Medicaid in New York

Rick and Tina Fitzgerald have been married for 17 years.

They have jobs.

They dream about having their own home.

They also need someone to help them with tasks others barely give a thought to. Both have cerebral palsy that keeps them in wheelchairs.

Rick's day starts with someone lifting him out of bed, putting him in his wheelchair and getting him into the shower. If he has an assignment that day, the freelance writer for The Catholic Sun has another helper who goes with him to set up his tape recorder and take notes on anything that can't be recorded. That person also meets with him twice a month to talk about his job goals.

And the couple has someone helping them find the home they want: a little ranch-style house with a yard. When they find the home, they'll need help to make it accessible.

Medicaid pays the $40,000 annual bill for all of those people who help the Fitzgeralds. The couple has private insurance and Medicare, but Medicaid fills the considerable gaps left by both.

"To me, what we get is absolutely priceless because I can't imagine going back to a time when we couldn't or didn't have these things," Tina said. "It would set us back and definitely keep us from achieving our goals."

But every year, services the Cicero couple and others receive through New York's Medicaid program come under a microscope as the debate over the cost of the $46 billion program heats up.

The Fitzgeralds worry that they will lose the help that substitutes for their arms and legs the people who reach things on top shelves, the people who shop for their groceries, the people who enable them to live outside an institution.

Many of the services they and others receive are extras that states can choose to provide under the federal law that dictates what Medicaid must offer. And they are part of the reason New York's Medicaid program spends an average of $7,609 per enrollee, more than any other state, according to the Kaiser Family Foundation's Commission on Medicaid and the Uninsured.

New York covers a wider range of people, offers more services and pays higher reimbursement rates than most other states, according to information from the commission and analysts who study Medicaid. It spends more on long-term care than any other state.

New York spends most of its Medicaid funds on the elderly and the disabled, not the poor, the group Medicaid was designed to serve in 1965 when it was created as part of President Lyndon Johnson's War on Poverty. The program has expanded every decade. This year, it is expected to cost $329 billion nationally, straining budgets and providing health coverage to more than 50 million people.

Is all of that good or bad? It depends on whom you ask.

Karen Schimke, president of the Schuyler Center for Analysis and Advocacy, says New Yorkers have reason to celebrate the 40th birthday of Medicaid this year.

"Think of the children who got immunizations," she said. "Think of the elderly who had better care."

But she acknowledges that many see it differently.

"I think there's been probably unprecedented newspaper stories and letters to the editor on Medicaid that mostly characterize Medicaid as this big chomping monster that is taking New York state down," Schimke said.

In Onondaga County, Medicaid has been gobbling up the budget. In 2001, local Medicaid costs took 23 percent of the local budget. That number was up to 30 percent last year. This year, Medicaid costs account for 50 cents of every property tax dollar collected by the county, county officials say.

"It's good for the people getting the service, but it's bad for the people paying the bill," County Executive Nicholas Pirro said.

He and other county executives from around the state have been fighting to keep more of their money from ending up in the monster's mouth. They had some success this year, when the Legislature enacted a 3.5 percent cap on local Medicaid increases.

Gov. George Pataki proposed limited benefit cuts this year, too, but they were not passed by the Legislature.

While the overall health of a state is difficult to measure, one study found that New Yorkers on Medicaid are happier with their care than those served by Medicaid in California.

California is the only state that has more people enrolled in Medicaid than New York. But while New York spends the most per enrollee, California spends the least: $2,068. That's more than $5,500 less than New York spends.

A survey by the New York City-based United Hospital Fund that compared Medicaid in New York and California found that Californians were twice as likely to be dissatisfied with their care as New Yorkers.

The survey also found that twice as many Californians on Medicaid don't have a regular doctor, in part because the copayments they must make dissuade them from going for checkups.

And New York covers a wider range of people. Parents who live at up to 150 percent of the federal poverty level and childless adults up to 100 percent of the poverty level are covered in New York. California covers parents up to 100 percent of the level, and doesn't cover childless adults at all under Medicaid, according to the survey.

Barbara Lyons, deputy director of the Washington, D.C.-based Kaiser commission, said New York is ahead of other states when it comes to helping people obtain the long-term care they need at home and in day programs instead of at nursing homes and hospitals. She said that saves money in the long run.

"It's easy to have a cheaper program if you don't cover people," Lyons said. And that is the choice some states have made as they grapple with increases in health care costs and other budget pressures.

She pointed to Missouri, where legislators recently passed a budget that cut Medicaid benefits for 90,000 people and slashed less traditional programs like the one that allows the Fitzgeralds to work and still qualify for Medicaid.

Robert Ward, director of research at the Public Policy Institute in Albany, said there is a middle ground that New York can stand on. It doesn't have to cut benefits to needy people to save money. It doesn't have to be like Missouri or California. It can be more like Massachusetts, which spends $4,862 per enrollee and offers benefits comparable to New York's.

"Most states want to provide good health care, but they want to balance it with affordability," Ward said. "New York has never been concerned about affordability, and that's our fundamental problem."

He said the state should stop providing coverage for middle-class elderly people who he says have abused the system by putting their assets in trusts so Medicaid will cover nursing home expenses something allowed under state law. This can't be done as easily in Massachusetts.

"We can save billions in long-term care without harming the services for the needy," Ward said. "We know that because New York spends so much more on long-term care than other states."

Assemblyman Richard Gottfried, chairman of the Assembly's health committee, isn't convinced the abuse is as prevalent as Ward and others think.

"First of all, there aren't that many rich people in our society to account for the number of people in nursing homes on Medicaid. And really rich people don't want to be in a nursing home on Medicaid," Gottfried said. "They can finance much better care."

For many low-income elderly, Medicaid provides more than health care. It helps fill the empty spaces in lonely days.

Jenny Walsh, an 87-year-old widow, looks at the world through wide blue eyes and glasses paid for by Medicaid.

On Mondays, Tuesdays, Thursdays and Fridays she attends an adult day program through Loretto that's covered by Medicaid. She's been going to Daybreak on James in Syracuse for seven years ever since she broke her back and ribs and was unable to leave the home she shares with her son.

"I got depressed," she said, fingering the black yarn on a toy dog she was making while at the program. Her doctor recommended the program to get her out of the house. She qualified because she needed therapy for her back. The program provides lunch, medications, wound care and even a bath if she wants one.

The cost: $87 a day, paid for by Medicaid.

Over a lunch of chicken and green beans, Walsh explained that she wouldn't be able to come if Medicaid didn't pay. The retired baker would still be at home, alone, missing the things that make her feel useful. At Daybreak, she heads an association that helps choose day trips and entertainment.

"When I first came here, I thought, 'I don't belong here,' " she said. "Then I thought maybe I could help somebody else."