Cuts to Medicaid threaten real pain

Washington budget realities could put end to life-saving services

By Kathie Durbin, Columbian staff writer

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Debb Snyder’s slender lifeline to independent living is her government-paid prescription for Klonopin, the expensive anti-seizure drug that controls her grand mal seizures and allows her to remain in her small apartment off St. Johns Road. She’s been taking 0.5 milligrams of the drug six times daily for 20 years.

That’s why it was intensely personal for Snyder when she saw the list of cuts to Medicaid programs the Washington Department of Social and Health Services is preparing to implement between Jan. 1 and March 1 to achieve its share of 6.27 percent across-the-board cuts in state agency budgets.

The department will eliminate coverage for outpatient prescription drugs provided by retail pharmacies to an estimated 277,000 clients, effective March 1. As a “discretionary” program under Medicaid, the prescription drug program is one the state has the option to discontinue while still maintaining its partnership with the federal government in providing health coverage to the poorest of the poor under Medicaid.

Drugs administered in a hospital, doctor’s office or long-term care setting won’t be affected by the cut

DSHS’s Medicaid Purchasing Administration pulls no punches in describing the impact of the decision, which will save the state $39.4 million in the current budget year:

“Inpatient hospitalizations and emergency room visits may increase for treatment of infections that have reached a severity where they now require IV antibiotics,” the administration predicts in its budget-cutting plan. “Hospitalization may also be the alternative care for clients who do not have access to insulin, mental health medications, respiratory and cardiac medications, anti-coagulants and other life supporting medications. There will be a decline in health status and an increase in costs associated with more intensive services required to treat the more severely ill.”

At the pharmacy counter, the difference between brand-name Klonopin and generic clonazepam is eye-popping: $18 for generic, $627 for the brand-name drug.

Snyder said she tried the cheaper generic version of the anti-seizure medication years ago to treat the congenital, inoperable tumor that causes her seizures, but it did not control them. “If you stop taking it abruptly, or even gradually, it can drop serotonin levels dramatically,” she said. As each of her six daily doses wears off, she said, “I can feel it go out of my system. “

As things stand now, Snyder can fill her Klonopin prescription at Walgreens with no co-pay. No one has been able to tell her whether her status as a permanently disabled Social Security beneficiary might allow he to keep getting the drug free of charge, or whether she might be eligible for charitable coverage. If not, she says, it’s “meltdown” time; she says she knows of two people who died after being abruptly taken off the drug.

Other cuts proposed

Retail prescription drugs are just one of several Medicaid services that will go away within weeks under Gov. Chris Gregoire’s $520 million cut in the budget of DSHS, the state’s largest agency. Of that total, $113 million will come from “discretionary,” or optional, Medicaid programs.

All physical, occupational and speech therapy services for adults, including rehabilitative therapies for traumatic brain injury and stroke, will be discontinued. So will all adult dental services except emergency treatment of pain. So will adult visions services, which as DSHS acknowledges will cost some clients their independence and ability to hold a job, or even result in accidental injury or death.

Prenatal care, family planning services, school-based special education services including physical and speech therapy for children, and Medicare Part D co-pays for very low-income seniors also will be discontinued.

Elsewhere in DSHS, clients who receive help in their homes with bathing, eating and other personal care will lose hours of service, rates paid to providers to care for people in assisted living centers and long-term care facilities will be lowered, senior referral services will be reduced, and training programs for long-term care providers will be cut. Hospice care will be eliminated for 2,600 low-income people, and the state will cuts at least $19 million from child care subsidies for families in which parents are trying to make the transition from welfare to work.

Vigorous response

Providers and clients served by social service programs are not sitting quietly by.

Last Wednesday, about 100 activists showed up for a candlelight vigil at the Capitol in Olympia and warned that the cuts scheduled to take effect beginning Jan. 1 will shred the safety net. The vigil was organized by AARP, ARC of Washington, PAS-Port for Change, SEIU Healthcare 775 NW and the Washington State Senior Lobby, among other groups.

Walt Bowen of the Senior Citizen Lobby told The Olympian newspaper he fears he is seeing the dismantling of a long-term care system that allows seniors and the disabled to stay in their homes and that took 30 years to build.

The advocacy group Disability Rights Washington is urging people to contact its office and share their stories about how the cuts will affect them. It’s also threatening litigation to halt the cuts.

Dr. Jeff Thompson, chief medical officer for the Washington Medicaid program, says the state, faced with a projected $5.7 billion budget gap in the 2011-13 budget cycle, has few options.

“When there is a budget crisis, we are always looking at opportunities for changing eligibility, changing rates or changing benefits,” Thompson said.

But because Washington’s Medicaid program received federal stimulus funds, he said, the state must show “maintenance of effort” and is not allowed to change Medicaid eligibility standards until 2014, when new health insurance exchanges will be established under the national health reform law.

And when the state has reduced rates to medical providers in the past, it’s been sued, Thompson said. “You can’t take the rates down because your clients will lose their providers. Then it becomes an issue of whether they have access to services.”

That leaves cutting benefits as the only option, he said.

“The governor doesn’t have the option to take a surgical scalpel to the budget,” he said. “She has to do across-the-board cuts.”

The Legislature has more discretion. And some legislators say they find the DSHS cuts, especially cuts to prescription drugs, unacceptable and hope to reverse them.

“Taking medications away from the disabled community is not really a good cut to make,” said state Rep. Ed Orcutt, R-Kalama, last week.

“We are all having sleepless nights about these cuts,” Thompson said. “We are hopeful the state Legislature can figure out a solution. In the event these cuts do happen, we can steer clients to pharmaceutical companies that may be able to help them with grants. We will help the community out in any way, shape or form that we can if the Legislature decides we can no longer afford a drug benefit.”

Asked the worst-case scenario, Thompson paused.

“There is one state that limited the absolute number of prescriptions, and they did see the downstream effects in emergency room admissions,” he said. “We do know that there will be extreme impacts. There is a possibility that there would be a public health crisis.”

Kathie Durbin: 360-735-4523 or kathie.durbin@columbian.com.