As I’ve said before, there so much joy and wonderment that comes with having a person like Koan around. But, there’s also a fair share of worry, too. At the end of October, Amerihealth Caritas announced they were leaving the Iowa Medicaid program. This is a big deal and will impact tens of thousands of Iowans. Koan won’t be directly impacted, yet. One of the hardest things to do when caring for a person like Koan is to figure out how to navigate and coordinate services. So, I thought I’d write a bit about how all of these systems work from our family’s perspective — understand that I don’t have all of this figured out. But, more importantly, I’m going to try and explain why the Amerigroup defection could impact Koan and what you can do to help him going forward.
A couple of years ago, the Branstad administration put forth a proposal to privatize the Iowa Medicaid system and moved it through the legislative process. In this new system, the Iowa legislature removed most of the Iowa of Department of Human Services (DHS) ability to administer Medicaid. And, they gave Medicaid management to three private companies (with very similar names): Amerihealth Caritas, United Healthcare, and Amerigroup. These three Managed Care Organizations (MCOs) would be responsible for providing services for virtually all Iowans who need Medicaid.
The MCOs were given a flat rate for each patient annually (a per capita spending limit) and the thinking was that this plan would not only be more cost-effective because it controlled spending, but the quality of care would be better due to market pressure to provide good service. It’s hard to argue with either of these points. But, good ideas are not worth much if they are not implemented well. Medicaid is a big umbrella program. It covers both low-income and disabled people — a large, diverse population. It’s a really really complex, multifaceted system. I would argue that Medicaid is also a high-reliability system — like a bridge or a nuclear power plant. There’s very little room for error — it must work correctly and predictably all the time to fulfill its main function. There’s little or no room for large-scale, iterative improvement.
The full conversion to the privatized system was done in less than six months. This rush to implement is a key factor in why the program is performing so poorly. What makes this particularly frustrating is that the fast track to rollout was done to minimize political pain and not with the wellbeing of constituents in mind. Each of the MCOs has lost tens of millions of dollars and Iowa has needed to dip into the State’s “rainy day” savings fund to subsidize and keep the program afloat in both of the last two fiscal years. Even more troubling is that mismanagement by the MCOs has cost lives. Disability Rights Iowa has a pending class-action lawsuit against the State of Iowa based upon several deaths related to MCOs inability to provide services. The personal stories I’ve heard from people who rely upon the MCOs are horrifying. Essential services such as medication and other medical treatments being denied in long drawn out exchanges that sometimes take weeks. It’s costing the taxpayers more and it’s directly responsible for loss of life. By any (and every) measure that matters, the privatization of Medicaid in Iowa has failed.
But, like many things with Koan, in particular, issues are not black or white or cut and dried. To further complicated matters, when the privatization took place, the legislature left a very small segment of Iowa Medicaid in place. And, because he’s anything but typical, Koan was able to stay enrolled in what was left of Iowa Medicaid through a program called, HIPP — Healthcare Insurance Premium Program. The way it works is that we keep Koan covered under our private insurance and anything that Wellmark (my insurance provider) won’t cover, Iowa Medicaid will pay for with prior approval. So, for example, Wellmark will typically pay for about $1,200 of Koan’s AFOs (leg braces). Iowa Medicaid picks up the other $1,000ish. In addition, we receive a monthly check (proportional to Koan’s portion our Wellmark premium) as an incentive to stay in the program (to keep Koan on our plan). We’ve been enrolled in HIPP since Koan was born, and it has worked really well for us. We’ve gotten what we need when we needed it. This is a stark contrast from the experiences I’m hearing from friends who are now forced to use the MCOs. We are so thankful that Koan qualifies for HIPP and we pray each July 1 that he continues to qualify to be enrolled.
So, aside from altruism, why would I care about the privatization of Iowa Medicaid if Koan is not directly impacted? It’s very, very hard to hear stories about individuals and families struggling with already complicated lives having to battle bureaucrats inside the MCOs for essential services. So, it’s pretty easy for me to line up against this type of legislation just based upon that. However, the main reason does come back to Koan. We can only keep Koan in HIPP and Iowa Medicaid until he’s 26 (unless the US legislature makes changes to that provision in the ACA). Eventually, if nothing changes, Koan would be part of this flawed system. So, I’m starting work now to hopefully change the system for him and all of the others that are languishing under this terrible system.
My goal is that like many other states that have tried privatization, Iowa will reinstate its own Medicaid program again. One proposal currently being considered is to move all medically complex disabled people back to Iowa Medicaid. This would effectively decouple the low-income population from the disability population. I fully support this concept as well. So, at long last, here’s what I’m asking everyone who loves Koan to do:
- Please contact Jerry Foxhoven, the Iowa DHS director, and urge him to support moving all disabled people back under Iowa Medicaid.
- Local politics are incredibly powerful. Engage with your Iowa House and Iowa Senate candidates. To be crystal clear — I’m talking about specifically the Iowa legislators, not the federal reps like Grassley and Blum. It’s still good to talk to those type of folks, too, but they don’t directly influence Iowa law. When you vote in the 2018 elections next year, please ask your Iowa House and Iowa Senate as well as gubernatorial candidates their stance on privatized Medicaid. If they support this flawed, expensive, and dangerous policy, let them know you don’t approve. Please consider voting for a candidate that opposes privatization of Medicaid services for disabled people.
The departure of Amerihealth is an opportunity for the elected officials that initially supported privatization to re-think and re-evaluate the value of this program. But, even if all disabled people were moved out of the privatized system, the Iowa legislature would also need to allocate resources to rebuild and refund Iowa Medicaid. Your voice and vote really matter. I strongly urge everyone to get out and talk to your state rep and senator. Ask them not to support privatized Medicaid services for disabled people. Please speak for Koan.