At a time when other states are kicking people off Medicaid to save money, Massachusetts is headed in the opposite direction.
Over the past year, the state has added 50,000 people to its Medicaid program, which provides health insurance for the poor. Enrollment reached 985,000 this spring, and in the coming months, it could top 1 million, an all-time high, according to state officials.
There is no single explanation for the surge, say those who follow Medicaid's fortunes, but the most critical one may be a change in the political climate. Governor Mitt Romney has promised to provide health insurance to everyone in Massachusetts, and his administration has concluded that signing more people up for Medicaid is one way to accomplish that goal.
''I'm not a giant fan of the governor's, but I will give him credit for putting his money where his mouth is," said John E. McDonough, executive director of Health Care For All, an advocacy group based in Boston.
Romney insists putting more people on Medicaid is affordable. ''When everyone is insured, care will be better and costs will be lower," said Romney in a telephone interview.
Nationally more than 50 million low-income people get health insurance through Medicaid. The federal government and the states share the cost of care.
Rising Medicaid bills have put pressure on state budgets across the country, and a number of states have concluded that the only way to cut costs is to cut people. Tennessee is removing more than 300,000 people from its Medicaid rolls. Missouri plans to cut 68,000 people in the next year by tightening eligibility standards. Mississippi recently put a strict limit on how many prescriptions drugs Medicaid recipients can get at one time.
Massachusetts was in the cutback camp as recently as three years ago. At the height of the fiscal crisis in 2002, the Legislature dropped about 40,000 people, mainly men, from the Medicaid program. The state also stopped spending money to find people eligible for Medicaid and, according to advocates, forced those already on Medicaid to fill out more paperwork to stay in the program.
''There was a deliberate choice made to winnow down the population," said Neil Cronin, who handles Medicaid issues for the Massachusetts Law Reform Institute.
The strategy worked. Between August 2002 and August 2003, Medicaid enrollment fell by 80,000.
But costs did not drop commensurately. Many of those who lost Medicaid coverage showed up at hospitals and qualified for free care, an alternative system for the uninsured that is paid for by hospitals, insurance companies, and government. In the fiscal year that ended June 30, 2004, free-care visits statewide rose 32 percent, which translated to more than $100 million in extra spending.
''The taxpayers are going to pay one way or another," Romney said.
Daniel Kitterick, 53, provides an illustration of Romney's point. Kitterick, who lives at the Pine Street Inn, was part of the group that temporarily lost Medicaid coverage. Kitterick has had a range of health problems including cancer, strokes, and arthritis. When he was off Medicaid, he continued to receive services, at hospitals and community health centers. ''The care here is nice," he said last week from the Barbara McInnis House in Jamaica Plain, which treats Boston's homeless population.
The problem, say administration officials, is that services provided through the free-care system are uncoordinated and expensive. Detoxification treatment for alcoholism, common among the homeless, can cost $1,000 a day at a hospital, compared with $200 a day in the community settings Medicaid uses.
In 2003, the Legislature restored funding for the 40,000 people it previously dropped from the program. Romney got involved in November when he promised to come up with a plan for providing health insurance to everyone in Massachusetts. At the time, the governor said that roughly 460,000 people in the state lacked insurance and that about 100,000 of them were poor enough to qualify for Medicaid.
In addition to political support, the Romney administration has contributed new technology to the effort. Over the past year the state has rolled out software called the ''virtual gateway," to speed up the process of registration. Historically, low-income patients who came to hospitals and health centers had to fill out separate and lengthy forms for Medicaid and free care. ''It was the equivalent of sending something by Pony Express," said Mark Goldstein, director of finance at Boston Medical Center, which handles several hundred such applications a day.
The gateway has simplified the process and eliminated most of the paperwork. The result: People eligible for Medicaid are flagged faster, and more people wind up on the rolls.
So far, the rise in enrollment has not had a huge impact on state finances. Massachusetts' $7.4 billion Medicaid bill is projected to increase only about 5 percent this year, in part, because the state now uses many of the same managed-care techniques as private insurers. Hospitals and nursing homes have contended that the state also holds down costs by skimping on reimbursement.
While most healthcare advocates applaud the state's renewed commitment to Medicaid, some say the strategy has risks. With Washington concerned about its budget deficit, there could be attempts to scale back the federal government's support for the program. That could leave Massachusetts on the hook for higher costs down the road.
Others worry about the state's commitment. ''It was just three years ago that we were cutting Medicaid here," said Michael DeChiara, director of Community Partners, an Amherst group that works with the uninsured. ''It is great that we are talking about insuring everyone, but the whole thing is new and tenuous. I'm not sure how fully everyone has embraced the idea."
Charles Stein can be reached at firstname.lastname@example.org.