When Shantel Shelby noticed that her once bubbly 2–year-old daughter was acting lethargic and preferred napping over playing with her Legos, she took her daughter to the emergency room. After four months of seeing different doctors and making a series of emergency room visits, her daughter was diagnosed with a hormonal imbalance that required medication and surgery.
Today, Shelby, who has Medicaid, but no primary care doctor, still races her now 3-year-old to the closest emergency room when she spikes a fever or has an ear ache or a stomach bug.
“I don’t have time to go searching for a doctor when my baby is sick,” said Shelby, a Chicago resident expecting her second child in the fall. “It’s a pain starting over with a new doctor each time, but going to the emergency room is easier than going across town to find a doctor that takes Medicaid.”
The single mom and her growing family may soon spend less time frequenting emergency rooms and gain greater access to a primary care physician as a part of the Medicaid reform bill.
In January, Gov. Pat Quinn signed legislation implementing an overhaul of the Medicaid system in Illinois, which his administration says is expected to save the state $800 million over five years.
“Medicaid is an archaic and chaotic system,” said State Sen. Dale Righter, R-Matoon, who sponsored the Medicaid reform bill with bi-partisan support. “It needed to be changed so people can be better taken care of for the long haul.”
Under House Bill 5420, the Department of Healthcare and Family Services will require that half of Medicaid patients receive coordinated care by 2015.
Currently, 195,000 of the 2.8 million low-income individuals and families, people with disabilities and older adults that are enrolled in Medicaid have a primary physician, or “medical home.”
“Up until now the Medicaid population have been doctor shopping, bouncing from one doctor to the next, in and out of emergency rooms, and are without a medical home,” said Rep. Patricia Bellock, R-Westmont. “These people need a primary doctor that can address disease prevention and wellness on a regular basis.”
The bill also authorizes the department to tighten the eligibility process by requiring proof of Illinois residency; tighten income verification by requiring a month’s worth of income information, instead of a single pay-stub; and require annual re-determination of eligibility.
The legislation also puts a cap on the All Kids program, the state’s health insurance for children of parents who earn too much to qualify for Medicaid. Parents participating pay health insurance premiums based on their income, which will be limited to 300 percent of the federal poverty level-or $66,150 for a family of four. The bill also expands the program to 2016.
The nearly 3,000 participants above the poverty level enrolled now in the program will have a year to find health coverage, although State Sen. Heather Steans, D-Chicago, says that was one part of the reform she was troubled by.
“I wouldn’t have pressed limiting access to covering the kids,” Steans said. “It concerns me, but hopefully all the children will be covered soon enough under Obama’s plan.”
Steans was more excited about the portion of the bill that allows the government to transfer up to 4 percent of funds from long-term care facilities to community-based alternatives as part of a shift to more in-home care, at an annual savings of $100 million.
“Not only is this a more cost-effective way to take care of our seniors, “ Steans said. “But this allows them to live independently as long as possible and improve on their quality of life.”
But opponents say the quick switch to managed care may leave some of the most vulnerable on Medicaid without access to the specialty services they need.
“We got something we really wanted but we had to pay a price,” said Amber Stock, director of advocacy for Access Living, a cross-disability organization on Chicago’s West side, who testified at the Medicaid reform hearings.
“We fought long and hard to rebalance long-term care funding, but we are concerned about managed care; we don’t want it to fail, but they don’t have the best track record.”
Righter said that the cost cutting initiatives in the bill would allow more money to go to services that are necessary for the disabled, seniors and chronically ill, such as paying for specialists and physical therapies.
Over the last six weeks, both parties came together to face the $15-million state-federal health care system that was growing at a rate of 8 percent each year and crowding out other issues like education, which requires a large portion of the state’s budget, said Rep. Barbara Flynn Currie.
“Both sides came with all the cards on the table and worked cooperatively to pick up the deck and stack it a little differently in ways that will improve the quality of health care,” Currie said. “It’s win-win for clients and for the fiscal health of the state.”