"If a brother or sister is naked and lacks daily food, and one of you says to them, 'Go in peace, keep warm, and eat your fill,' and yet you do not supply their bodily needs, what is the good of that? So faith by itself, if it has no works, is dead." (James 2:15-17, NRSV)

The debate about faith versus works began with the early church and continues today but manifests itself in different ways. As a consequence, social justice issues have often been stereotyped as "works" devoid of "faith." Rather than prod the debate or become judgmental, I shall simply remind readers that Jesus in the parable of "The Great Judgment" (Mt. 25:31-46) proclaimed that God will judge the people based on what they have or have not done. In the original Greek that the gospel of Matthew was written, "you" is plural; God will judge the responsibility of a people, not just of individuals.

So what does that say to American Christians as the nation struggles with issues related to Medicaid? Medicaid is the nation's major public financing program that provides health and long-term care coverage to low-income people. Medicaid is authorized under Title XIX of the Social Security Act. Although it is financed by both federal and state governments, it is administered by the states. The Medicaid program is a partnership between the federal and state governments. The federal share ranges from 50 percent to 80 percent of Medicaid expenditures and averaged 56 percent in 1997.

Eligibility for Medicaid

Eligibility criteria for Medicaid is primarily reserved for persons in categories such as low-income children, pregnant women, the elderly, people with disabilities, and parents meeting specific income thresholds. Since the Temporary Assistance to Needy Families (TANF) welfare reform was passed by Congress and signed into law by the President in 1996, Medicaid coverage is no longer automatic for families who receive cash assistance. Within federal guidelines, states set their own income and asset eligibility criteria for Medicaid, resulting in large state variations in coverage.

This situation becomes even more exacerbated when former welfare recipients are viewed as a real person and not just as a number. Although politicians have been crediting the decrease in the welfare rolls and the moving of former recipients into jobs, attention needs to be given to the health coverage of those who lose welfare benefits.

One of the unintended consequences of welfare reform is that many people who are still eligible for Medicaid coverage do not know it because it has become de-linked from welfare. Thus, these people become uninsured.

The Families USA Foundation found that over two-thirds of a million low-income people-approximately 675,000 lost Medicaid coverage and became uninsured as of 1997 due to welfare reform (based on data from the U.s. Census Bureau's Current Population Survey and from the health Care Financing Administration). The majority (62 percent) of those who became uninsured due to welfare reform was children, and most of those children were, in all likelihood, still eligible for coverage under Medicaid.

Because 1997 was the first year of welfare reform implementation, the Families USA report (Losing Health Insurance: The Unintended Consequences of Welfare Reform, May 1999) shows only the earliest effects of welfare reform, before many of the time limits imposed by the new law take effect.

In 1997, Medicaid financed health care for 40.6 million low-income children, adults, elderly and disabled persons at a cost of $167.6 billion. Of that, $161.2 billion was spent on services and $6.4 billion on administration. Between 1996 and 1997, Medicaid spending grew by only 4.1 percent and Medicaid enrollment actually declined by 1.8 percent, decreasing for the second year in a row.

Enrolling Children in Medicaid and Children's Health Insurance Program (CHIP)

Over 11 million, or one in seven children in this nation, are uninsured (Source: Kaiser Commission on Medicaid Facts, January 2000). Two-thirds of these children are from families with incomes below 20 percent of poverty ($33,400 for a family of four in 1999). A critical safety net for low-income children has been the Medicaid program; I covered 21 million children in 1998.

In addition, the State Children's Health Insurance Program (sometimes referred to as CHIP) has extended coverage to an additional 2 million children who do not qualify for Medicaid. Unfortunately there has not been adequate outreach to the parents of children who are eligible for these programs, therefore, many children remain uninsured.

Low-income uninsured children typically live in two-parent, working households and have little contact with the welfare system. Because there is no insurance coverage for this population, the children's lack of access to health services makes them more vulnerable than children who receive health coverage through either public or private insurance. An example of this is that parents of uninsured children often postpone seeking medical care for their child because they cannot afford it.

Complex eligibility rules make it difficult for parents to enroll children who are eligible for CHIP and Medicaid programs. They often have different eligibility levels depending on a child's state of residence, age and family income. Fluctuations in family income could result in children moving on and off either program. Despite the basic lack of information on how or where to enroll, parents who are not in the welfare system may not be aware that their children qualify for Medicaid or CHIP.

Other problems related to enrolling a child is the perceived difficulty, which is sometimes real, and the inconvenience. Many parents report that they did not complete the process because it was too complicated and confusing. Others cited difficulty in getting all the required documentation. Another important barrier may be language. Non-English speaking parents who assume the enrollment materials will not be available in their language are discouraged from even trying to enroll their children. These and other problems must be resolved between the federal government and each individual state.

A great concern is that outreach and enrollment efforts should be supported with measures to ensure that eligible children retain their coverage during a time of predetermining process as federal requirements are minimal for Medicaid and nonexistent for CHIP.

Medicaid and Disproportionate Share Hospital (DSH) Program

DSH payments are made to hospitals that provide a disproportionate amount of medical care to low-income patients. DSH acted as a safety net for underinsured the uninsured and Medicaid patients. The Balanced Budget Act of 1997 made some reforms in Medicaid-the vast majority were in DSH payments. The budget act sets DSH allotments in the statute. A flat cap was placed on states' DSH funds for the first time and will last beyond the five-year budget agreement.

Congress' attempt to curb abuses in the program have had unintended consequences. Hospitals that provide a disproportionate share of services have complained about the devastating effect of the DSH cuts. Some members of Congress have also raised concern for hospitals in their districts that have had their funds cut; yet are serving more patients.

A bill, H.R. 3710, has been introduced by Reps. Diana DeGette (D-Colo.) (a Presbyterian) and Brian Bilbray (R-Calif.). The bill called the "Medicaid Safety Net Hospital Preservation Act of 2000" was introduced in the House Commerce Committee on February 29. It has been referred to the Subcommittee on health and Environment on which both Ms. DeGette and Mr. Bilbray are members.

The bill calls for amending Title XIX of the Social Security Act to assure preservation of safety net hospitals through maintenance of the Medicaid disproportionate share hospital program. The purpose of the bill is to freeze the federal cuts a fiscal year 2000 level because the 2001 and 2002 cuts will be larger.

With a short session of Congress expected this year due to campaigning for elections, there is little evidence that although Medicaid issues may be crucial to those who need the services of the program that, therefore, this will translate into legislative action. All seats in the House of Representatives are up for re-election as well as a third of the Senate. Medicaid is an issue that does not seem to evoke political or economic power.

The witness that Christians are called to express must be aware of political and economic power but must be guided by the power of the Holy Spirit.

In the words of "A Brief Statement of Faith,"

In a broken and fearful world,
The Spirit gives us courage…
To hear the voices of peoples long silenced,
And to work with others for justice, freedom, and peace.

The Medicaid Population

The diverse Medicaid population is comprised of:

21 million children (one in four U.S. children)
8.6 million adults in families
4.1 million elderly persons
6.8 million blind and disabled persons.
(Source: Kaiser Commission on Medicaid Facts, Medicaid and the Uninsured, July 1999)

The number of legislative days remaining in the 106th Congress is expected to be shorter than a regular session because this is a national election year. The house will be in recess for Passover/Easter from April 17 to 28 so that will be a good time to contact your Representative while he of she is in your home district. You may also want to contact their Washington offices.

Suggested Action

1. Contact your Representative and urge her or him to maintain DSH payments at FY 2000 spending level. Acknowledge that fraud and abuse must be addressed, but while lifting up that this should not be done at the expense of vulnerable populations needing services. If there is a hospital in your community that has taken on the extra burden but now has fewer resources as to deliver appropriate services, use that as an example for your Representative. Identify if you know of a problem related to a hospital cutting back on providing medical care to a community in need.

Address

Honorable________
U.S. House of Representatives
Washington, D.C. 20515

If your Representative is on the House Committee on Commerce, especially the Subcommittee on Health and Environment, advocate to get H.R. 3710 or a similar type bill out of Committee and to the full house for a vote.

House Commerce Committee:
Republicans: Bliley (Va, chair), Tauzin (La.), Oxley (Ohio), Bilbray (Calif.)*, Largent (Okla.), Burr (N.C.)*, Bilbray (Calif.)*, Whitfield (Ky.)*, Ganske (Iowa)*, Norwood (Ga.)*Coburn (Okla.)*, Lazio (N.)*, Cubin (Wyo.)*, Rogan (Calif.), Shimkus (Ill.), Wilson (N.M.), Shadegg (Ariz.)*, Pickering (Miss.)*, Fossella (N.Y.), Blunt (Mo.), Bryant (Tenn.)*, Ehrlich (Mich.)

Democrats: Dingell (Mich., ranking member), Waxman (Calif.)*, Markey (Mass.), Hall (Tex.) 8, Boucher (Va.), Towns (N.Y.)*, Pollone (N.J.)*, Brown (Ohio)*, Godon (Tenn.), Deutsch (Fla.)*, Rush (Ill.), Eshoo (Calif.)*, Klink (Pa.), Stupak (Mich.)*, Engel (N.Y.), Sawyer (Ohio), Wynn (Md.), Green (Tex.)*, McCarthy (Mo.), Strickland (Ohio)*, DeGette (Colo.)*, Barrett (wisc.)*, Luther (Minn.), Capps (Calif.)*

*Health and Environment Subcommittee; Bilirakis is chair, Brown is ranking member.

2. Subscribe to PC(USA) Washington Office list serve on Health Care. Send an e-mail message to washhealth-request@halak.pcusa.org and include in the message the word, subscribe. This is a read-only list provides action alerts, legislative updates, and background documents on public policy related to health care.

General Assembly

The 211th General Assembly (1999) adopted two reports from the Advisory Committee on Social Witness Policy: "Health care: Policies and Activities" and "Managed Care." Concerns for beneficiaries of Medicaid are addressed in both.