Florida taxpayers keep Evelyn Williams alive by paying for kidney dialysis.
Ralph Pineiro's liver transplant succeeded because Medicaid bought antirejection drugs.
Tina Cohen fights off leukemia with state-aided chemotherapy.
This week, the Florida House and Senate will try to lop at least $1-billion off health care budgets. Dozens of programs will come under the knife. Thousands of Floridians like Williams, Pineiro and Cohen will be left to wonder:
What will happen to me?
Cutting Medicaid, the health care program for poor people, is no easy task.
Slash services too much, and fragile clients land in nursing homes and hospitals, driving up costs instead of saving money.
Federal matching funds pay more than half of Medicaid's bills. So when the Legislature cuts back $100, clients lose more than $200 in services.
"If we don't spend that money, it just goes to another state," says advocate Karen Woodall. "We already paid the taxes. It's just in Washington. If we don't bring it back into the state, then we've just lost it."
Nevertheless, large budget deficits make Medicaid hard to ignore. Its $16-billion cost was nearly one-fourth of all state spending last year. Absent a tax increase, legislators have to cut Medicaid or cripple education and other essential services.
Here is a sampling of possible cuts, and people whose lives might change.
• Almost 20,000 clients.
• House cut: $170-million.
• Senate cut: $233-million.
Tina Cohen noticed the first pain while dieting for her high school prom.
It was chronic leukemia. Modern drugs can keep it at bay, maybe forever, but they cost $5,000 a month.
Doctor visits, bone marrow tests and other complications push her medical bills toward $50,000 a year.
Cohen, now 21, lives in Brandon with her 2-year-old son and boyfriend. Chemotherapy "was crippling at first," Cohen says. "It's really nasty stuff."
She has squeezed in a few small telephone jobs between nausea and taking care of her son, but that rarely brings in much.
Her boyfriend works in a pawn shop and earns less than $30,000 a year. They can't cover her expenses but they earn too much to qualify for regular, poor people Medicaid.
That's where Florida's "Medically Needy" Medicaid steps in. It helps when catastrophic expenses overwhelm incomes.
"Nobody will insure me. Only the state will," Cohen says. One health maintenance organization she called "told me I would have to pay $500 a week and they wouldn't pay the prescriptions."
Without chemo drugs, she says, "I run a big risk of winding up in the hospital. The cancer would attack my body and possibly kill me over time."
Ralph Pineiro, a 56-year-old Tampa resident, lost his liver a year ago to hepatitis C from old blood transfusions.
Medically Needy buys the $2,500-a-month antirejection pills that protect his new liver.
Pineiro, who gets $1,100 a month from Social Security, will qualify for Medicare disability later this year, and get his drugs that way.
For now, Florida fills the gap.
Pineiro is typical of many transplant patients, says Tony Carvalho of the Safety Net Hospital Alliance of Florida. Many are disabled with a multitude of complications. Medicare usually kicks in after two years, but people often can't wait that long.
Just to get on a transplant waiting list, people must demonstrate that they can pay the cost of aftercare, Carvalho says.
"Hospitals are not going to perform a quarter-of-a-million-dollar operation to put someone on the street who cannot then afford their drugs."
"If Medically Needy gets taken away, people are going to die."
Inpatient and outpatient care
• 2-million potential clients.
• House rate cut: $330-million.
• Senate rate cut: $205-million.
Evelyn Williams' life turned upsidedown seven years ago at age 16.
A bad heart valve, brain aneurysms, strokes, seizures and failing kidneys robbed her capacity to work, even at her old Dunkin' Donuts job.
Her meager disability check makes her poor enough to qualify for traditional Medicaid, which pays for kidney dialysis three days a week at Fresenius Medical Center in Tampa.
The four-hour treatments are exhausting, Williams says. Throw in bus rides going and coming, and it's all she can do to care for her twin boys, 4, and daughter, 3.
Williams' treatments cost the center $155 a pop, says Fresenius vice president Robert Loeper. Medicaid pays $125. The company compensates by soliciting donations and dipping into other revenue streams.
The Legislature now plans to drop dialysis reimbursement to $90, as part of a broad range of rate cuts to outpatient and inpatient service providers.
"We'll be losing $10,000 on nursing care and medical supplies alone," says Loeper.
Fresenius will continue to serve Williams and other current Medicaid clients, he says, but may have to turn away new ones.
"A lot of facilities are going to say, 'that's it. I can't take any more Medicaid patients or go bankrupt. They can stay in the hospital, where Medicaid pays $1,000 a day.' "
Williams would like to get a kidney transplant, get off dialysis and make her own way in the world. But she didn't work enough to qualify for Medicare disability so she is stuck with lower-paying Medicaid.
Transplant hospitals and doctors, now in line for their own Medicaid rate cuts, may not accept her.
• Roughly 45,000 clients.
• House cut: $278-million.
• Senate cut: $164-million.
Bernice Goodman, 86, looks forward to exercise group three days a week at Palm Garden of Largo. She and fellow residents spend 20 minutes lifting legs, marching in place, stretching arms and rotating ankles.
"It helps me not get stale and sit in the room all the time," says Goodman, who has suffered three major strokes.
Such exercise classes are now under the budget-cutting gun, as are movie nights, dances and other activities that spice up a nursing home day.
Medicaid pays for more than half of Florida's nursing home residents. Proposed rate reductions could reach 10 percent.
Florida has some of the country's best nursing homes because high mandatory staffing for nurses and nursing assistants. That's the hands-on care.
So when money gets tight, homes must cut other staffers: activities workers, social workers, housekeeping, food service workers, maintenance.
Even that may not be enough, given the magnitude of current proposals, says industry spokesman Ed Towey.
"The average facility is under-reimbursed by Medicaid by $12.24 per patient, per day," he says. "You now add a $17.50 cut to that and you will see what we saw in 1998," when Medicare cut reimbursement — "Bankruptcy filings, facilities announcing that they are closing, and then your hospitals are going to fill up with people who can't get into nursing homes."
Palm Gardens executives have not decided where they would cut back. Bernice Goodman hopes that the exercise leaders, Diane and Erica, won't leave.
"I feel loved by all of them," Goodman says. "My daughter-in-law told me they are spoiling me. I said, 'Yes they are.' "
Other large cuts
Medicaid HMO rate cut:
• House, $96-million.
• Senate, $55-million.
• Eliminate hospice benefit, House proposal only: $52-million.
• Eliminate MEDS-AD program, Senate proposal only: $237-million. (This serves about 24,000 aged and disabled people not eligible for Medicare whose incomes are just a bit too high for regular Medicaid. The cut would leave many without any insurance option.)
Stephen Nohlgren can be reached at firstname.lastname@example.org or (727) 893-8442.