Monday, December 6, 2010

is this acceptable? Arizona refuses to pay for medicaid patients' transplants

Arizona Medicaid Cuts Seen as a Sign of the Times
Published: December 4, 2010

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With enrollments exploding, revenues shrinking and the low-hanging fruit plucked long ago, virtually every state has had to make painful cuts to its Medicaid program during the economic downturn.

Mounting State Debts Stoke Fears of a Looming Crisis (December 5, 2010)

What distinguishes the reductions recently imposed in Arizona, where coverage was eliminated on Oct. 1 for certain transplants of the heart, liver, lung, pancreas and bone marrow, is the decision to stop paying for treatments urgently needed to ward off death.

The cuts in transplant coverage, which could deny organs to 100 adults currently on the transplant list, are testament to both the severity of fiscal pressures on the states and the particular bloodlessness of budget-cutting in Arizona.

“It’s a real sign of the times,” said Alan Weil, executive director of the National Academy for State Health Policy. “And I think this is a precursor to a much larger number of states having this discussion.”

Policy choices with such life-threatening implications are all the more striking given the partisan framing of the health debate.

Republicans have argued that the new health law will lead to rationing, warning even of “death panels.” Democrats have responded that care is already rationed, with 50 million people going largely without insurance, and that the law will bring greater equity.

The Arizona case, said Diane Rowland, director of the Kaiser Commission on Medicaid and the Uninsured, “is a classic example of making decisions based not on medical need but based on a budget.” And, she added, “it results, potentially, in denial of care to individuals in a life-or-death situation.”

The federal Centers for Medicare and Medicaid Services do not monitor which states use Medicaid money for transplants. But health experts said no other state had withdrawn coverage for patients pursuing transplants.

Arizona’s decision, by Gov. Jan Brewer, a Republican, and the Republican-controlled Legislature, was made after state officials assessed success and survival rates for a number of transplant procedures. National transplant groups call the figures misleading.

“It seems inappropriate that life-saving care has the potential to be withheld based solely on budgetary issues and the bureaucratic determination of relative benefits,” said Dr. Robert S. Gaston, president-elect of the American Society of Transplantation.

There is usually a long-term consequence to short-term cuts in safety-net programs like Medicaid, which insures low-income Americans and is financed by state and federal governments.

When payments to doctors are cut, fewer providers are willing to treat Medicaid patients. When eligibility levels are lowered, more people are left to seek charity care in emergency rooms. When optional benefits like dental services and prescription drugs are eliminated, conditions worsen until they require more expensive care.

But no other state in recent memory has made such a numbers-driven calculation pitting the potential loss of life against modest savings.

Jennifer Carusetta, the legislative liaison for Arizona’s Medicaid agency, said the transplant cuts would save a mere $800,000 in the current fiscal year, and only $1.4 million for a full year.

The cuts were imposed in an effort to close a $2.6 billion shortfall in the state’s $8.9 billion budget for this year.

The options available to states for cutting Medicaid have been limited because the federal stimulus package and the health care law have required them to maintain eligibility levels. That has left states to cut payments to providers and trim benefits not required by federal regulations.

Many states, including Arizona, have done both. A September report by the Kaiser Family Foundation found that 39 states cut provider payments and 20 cut optional benefits in their 2010 fiscal years, with similar numbers planning to do so in 2011.

Arizona reduced Medicaid payments to doctors by 5 percent last year and has frozen payments to hospitals and nursing homes for two years. All providers will undergo another 5 percent cut on April 1, Ms. Carusetta said.

This year, Arizona became the only state to eliminate its Children’s Health Insurance Program, which would have affected 47,000 children of working-class parents. Lawmakers reversed course before the effective date only after concluding that the state might run afoul of federal requirements and lose billions of dollars in matching money.

The state has also enacted a wide range of Medicaid cuts, eliminating coverage for emergency dental procedures, insulin pumps and orthotics. “We realize this has serious impacts on people,” Ms. Carusetta said. “Unfortunately, given the fiscal constraints facing our state, the Legislature has limited options at this point.”


  1. In situations like these, it's extremely difficult to say whether or not such actions taken were unethical. Given the facts, budgets must be cut from spending in one way or another in order to stay within their limit. With this said, in class discussions, it has been argued, and partially established that health care is an inherent right, and it is the responsibility of others to take care of those that are ill and in need of care.

    Therefore we must ask, could these budget cuts be taken out of any other funds? Because organ transplants are often needed in life or death situations, taking away funding for these procedures will most likely cause the death of those individuals waiting for a transplant. Therefore, the amount of harm being done by cutting the budget is so high that when analyzing the benefit/consequence analysis, the consequences potentially outweigh the benefits.

    Though budget cuts may be necessary, or unavoidable, these cuts don't necessarily have to come from one area, but should be spread throughout the system so that the least harm is done to the least amount of people.

  2. This comment has been removed by the author.

  3. This story gives all the more evidence that the United States health care system is rapidly moving towards imploding on itself. The fact a state can suddenly take the prospect of continued life from a whole population that depends on government assistance to stay healthy is terrifying. It is only worse that the state is saving only 1.4 million dollars per year and 800,000 for the current year, as a part of an attempt to close a “2.6 billion dollar shortfall in the budget.” It is completely unacceptable that many lives are going to be surrendered for the state to recover roughly 1/2000 of the budget shortfall. Unfortunately in this country medicine and healthcare is viewed a for-profit business, leading to disturbing stories such as this. If we are going to prevent the health care system from completely falling apart here, assuming it hasn’t yet, we need to change this notion. Healthcare cannot be effective as a business and changing this is going to start by eliminating private for profit insurance companies. There is no reason for an insurance company to profit off of people getting sick or fearing getting sick. Capitalism works great for some industries; healthcare isn’t one of them.

  4. "Democrats have responded that care is already rationed, with 50 million people going largely without insurance, and that the law will bring greater equity."

    I fail to understand how this law will bring greater equity to the people of Arizona. If I am inferring correct that they are talking about the Medicaid cut, how does this create equity among the people? If anything, it would cause a greater inequity to the people on Medicaid that can't afford healthcare. They are already unable to afford other type of insurance- a system which is inherently unequal. Pushing them even more to be unable to afford the care they need is anything but equal. If I am mistake about which law they are discussing, then I apologize.

    I agree with Katrina that the cuts they are making could potentially be taken from other resources. It IS unethical to deny people who can't afford healthcare the care they need- if I have learned anything from this class, it's a more solid understanding of the reasons why healthcare is (and needs to be recognized by the US as) a human right. As a student of public health, I understand that healthcare must be "rationed", for lack of a better term. But denying life-saving and necessary procedures to people who need them is an atrocity. How about a more well-informed and EQUITABLE budget as a basis, a reorganization to include more primary care for the people who can afford private insurance so they don't spend all off the health budget seeing specialists when in some cases, it is unnecessary.

    I firmly say no, this is unethical. It denies human rights and increases the gap for those that can't afford private insurance.

    -Annie McCormack

  5. by no, I meant YES this is unethical.

  6. This issue of budget cuts to Arizona’s Medicaid program regarding transplant coverage is an unfortunate reality. In a stressed economy cuts have to be made programs. Whether or not cutting transplant coverage for those supported by Medicaid is ethically the best choice is up for debate. In an idealist sense, of course limiting healthcare coverage to those who need it is unethical. Especially when the situation is one of life or death, money should not be a factor. However, in a pragmatic sense health care is not deemed a right in our country; and therefore, if budgets to state and federal health programs are cut, there should not be a question as to whether those actions are fair or not.

    Living in a country that relies heavily on cost-benefit analyses to make monetary decisions, the greater good is considered over the individual. Not to say that those lives in need of a transplant are expendable, but in Arizona’s case of cutting these funds you have to trust the costs and benefits were weighed considering the future health of the state as a whole. Now, making a decision like this was sure to draw criticism, which brings its own detriments, so I do question this aspect of it. If making these cuts is only estimated to save 1.4 million dollars over the year, I do not see how the loss of potentially 100 lives could be considered less than that. You have to imagine that 1.4 million dollars could have been taken from another larger budget, such as education, which could absorb that monetary loss easier.

    Either way, I do not support such cuts, but I am okay with it. The problem here lies with the fact that Medicaid is a federal program from which states receive money. As these resources are of a federal origin, residents take ownership of them, as they become expected resources to rely on because the amount of money a state will receive is dependent upon the makeup of its residents. So, taking away resources meant for a program that obviously has heavy strings attached to it is not ethical according to justice, but living in time with increasing state deficits it is understandable.

  7. I think Arizona's cuts are extremely unethical and is extremely disturbing. It's sad to see that thousands of people are denied benefits because of costs. It is understandable that our country has issues with money regarding health insurance, however, I think there could be a way to cut costs in other areas not health.
    Arizona cutting out the Children's Health Insurance for one is extremely sad to read about. It is unfair to take away resources for young children if they need it. I think our country makes promises and goals to each other to make us stronger and seem as though we care for one another, but we don't. I think we have become a very selfish and greedy country, and we need to start looking at ways that will benefit everyone, not just ourselves.

  8. Arizona's Medicaid cuts are extremely unethical. Just being on the organ transplant list is enough of wait, now the fact that they are denying these people organs is extremely wrong. These people are basically being handed a death sentence. The Medicaid program was designed to help people who couldn't afford this type of care but now it is being revoked. It shouldn't matter what type of crisis our country or the state of Arizona is in, cutting other government spending or other programs in the health field would be much more efficient in saving lives and money. The fact that organ donation or transplantation is being revoked is an extreme eye-opener to how our health care system is operating. Since when did we stop caring about the well being of the human beings and strictly focus on money.
    The fact that dental programs and insulin pumps and other life saving devices are being cut from this program is also very scary. The fact that Children's Health Insurance program is being cut is extremely dangerous. What type of outlook are we expected to have for the future of America if they can't receive health care or medicine to stay alive on this earth. It is extremely unethical to even think about cutting childrens health insurance, these are young kids who haven't even been given a chance to thrive in society. The fact of the matter is, it seems as though there are other areas that can be cut to help with the budget deficits that have been occurring.

  9. I absolutely agree with the previous posters in saying that Arizona's decision to cut off funding is unethical. For the sake of money, the government is withholding care from patients that desperately need it. The reasoning behind this decision also does not make much sense to me. Cutting funding for transplants only saves $1.4 million per year, which is only a small percentage of the amount Arizona's budget fell short - isn't there another way to close the gap that does not affect a life or death situation for hundreds of people. It is even more appalling that the state government only repealed their decision to abandon the Children's Health Insurance Program after they were at risk of losing funds. This only reinforces that instead of looking out for what is best for the citizens, the government is concerned purely with financial gain. Although I empathize with Arizona's need to keep to their budget, they should not make that a higher priority than doing what is best for their citizens.

  10. The actions taken in Arizona are definitely unethical. The Medicaid program is in place to benefit poorer Americans, and to have funding for life saving procedures cut is not acceptable. People should not denied necessary organ transplants just because they are unable to afford it. This cut was also shown to have a very small effect on the overall deficit that Arizona is currently facing. This goes to show that the harm of this act will definitely out weigh the benefits as people will lose their lives because they are denied a transplant.

    Other ways of decreasing the current deficit in Arizona should be looked into. This cut targets and effects a very small and defined population of Americans. The population targeted is most in need of funding for transplants and denying them this funding will lead to people losing their lives.

  11. I think that it is both unacceptable and unethical for Arizona to refuse to pay for life-saving procedures that some of its Medicaid patients need. Health care is an inherent right of all people. Our country is working towards making sure there is healthcare for all, and Medicaid is one of its current programs that ensures health care for Americans of low socioeconomic status. The point of Medicaid is to strive towards health care equality by providing healthcare, not taking it away and putting these people at even less of an advantage or making them less equal. The long term consequences and obvious harms greatly outweigh the benefit of saving money. No one’s life should be compromised due to budget constraints. Although the budget issues must be dealt with somehow, Arizona must find a better way then denying transplants to dying people. Arizona’s government is clearly not looking out for the best interests of their citizens, but is solely focused on money, which is evident through their last minute decision to not cut the Children’s Health Insurance Program so they would not lose billions of dollars.

    -Erica Jordan

  12. Arizona's decision to stop Medicaid payments for transplant patients is deeply troubling and unethical. The state government and legislature should have the interests of the citizens of Arizona as a foremost consideration. To make a decision that has real life and death consequences for the people of Arizona because of budgetary concerns is not justifiable. Yes, I understand the need to balance the budget. It an an important part of governing, but I dare say not as important as human life. The decision by Jan Brewer and the state of Arizona is wrong not because they tried to balance the budget, but wrong because of the way in which they tried to do it. They put fiscal concerns above the life of very ill patients (those on the transplant lists). The point is that the state of Arizona could have chosen some other area in which to cut costs -an area in which cutting costs will not so severely threaten human life. They could have cut pay from some public works department to achieve the same savings as stopping Medicaid payments. By choosing to stop payments for transplant patients, the state government of Arizona has demonstrated that it does not place a premium on the value of human life.

    Jill Grodman

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  14. At first it isdifficult to say in such a situation, what ought to be considered ethical or unethical. What is clear is that the state has cut budgets based clearly on numbers and money and has disregarded the need to save lives. This in itself seems to be an operant of greed, and in breach of the principles of nonmaleficence and benficence. It seems to be a very cold clear cut calculated decision, strictly based on numbers. There is an apparent absence in remembering to think of saving human lives, minimizing harm, and doing what is the greatest good for the greatest number. It is unclear why the budget cuts are done and where the money would be otherwise spent, but human life and health ought to be the utmost priority, well above things such as road and highway costs, building, self defense, and other state costs. It seems as though they've put healthcare on the backburner and put other things to be more important, although what these are is uknown given the article. This is certainly a bit concerning. After review it seems as though it would be most ethical to put the health of ones citizens above all else, although Arizona clearly has a different agenda.

  15. This article is a grim reminder of the realities that we all will be facing very shortly. The author walks a line in his story carefully plotting out the most probable course that many states will take in order to rein in costs while presenting Arizona as a first case scenario that has obviously overreacted and confused healthcare for politics. He provides enough information to get a sense of what is happening but also concedes that there are simply too many unknowns to chart an accurate course. Sadly, candidates for major organ transplant are already rejected if they have inadequate insurance to get rejection medicine, poor social support, or are deemed at high risk to take poor care of such a scarce resource. To throw a nearly insurmmountable financial barrier in as well is the epitome of class warfare. Not surprising that this comes from those loudly opposed to "socialized medicine." Of all the places to look to cut the budget, this seems the cruelest. If a state does not offer financing for a life-saving procedure, or never did, it would be one thing. But to take away the hope of a patient who has been on a waiting list for months or years for a life-saving procedure is too harsh. While my personal bent is that the state should restore the funding to all patients who need assistance, at least the state could compromise for now by continuing to offer funding for the patients who were on the list when the bill was to take effect.

    Handi Wu

  16. This is quite a depressing article to read. Money is important, but the health of the people are more important. These politicians are elected to represent the people who elected them. Do they really think the people they've been chosen to represent want cuts to medicaid/medicare? There are ALWAYS other options when it comes to tax cuts. I propose they cut their own paychecks by a few dollars, and put that money back towards their constituents. Unfortunately, the first things always cut have to do with healthcare and education.

    As far as the actual ethics go: the legislature is doing their job. That job, however, doesn't seem to really be benefiting their constituents; they're harming them by withholding the money for treatment. The best option would be to make a less drastic cut to the system and look for excess money or places to cut elsewhere. That would benefit the most people in the long run.

  17. An organ transplant is a necessary medical procedure. Without it many patients will die. Some people wait on organ transplants lists for years until they move up high enough to find a match. It is extremely unacceptable and inhuman for Arizona to deny to pay for such necessary procedures for medicaid patients. This legislation just insults the reasoning behind having health insurance. Your health insurance company is supposed to be there for you and for them to deny such a necessity to save money should be unlawful. Arizona should find other places to make cuts because this is clearly not the right move and it is also quite disheartening.