By Brian Etheridge, MD, FAAP

New Mexico’s Human Services Department (HSD) wants to make changes to its Medicaid program that would not only hurt our state’s children and families, but would also place financial burdens on its healthcare workforce. As both a pediatrician and the president of the New Mexico Pediatric Society, I must voice my concerns. The draft plan, which is open for comments until November 6 and must be approved by the federal government, has some strong points, including pilot projects for Medicaid-funded home visitation, improved coverage for young adults who have aged out of foster care, and increased access to long-acting reversible contraceptives. These proposals not only make sense but have sound data supporting their efficacy.

There are, however, several elements in the plan that are not in the best interest of New Mexico’s children, would limit access to care, damage an already fragile health system, may actually cost more than they are supposed to save, and should be withdrawn prior to submission.

HSD plans to introduce co-pays for both prescriptions and office visits except for preventative visits. Co-pays are a bad idea. Healthcare practitioners and organizations assume not just the burden of co-pay collection, with the associated administrative costs, but also the moral responsibility of deciding whether to offer treatment when a sick child comes in with parents who cannot afford to pay. Already I have patients who must drive two to three hours for an office visit, live pay check to pay check, and  can’t always put food on the table. This is just one more barrier that will prevent many patients from receiving care or a needed prescription. Patients with chronic or severe health conditions will have to shoulder a heavy burden of multiple fees that will create further financial hardships and likely result in poor outcomes. Finally, there is no peer-reviewed study that has linked co-pays with improved outcomes.   

HSD also plans to eliminate retroactive Medicaid eligibility, which allows medical professionals and hospitals to be paid for any services rendered in the 90 days before a patient applies for and receives Medicaid. This allows practitioners to provide care with the reasonable expectation of getting reimbursement. This is particularly important in emergency scenarios which, because of their life-threatening nature, do not make real-time applications possible. Losing this protection could erode an already stressed system of practitioners and healthcare organizations and be financially ruinous to parents. On more than a few occasions I have cared for a child with a life-threatening condition knowing that at the end of the day neither I nor the health system as a whole would be penalized for doing the right thing. HSD claims that an “insignificant” number of people use retroactive Medicaid,  I don’t believe that 10,000 people is an insignificant number. Put another way, this is the entire population of Silver City. HSD should eliminate this provision.

Finally, HSD wants to charge a monthly premium of up to $100 for families making $12,060 to $36,180 a year, and if they cannot pay their premiums for three months, they lose coverage. Let’s remember that for every dollar charged in premiums or co-pays, there is an associated overhead cost for administering that transaction, in addition to a loss of federal match dollars. HSD already has extensive struggles in administering the SNAP and Medicaid programs and is being held in contempt of court for systemic failures in its management. It is highly doubtful the agency could take on the management of a complex system of collecting insurance premiums without extensive costs to the state or bureaucratic snafus that ultimately could imperil New Mexicans. Taxpayer dollars should not be wasted on inefficient fee collections. Co-pays and premiums for Medicaid patients have been well studied. They burden practitioners, reduce access to care, and do not increase revenues.

Changes to Medicaid should be based on a sound foundation of the best available evidence, not political ideology. It benefits all of us, no matter how our healthcare is paid for, to have a Medicaid program that is both efficient and effective in providing critical services and improving health outcomes. HSD should modify the current waiver application so that it benefits all New Mexicans.

Brian Etheridge is a pediatrician practicing in Silver City and is president of the New Mexico Pediatric Society.