Caring for Flint: Medicaid's Enduring Role in Public Health Crises
It’s fair to say Flint, Michigan, is facing a public health catastrophe: Thousands of city residents, including as many as 9,000 children, may have been exposed to toxic levels of lead through contaminated water. While the problem was entirely preventable, the question now is what will be done for its victims—not only to end the health threat but also to address the health and developmental damage Flint’s children will endure, potentially for a lifetime.
On February 13, Governor Rick Snyder asked the secretary of the Department of Health and Human Services to exercise her special powers under Section 1115 of the Social Security Act to allow the state to put Medicaid to work. The state proposes to do three things. First, to ensure Flint’s low- and moderate-income children and pregnant women have comprehensive health insurance coverage, the state would raise its income eligibility standard for Medicaid and the Children’s Health Insurance Program from 200 percent of the federal poverty level to 400 percent of poverty ($47,000). This doubling would provide assistance to an additional 15,000 pregnant women and children under 21. The state also would allow pregnant women and children whose family incomes exceed the financial cutoff to purchase public coverage on an “unsubsidized basis.”
Second, the state would provide targeted case management, through nurses and social workers, to all Medicaid-enrolled children and pregnant women affected by Flint’s water (about 30,000 people) to ensure they gain access to necessary medical, educational, and social services. Third, and perhaps most uniquely (but not without precedent), the state would apply Medicaid funds toward the cost of lead abatement services in affected homes, focusing on lead paint, lead-affected surfaces and fixtures, and lead-exposed soil hazards. Abatement costs covered under the demonstration would include preparation, cleanup, disposal, and post-abatement testing.
To those familiar with the program, it comes as no surprise that in times of crisis—whether natural or manmade—policymakers would turn to Medicaid, the workhorse of the American health care system. Medicaid is an insurer so unique—especially when enhanced by an 1115 demonstration—that it has become a centerpiece of the national response to public health disasters. Targeted expansion of Medicaid coverage followed both the World Trade Center attacks and Hurricane Katrina. And during the 1990s, Rhode Island used Medicaid to fund lead abatement services aimed at households whose children were harmed by exposure.
Because it functions as both an insurer and an integral part of the social safety net, Medicaid has eligibility rules and benefits that stand apart from private insurers. For example, people can enroll in Medicaid at any time, unconstrained by the designated enrollment periods in any risk-based health care financing system. And as Michigan underscores in its 1115 application, Medicaid’s benefit structure is broad, covering not only standard treatments but the additional care and services necessary to address the long-term health effects associated with a contaminant as severe as lead. Similarly, there is no private health insurance equivalent to Medicaid’s child health benefit, early and periodic screening diagnosis and treatment, which offers comprehensive coverage spanning preventive and primary care to health care over a lifetime for children with permanent physical, mental, and developmental disabilities.
Still, Michigan’s proposal raises issues that presumably will be addressed during the federal review process. First, its Medicaid eligibility expansion proposal may not help everyone who needs it. Given that, what costs would be incurred by families whose incomes exceed 400 percent of poverty but who need Medicaid’s special protections for their children and who thus would be required to buy into the program? Second, the proposal would terminate Medicaid eligibility when children turn 21, but the damage done by lead can last a lifetime .What would happen when Medicaid eligibility ends? Finally, family members with coverage through the Affordable Care Act’s marketplace who are exposed to lead poisoning but not covered by the Medicaid expansion will continue to depend on their private insurance. What steps, if any, will be taken to ensure that the additional treatment they may need will be readily available?
These issues have yet to be resolved. Once again, however, Medicaid’s role in addressing a national public health crisis should remind Americans about its place in the public health firmament.