EDITORIALS

LePage’s Medicaid consultant ought to deliver cost-saving solutions fit for Maine

A doctor checks the blood pressure of a patient at the J.W.C.H. safety-net clinic in the center of skid row in downtown Los Angeles in this July 30, 2007, file photograph.
LUCY NICHOLSON | REUTERS
A doctor checks the blood pressure of a patient at the J.W.C.H. safety-net clinic in the center of skid row in downtown Los Angeles in this July 30, 2007, file photograph.
Posted Dec. 02, 2013, at 12:50 p.m.

The consultant Gov. Paul LePage’s administration has charged with conducting a far-reaching — and controversial — review of Maine’s Medicaid and public welfare programs faces a key deadline in the coming weeks.

On Dec. 20, Gary Alexander — the former health and human services chief in Rhode Island and former welfare chief in Pennsylvania — and his colleagues are expected to deliver their blueprint for a “global redesign of the Medicaid-welfare system and operations,” according to Alexander’s contract with the state.

Regardless of political persuasion, there should be universal agreement that Maine’s Medicaid system is in need of reform. It’s our hope Alexander’s report offers a viable path forward upon which Democrats and Republicans can agree, though it wouldn’t hurt for lawmakers to be slightly wary of its advice.

Maine’s above-average health care spending extends to MaineCare, the state’s Medicaid program. In 2009, Maine spent $8,077 per Medicaid recipient, the 16th-highest total nationwide and 18 percent more than the national average, according to the federal Centers for Medicare and Medicaid Services.

Medicaid now accounts for about a quarter of Maine’s state budget. And even though Maine is not among the states expanding Medicaid under the Affordable Care Act, the state’s Medicaid program is still expected to grow as uninsured residents look for insurance to comply with the federal law’s individual mandate and discover they’re Medicaid-eligible. In October, that happened to 623 Maine people. That number can be expected to grow as healthcare.gov recovers from its bungled rollout and enrollment deadlines approach.

Within Medicaid, there are several areas where change should happen, lowering costs and improving the quality of care. One expensive example is emergency room use. In 2006, Maine’s overall emergency room use was 30 percent higher than the national average, and Medicaid recipients were more likely than those with private insurance and the uninsured to visit the emergency room for care.

We wouldn’t be surprised to see Alexander recommend Maine pursue a “global waiver” from the federal government that would allow the state to administer more Medicaid services as it sees fit in exchange for sticking to a defined budget cap. LePage and Mary Mayhew, Maine’s health and human services commissioner, have often spoken of a need for a global waiver, and Alexander is noted for the global waiver he secured for Rhode Island. In a consulting report he completed earlier this year for Arkansas’ General Assembly, Alexander recommended a global waiver for that state.

Rhode Island’s waiver wasn’t exactly global, since the federal government didn’t allow the state all the flexibility it requested. But the flexibility it did grant could be a type of flexibility that serves Maine well. Though the state could have made many of the changes it did without the waiver authority, Rhode Island’s waiver allowed the state to change the way it delivered long-term care to adults with disabilities and the elderly, allowing the state to claim federal reimbursement for more services provided at home and in community settings rather than in nursing homes.

Rhode Island has also shifted its Medicaid program to a managed-care model in which health care providers have incentives to keep patients healthy rather than perform multiple tests and procedures. That’s a change Maine can make without a global waiver, and it’s a change several other states have made.

Tennessee was the first state in the country to make the change and has seen promising results: virtually unchanged per-recipient Medicaid costs since 2004 and 95 percent satisfaction among recipients. Arkansas hasn’t adopted managed care, but it’s experimenting with a model in which it rewards primary care doctors substantially for keeping their patients healthy and out of the hospital.

If Alexander recommends a global waiver for Maine along the lines of Rhode Island’s model, policymakers should know that Maine is unlikely to receive the same arrangement Rhode Island received in the last days of George W. Bush’s administration in 2009. While the Ocean State agreed to stay under an aggregate $12 billion, five-year budget gap in exchange for the flexibility, the state never expected to come close to spending that much. Critics have called the arrangement a “sweetheart deal.”

There are lessons Maine can learn from Rhode Island’s experience. Alexander should make sure they can translate to Maine before recommending them here.

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