SD11 - The Governor's Task Force on Indigent Health Care

  • Published: 1988
  • Author: Office of the Governor
  • Enabling Authority: Senate Joint Resolution 151 (Regular Session, 1987)

Executive Summary:
Background

In accordance with Senate Joint Resolution No. 32, introduced by Senator Dudley J. Emick, Jr. in the 1986 General Assembly, the Governor of Virginia, the Honorable Gerald L. Baliles, appointed a Task Force to study all aspects of the Commonwealth's indigent health care problems. The study was expected to:

* consider the feasibility of establishing a special program to fund medical care necessary for indigent mothers and children;

* identify problems of the indigent which are specific to the Commonwealth; and

* recommend appropriate actions to resolve these problems.

After appointment by the Governor, the Task Force began its review of the problems associated with the provision of medical care for Virginians living in or near poverty. After all involved State agencies had provided details of their programs, an Interim Report was made by the Task Force in December 1986 on the history and current scope of medical services being provided to the indigent. The report also presented a broad assessment of the State policy questions to be faced. These related to:

* recognition of the need for better information on the characteristics of the medically indigent and those at risk of becoming indigent;

* identification of specific health service requirements of various segments of the indigent population;

* determination of the responsibilities for the delivery and of solutions for the problem of inequitable distribution of uncompensated health care;

* effectiveness of the organization of State efforts to render health care for the poor and near poor; and

* methods for controlling the growth of costs to the Commonwealth for its array of health-related programs.

In the Interim Report, the Task Force identified every State agency program which contributed health care services to the indigent, the funding sources for these programs, the number of clients utilizing State services, and the amount of Fiscal Year 1986 funds (General and Special) expended in each program and in total ($1,010,382,000). Fifty-seven percent of this total was provided from General Funds of the Commonwealth, 36 percent from federal appropriations, and 6 percent from local government and other sources.

The 1987 General Assembly, by Senate Joint Resolution No. 151, patroned by Senator Emick, recommended that the Governor continue the Indigent Health Care Task Force and add to its responsibilities determinations on what new actions the Commonwealth could take to:

* maximize the use of available resources in the provision of indigent health care services.

In its work, the Task Force benefited particularly from information provided in:

* House Document No. 29 (1986), "Alternatives for a Long-Term Indigent Health Care Policy"; and

* House Document No. 20 (1987), "The Degree of Health Care Insurance Coverage in Virginia".

It was handicapped in its efforts to develop specific action recommendations because of the unavailability of information on the size and needs of the indigent population. Collection of such data continues to be essential to allow a comprehensive assessment to be made of how Virginia resources should be adjusted to meet the priority requirements of those most in need of medical care services.

Medical Indigency

The Task Force found that persons without means to obtain adequate medical care include more than those subsisting near or below the federal poverty income level. All uninsured and underinsured face becoming indigent in the event of serious illness and therefore must, potentially at least, be considered as part of the "medically indigent" population of the Commonwealth. Less obviously, nearly all Virginians face the potential for indigency in the event of major or catastrophic illness.

Current Situation

Nearly two-thirds of all expenditures now made by the Commonwealth to provide general health care for the poor are expended through its Medical Assistance Program (Medicaid). The severe health care problems of the elderly population and the ever increasing need for long-term care of this population are placing a heavy fiscal burden on the Medicaid Program. The dollar value of uncompensated care provided by the Commonwealth, its medical delivery system, businesses, and paying patients continues to increase. The burden of uncompensated care is not being equitably shared within the health care field and present trends indicate increasing reliance will be placed on the State for care of the poor. The health care industry should assist government in providing this care to the fullest extent of its capability.

Summary

The Task Force characterizes the general situation, in regard to the provision of adequate health care for the medically needy, as critical. It predicts that unless more reliable information on the needs of the poor is quickly obtained, and followed promptly by significant additional private and public resources for new initiatives and selected ongoing programs, the plight of the medically needy in Virginia will deepen and their numbers will continue to grow (see Preamble, p. 2).

Indigent health care problems are recognized to be a societal responsibility. If proper priority assessments are made and the cooperation of the private and public sectors is obtained, the Task Force believes sufficient resources exist in Virginia to resolve these problems.

Precise determination of solutions on some issues was beyond the capability of this Task Force because of data, time and resource limitations. Consequently, continuing State leadership on actions to improve the health of indigent citizens is essential.

Recommendations

General

The recommendations of the Governor's Task Force are intended primarily to define the path the State should take in policy decisions. Some recommendations will require further analyses to determine specific costs and long-term implications; other recommendations may warrant "pilot" efforts to prove the anticipated benefits. Nevertheless, ·the Task Force is confident that the major issues have been identified and that actions proposed under each will result in substantial improvements in State medical services for its indigent citizens. The Task Force was pleased to note that as the current status of problems and alternate courses were being reviewed, some agencies were motivated to begin Task Force Subcommittee-suggested improvement actions immediately if adequate resources were available.

Sixty-two recommendations were generated from the Task Force study of 2l major issues facing the Commonwealth. They are shown in this report following the issues which they address, and are also listed separately in Appendix A. Among the recommendations deserving of special attention by the Governor and/or the General Assembly of Virginia are:

INDIGENT MOTHERS AND CHILDREN

To provide the most urgently needed medical care for the indigent mothers and children, the Commonwealth should:

1. PROVIDE SUFFICIENT ADDITIONAL STATE FUNDING FOR IMMEDIATE EXPANSION OF THE MEDICAL ASSISTANCE SERVICES PROGRAM TO INCLUDE THE NEW FEDERAL OPTIONS FOR PREGNANT WOMEN AND CHILDREN (UP TO ONE YEAR OF AGE). EXPANSION IN SUBSEQUENT YEARS OF THE ELIGIBILITY AGE LIMIT FOR CHILDREN TO AGE FIVE SHOULD ALSO BE FUNDED (pp. 50 and 63).

Adoption of this option will result in additional federal funds being obtained, more mothers and children being served, and reduced amounts of State-only dollars being required for the State teaching institutions and the Health Department.

2. MODIFY THE MEDICAID PROGRAM TO ALLOW REIMBURSEMENT FOR IN-HOME USE OF APNEA MONITORS FOR HIGH-RISK INFANTS, SUCH AS THOSE DIAGNOSED AS HAVING APNEA PREMATURITY (p. 50).

High-risk infants are those identified as such only after a comprehensive medical workup that clearly demonstrates the need for cardiopulmonary monitoring which, if not provided, would necessitate continued hospitalization. No additional State funding should be required to implement this recommendation, as offsetting savings will occur from the reduction in necessary hospitalization for these infants.

MAXIMIZING UTILIZATION OF RESOURCES

To assure that available resources are effectively and efficiently used, the Commonwealth, in addition to the above, should:

3. COMPLETE A COMPREHENSIVE HEALTH PREVENTION PLAN AND PROVIDE FUNDING IN THE 1990-92 BIENNIUM FOR ITS PROPOSED PRIORITY ACTIONS (p. 20).

The economic and other benefits of health education and/or supportive actions on lifestyle changes, which provide avoidance of disease and illness, have been proven at all levels of society.

4. EXPAND MEDICAID PROGRAM COVERAGE TO INCLUDE ADULT DAY CARE AND OTHER COMMUNITY-BASED SERVICES WHICH CAN SERVE AS ALTERNATIVES TO INSTITUTIONALlZATION (pp. 26 and 50).

Before allowing admittance of Medicaid-eligible persons into nursing homes, a screening is conducted to determine if less-costly services are suitable and available. In some cases, families can and will keep elderly parents in their homes overnight and on weekends if substitute adequate care is available during daylight work hours. Community-based services such as adult day care, respite care and home or community therapeutic care provide additional opportunities for maintaining family structure .and a less-costly service for Medicaid recipients.

5. REQUIRE CASE MANAGEMENT PROCEDURES TO BE FOLLOWED BY MEDICAID AND ALL OTHER STATE PROGRAMS WHlCH ARRANGE OR PROVIDE OUTPATIENT CARE FOR INDIGENT CITIZENS (pp. 50 and 54).

Individual case management is a uniquely effective method for assuring maximum· response to individual needs for non-institutional medical services. Under this concept, a designated medical coordinator, pursuing an objective of healthful living, assumes responsibility for focusing the utilization of services to the specific requirements of the patient.

6. HAVE THE SECRETARY OF HUMAN RESOURCES CONDUCT A STUDY TO IDENTIFY THE VALUES AND DETERMINE THE FEASIBILITY OF DESIGNATING ONE STATE AGENCY AS THE PRINCIPAL RESPONSIBLE AGENCY FOR ESTABLISHING STATE HEALTH CARE POLICY AND FOR COORDINATING MANAGEMENT OF ALL STATE FUNDS APPROPRIATED FOR INDIGENT HEALTH CARE (WITH THE EXCEPTION OF FUNDS APPROPRIATED TO THE TEACHING HOSPITALS AND THOSE PROVIDED SOLELY TO FUND VIRGINIA PARTICIPATION IN THE MEDICAID AND OTHER FEDERAL PROGRAMS) (pp. 34 and 45).

State institutions and departments now provide different health-related services for much of the same clientele. Coordinated objectives and service policies are important for assuring against fragmentation of effort, for promoting holistic care, and for preventing waste of resources. Having a lead agency responsible for overall direction and general application of State appropriations for medical care of the indigent should result in more equitable distribution and better accountability of funds.

7. DESIGNATE ONE STATE AGENCY TO BE RESPONSIBLE FOR DETERMINING CLIENT ELIGIBILITY FOR ALL STATE HUMAN RESOURCES PROGRAMS WHICH OFFER SERVICES AT LOCAL GOVERNMENT LEVELS (p. 68).

Citizens face many different criteria and must travel to several locations in order to receive Human Resources program services. The Department of Social Services establishes the eligibility for the Department of Medical Assistance Services, but all other agency programs make their own evaluations of applicants. More efficient use of resources and better service to the public would be expected by having one agency required to determine eligibility for all State health and social programs.

OTHER SUBJECTS

In order to improve access and promote more effective services for the indigent, the Commonwealth should:

8. REVISE THE STATE CODE TO REQUIRE ALL LOCAL GOVERNMENTS TO PARTICIPATE IN, AND TO ADHERE TO STATE ELIGIBILITY STANDARDS FOR, THE STATE-LOCAL HOSPITALIZATION (SLH) PROGRAM AND THE GENERAL RELIEF PROGRAM (p. 67).

Virginians do not now have equal access to the services offered by these State programs because of the existing local option to participate and to determine who may be served. A local government decision not to participate in SLH or General Relief denies local citizens access to services which are being offered to citizens in other areas. It also places a special financial burden on area hospitals and accentuates the inequitable distribution of uncompensated care.

9. REQUIRE THE SECRETARY OF HUMAN RESOURCES TO DEVELOP A PLAN FOR PROVIDING MORE BALANCE AMONG ALL HOSPITALS IN SHOULDERING RESPONSIBILITY FOR THE BURDEN OF UNCOMPENSATED CARE (p. 73 and 74).

Several states have already reacted to obtain a more even distribution of the costs of indigent patient care in hospitals. Some have raised funds to offset the imbalance by imposing a tax on hospitals; others have assessed insurance premiums, taxed employers or made adjustments to State-controlled charges on hospital services. The various approaches taken by states to alleviate the growing problem of uncompensated care deserve thoughtful evaluation and consideration in regard to their possible value for emulation by the Commonwealth.

10. HAVE THE STATE CORPORATION COMMISSION'S BUREAU OF INSURANCE MAKE FORMAL STUDIES AND PREPARE RECOMMENDATIONS FOR LEGISLATION TO CREATE: A) TAX INCENTIVES FOR EMPLOYERS TO OFFER HEALTH INSURANCE BENEFITS TO ALL EMPLOYEES; AND B) A STATE-OPERATED HEALTH INSURANCE RISK POOL (p. 87).

More than half of the Virginians who do not have health insurance protection are employed and earn incomes in excess of the federal poverty level. Many of these work in service industries, are temporary workers, or receive minimum wage pay; others have applied for health insurance and have been rejected because of physical problems.

Additional proposals to assist the medically needy of Virginia are described in this report. They include actions to re-orient State services and increase their effectiveness, resolve specific problem areas, and/or promote a higher level of health. Steps taken toward better health for the medically indigent population will allow more Virginians to become employed, thereby reducing the future quantity of needed State assistance and promoting happier, more responsible, and productive citizens.