Tag Archives: Medicaid

Catch-22 Policies: Medi-Cal and Transplants

I ran across a situation recently that required me to figure out how the Medi-Cal program – California’s implementation of the Medicaid program, which provides government-funded health insurance to low-income people – handles people who have received transplants. What was happening was so illogical and ill-conceived that I was astounded to find out that it was exactly what the regulations and structure of the program wanted to happen. This is an example of state and federal policy just Not Making Sense.

Not all low-income people can qualify for Medicaid, but have to have a “linkage” to the program in addition to being poor. One of the linkages is have a disability that meets the Social Security Administration’s (SSA) definition of “disabled”: having a physical and/or mental impairment that prevents the individual from engaging in “substantial gainful activity” for at least 12 months. “Substantial gainful activity” just means work where the individual is earning a certain level of wages that SSA thinks is enough to support themselves, a fixed dollar amount that SSA adjusts every year. So, basically, a person has to be completely unable to work for at least a year in order to be eligible. Once they start getting Medi-Cal on the basis of disability by proving they meet that standard, the program will periodically re-evaluate them to see if their condition has improved and if they could now return to work. If the Medi-Cal program thinks the person’s disability has improved, they’ll be cut off the program and no longer have access to health insurance.

This reflects the underlying policies and values that caused the program to exist – policymakers want people to work and support themselves and will only step in to provide benefits if there’s some compelling reason the person is unable to do so. (Note: I have a lot of problems with those assumptions and am not endorsing them myself, just outlining what we can assume the policymakers believed and intended.) So, if a person is later able to support themselves through work, we’ll cut off the benefits because there’s no longer a compelling reason for them to not be supporting themselves.

It’s easy to anticipate a number of potential problems with those policies, mainly around the cyclical nature of many disabilities. But I want to focus on specifically is people who have received organ transplants. When a person needs a transplant, they will certainly meet the disability standard and be able to get on Medi-Cal. Someone in dire need of a kidney or liver transplant is not going to be working 40 hours a week – they are likely going to be in the hospital for a lot, if not all, of their time. So they’ll get Medi-Cal coverage, which will pay for the transplant surgery and hospitalization and all that sort of thing.

After the transplant, time goes by. SSA says they will assume someone will continue to be disabled for one year after a transplant operation, but after the first 12 months, the Medi-Cal program will start evaluating the person to see if they continue to meet the disability standard. Most times, people won’t, because recovering from transplant surgeries is difficult and takes a long time, even if there’s no significant complications or organ rejection problems. So people continue to be covered by Medi-Cal.

Now, some more time goes by. And for some people, the transplant has resolved their underlying health problems. (This certainly isn’t true for all transplant recipients.) They’ve recovered from the transplant surgery. They’re doing well. And when Medi-Cal comes around to re-evaluate their disability, the may not meet it anymore. They may not be so severely impaired that they’re unable to do any work at all. And for most people, this would be a good thing. They’re getting better. They’re improving. They have more ability to function, to care for themselves, to be independent. And most of them are immensely excited about and proud of that progress. They have worked hard for it.

But it can mean that their Medi-Cal gets cut off. That their health insurance goes away entirely. And this is an enormous problem, because no matter how well someone has recovered from transplant surgery, she has to keep taking immunosuppressant anti-rejection drugs so her body doesn’t begin to reject the transplanted organ. And my understanding is the vast majority of transplant recipients have to keep taking anti-rejection medications for the rest of their lives. So when a transplant recipient’s health insurance gets cut off – how are they supposed to afford those expensive immunosuppressants? The Transplant Recipient’s International Organization estimates that “the average annual cost for immunosuppressive medications for kidney transplant recipients is approximately $11,000.Transplant Living estimates the costs to be even higher, ranging from $17,200 to $27,500 per year, depending on which organ was transplanted.

For transplant recipients cut off Medi-Cal for disability reasons – which means they are still poor enough to qualify for the program – those costs are completely beyond reach. This is especially true because the person has likely also just lost eligibility for cash benefits from Social Security for no longer meeting the disability standard – so they must go out and figure out how to start earning enough to pay for rent, food, utilities, transportation, and the medication costs. And if they can’t manage to get enough money for the drugs? Their body will start to reject the transplanted organ, and they’ll go into kidney failure, or liver failure, or heart failure, or other organ failure. At which point they will go back to the hospital, extremely ill, and go back on the transplant list . At which point they will be so sick they can get back on Medi-Cal, which will pay for their hospitalization and the next transplant surgery.

Obviously, this is immensely cruel. Requiring someone who has just managed to recover from the first transplant surgery to abandon their medical treatment so they get increasingly sick, potentially fatally sick, to undergo another invasive and traumatic transplant surgery – if an organ even becomes available! – is beyond inhumane. But even from a purely economic perspective, it makes no sense. Certainly immunosuppressant medications are expensive – expensive enough that people can’t afford them without help, so it’s not without cost for the Medi-Cal program to pay for them. But organ failure and transplantation are way more expensive in comparison. Looking at a kidney transplant, the 30 days of hospitalization during pre-transplant organ failure cost $16,700; organ procurement costs are $67,500; admission during the transplant procedure and recovery is $92,700; the physician for the transplant surgery is $17,500; the post-transplant admission is $47,400; and then the immunsuppressant drugs cost $17,200. A report by Milliman Research (pdf) has even higher numbers, estimating the cost of a liver transplant at $523,400.

I think there are compelling arguments for a policy change that fit within my values and priorities – to avoid human suffering – but this cost data suggests a strong argument for a policy change that fits within the values of those in power – reducing costs. To make this argument to those people, I would analogize: if you buy a house, you put in maintenance, you don’t just abandon it to fall apart. It makes sense to put in upkeep and maintenance on property to protect the value of the property. The Medi-Cal program is buying these people organs, it should maintain those organs. But that’s not what the program rules say should happen. That’s not the policy. Continue reading Catch-22 Policies: Medi-Cal and Transplants

Medicaid: I’m Sorry, Did You Want Social Services With That?

While doing some unrelated research for work recently, I happened upon some information about Medicaid transportation services in Oregon which I found rather fascinating. And also rather annoying. Medicaid will, it turns out, pay for medical transportation for appointments covered by Medicaid (of course, this assumes that “transportation” can take any number of forms, including buses, taxis, and so forth), if other options aren’t available and the recipient is “eligible.” This does not include transport for medical appointments and evaluations which are not covered by Medicaid; you’re on your own there, apparently.

And, while I would hope that Medicaid would not, say, force a wheelchair user to use transportation which is not accessible by wheelchair, I could see them forcing someone with social anxiety to take the bus, or insisting that someone with PTSD from a traumatic car accident take a taxi, even if this is triggering. Let’s not think that Medicaid would be too generous, here, when it comes to covering transportation.

What’s really interesting to me is Medicaid’s approach to non-medical transportation.

Non-medical transportation falls into the category of anything not related to medical appointments and medical care. Which includes things like buying groceries, attending school, taking yoga classes, going to social events, heading to work, whatever. Living your life, in other words. Medicaid apparently will cover some types of non-medical transportation, for “certain” clients, although the site doesn’t go into detail about who might qualify for this magnanimous benefit. Which is, honestly, more than I would have expected of them, although it’s less than Medicaid should be doing.

The framing of this informational page intrigues me. It seems to be stressing that people should try to arrange for themselves whenever possible; it assumes, for example, that people will/should get prescriptions by mail, or that they should rely on their friends for transportation, including medical transportation, with transportation being covered only grudgingly. Presumably it also thinks that people should always order groceries and other things they need for delivery, rather than going out, and that people on Medicaid should not do things like going to dance classes or socializing at the coffeehouse or going to work or anything, really, other than sitting at home.

It’s also important to note that paid transport has to be preauthorized. People should not assume, in other words, that Medicaid will pay for transport.

This seems to me to be a deliberate ignorance of class issues, and of day to day life for people with disabilities.

It’s a class problem because it assumes that most people have friends with cars (and schedules flexible enough for them to take time out of their day to provide transport), and because it assumes that everyone has access to safe, accessible transit. Neither of these things is the case. In fact, for Medicaid beneficiaries, both of these things are actually seriously in question. Friends might have cars, for example, but they might not be safe or accessible. Or those friends might not be able to provide transport when it’s needed. Likewise, assuming a bus route goes close enough to get someone where ou needs to go, that doesn’t mean the bus is safe.

A friend might be able to go along on the bus ride for safety and to help carry things, but not necessarily. Again, friends might not be able to take time off from work to accompany someone to a medical appointment. Or friends might have very limited schedules, which means that if an appointment runs over, the friend has to leave. Even if that means that there is now no safe ride home.

And, of course, it ignores the fact that some people with disabilities are isolated, and that many of us are running out of favors. When you’re temporarily sick, friends are usually willing to pitch in and help out. They imagine themselves in that position and they figure what goes around comes around. But when you are disabled, and you have been for years, friends are less and less willing to help out. They’re tired, you’ve drifted apart, they feel like they’ve already given too much. In turn, there’s awkwardness when it comes to asking people for help when it feels like one is always asking for help, and when you’ve been constantly reminded that you need to be a good cripple and be nice and well behaved and not be a bother.

And that means that no, it’s actually not at all reasonable to demand that Medicaid recipients ask their friends for rides. It’s also not really reasonable to insist that they restrict their social lives because non-medical transportation is only available for a limited list of things. Medicaid focuses on providing the narrowest and most limited set of benefits possible, and on denying those benefits whenever it can see a way to do so.

That contributes to isolation in a pretty major way. If leaving your house is a huge production which involves a great deal of work, you’re less inclined to do it. And that means that you are less inclined to spend time with other people, to attend events which look interesting, to do things that you want to do. And, of course, over time that means that your friends assume that you can’t leave. Policies like this effectively trap people in their homes.

That’s not social services. That’s just injustice.