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Agencies Warn Medicaid Shifts Could Imperil Elderly, Refugees

WASHINGTON — Jewish welfare and refugee agencies are watching nervously to see the impact of a new Bush administration regulation that could restrict access to emergency room services for poor patients on Medicaid.

The regulation, issued last month in a letter to state Medicaid directors from the federal Department of Health and Human Services, allows states to limit coverage of emergency room care by Medicaid, the federally funded health-insurer for the poor.

“Our local groups are watching to see the impact,” said Diana Aviv, chief Washington representative of United Jewish Communities, which coordinates federated Jewish philanthropies around the country. “The question is whether states will take the opportunity, and what shape the opportunities will take.”

Some states have expressed interest in restricting Medicaid patients to three visits per year, while others are said to be considering limiting the number of days of hospitalization covered for patients admitted through emergency rooms.

Some 40 million low-income Americans are insured through Medicaid. The numbers of Jewish poor around the country are not available. However, in New York City, home to about one-fifth of the nation’s Jewish community, about 180,000 low-income Jews are eligible for Medicaid, some 16% of the overall Jewish population — although not all exercise their eligibility, said William Rapfogel, executive director of the Metropolitan Council on Jewish Poverty.

“In New York such people could have real problems” under the new regulation, said Leighton Ku, a health-care analyst with the Center on Budget and Policy Priorities, a liberal Washington think tank. “They may find that they have an emergency at a point when their primary care doctor can’t see them, and then they can only get care through emergency rooms…. If you limit their access to emergency rooms — particularly to people with chronic conditions such as heart conditions who may need to see a cardiologist on an emergency basis — you put them at a serious risk.”

Around the nation, experts said the Jewish populations most at risk from the new regulation would be the low-income elderly, including a disproportionate number of Holocaust survivors, as well as refugees who have arrived during the last seven years and remain eligible for social services under federal refugee guidelines. Approximately 65,000 Jewish refugees have arrived during the last seven years, mostly from the former Soviet Union and Iran, according to figures provided by the Hebrew Immigrant Aid Society.

“If this is implemented, it could negatively impact our Jewish refugee population,” Aviv said. “We will be communicating with all of our communities to encourage them to monitor this very carefully.”

The new directive all but reverses a policy set by the administration less than a year ago. Last June, the Health and Human Services Department issued a regulation that said health plans “must pay for a Medicaid beneficiary’s emergency room care whenever and wherever the need arise.”

The new limits authorized last month by the Bush administration could “facilitate more appropriate use of preventive care and primary care,” said the letter sent to the states by the director of the Center for Medicaid and State Operations at the Health and Human Services Department, Dennis Smith.

In an interview last week with National Public Radio, Smith said that according to the law, “the states clearly have the right under Medicaid to set limits on [emergency room] services.” Some states already set such limits on people insured by an HMO, Smith said. The new policy would only extend the limits to Medicaid recipients, he explained.

Critics say the comparison between HMO-insured and Medicaid patients is strained, because Medicaid recipients typically have greater need of emergency care. Putting limits on their access to the emergency room may deter them from seeking such care in real emergencies.

Most analysts agree that the administration’s reversal on the issue is an attempt to assist states, which have to close budget gaps of $17.5 billion in the fiscal year 2003and a projected $60 to $85 billion deficit in fiscal year 2004. Unlike the federal government, states must balance their budgets.

Following harsh criticism from healthcare watchdog organizations and from the medical community, the administration has pledged to reexamine the policy and issue clear guidelines to states. Aviv said she sensed that Congress also intends to scrutinize the new policy.

The UJC, Aviv said, does not intend to launch a “preemptive” battle in Washington against the new regulation. “We have so many issues that we have battlegrounds on, that we try not to preempt things that we don’t need to preempt,” she said.


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