The governor has put forth a concept paper for a major restructuring of Medicaid in the state, and he is to be congratulated for his initiative. That paper, the West Virginia Comprehensive Medicaid Redesign Proposal, is available online at http://www.wvdhhr.org/MedicaidRedesignDraft.pdf.

An initial meeting with the Centers for Medicaid and Medicare Services has evoked interest. Various committees have been set up to flesh out the concept for resubmission in late September. The problem is, the current proposal may risk more than it gains. Indeed, it may not even be needed.

While this is only an initial draft of a concept paper, the tenor and lack of specifics raise many concerns. At the least, a more deliberate process is required. At worst, we may be giving away the proverbial store.

First, let’s get past the myths. Medicaid is not handouts to welfare mothers. Its primary recipients are children and the aged, blind and disabled, with heavy expenditures for long-term care. It covers 350,000 West Virginians, 200,000 of them children. And Medicaid is a major factor in our economy: $2.2 billion is spent yearly on services in the state.

Overall, the concept paper is more ideological (or actually, rhetorical) than practical. It is dotted with the rhetoric of waivers: being freed from constraints, reconfiguring, redefining and being unfettered from current regulations. It is resplendent with inspirational terms: streamline, coordinate, flexibility and efficiency. States need flexibility in how they run their programs, and any regulation, by its very nature, restricts flexibility. But exemption from existing regulations is only beneficial when you can leverage that flexibility into meaningful gains for the state.

The proposal boldly advocates radical reform, but it does not indicate how those changes will result in meaningful benefits. Clearly, budgetary considerations lie behind the whole effort, but they are never spelled out.

The success of federal waivers ultimately relies on the state’s ability to negotiate for its interests in battle with the federal government’s desire to limit expenditures. Waivers are Faustian bargains. They allow flexibility from current regulations, but they require budget neutrality — the federal government will provide no more money than it did before the waiver. For years, the federal government has talked of block grants as a way of capping federal expenditures. Are we walking into a sucker punch?

The paper’s long-range goals are overly general. If successful, it is said, Medicaid would be expanded to allow low-income working adults to buy into Medicaid — but that’s not cited as a basic goal. One of the few goals mentioned is streamlining administration. And yet the proposal suggests new and cumbersome administrative tasks. Health Investment Accounts would be set up, offering incentives and penalties for various health-related behaviors (e.g., misusing services and inappropriate use of the emergency room). How these would be measured, monitored and implemented is not spelled out. The paper speaks of ongoing consumer education as a key to success, but does not address the expense or personnel necessary to achieve that goal.

The issue of Health Investment Accounts is introduced in the context of personal responsibility, an area in which rhetoric often overwhelms both logic and evidence-based health policy. Medicaid recipients, many argue, don’t show enough personal restraint in their utilization of the state’s largess; only when people actually have to pay will they take more responsibility. But health advocates tell us that more and earlier health interventions reduce the total cost over time. We need an incentive for increased health care for the poor and very sick, not a disincentive!

Currently, various eligibility categories — child, pregnant women, etc. — receive benefits at varying income levels. The concept paper advocates making income the sole criteria for eligibility — everyone below a certain income level would be eligible. Simpler, yes. But what level of coverage are we talking about? And if newly eligible beneficiaries are to gain benefits, who is to give them up? The paper is silent.

The policy paper laments the “one size fits all — carte blanche” (a confusing concept at best!) notion of health care, and offers as more reasonable the notion of tailoring different health packages to the needs of the different eligibility groups. Again, sounds reasonable on the face of it. Children do not need the same care as the blind; the institutionalized need different care than well adults. But what are the practical implications? Again: who gets what, and who loses what to make it possible? Or is the whole idea to combat potential overuse and fraud by requiring prior authorization for certain procedures? But that can be done without a waiver, and without changing the categories. Why fix what ain’t broke?

Finally, what will be the effect of upcoming federal cuts (to the tune of $10 billion over five years) slated to go into effect at roughly the same time as this waiver? Do we even know?

The notion of Medicaid reform, even radical reform, should not frighten us. Serious problems in funding and coverage within the system must be resolved. The question is: How? Overall, the concept paper reads like a campaign document rather than the considered deliberations of experts in the field. Again, it’s only a concept paper; it is not intended as a full-blown proposal. But it provides a very confused vision for further discussion. Instead of focusing on reducing the cost of the system and making the delivery of care more efficient, it focuses on reducing benefits to spread current spending around.

At the very least, the rush to resubmit the concept paper must be slowed. West Virginia is blessed with many experts, in both state service and the advocacy community, capable of assuring a sound and successful reform of the Medicaid program. They should be allowed time and opportunity to do so.

Kurland is health action coordinator of Covenant House and creator of the Web site http://www.criticalreading.com.