinnings of the plan are untested).

This week’s New England Journal of Medicine takes the discourse to a whole new level, practically issuing a call to arms to West Virginia physicians:

The plan asks physicians to violate all three fundamental principles enumerated in the Physician Charter on Medical Professionalism: the primacy of patient welfare, the principle of patient autonomy, and the principle of social justice.  It raises potential conflicts by placing physicians in a reporting situation in which the public health is not at issue, possibly asking them to harm their patients or their relationships with patients. As physicians become agents of the state, poor patients’ distrust of the medical system can only increase. Although the plan’s member agreement mentions the patient’s right "to decide things about my health care and the health care of my children," it does not recognize that noncompliance can be an expression of disagreement with the physician. The plan promotes discrimination not only on the basis of socioeconomic status, but also on the basis of diagnosis: surely, people with mental illnesses who have trouble managing activities of daily living such as keeping appointments will be discriminated against under a plan that rescinds their mental health benefits because of such lapses.

While we all know that states are burdened by their budget-busting Medicaid programs, and states are supposed to be the laboratories for health care reform, this experiment (which was rolled out in three rural counties July 1) may need to go back to the drawing board.