Judge: Some Medicaid copays harmful

Says poor can't afford them, so need more expensive care later
2013-02-09T00:00:00Z Judge: Some Medicaid copays harmfulHoward Fischer Capitol Media Services Arizona Daily Star
February 09, 2013 12:00 am  • 

PHOENIX - A federal judge has again rebuffed efforts by the state to justify copays for medical care on some adults in Arizona's Medicaid program.

Judge David Campbell said there was no evidence U.S. Health and Human Secretary Kathleen Sebelius, who approved the charges, actually considered evidence the payment requirements can cause harm to patients who might forgo otherwise needed care. The result, according to attorney Ellen Katz, whose public- interest law firm sued, is that people wait until they are really sick and end up needing far more extensive - and expensive - treatment in emergency rooms.

"Copays are a barrier to the receipt of health care," Katz said.

In his ruling, the judge said Katz had presented evidence that copays for prescriptions "cause low- income beneficiaries to forgo essential and effective medication, leading to higher incidences of serious medical conditions such as heart attacks and strokes."

The ruling does not permanently strike down the payments. Instead, Campbell gave Sebelius 60 days to review the evidence and make a new decision.

But Katz, director of the William E. Morris Institute for Justice, said she hopes officials of the Arizona Health Care Cost Containment System, the state Medicaid program, do not pursue the issue.

She pointed out the state's permission to charge the higher fees is set to expire at the end of the year. That's when the federal Affordable Care Act kicks in and all those affected automatically become part of the full Medicaid program, without additional charges.

An AHCCCS spokeswoman said the decision is up to Health and Human Services. Federal officials did not immediately return calls seeking comment.

At the heart of the fight is an effort by the state several years ago to save money.

The federal government provides the majority of the funding for Medicaid patients. In exchange, the state agrees to cover certain groups, like families and children below the federal poverty level.

But there is no federal requirement to cover childless adults.

Arizona decided it would not enroll any new childless adults, though it would not kick off any of the approximately 220,000 already in the program, of which only about 84,000 remain.

The other half of the cost-savings measure involved a new charge of $4 per prescription of a generic drug and $10 for a brand name when a generic is unavail-able. The agency also sought to raise the cost of a visit to the doctor's office to $5, with a $35 charge for nonessential emergency-room care.

Generally speaking, Medicaid does not permit these kinds of copays. In fact, another federal judge blocked similar copays when the state first tried to implement them a decade ago.

But this time the state got the federal government to approve it as a "demonstration project" to see if the charges are effective at saving money.

Campbell noted a declaration submitted by Katz from Dr. Leighton Ku, who said copays already have been studied for years. The judge said that declaration also had other evidence that Sebelius should have considered.

"The research reviewed by Dr. Ku showed, in part, that the imposition of copayments for preventative, primary care leads to low-income beneficiaries seeking fewer essential medical services and relying more on emergency-room care and hospitalizations," Campbell wrote.

Katz said even small copays for prescriptions can hurt the poor, pointing out there is no cap on how much someone might have to pay.

"A lot of these folks have seven and eight medications," she said.

"When they can't get their medication and have significant medical problems, they end up using the emergency room, which is the most costly ... care," Katz continued, noting hospitals cannot legally turn away people in life-threatening situations.

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