Another Waiver

We have tipped past the equinox so we are officially in fall season. But the passel of work the Idaho Legislature dropped on the Department of Health and Welfare this last legislative session is churning out another waiver request. So, it’s still Waiver Season.

If you’ve forgotten, after voters approved Prop 2 last November, the Idaho legislature felt the need to fix it. This same legislature who had not studied the options, had not debated any proposals for six years, decided last session they knew better than the voters about how to expand Medicaid eligibility for Idaho residents. So, they got busy passing laws, Governor Little signed them, and so our taxpayer funded agencies are doing the work as directed.

The first waiver request, Idaho Choice, is dead. It got nixed by the Feds because it was going to cost more and provide worse coverage. But since it’s what the Idaho legislature wanted, the Idaho Department of Insurance and DHW did the work of researching it, holding hearings, taking testimony, and submitting the request.

The second waiver “Work Requirements” has finished with public input. All who testified were opposed and over 90% of the 1800 written comments were opposed. It will be submitted to the feds in the coming weeks. It will be approved, then contested in court.

The third waiver now open for public comment is a head scratcher. But that is only if you don’t understand the intent. This third waiver requires all Medicaid participants who want to get family planning care somewhere other than with their designated primary care provider (PCP) to obtain a referral. This is from the same legislative body who bows before the “free market” and salutes school choice. I wonder where the Freedom Foundation is on this one.

The reason I’m scratching my head on this one is because, it’s what Idaho Medicaid already does. If you enroll in Medicaid you can choose a PCP or you are assigned to one. That PCP is supposed to “manage and coordinate care”. That means making referrals when the PCP decides she needs some help from a specialist.

So why the direct reference to “family planning” for this statutory referral requirement? Most agree it’s a weak attempt to shunt money away from Planned Parenthood, where some low-income women get their care.

But as I read the waiver, there are no consequences for the PCP if they give the referral, and there are no consequences for the specialist if they provide care without the referral.

A while back a patient came in about his chronic medicines and asked me to give him a referral to a dermatologist. “Why?” I asked.

“Oh, I have these spots.” He held out his hand.

“Those are seborrheic keratoses. They are benign. You will get more as you get older. Do you want me to freeze them off? They, or others will come back. It’s OK just to watch them if they aren’t bothering you.”

“I want to see a dermatologist.”

A month later I get the letter from the dermatologist telling me the patient had seborrheic keratoses and she had frozen them off.

One way to control health care costs is to provide the most appropriate care in the lowest cost setting. If I’m going to have to fight with a patient about referrals, and believe me, it can be a fight, what’s in it for me to get all this ill will? Where’s the leverage?

As far as I know, this is the only statute on the books in Idaho about patient referrals. This sort of bureaucracy does not befit a conservative; but I guess it’s worth it to them if it hurts Planned Parenthood, even a just little bit.

 If the legislature wants to get in the business of writing laws to manage health care, I suggest they do a better job. But this waiver isn’t worth arguing over. It’s a dog whistle; don’t bark.

About ddxdx

A Family physician, former county coroner and former Idaho State Senator
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