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Health Care

The relationship between poverty and health is clear. People living in poverty are sicker and die younger than those who are not poor. This is because they lack access to healthcare; are diagnosed at more advanced disease stages; and, once diagnosed, tend to receive less therapeutic care. Health conditions also are created and exacerbated due to the poor conditions in which those in poverty are forced to live and work. Nationally, 45.8 million Americans were uninsured in 2004, an increase of 800,000 over the previous year and 6 million since 2000. This number includes an estimated 810,000 Marylanders. At least 34% of all Marylanders below 100% of the FPL lack comprehensive health coverage. Among Marylanders so poor they experience homelessness, as many as 80% are uninsured.

Medical coverage for the poor in Maryland is provided through a fragmented series of population- or disease-specific programs that leave out certain individuals — particularly poor adults under 65 who do not have dependent children, including people with medical conditions that are quite serious but not sufficiently severe or debilitating to meet certain eligibility criteria. Historically, Maryland provided health benefits to poor individuals not covered by the federal/State Medicaid program through the Medical Assistance State Only (MASO) program. When this program was eliminated in 1992, more than 32,000 single adults lost comprehensive coverage. About 8,000 individuals who would have been served by MASO currently receive primary medical care at specific clinics throughout the state, but these individuals lack access to comprehensive services. The current program, Maryland Primary Care, is capped at its current level.  In FY ’07 the Adult Primary Care Waiver program will further expand primary care coverage.

Sick and uninsured, many single adults have few places to turn for primary and secondary care other than emergency rooms, a visit to which costs 6 to 12 times the amount of a primary care visit. A study has found that insured households incur an average of $26,957 in medical costs after the diagnosis of a serious new health condition; uninsured households incur $42,166 in costs, which are eventually absorbed by all consumers through higher insurance rates, higher charges for medical care, and public subsidies for uncompensated care.

Current Services

• Medicaid: The federal/State Medicaid program and the Maryland Children’s Health Program (MCHP) provide health coverage to children, poor families, people with documented medical disabilities, and designated special needs populations. Together, the programs served over 600,000 Marylanders in FY ’04.  Additional populations receive limited services through Medicaid waivers — e.g., individuals with long-term care, traumatic brain injury, etc. The federal government shares 50% of Maryland’s Medicaid cost. With some exceptions, Medicaid enrollees participate in HealthChoice — Maryland’s mandatory Medicaid managed care program. In FY ‘07, Maryland will implement an Adult Primary Care Waiver to extend primary care services to low-income adults.

• Pharmacy Assistance: Maryland has long provided prescription drug assistance to residents below 116% of the FPL. In 2003, Maryland received a federal waiver, allowing the program’s 45,000 participants access to a wider range of prescription medications and allowing the State to receive partial federal reimbursement. In FY ‘07, the program will become a part of the Adult Primary Care Waiver.

• Public Mental Health System: Since 1997, mental health services have been “carved out” of HealthChoice (Medicaid), meaning they are provided outside the standard managed care system. Prior to legislative mandate for FY ‘03, Maryland’s public mental health system provided appropriate mental health services to the uninsured as well as those with public insurance through an easy-to-navigate fee-for-service system. The system consisted of two so-called “gray zone” populations — one earning too much to qualify for Medicaid, the other often too poor and too sick to navigate the Medicaid eligibility system. The State removed the upper-income “gray zone” population from the fee-for-service system in FY ‘03.  The other population, poor and vulnerable individuals with incomes less than 116% of the FPL, remains.

• Maryland Primary Care: When Medical Assistance State Only (MASO) was eliminated in 1992, more than 32,000 adults lost comprehensive health coverage. Today, the Maryland Primary Care program provides limited assistance to 8,000 vulnerable adults who receive pharmacy assistance and require at least four medical visits annually for a qualifying diagnosis. Services are provided through participating clinics only. In FY ‘07, the program will be merged with the Pharmacy Assistance program and expanded to 30,000 Marylanders as a result of the Adult Primary Care Waiver. The new program will be administered by HealthChoice Managed Care Organizations.

• Community Health Centers: Maryland has a network of federally-funded Community Health Centers, including four Health Care for the Homeless project sites, that provide a range of services for the low-income, uninsured, and those covered by Medicaid or Maryland Primary Care. Uninsured health center clients often lack access to secondary or specialty medical services. Many health centers impose a sliding scale fee, which may serve as a barrier to care for low-income individuals and families.

• Additional Services: Additional medical services for the uninsured can be provided by local health departments or through foundation grants.

Gaps and Challenges

·        Maryland’s fragmented health system costs too much, provides too little, and covers too few. Some 34% of Marylanders living below 100% of the FPL are uninsured. Childless adults only qualify for coverage once they become disabled, cutting off access to early treatment and preventive care.  

·        Low income, non-elderly adults who work are not eligible for Medicaid. Adults with serious, chronic health conditions such as HIV, hypertension, or Hepatitis C are not automatically eligible for Medicaid; instead they must wait until their condition is so serious that they are permanently disabled. The Adult Primary Care Waiver, to be implemented in FY ‘07, will partially address this gap by providing primary-care only to 30,000 adults below 116% of the FPL. Specialty care and hospitalization are not currently available.

·        The current healthcare system threatens the stability of mainstream and safety net providers. Without the ability to bill an insurer for uninsured patients, many health centers lack financial stability with which to provide comprehensive health services. Even for private providers working mostly with insured patients, reduced reimbursement rates (to account for budget deficits) threaten the comprehensiveness and continuity of patient care.

·        Low-income people with mental illness are in danger of not receiving the services they require.  Individuals too poor to pay for services but earning too much to receive Medicaid do not have access to services.  Those with incomes below 116% of the FPL must continue to be served.

·        Effective healthcare programs must provide a multidisciplinary range of services. Maryland should continue to seek ways to foster access to a comprehensive range of services accessible to vulnerable populations at the same location. The medical, mental health, social services, and addiction treatment needs of low-income Marylanders must be addressed simultaneously in order to improve health outcomes.

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