Spotlight on co-pay proposal

CARSON CITY – Requiring Medicaid recipients to pay a small co-pay before they get medical care would “help their own self-dignity” and induce them to see doctors only when necessary, according to the new Republican leader of the Assembly.

Minority Leader Pat Hickey of Reno has been mentioning for months that he intends to introduce a bill to require Medicaid recipients to pay a small sum out their own pockets before they receive care under the federal-state paid health care program. But only after Gov. Brian Sandoval expressed interest on Dec. 12 did Hickey’s proposal get much attention.

Sandoval noted that the state Medicaid population, now 313,000, will grow to 490,000 in mid-2015.

That growth is in part because of the governor’s decision to provide Medicaid health care, now free for participants, to all individuals and families who earn less than 138 percent of the federal poverty level. That is $15,415 a year for an individual and $31,809 for a family of four.

The governor spoke of a $2 to $10 co-pay per visit but did not go on record as backing co-pays. Hickey has not decided on an amount.

The average American makes four doctor’s office visits a year, according to the U.S. Centers for Disease Control and Prevention. If the co-pay in Nevada for Medicaid were $5, that would be
$9.8 million in 2015.

In the 20 states that now have Medicaid co-pays, the money does not go to the state, but to the doctor.

Hickey said he got his idea for the Medicaid co-pays from reports of how prison systems were using co-pays to dissuade inmates from seeking unnecessary medical help. “Many other states have done versions of co-pays. I don’t see it as punitive, but practical. We all pay co-pays,” he said.

Based on court decisions, the National Commission on Correctional Health Care’s policy has been that inmates can be charged small co-pays, but medical care cannot be denied to those who cannot afford to pay even a small amount .

The co-pays could be considered a fee or tax increase, which would require a two-thirds vote of legislators in Nevada.

Sandoval acknowledged that might be true, but he doubts the income received would be much.

Hickey also said a two-thirds vote might be required but did not think that would pose a problems for Republicans, many of whom have gone on record against any tax increases.

In co-pay states, it is up to doctors to decide whether to provide free care or to work out payment arrangements with patients who say they do not have money to pay a small charge.

Stacey Shinn, the legislative lobbyist for the liberal-leaning Progressive Leadership Alliance of Nevada, said it would be a mistake to require any co-pays.

Shinn, a licensed social worker who worked in mental health clinics, said most of her clients were on Medicaid, and she saw “their everyday struggle to make ends meet.” A co-pay is almost a regressive tax on them, and instead of requiring the “most poor” to provide state resources, the Legislature needs to require the mining industry to pay more and support a business margins tax, Shinn added.

Dr. Ron Kline, president of the Southern Nevada Medical Industry Coalition, likes the idea of people “having skin in the game” by paying even a small share of their care costs. But he questions whether “really destitute people” can pay even $5. His organization had urged Sandoval to expand Medicaid.

Kline said if the state approves co-pays, then it might be “used as an excuse” to reduce its reimbursement rates to doctors, regardless of whether they collect the co-pay.

The federal Medicaid law allows nominal co-pays but does not let doctors refuse treatment to those who cannot pay.

Jon Sasser, a lobbyist for legal aid programs in Washoe and Clark counties, said he and others previously met with Hickey and outlined their concerns about co-pays. “There is no evidence that poor income folks overuse the system,” he said. “But national studies show co-pays keep them from needed medical care.”

The 9th U.S. Circuit Court of Appeals ruled last year that Arizona’s $4 to $30 co-pays violated federal law because their sole purpose was to reduce state Medicaid costs. The court said the federal Medicaid law does not allow co-pays just to save the states money. Arizona had no alternative for patients who could not afford the co-pays.

Federal Medicaid officials threw out California’s plan for a co-pay in February because it also was used just to save money. The state planned to save
$575 billion through mandatory co-pays. Some doctors in California applauded that decision because they did not expect many Medicaid participants could afford the costs.

Illinois in July began charging many Medicaid recipients $3.65 for a visit to a doctor’s office and $2 for each prescription. Exceptions were made for doctor’s office visits by children and by women when it comes to reproductive needs. Idaho has a similar law.

Contact Capital Bureau Chief Ed Vogel at evogel@reviewjournal.com or 775-687-3901.