By Christopher Guadagnino, Ph.D.
Gov. Ed Rendell’s recently released budget proposal estimates that the state’s Medicaid program will be $400 million in debt next fiscal year, as a significant chunk of federal Medicaid funds is being phased out and the Bush Administration proposes to trim another $60 billion from federal Medicaid spending nationwide over the next decade.
The state’s Medicaid cost growth over the years has been fueled by spiraling prescription drug costs – outpacing all other health care costs – and by a seven percent annual enrollment increase driven by the state’s growing elderly and uninsured population.
Cutbacks come as good news to no one, and they will inevitably erode patient care and negatively affect the health of some of Pa.’s poorest and most frail citizens. Medicaid recipients, physicians, hospitals and nursing homes will feel some sting from inevitable reform, while deliberations on the shape of that reform have begun with the release last month of Rendell’s proposed Medicaid reform package. State legislators plan to hold budget hearings this month – which will include discussions of Medicaid reform – after which Pa. House members are expected to send their proposals to the Senate for a consensus version to be achieved by June 30.
Rendell’s Medicaid reform proposal seeks to squeeze savings from several components of the program and recommends new limits on health care services and prescription drugs, net reimbursement decreases to hospitals and nursing homes, reimbursement cuts to pharmacies and use of a preferred drug list. The proposal has received qualified support from legislative leaders and others for what is does not do, and what 13 states have already done and 13 more have proposed doing: cutting people from the Medicaid program altogether.
Consumer advocates maintain that the reforms would cause unacceptable erosion of care and jeopardy to the most vulnerable patients, while physician advocates believe that implementing the proposed service limits would entail a logistically untenable recordkeeping burden and would inevitably require physicians to render more uncompensated care. Hospital and nursing home advocates predict that net reimbursement cuts will produce serious economic harm to their institutions, some of which are already struggling to remain operational within their current budgets.
Dire Status Quo
The Pa. Department of Public Welfare (DPW), which oversees the state’s Medical Assistance Program, notes that all state Medicaid programs are finding it increasingly difficult to balance the needs of a growing client base with the increasing cost of health care, and cites recent Kaiser Foundation data showing that Medicaid costs nationally have grown 63 percent over the past five years as a result of these pressures. Pa. has seen an eight percent growth in eligible Medicaid clients from FY03/04 to FY04/05, and currently covers over 1.7 million Pennsylvanians, up from 1.3 million in 1990.
Pa.’s challenge is significantly fueled by the longer life expectancy of Pa.’s elderly population, as expenditures for the elderly make up 34 percent of the state’s Medical Assistance budget, according to DPW. The number of persons older than 85 is expected to increase by nearly 39 percent between 2000 and 2010, while the number of persons with severe disabilities living into adulthood and needing life-long care continues to grow, DPW adds. The size of Medicaid’s long-term care eligible population in Pa. has also increased by 16 percent in four years, from 85,000 in FY99/00 to 99,000 in FY03/04, averaging 3.8 percent per year, while one-third of Medicaid spending goes to long-term care, and 70 percent of the 80,000 nursing home residents in the state are on Medicaid.
State spending on Medicaid health care services has grown dramatically. From FY98/99 to FY04/05, pharmaceutical expenditures for Medicaid fee-for-service eligibles have grown by 99 percent, inpatient hospital expenditures by 44 percent, and managed care expenditures by 129 percent, says DPW.
While state spending is increasing, federal support is declining, with the most significant loss stemming from tightened rules for matching funds – in the form of a federal phase-out by 2008 of funding for the Intergovernmental Transfer Program (IGT), which allows county or city governments to send money to the state, which is in turn used to qualify for additional federal Medicaid payments, and which DPW says has netted Pa. as much as $820 million annually. The Bush Administration’s overall goal is to trim $60 billion over ten years from what it calls “overpayments” by the federal government to Medicaid, which will require Pa. to shoulder more Medicaid costs on its own.
DPW says Pa. has implemented several cost control initiatives over the last two years to rein in Medicaid costs of its fee-for-service program, including expanded case management, increased prior authorization of services, increasing the use of community alternatives to nursing homes, and holding the line on reimbursement rates to hospitals, nursing homes and managed care companies. DPW implemented a new claims processing system a year ago, which it says has allowed for greater control of unnecessary service utilization and expanded fraud and abuse detection efforts.
Similar controls have contained the rate of expenditure increase in HealthChoices – Pa.’s capitated Medicaid managed care program mandated for one million enrollees in the southeast, southwest and central Pa. regions – where DPW says its staff conduct regular contract compliance reviews, and that its seven contracting health plans are required to have disease management programs, provider credentialing and profiling, preventive care and lifestyle programs.
This spring, DPW expects to convert about 250,000 fee-for-service Medicaid recipients in the 42 Pa. counties without mandatory managed care to an enhanced primary care case management system called the ACCESS Plus Program, which will link each enrollee to a primary care provider and will utilize disease management and other program controls aimed at further improving service delivery and controlling Medicaid costs, says David Feinberg, deputy secretary of DPW’s Office of Medical Assistance Program.
In the last year, DPW also says it has successfully negotiated federal approvals for a nursing home assessment and a managed care assessment, resulting in an increase of $145 million in federal funds for nursing home reimbursements and $175 million for managed care reimbursements.
These initiatives have nevertheless failed to keep pace with rising Medicaid health care costs, while DPW projects an additional 100,000 Medicaid eligibles in FY05/06.
In its Medicaid Program Revision Request for FY05/06, DPW writes that, “Fundamental program changes are needed in order to bring the Medical Assistance expenditures in line with available Commonwealth revenues. While state revenues are growing at a rate of three to four percent, Medicaid’s demands on these revenues would have exceeded 20 percent absent any changes.”
Rendell’s Reform Proposal
In an effort to fill the anticipated $400 million hole in the state’s Medicaid budget next fiscal year, part of Rendell’s Medicaid reform package seeks to reallocate the way available Medicaid funds are used, rather than to trim the number of Medicaid eligibles or drop covered services from the program, as several other states have done to rein in their Medicaid spending.
“This is not the time to eliminate eligibles,” DPW declares in the preamble to its proposal. “Those who remain on the rolls are those who cannot afford to obtain health care elsewhere. The only other options are to re-look at what services are provided and what contributions clients are expected to make to the cost of care provided, and to make certain that those who are eligible for care are truly the most in need.” Cutting eligibility and/or covered services also risks cost-shifting by forcing individuals to seek out other government programs to meet their needs, or shift costs to local governments already facing deficits, DPW adds.
Rendell’s proposal places limits on the amount of some services for the adult and General Assistance Medicaid populations and increases copays, declaring that the modifications bring the scope of benefits and drug coverage more in line with those available in other third-party health care packages, while providing the Medicaid client with “the ability to make some choices regarding the services they need most.” None of the changes affect care available for children.
Proposed changes to the adult package – which would affect 670,000 parents, elderly persons and others, including about 246,000 elderly and 381,000 disabled persons – include limiting annual coverage to two hospital admissions for physical services and one admission for rehabilitation services, and limiting the number of visits to physicians and other health care providers (such as podiatrists and optometrists) to 18 per year, while current Medicaid coverage imposes no limits on medically necessary hospitalization or provider visits. Pregnant women would be exempted from the new visit limits. The proposal would also put a $5,000 annual coverage limit on medical equipment, such as wheelchairs and oxygen tanks, and would limit drug coverage to six prescriptions per month and raise the copay for brand-name drugs to $3 each, up from $1, while copays for generics would remain $1.
Changes to the adult package are projected to save the state $80 million in the next fiscal year.
Persons eligible for both Medicare and Medicaid would be exempted from the pharmacy limits for the first six months of FY05/06, after which they will have all drugs covered by the new federal Medicare Part D. Others may become eligible for Pa.’s adultBasic and Pharmaceutical Assistance Contract for the Elderly (PACE) programs, which Rendell hopes to expand by drawing down more money from the state’s tobacco settlement fund, according to Feinberg.
Proposed changes to the General Assistance package – which would affect 115,000 non-elderly adults without children or permanent disabilities – include limiting annual coverage to one hospital admission for physical services and one admission for rehabilitation services (both are currently unlimited when medically necessary), and maintaining the current limit of 18 annual visits to physicians and other health care providers. The proposal also puts a $5,000 annual coverage limit on medical equipment, caps coverage for ambulance trips to one per year (there is currently no cap), limits drug coverage to three prescriptions per month (down from the current limit of six) and raises copays to $12 for brand-name drugs and $6 for generic drugs (up from the current $3 copay for both). Additional drugs would also become subject to copays.
Changes to the General Assistance package are projected to save the state $67 million next fiscal year.
Feinberg says that the new limits on medical services would, in the aggregate, impact about 20 percent of Medicaid utilizers, based upon paid claims history for FY02/03. DPW’s medical reviewers would examine claims that exceed the new medical service limits to determine whether coverage would be granted, he adds. Approval for those claims, however, will require a higher standard than is currently used for determining medical necessity, Feinberg explains: a person must be either at risk of imminent death or serious deterioration of health and well-being, or at risk of long-term institutionalization – in a nursing home or mental hospital, for example.
DPW currently has two full-time physicians who review physical health claims and six part-time reviewers for behavioral health claims, and Feinberg says the department may need to hire additional staff to handle an increase in claim reviews. HealthChoices health plans will continue to conduct their own medical reviews.
A proposal aimed at saving another $21 million would charge parents of mentally or physically disabled children whose incomes are above 200 percent of the federal poverty limit a monthly premium, on a sliding scale, to continue the disabled child’s Medicaid coverage. There are currently about 40,000 children in the program.
A proposal to modify “spend down” calculations, aimed at saving $16 million, would limit the number of unpaid medical bills that can be used to calculate income for Medicaid eligibility by allowing only medical bills incurred within three months prior to application.
A proposal aimed at saving $10 million would restructure behavioral health benefits by limiting covered psychiatric inpatient stays to 30 days per year, which DPW says is consistent with limits for drug and alcohol rehab hospitals, and would limit coverage to five psychiatric outpatient visits per month (excluding medication checks), and 540 hours per year of partial hospitalization services.
Another proposal would allow, although not require, managed care organizations to charge up to the maximum co-pay allowed by federal government. While DPW uses copays in the Medicaid fee-for-service program, HealthChoices HMOs have not been permitted to charge copays, in order to make managed care more attractive to consumers – incentives that DPW says are no longer needed. The proposal is projected to save the state $5 million in lower capitation rates that DPW can set next fiscal year.
Total state savings from Rendell’s “reallocation of benefits and services” proposals are projected to be just over $200 million. The DPW acknowledges that the proposed changes may result in increased uncompensated care costs to health care providers.
The second broad category of reforms proposed by the Rendell Administration are “administrative and program efficiencies” and include reducing or eliminating Community Access Fund, Medical Education, Outpatient Disproportionate Share, and Tobacco Settlement payments to any hospital when making such payments would contribute to that hospital having an operating margin greater than one percent. DPW projects that the special hospital payment change would trim state Medicaid spending by over $53 million in FY05/06.
Rendell’s broader budget proposal includes what it calls a “modest” Medicaid reimbursement rate increase of two percent to hospitals and nursing homes, while Feinberg notes that the state will expect health care providers to treat Medicaid enrollees who are “over the limit” of covered services as part of their charitable mission.
The budget proposal also seeks a 20 percent increase in the number of home and community based waivers, to permit elderly Medicaid recipients to receive care in less costly settings than nursing homes, which Feinberg says cost DPW $34,000 annually per resident, with 80,000 Pa. Medicaid recipients currently in nursing homes.
DPW’s administrative reforms also include significant changes in the way Medicaid has historically paid for prescription drugs – the most inflationary segment of the Medicaid budget, according to DPW. Under existing policies, DPW says its drug payment rates exceed those paid by most commercial and HealthChoices plans, with pharmacy costs averaging well over $2,000 for every fee-for-service eligible – up over 98 percent from FY1998/1999.
DPW is proposing by July to establish a preferred drug list, something that 27 other states currently do for their Medicaid programs, which would cover all therapeutic classes of drugs and require prior authorization for brands within a class not on the list. The list would be clinically based and administered by a contractor, while DPW will use the list to seek price concessions from drug manufacturers, and will seek CMS approval for extending the list to its capitated managed care programs. DPW projects that the drug list would trim state Medicaid spending by nearly $51 million in FY05/06.
Pa. hopes to save an additional $36 million next fiscal year by reducing the Medicaid rate paid to pharmacies. For name brand drugs, DPW wants to convert to wholesale acquisition cost (WAC) plus six percent. The current Medicaid payment is based on average wholesale price (AWP) minus 10 percent, while the proposed change would be equivalent to AWP minus 15 percent, which DPW says would lower the average claim by about $2.50.
For generic drugs, DPW wants to move to a more aggressive State Maximum Allowable Cost (MAC) program to reduce their price by making Medicaid generic rates more consistent with other payers. DPW says that Pa.’s Medicaid HMOs have adopted an aggressive generic pricing program without an impact on consumer access, and that most other states have already adopted MAC programs.
The state hopes to save $21 million next fiscal year by strengthening DPW’s ability to pursue third party payers and reduce fraud and abuse, for example, by requiring commercial insurance carriers to participate in data exchanges to identify third party coverage of Medicaid consumers, and by contracting with a vendor to augment its existing provider review activities. The vendor would use specialized software to flag suspicious claims submitted by hospitals and other providers, and review medical records for possible overpayments. DPW has also enlisted the assistance of over 14 investigators from the Office of Inspector General to provide resources to conduct expanded reviews of pharmacies and durable medical equipment suppliers.
The total projected state savings from Rendell’s “administrative and program efficiencies” would be $178 million.
While Rendell’s Medicaid reform proposals represent the first step in the state’s budget negotiation process, they shape the debate and stimulate discussion of important health and financial impacts that any reform will have on patients and providers.
Initial reception by key Pa. legislators appears favorable. “By restructuring the guidelines, you’re still providing care, although a restricted level of care. That’s an important approach – the key is that nobody falls through the cracks, and that there is no undue or excessive burden on anyone,” says Tom Andrews, press secretary for House Minority Leader H. William DeWeese (D-Greene). “Our number one concern is that services are provided the best that we can, without cutting eligibility,” he adds, noting that House Democrats do not yet have a specific set of reforms they will promote.
“Rendell addressed a tough situation the best he could – a lot better than many other states that are cutting people from the rolls,” according to Teresa Candori, press secretary for Senate Minority Leader Robert J. Mellow (D- Lackawanna).
“I see this as first in a set of incremental proposals. No one was dropped this time; money was shifted around. We may not have that luxury in coming years, and may need more dramatic mechanisms,” says Drew Crompton, aide to Sen. Robert C. Jubelirer (R-Blair). “I expect that the Senate Republican leadership is going to endorse a fair or large portion of Rendell’s plan. At first blush, there may be more Republicans than Democrats who are supportive of it, but we expect the negotiations to be bipartisan,” he adds.
Particulars of Rendell’s proposal have provoked concerns by key stakeholders.
Pa.’s Medicaid HMOs have yet to see the new capitation rates that DPW will offer them, which are expected to be actuarially adjusted commensurate with the new service coverage limits, says Robert Tremain, president and CEO of Health Partners, which is one of three HealthChoices managed care plans in southeastern Pa., and which covers 145,000 Medicaid enrollees. “Whatever the actuarial value of the limits, DPW will take it out of our rates and leave the coverage decisions up to us,” he adds, noting that there is always a potential for managed care companies to exit the Medicaid market – as they exited the Medicare market – if reimbursements do not adequately cover expenses. Current profit margins in Medicaid managed care are “razor thin, at best,” Tremain warns, depending on patient mix and how well rates are risk adjusted. That rate adjustment is made by reviewing claims retrospectively, so it is always 12 to 18 months behind, he says.
As a trickle-down effect of potential losses from adjusted DPW rates, Tremain says that Health Partners may have to lower reimbursements to physicians and hospitals, although he says it is unclear whether DPW’s rate adjustment will keep up with patient mix trends. “We’re not expecting it to be easy to respond and be able to make it work,” he says.
Another complication is that medical review criteria for granting coverage exceptions to the benefit limits are still undefined, says Tremain: “There’s a huge gray zone between ‘medical necessity’ and ‘risk of imminent death.’” Practice guidelines end at medical necessity, and would need to be modified for the new thresholds, he adds. How health plans will police the new limits is also unclear, as members can switch plans every month, and keeping track of prescription and provider visit tallies across plans will be a complex task, Tremain says.
UPMC for You, which covers 90,000 Medicaid enrollees in southwestern Pa., is also concerned about the process for granting coverage for exceeded limits. “I know there will be people who will run out of benefits before they run out of need. The limits will affect the top 10 to 15 percent of users, who are our sickest members,” says John Lovelace, vice president of Medical Assistance Programs, UPMC Health Plan. “It’s better that we have some flexibility, rather than blanket enforcement, over how much we pay providers and cover services,” he says, claiming that because of its affiliation with UPMC Health System, the health plan historically has a more ill population – more sickle cell, hemophilia, cancer and transplant patients – than the other HealthChoices plans in the region.
New service coverage limits bring additional challenges for a health plan that would transfer costs of coverage denials to hospitals in its own UPMC corporate network. “If we don’t pay, the hospital eats the cost. Coverage denial simply takes money from another pocket,” says Lovelace. In its decisions to cover services exceeding the new limits, “We may be more influenced by the medical need of the patient, and less influenced by the fiscal health of the health plan,” Lovelace says. Considering that coverage for exceeded service limits are to be based on a range of criteria stricter than medical necessity, but short of imminent threat of death, Lovelace notes: “The assumption is not that there is waste in the top 20 percent of utilizers. This is rationing of health care by DPW, and has nothing to do with medical necessity.”
“There will be an inevitable erosion of health status because of medically necessary denials of prescriptions, inpatient hospitalizations and provider office visits,” says Lovelace. “We will do what we can to discuss with physicians and patients whether they could defer care until next month or next year,” when the coverage limit clock is reset, he adds.
While the Pennsylvania Medical Society (PMS) recognizes that it is impossible to come up with a Medicaid budget fix that doesn’t hurt anyone, it is concerned that a greater volume of prior authorization requirements – for service limit appeals and for prescribing drugs not on the preferred drug – will bring another administrative burden to physicians and another delay in treatment of patients, according to Don McCoy, vice president of health policy and regulatory affairs. The medical review process must take into consideration a patient’s condition and a physician’s prescribed regimen, and the PMS hopes to see a quick and clinically valid apparatus in place for such review, especially for emergency regimens, says McCoy.
McCoy also wonders how a Medicaid patient’s tally of services will be coordinated, as patients see multiple providers, and to what extent the new service limits will result in a greater use of hospital emergency rooms by Medicaid patients for nonemergency care.
McCoy chairs the physician subcommittee of the Medical Assistance Advisory Committee, which meets monthly, and plans to voice PMS’s concerns at those meetings.
While the PMS is concerned that some physicians will shoulder additional uncompensated care in the face of new service limits, McCoy notes that Rendell’s proposals do not call for overt physician reimbursement reductions beyond care rendered above those limits, for which a physician can expect to sacrifice a maximum of $1,000 – Medicaid’s current reimbursement cap per provider for all hospital inpatient services, which McCoy says has not changed in over a decade. McCoy doubts whether Medicaid reimbursement lost to service limit denials will cause a large number of physicians to stop seeing Medicaid patients. He notes that Pa. has a relatively high and stable percentage of physicians accepting Medicaid – in the 75 to 85 percent range – and because Medicaid reimbursement for office visits is so low (about $25, compared to Medicare’s rate of $120) and has not increased in 25 years, McCoy believes that physicians’ feeling of responsibility to patients plays a large role in motivating them to continue to see Medicaid patients.
The PMS is pleased that Pa. is moving away from mandated Medicaid managed care and toward an enhanced primary care model – the ACCESS Plus Program – for the 42 Pa. counties that are not part of the HealthChoices program. Such a model will require a primary care physician to be the care coordinator for Medicaid enrollees, which McCoy says will keep medical decision-making where it belongs – with a patient’s physician – while also eliminating the administrative layer of a managed care organization, which he says takes money out of the health care delivery system.
PMS is also pleased that Rendell’s proposal did not cut coverage for entire categories of Medicaid program services, as other states have. “Pa. is in the top 10 percent of states in terms of richness of benefits in its Medicaid program,” says McCoy, noting that federal law requires states to cover 16 types of services, and Pa. covers about 27 types – including those cut by other states, such as dental, optometry and chiropractic.
The Hospital & Healthsystem Association of Pennsylvania (HAP) is vigorously critical of Rendell’s proposals, and estimates that Pa.’s hospitals would lose $275 million next year in medically necessary, uncompensated care from limiting coverage of hospital admissions, according to Paula Bussard, senior vice president of policy and regulatory services. That estimate was based on a review of PHC4 data showing that about 18,000 Medicaid recipients are admitted to a Pa. hospital three or more times per year, and Bussard notes that many of those patients are elderly, disabled or medically complex individuals.
HAP is also critical of the state’s proposal to index supplemental payments to hospitals to an operating margin maximum of one percent, which Bussard says represents a tenuous stability margin when hospitals must replenish infrastructure, and that a healthy operating margin would need to be in the three to six percent range. Ninety-eight hospitals would lose all of their supplemental payments, out of the 199 hospitals that currently receive them, and the loss would hit urban and rural hospitals the hardest, says Bussard.
The state’s proposal to increase hospitals’ Medicaid reimbursement by only two percent, compared to last year’s reimbursement, translates into another $138 million loss to Pa. hospitals – in foregone state funds and federal matching funds – on top of the losses accruing from cuts in Medicaid’s benefits package, Bussard adds. HAP believes that there are sufficient funds available elsewhere in the state’s budget to restore the proposed cuts, and will be lobbying to that effect, she says.
Federal cuts are hitting Pa.’s nursing homes particularly hard. Long-term care, including nursing home and home and community based care, consumes one-third of Pa.’s Medicaid spending, while long-term care utilization has increased 15 percent since last year, according to Alan Rosenbloom, president of the Pennsylvania Health Care Association, with represents the state’s long-term care industry. He says that Pa.’s long-term care facilities are losing about $150 million per year in federal matching funds because of the IGT phase-out.
Bush’s Medicaid reform proposals threaten to eliminate other funding, such as an assessment whereby Pa. levies a per-bed state tax on nursing homes and adds the amount to its Medicaid expenditure tally, which draws a federal matching amount. The taxed amount and its federal match then go back to Pa.’s nursing homes to cover Medicaid expenses. Cutting this mechanism would eliminate another $145 million from nursing home budgets, and Rendell’s proposals do not restore it, according to Rosenbloom.
Nursing homes have historically seen four to five percent annual Medicaid reimbursement increases, says Rosenbloom, and Rendell’s proposed two percent increase next year is equivalent to a $71 million annual loss in state and federal dollars, at a time when reimbursement is already less than the cost of care – covering about 92 percent of cost – and utilization is increasing, Rosenbloom says, while federal funds that used to buffer that shortfall will no longer be available.
Rosenbloom maintains that the solvency of some nursing homes may become jeopardized by these budget reductions, and he notes that 80 Pa. nursing homes stopped operating during the last five years. Pa.’s 735 existing nursing homes are operating at a 90 percent bed capacity and, with the rapid growth of Pa.’s population over age 80, “We will never need fewer beds,” says Rosenbloom.
“Rendell’s cuts are devastating to the poorest and sickest Pennsylvanians,” says Michael Campbell, Esq., executive director of the Pennsylvania Health Law Project. “Finding efficiencies elsewhere in the budget is preferable to throwing individuals into a situation of losing their homes, getting sicker, or dying. People with HIV, cancer, diabetes and asthma will be the ones who will go without services,” he says. Rendell’s Medicaid reform offers no mechanism for improving care management, Campbell notes, and he says that a care rationing proposal with a “bright line cutoff” represents a “sea change” for the worse in the state’s Medicaid policy.
A statewide preferred drug list proposal, on the other hand, could represent an improvement if it replaced the confusing variation in drug lists currently used by the state’s different Medicaid health plans, says Campbell. He also applauds the proposal to increase the number of home and community based waivers, and says the state should shift more of its dollars away from institutional care and into home-based care.
Medicaid funding is a lifeline for hospitals and physicians with a high proportion of Medicaid patients and Rendell’s proposed service limits can be criticized as being draconian and arbitrary, but it is fiscally impossible to do nothing, and options chosen by other states – such as provider rate cuts and program eligibility restrictions – would be worse, believes Robert I. Field, Ph.D., MPH, J.D., director of the Health Policy Program, University of the Sciences in Philadelphia, and fellow of the Leonard Davis Institute of Medical Economics in Philadelphia.
Restricting program eligibility offers better savings in the short-term, but risks a greater increase of chronic illness among the population, and Rendell’s option to keep broad eligibility at the expense of rationing benefits is a better public health policy, believes Field. While the acutely ill will be most affected by restrictions on care frequency, he says, “The more people who are eligible for basic, preventive services, the better their health status down the road. You are trading short-term for long-term public health benefits by keeping more people healthy, for longer.”