Minnesota Medicaid Confronts EMTALA

States are finally realizing that the ObamaCare Medicaid expansion makes it difficult or impossible to control their Medicaid expenditures. They are responding to the challenge in a variety of ways, some of which will likely put people’s lives at risk. In Minnesota, officials are trying to control the cost of treating the illegal aliens on Minnesota’s Medicaid rolls by creating a list of medical services that are not considered emergency care. According to Minnesota Public Radio, these include doctor visits, home health care, treatment for certain chronic conditions, and prescriptions from outpatient pharmacies. As of January 9th, 200 of the 2,300 noncitizens notified that they would no longer be allowed to use Medicaid for nonemergency conditions had appealed the state’s decision.The problem, from the perspective of Minnesota officials, is that the state Medicaid program has been paying for treatment for non-citizens who are ventilator dependent patients housed in nursing homes, receiving chemotherapy, and undergoing routine kidney dialysis. Under the proposed Minnesota statute, officials say, such services would not be considered “emergency” care.

Groups protesting the new law include the Minnesota Health Care Safety Net Coalition which represents the clinics, hospitals, and non-profits that receive substantial portions of their budgets from Medicaid and Medicare. They properly note that denying dialysis or ventilators to people who need them constitutes a death sentence. They do not indicate whether they have any plans to raise private money to pay for the continuing medical care for those may no longer qualify for tax funded services.

All aliens in the United States are eligible for emergency medical assistance under Medicaid as long as they meet the Medicaid eligibility requirements of the state in which they apply for benefits. Alison M. Siskin of the Congressional Research Service explains that in 1986, Section 9406 of the Omnibus Budget Reconciliation Act (P.L. 99-509) amended Section 1903(v)(3) of the Social Security Act to define an emergency medical condition as:

“…a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in — (A) placing the patient’s health in serious jeopardy, (B) serious impairment to bodily functions, or (C) serious dysfunction of any bodily organ or part.”

The GAO further notes that 42 CFR §440.255 specifies that there must be a “sudden onset” of the condition.

The problem with government entitlements, as Margaret Thatcher noted, is that sooner or later one runs out of other people’s money. When that happens with health entitlements, someone must decide who will and will not get care. If ObamaCare outlaws scaling back Medicaid income eligibility or the benefits it provides for the generally healthy, then officials will resort to implicit or explicit death panels for the expensive, gravely ill.

The evidence suggests that U.S. health entitlements have expanded beyond the point where marginal benefit equals marginal cost. One reason for this is that those who live off the river of funding from Medicaid and Medicare know that their best protection against budget cuts is being able to maximize the political outcry when cuts are proposed. They do this by maximizing enrollment. Enrollment has been maximized by nearly continuous lobbying for expanded eligibility, reduced verification of client claims, looser state residency requirements, and the redefinition of what constitutes emergency conditions.

Before entitlements, a vast network of private charities and mutual aid associations provided everything from low cost medical services to income support and outright charity. Since tax dollars were not involved, the focus was on the person rather than on his citizenship or income. People were free of the intrusive monitoring systems that government now requires they participate in in order to run its programs, and innovative independent private groups developed an array of techniques to control moral hazard, techniques that invariably combining rights with private duties and obligations. Since these groups actually used their own money to actually pay for medical care, they had a strong incentive to resist regulatory initiatives that would make it more costly.

As health entitlements expanded, non-profits placed less emphasis on paying individual medical bills. Today, many of the largest health foundations in the United States provide no private support to individuals in need. Instead, they seek to do good by spending other people’s money. They use their money to fund grants, research, and so-called “technical support” efforts that influence people in favor of entitlement program expansion. One result of their efforts is that the expanding entitlement web has effectively outlawed historically important forms of medical charity and moral hazard control and health spending, and costs, have skyrocketed. When fraternal societies provided medical care in mutual self-help societies, for example, receipt was dependent upon prior membership and appropriate conduct by the recipient. When private insurance companies provided individual health insurance, rates were dependent upon health behaviors and individuals were required to pay for a part of their care.

David G. Green neatly summarized one of the main drivers of health care spending in an essay on “Medical Care through Mutual Aid” in Beito, Gordon, and Tabarrok’s book The Voluntary City. “…[I]n the voluntary associations that predated the welfare state,” he writes, “the link between personal payment and entitlement was clear. Once the state intervened, “rights” increasingly became claims to benefits at the expense of other people and no longer the just entitlement of shared responsibility.”

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