As the General Assembly considers whether to approve the Medicaid global waiver that Gov. Donald L. Carcieri successfully negotiated with the Centers for Medicare & Medicaid Services, legislators have heard many concerns from the long-term care industry, people with disabilities, seniors and their families, policy experts and advocates.
Among those urging caution has been the Rhode Island Public Health Association, a group of health care practitioners, policymakers, nonprofit leaders and others focused on policies and strategies to improve the health and well-being of the population as a whole.
Patricia Markham Risica, an associate professor of community health at Brown University, past president of RIPHA and chair of its advocacy committee, answered questions about the group’s position on the waiver.
PBN: How closely has the association watched the discussion of the global waiver? Did you testify against it before it was approved, or before the General Assembly?
RISICA: We have not testified. We did write a white paper on it and released it in October. The white paper is mostly about long-term care, but the waiver is much broader than that. It can have ramifications for many different kinds of health care funding. And the issue is not that it’s a problem to consider other ways of providing care; for example, in long-term care, the idea is to really have patients cared for at home, which is less expensive than inpatient care. A lot of patients would love to have that … it’s just that we’re not prepared. Rhode Island does not have those kinds of community services yet; we don’t have ways to help family members provide appropriate care. We can’t make the change until the infrastructure is in place.
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PBN: The Carcieri administration has indicated that they believe if they create demand through policy change, service providers will step up.
RISICA: That’s certainly the capitalist way to go about it. It’s not so much that you want to provide capacity and have capacity sitting there waiting – that’s not feasible, either. But what needs to happen, and the leadership that the state needs to provide, is the oversight to ensure that care is being given, that people aren’t sitting at home trying to find nursing care that doesn’t exist or refusing nursing care and having patients languish at home, which frequently happens. … Frequently family members and patients don’t call for help, because they don’t know there’s someone there to help them, and they don’t know what a bad situation looks like. So it’s not necessarily the kind of situation where you can depend on people to raise the red flag when it needs to be raised. There need to be resources in place so that people don’t fall between the cracks, and right now I think the cracks are really big. The likelihood of people going without care outside of oversight from the state or their own health care provider is pretty high.
PBN: Isn’t that a problem even without the waiver or any system changes?
RISICA: Not to the degree that I think that it will. … But when we’re decreasing the inpatient services … there are going to be patients with greater needs than are currently staying home who will not be admitted to nursing homes and for whom services will have to be arranged. So the level of care required is going to increase outside the inpatient setting … and how long does it take to ramp up services? I don’t know. How many months does it take for an increased number of visiting nurses to become available? So while these patients are not being seen on an inpatient basis, their needs are not going to be met.
PBN: Is the spending cap in the waiver a concern for you as well? Gary Alexander, the director of the R.I. Department of Human Services, said recently that the cap is a non-issue given that projected state spending amid this financial crisis is going to be much lower.
RISICA: That’s scary right there. Does that mean the level of services is going to be cut back to that extent? And I think that the cap is a potential concern, and it’s a shame if there are federal dollars to pay for services that the state isn’t going to provide because the state doesn’t want to cut back. … I understand the reasoning behind cutting services to balance the budget, but I’m not sure it makes sense to do that in this financial environment. … We have excellent health care in Rhode Island. RIte Care is a model for the country. … Rhode Island is one of the top in the country for early prenatal care; well over 90 percent of pregnant women get early prenatal care in this state. I’m very concern that the cutbacks will make that not true.
PBN: What do you think the General Assembly should do with this waiver, then?
RISICA: I’m not sure that the waiver is a good idea at all. If I were part of the General Assembly, I would vote no. We are not prepared to make these changes, and sadly, I think that there will be draconian changes to level the budget, without a lot of forethought on the ramifications, the implications for health care, and overall public health. I think some people feel that’s just what we need to do, and taking care to do it correctly would make a big difference, but I have not been reassured by any words from the governor’s administration that this is going to be done well. So I would vote against it, but if it’s going to pass, I think the General Assembly needs to attach enough strings so they’ll be assured that at every step, capacity is increasing before or during the time period when these policies are changing, and not waiting for a year of poor case before we say, “Oh wow, we’re finally going to have enough nurses next year.” And I think Rhode Islanders across the board need to be vigilant.
