Poor adults in Medicaid would get fewer dental cleanings and have to chip in for the cost of medical care under Gov. Dannel P. Malloy's proposed budget.
Seniors receiving home care would have to pay more for the services, and a portion of the program aimed at keeping seniors out of nursing homes would be capped.
Non-citizens who rely on the state for food assistance would see their benefits cut by a third, and state funding to help people pay for HIV and AIDS medication would be eliminated.
The budget calls for cuts to a wide range of programs that help some of the state's most vulnerable residents. But some advocates for people served by the programs said they had expected worse, and were relieved at much of what was and wasn't, in the budget.
Some proposals even drew praise, such as the decisions to add coverage of smoking cessation services to Medicaid. Some advocates also praised the proposal to replace ConnPACE, a state-funded program that helps seniors and people with disabilities pay for medications, with the Medicare Savings Program, which provides federal subsidies.
But advocates raised concerns about other proposals, some of which they said would threaten the safety net Malloy pledged not to shred.
In proposing Medicaid copayments, the Malloy administration echoed its predecessor in pointing out that Connecticut is one of only a handful of states that does not require Medicaid recipients to pay anything toward the cost of their care. Adding copayments of up to $3 could save a projected $17.7 million over two years.
The proposed copayments would only apply to some services and some people. Inpatient care, home health care, lab work and transportation services would not require copays, and groups including children under 18, people below 100 percent of the poverty level and pregnant women would not pay anything.
But patient advocates said requiring even small copayments in Medicaid is bad policy because it leads patients to forego care or medication, potentially leading them to need more costly care later. The state has tried Medicaid copayments in the past, but eliminated them. Former Gov. M. Jodi Rell proposed bringing them back, but legislators rejected the idea.
Some health care providers say they ultimately pay the cost of Medicaid copayments because they are responsible for collecting the money from patients and often don't get it. Ellen Andrews, executive director of the Connecticut Health Policy Project, said her clients are more likely to go without care or forego something else to pay their doctors.
"Whether you need to go to a doctor shouldn't depend on whether you have $3 in your wallet at the time," she said.
Office of Policy and Management Secretary Benjamin Barnes, Malloy's budget director, agreed that copayments in Medicaid are not good public policy and serve as a barrier to care.
"However, the underlying principle that we need to balance our budget and that we need to have shared contributions to that balance was the most important thing that we needed to address," he said. "I think we've done that in a way that leaves the core principle of the safety net intact."
He added that copayments would be limited based on income and the type of service to make them less burdensome.
The budget also calls for saving $9.5 million over two years from changes to a new Medicaid program for low-income adults, and describes the changes as an alternative benefit package, targeted copays and rate changes.
The program, known as Medicaid LIA, has grown larger and more costly than state officials expected. It was originally expected to save the state money by transferring adults covered by state-administered general assistance into Medicaid, which brings the state federal funding. But in converting the program to Medicaid, the eligibility expanded, and enrollment grew faster than had been expected. Barnes said the administration is exploring adding an asset test to the program, particularly for 19- and 20-year-olds who can receive Medicaid LIA coverage even if they live at home and could be covered by their parents' health insurance.
Malloy's budget would limit but not eliminate coverage of nonemergency dental and vision care for adults in Medicaid, services that providers and advocates had worried would be vulnerable because they are not required by the federal government.
Under Malloy's proposal, healthy adults would be limited to one dental exam, cleaning and bitewing X-ray a year, part of $20.1 million in two-year forecasted savings. The state would save $1.77 million over two years by limiting adults to one pair of eyeglasses every two years.
The Connecticut Home Care Program for Elders would see significant changes under Malloy's proposal.
One portion of the program, which is fully state-funded, covers preventive services for people who would otherwise be at risk of requiring nursing home care. A second category, also state-funded, covers people who are frail enough to require nursing home care but who would not qualify for Medicaid to cover it. A third group is covered by Medicaid.
Under Malloy's budget, people in the state-funded portions of the program would have to pay 15 percent of the cost of services they receive, up from 6 percent. The current copayment level was set last year after the 15 percent copayments caused seniors to drop out of the program.
The budget also calls for freezing enrollment in the first category of the program. The state could instead serve some seniors who need preventive services through a Medicaid program, but the state must first apply for a waiver from the federal government to do so, and the budget says it will be implemented "to the extent that this is cost effective."
AARP Connecticut State Director Brenda Kelley said that could leave people who do not qualify for Medicaid without access to home-based services that could keep them out of nursing homes.
"We are in shock over some of the cuts to home and community-based services that we had been led to believe, quite frankly, by the governor that this was going to be a priority," Kelley said.
AARP supported seeking the waiver to have a portion of the program covered by Medicaid, Program Specialist for Public Affairs Claudio Gualtieri said, but with the goal of using the additional money to cover more people, not to leave out people whose care won't bring in federal money.
Malloy is expanding the Money Follows the Person program, which helps people receive care at home, but Kelley noted that people can only qualify for it if they spend time in a nursing home, requiring them to leave their home community and local support system first.
HIV and AIDS
The budget also eliminates state funding for the Connecticut AIDS Drug Assistance Program, which supplements federal funding to cover the cost of antiretroviral drugs and drugs that prevent infections related to HIV and AIDS. The administration said the state money--$606,678 a year--is not necessary because of the available federal dollars, and said many people served by the program are now eligible for the new Medicaid program for low-income adults.
But Shawn M. Lang, director of public policy for the Connecticut AIDS Resource Coalition, said the change could leave some people who rely on the program without coverage. The drug assistance program covers people up to 400 percent of the poverty level, well beyond the Medicaid income limit. The program also helps some people who have private insurance that does not cover AIDS medication.
"That is of grave concern to us for the state to completely eliminate their investment in a program that saves people's lives," Lang said. Noting Malloy's pledges not to shred the safety net, she added, "That's a significant tear in the safety net for people with AIDS."