Explain this one...

“By Robert Pear, New York Times

WASHINGTON — In a reversal, the Bush administration has ruled that managed care organizations can limit and restrict coverage of emergency services for poor people on Medicaid.

The new policy, disclosed in a recent letter to state Medicaid directors, appears to roll back standards established in a 1997 law and in rules issued by the Clinton administration in January 2001 and by the Bush administration itself in June 2002.

Under the 1997 law, states can require Medicaid recipients to enroll in health maintenance organizations or other types of managed care. But certain safeguards for patients were built into that law. Congress, for example, stipulated that managed care organizations had to provide coverage for Medicaid patients in any situation that a "prudent layperson" would regard as an emergency.



Now the Bush administration has decided that states can place certain limits on coverage of emergency services "to facilitate more appropriate use of preventive care and primary care," the letter said.

Administration officials said today that the new policy was consistent with President Bush's desire to give states greater flexibility in the operation of their Medicaid programs.

"Some states felt restricted and constricted by the old policy," said Gregory A. Vadner, the Missouri Medicaid director, who is also vice chairman of the National Association of State Medicaid Directors. "In a time of fiscal stress for states, it's all the more important that we have discretion to manage programs properly."

States say they are facing the worst fiscal crisis in more than 50 years and are desperately looking for ways to control health costs. Many have cut benefits or restricted eligibility in an effort to hold down Medicaid costs, which rose 13 percent in the last fiscal year, the biggest increase in a decade.

But Cindy Mann, a Medicaid expert at Georgetown University, questioned the legality of the new policy.

Senator Bob Graham, Democrat of Florida, a principal author of the 1997 law, said the new policy "would undermine access to essential emergency services for low-income Americans," including children, the elderly and the disabled.

Mr. Graham said he did not understand how the administration could, by a letter, make such profound changes in a policy established by statute.

Administration officials said the basic Medicaid law allowed states to set reasonable limits on the amount, duration and scope of services.

The letter was sent to state officials by Dennis G. Smith, the Bush administration official in charge of Medicaid. Under the old policy, Mr. Smith said, states could not limit coverage of emergency services for Medicaid beneficiaries in managed care. "When the prudent layperson standard is met," the old policy said, "no restriction may be placed on access to emergency care. Limits on the number of visits are not allowed."

More than 40 million people are insured through Medicaid. More than 55 percent of them are in some type of managed care.

The letter does not specifically say what kind of limits can be imposed, but state officials have discussed ideas like limits on the number of emergency room visits that would be covered.

Ben A. Bearden, the Medicaid director in Louisiana, said his state wanted to limit Medicaid coverage for adults to three emergency room visits a year.

"Three emergency visits a year for an adult may sound like a small number, but it's really not," Mr. Bearden said today in an interview. "I'm 60 years old, and I've been to an emergency room once in my life. The E.R. is very expensive, and people in this state use it inappropriately. They go in for a stubbed toe."

Louisiana used to have a three-visit limit, Mr. Bearden said, but, at the insistence of federal Medicaid officials, the state ended the restriction for people in managed care a couple of years ago.

Under one form of managed care, states pay primary care doctors to coordinate care for Medicaid recipients.

Mark D. Trail, the Medicaid director in Georgia, said that prior to 1997, his state required an emergency room to get authorization from the primary care doctor before treating a Medicaid patient enrolled in the state's managed care plan.

Georgia did away with that requirement because of the 1997 law. "Since then," Mr. Trail said, "use of hospital emergency rooms has spiked," and the state is seeking ways to reduce inappropriate use.

Mr. Vadner, the Missouri official, said states recognized their obligation to cover emergency care. But there is often a dispute over who should pay and what services are needed.

Michelle Mickey, a policy analyst at the National Association of State Medicaid Directors, said state officials had sought a clarification of federal policy on emergency care. The new policy, she said, is "above and beyond what the states ever requested or expected."

Senator Graham introduced a bill to establish the "prudent layperson" standard for all insurers in 1997. The standard was included in the Balanced Budget Act of 1997, as a requirement for managed care plans serving people in Medicaid or Medicare. The purpose, Mr. Graham said, is "to allow a person who reasonably believes that he or she is undergoing an emergency condition to be evaluated, treated and stabilized in the emergency room without fear that the health plan will later deny the claim."

A prudent layperson is defined in the law as a person with "an average knowledge of health and medicine."

Doctors and hospitals said the prudent layperson standard was needed because H.M.O.'s had often refused to pay for emergency care after concluding that there was no real emergency — if, for example, chest pains resulted from severe indigestion rather than a heart attack.

Under the law, the managed care plan is supposed to pay for the emergency care, regardless of whether the patient got "prior authorization." The patient can go to the nearest hospital, regardless of whether it is in the health plan's network of providers.

The Bush administration issued rules interpreting the law on June 14, 2002. In a news release at the time, the administration said, "Health plans must pay for a Medicaid beneficiary's emergency room care whenever and wherever the need arises."

Copyright 2003 The New York Times Company”

“It means poor people are not authorized to get sick. Interestingly, it was also announced today that the Veterans Administration is no longer accepting health care applications from veterans who earn more than stipulated salaries. The law had been expanded in 1996 to cover these veterans, but the VA was underfunded by Congress.”

“I think this guy nailed it,

Ben A. Bearden, the Medicaid director in Louisiana, said his state wanted to limit Medicaid coverage for adults to three emergency room visits a year.

"Three emergency visits a year for an adult may sound like a small number, but it's really not," Mr. Bearden said today in an interview. "I'm 60 years old, and I've been to an emergency room once in my life. The E.R. is very expensive, and people in this state use it inappropriately. They go in for a stubbed toe."”

“Wow, better hope they don't have heart problems! ...or severe respiratory problems, or any other serious health problems. And the poor do tend to have a higher incidence of serious health problems.”

“Yep, Ole Ben has been lucky enough to have no chronic life-threatening illness.

But hey, someone that has some condition like that should just work harder or educate himself so he can afford health insurance, right?”

“Oh, and Geobeet, when I was just out of the military in college and couldn't afford health insurance, I used my VA benefits to go to the emergency room 5 times in the span of six months.

Not to get into too much detail, but NONE of those visits was a stubbed toe.”

“And you'd better pray that you're not on disability and Medicaid because you have a chronic health problem that makes you unemployable...”

“It's funny somebody raised this issue, because a person can go through most of their life without having serious health issues and then, whammo, the ceiling falls in.

At most, I might have had two ER visits in a year, and in all cases for potentially life threatening illnesses or serious injuries. About the only insignificant was was when I was transported from a vehicular accident with chest pains and neck pains in order to get X-rays and checked out. Turned out everything was okay, but the ER staff assured me I had done the right thing.

I am beginning to feel that people with health problems and issues are seen as somehow weak or whiners, when in reality they have experienced serious medical conditions.

Now, are there whiners and hypochondriacs out there who go the the ER just to get attention? Yes, indeed there are, and they should be discouraged. In fact, they are being discouraged. ER copays with my insurer have gone from $35 to $75, unless you are admitted, in which case there is a $200 copay. As understandable as those increased charges may be, it makes me think twice about going to the ER, and I wonder whether the day might come when I decline to go to the ER because of the cost and end up suffering for lack of treatment.

After this past autumn and so far this winter, medical expenses are eating me up. The sad thing is, medical malpractice insurance and drug costs are eating up our health insurance and driving costs through the roof. I am beginning to wonder where it will all end and at what point some of us get left in the backwash.

I am a veteran who has never used the VA for health care. I recently looked into the possibility and was weighing my options when I saw the story this morning. I'm sure I'm among those who makes more than the cutoff amount. I don't see that as unfair. Like I said, I have never used the VA and was still uncertain whether I wanted to. But there are other borderline vets like me who for whatever reason might need VA health care, and now they may not be able to get it.

Meanwhile, the rich and the poor will get treatment. It's the working poor who are increasingly being left behind - people who pay their taxes and support themselves. Both political parties seem to have abandoned this economic group, and it makes me sick. One party wants to give my money to the rich and the other to the poor, and all I want is enough to take care of myself, buy some cheap gear to take cheap vacations, and maybe have a few shekels left over for my autumn years (which are looking increasingly bleak).

And I keep asking myself, who the hell got us into this fix?”

“i hadn't heard about the VA health care problem...i've been using a VA doctor as my primary health care provider since i got out 4 years ago...not to be selfish, but does this affect only new applicants or should i get out my yellow pages?”

“Is this part of the "Class Warfare" the Demos have been accused of starting?”

“Must be, Navi. It's an old trick, but a good one: do evil deeds and label the group that calls you on it divisive.

Of course, a lot of this will be forgiven (if not forgotten altogether) if we are into and out of Iraq quickly and decisively, right?”

“Apparently you are safe nia. It's just new applications from what I read. Here's a link to the story, which I found in the Richmond Times-Dispatch: link to story”

“thanks geo, i'll check it out...”

“i don't know much about VA's but my wife(the great buffalobabe) is a budget accountant for a huge hospital system here in NW ARK. she sees all the books and has to go through them and decide how they are going to make money. see, some of you may not realize this but hospitals are businesses. they are there to make money and if they loose money they will close. they have alot of expensive equipment and high payed doctors to pay for. brain surgeons don't come cheap these days. what this is all about is fraud, waste and abuse, which are rampant in the medicare-caid systems. the hospital, by law, CAN NOT turn down an emergency patient. this goes for the new law addressed here on this thread. the one phaedrus thinks is evil. what's happenening is people are abusing the system, thereby raising costs for the people who really need care. all this law does is say you can't come to the emergency room unless it's a real emergency. nothing evil about it. the hospital has to pay the bill when people skip town on them, and it happens alot more than you might think. hypocondriacs are coming in for a flu or a tummy ache. many of them just want or need the attention because they are lonely. womb to the tomb coverage will never happen in a free society because there would be no monitary incentive for doctors to excell or to do research on new treatments. fraud, waste, and abuse are what we should be concentrating on. if we could save a few billion here, it could go to another area where it is needed. or perhaps help more sick people who really need it. also malpractice suits drive up costs for everybody, but that's another subject alltogether.


















and tilt eats worms....”

“You're soooooooo full of crap.”

“As the health world turns.

A TT soap up next on the TrailTalk Network.

8)”

“ the hospital, by law, CAN NOT turn down an emergency patient. this goes for the new law addressed here on this thread.

Yeah, it's all about the bill afterward, though.

all this law does is say you can't come to the emergency room unless it's a real emergency. nothing evil about it.

No. It says that if you have more than three emergencies in the span of a year, you are not covered under the managed care plan. This means that if you are acutely sick and poor, you're absolutely screwed after the first three times. Again, God help you if you have asthma or a heart condition.

womb to the tomb coverage will never happen in a free society because there would be no monitary incentive for doctors to excell or to do research on new treatments.

Germany and Canada are not free societies?”

“so you think anybody should just get anything they want? ok man, gimme something. everybodies always talkin bout gettin stuff...well, i want my stuff. tilt, gimme your stuff dangit! i want violins stuff too and some of phaeddy's stuff and i think i'll have some of rosey's stuff while i'm at it. WHERE'S MY STUFF!?! all you'll out there making money and not givin me any, dang, i can't believe how insencitive you are. i should have all the same stuff you have, shouldn't i? i want that killer tent you have phaedrus. i want violin's pack and tilt's telescope cuz his his much nicer than mine and he doesn't really need a telescope that nice anywayz. i mean he has 3 old telescopes in his closet so it's just not fair that i have none. gimme all your freeking stuff or i'm gonna call you greedy and tell people you want to kill them for money. i'll tell people that you hate them and that you hope they get sick. if you don't give me your stuff then i'm gonna tell people you want the air to get dirty and the fish to die and that you are a racist. gimme your stuff and i will not ask for anymore stuff untill next week and then you'll have to give me more stuff or it'll be even worse next time. i'm not greedy for wanting your stuff, but you are greedy for having stuff that i don't have.I WANT MY STUFF!




classism is devisive , just like everything else the left tries which is why you are a dieing breed, which i suppose is why you are so frantic to mislead the people of your true motives; the aquisition of power by any means....maybe if you give stuff to 51% of the people, they will vote for you and you can give them more stuff and they will thank you for caring so much and pat you on the back for being so noble as to take other peoples stuff and giving to the dependant class that you have created.......








it's all about stuff in the end....”

“WOW!.....thays som heavy stuff,man....e”

“No, Strat, I don't think just anybody should get just anything they want. I never said that, and I don't really see how it relates to the discussion at hand.

Classism? Please.

The facts in this case point to a law that has a callous disregard for human health. By going the wrong way about trying to stem fraud and abuse as you call it, and disregarding the obvious exceptions to the "three times a year" rule this law will exclude people (of whatever class you want to call that can't afford health insurance) who are in actual need of health services.

This is a reprehensible law, and I can't see how YOU as an individual can condone it.”

“yo bare! gimme some stuff!”

“Okay. STUFF THIS! LOL
Hows it goin? Bufbabe? Yomgins?>>>>DOG? Did I say that! Mohaaaaaaaa!”

“I don't like the idea of my income being taken away from me and my family so other people can use it. I don't like it when I see abuse of the health care systems. Fraud is practiced by alot of health care providers and patients. It is not my fault the other people get sick or injured, but I have to pay for the cost of it and my own too. There are many ways to avoid sickness, most don't want to. We all are in the same boat heading toward's the same results. It is just that some are not rowing. I think they should be thrown over the side. I think I should have the right to charge what I want, and either you pay for it or don't buy my service's. I would start,by stopping prisoners from getting medical treatment unless they can pay for it themselves. Curing this problem won't be widely accepted, but in order to do so pruning and I think it will be alot will be the solution. But eating right and doing lots of hard work and exercise, and then getting plenty of sleep would work to. But why should I do that when I can just layaround get fat and get a check mail to the house. Stop the checks, please.”

“the hospital, by law, CAN NOT turn down an emergency patient. this goes for the new law addressed here on this thread.

Yeah, it's all about the bill afterward, though; Phaedrus



phaedrus, i want your stuff....”

“Yep, let's end all social services and lower taxes.

Here's a book that will let you read up on your next job.”

“Hey strat, who gets screwed when someone can't pay their hospital bill?”

“everybody but the patient”

“Everyone AND the patient.”

“Friggin' Insurance Companies.”

“i want tom terrific's stuff too....”

“Wel, grab a gun and take it, militia-boy!”

“malitia boy? puhleeze! i'll e-mail you my adress so you can send me your stuff.”

“No way. you're a good go-getter. Go get it.”

“you don't want to give me your stuff? i don't understand. i want it and you don't need it, you must be greedy and selfish......”

“You can't come take it? You must be weak and lazy.”

“see? you just care about yourself, you selfish american. and since i'm native american, it's because you are a racist angry white european male and hate poor trailor trash like me. give me your stuff or i will sue you on the grounds that you profitted from my toil and i want refferations too for my ancestors' suffering.”

“This all just sucks I think I am going to die so I don't have to go to the Hosipital.

HA HA!!!!!

8P”

“crazy mike's never die....they just hike off into the sunset....”

“And a footnote on all the Leftist class-warfare effluent being
spewed by the Demos, you might be interested to know who
the "classiest" guys are in the Senate. The wealthiest Democrat
could buy and sell the richest GOP senator more than 13 times.
Drum roll please.... First place goes to John "Ketchup King" Kerry
(D-MA) $675 million (more than half a billion inherited); In 2nd
place is bad-boy Jon Corzine (D-NJ), $400 million; 3rd place goes
to Herb Kohl (D-WS) $300 million; In 4th place, Jay Rockefeller
(D-WV), $200 million; 5th place goes to Dianne Feinstein (D-CA)
$50 million. Finally a Republican, Lincoln Chafee, shows up in
6th position. Hold the phone, there is a Republican
majority in the Senate, but the richest guys are all Democrats,
you know, the "Party of the People." Shouldn't there be some
"affirmative action" plan to raise up more rich Republicans?”

“Does it worry the conservatives that a system where the rich get richer and the poor get poorer is self-correcting? The have-nots should eventually realise that they are in the majority and vote.”

“what worries me is that you don't even have the nards to admit that the whole notion of conservatives all being rich and libs being for the "little guy" is a total load of crap and nothing but a scam. oh there's more examples, but i don't think you'd acknowledge them either. what worries me is that the "have nots" believe the "big lie" and that the libs telling the BIG LIE have no problem with being the big liars because the end justifies the means in their minds , and in the minds of people like you who defend and the BIG LIE, or simply lie about the BIG LIE. and every time you whine about the "have nots"(that would be me by the way) i'm gonna remind you that libs have NO room to talk on the matter when the top 5 richest senators and are worth over 1.6 BILLION dollors, and 7 out of the top 10 richest senators are democrats.




that's the BIG TRUTH. care to deny it? care to defend the big lie tilt, oh virtuos one? does truth mean nothing to you?



now ,i want you stuff tilt....”

“What a waste.”

“I hate family reunions. Everything starts out nicely until my uncle gets drunk and goes into his same old tired rant at the top of his lungs. Next thing you know he’s challenging everyone to a fight and breaking stuff. You can’t even hear yourself think.”

“Violin, if you don't go to your family reunions,how are you going to pick up any chicks?”

“You should a reunion from my husband's mother's side of the family. Everyone talks at once, and they get louder and faster as they try to talk over the others. Towards the end it sounds more like an auctioneer's reunion.”

“I think Violin was speaking metaphorically.”

“LMAO VIOLINSKY!”

“I like to pay too see things like that!

8)”