Medicaid realities

“Connie” is a 52-year-old Chamorro woman who is the mother of four children, the grandmother of seven. She is one of the CNMI’s 15,000 or so people on Medicaid. And she’s about to go blind due to a lack of Medicaid funding. Let me tell you her story.

Like may Pacific Islanders, Connie was at risk for developing diabetes before she was even born, a risk bestowed upon her by her genetics. Her environment-a culture where food is central to celebration and where calorie-rich foods are plentiful-gave her those few extra pounds of belly fat that served as fuel for her genetic risk, allowing it to flourish into full-blown diabetes by her early 40s. By her mid-40s she had developed damage to her blood vessels from the diabetes. And the area of her body most severely affected was her eyes. She knew that as a diabetic, she should get her eyes checked every year, but she was always too busy to get it done. When she did come in, she already had advanced diabetic eye disease. Modern medicine made it possible to save her vision, but a few missed appointments allowed her diabetic eye disease to explode into a severe form where new blood vessels were growing throughout her eyes. In January of this year, she started on treatment with an almost miraculous medication that I place into her eyes once a month. The medication made the new blood vessels disappear, and it saved her vision, but the medication is not a permanent fix. One month without the medication and she loses some of her vision. Two months without the medication and she is blind. Permanently.

Our clinic is facing the same realities of other clinics that can no longer provide services to Medicaid patients because of lack of payment. We have tried to hold on as long as we could. But we may not be able to do so much longer. The last check we received was for Medicaid services we provided in July 2011-no, that’s not a typo-2011. It’s hard to keep paying for the drugs we use, the staff we employ, power, and all the other expenses involved with running a medical clinic when payments are so far behind. I don’t know how things are going to get resolved. But I do know that without treatment, Connie will be blind in two months, and unless the Medicaid program is adequately funded, others will share Connie’s fate, and worse.

It’s a positive step that the local funding for Medicaid has been increased by $1 million for the coming year. But let’s examine what kind of funding is needed to provide the kind of care the Medicaid population needs. Do a Google search, and you’ll quickly find that the average spending per Medicaid member in the United States is somewhere between $1,000 to $2,000 per year. Budgets have to be built on realistic numbers. In building our local Medicaid budget, we can take the lower of these numbers ($1,000), and expect that the cost of care to the Medicaid program in the CNMI will be $1,000 per member per year. (Just for perspective, the CNMI’s current budget is $353 per member per year.) Currently, there are 15,000 or so people on Medicaid. (These numbers are increasing as the economy makes more people eligible to receive Medicaid, but let’s just stick with 15,000.) If we spend the “low” side of the national average-$1,000 per year-on 15,000 Medicaid patients, the program needs $15 million per year. That might seem like a lot, especially given the current budget at $5.3 million. But like it or not, it’s the reality. And it’s a very conservative reality. Budget less than this and you can expect that you’ll have difficulty paying for services. Don’t pay for services and you can expect that the services will no longer be available. These, too, are realities.

With a local-federal match of 45:55, our local government needs to budget $6.75 million (45 percent) in order to get the $8.25 million (55 percent) federal match . This number-$6.75 million-is the starting point for any discussion about the budget. In a proposed budget of $112 million, $6.75 million is barely 6 percent of the budget. Currently, the local allocation of $2.5 million is 2 percent of the budget.

Can we come up with the extra $4.25 million to adequately fund the Medicaid program? Of course we can. But will we? That’s the real question. And the answer is, “it all depends.” It depends where our priorities are and how we want to spend our money. If we allocate 2 percent of our budget on the healthcare of 15,000 people, and we know that this is not enough (and we do know that it is not enough), we are essentially saying that whatever we are spending the remaining 98 percent of the budget on is more important than the healthcare of these 15,000 people. Maybe some of it is. But I’d bet that there’s 4 percent of it that isn’t. By finding that 4 percent, we can get our local contribution up to $6.75 million. It’s just a matter of being honest about our priorities and the choices we make in setting a budget and in understanding the repercussion of those choices. Many of those repercussions are too complex for me to understand but I do understand the effects of inadequate healthcare.

Now, we can wish for all kinds of things-we can wish for the economy to get better, for spending to go down, for people to live healthier and therefore require less healthcare, for the federal government to lower our local matching requirements. These are all good wishes. But that’s all they are-wishes. I wish Connie had come in sooner. The wishes don’t change the reality.

So, what is the reality, stripped of the wishes? The reality is that the “low” national average for Medicaid spending is $1,000 per Medicaid member per year. The reality is that we have about 15,000 Medicaid members. The reality is that the local-federal match is 45:55, and that we need to budget a local match of $6.75 million to cover the healthcare costs of our Medicaid population at this “low” national average costs. That’s the reality.

Surely, somewhere in the budget, we can find $4.25 million that is less important than the healthcare of 15,000 people. And if we can’t, then there are other realities that are set in motion that we have to face and take responsibility for. When we budget less than the national average for Medicaid spending, we run out of money, Connie goes blind, Jose has a stroke, Carmen is disabled from a heart attack, and Henry dies of a head injury. Not because they had to, but because of the choices we made with our budget. And if that’s how it has to be, so be it. Let’s just be aware of the realities as we make the difficult choices.

David Khorram, MD is the CNMI’s only ophthalmologist and the medical director of Marianas Eye Institute. He is listed in Guide to America’s Top Ophthalmologists. For comments or questions, call 235-9090.