1. Kennedy, Maureen Shawn MA, RN, FAAN


Will Medicaid 'reform' render it useless?


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There are many great articles that deserve to be highlighted in this month's issue. In our original research feature, "An Investigation into the Safety of Oral Intake During Labor," Shea-Lewis and colleagues focus on one of the sacred cows of medicine and nursing-that oral intake should be restricted in preoperative patients and laboring women. Their analysis of data from the medical records of 2,784 women found that allowing laboring women unrestricted oral intake does not increase adverse maternal or neonatal outcomes, thus supporting practice changes to relax restrictions on oral intake in uncomplicated labor that many have been advocating for.

Figure. Maureen Shaw... - Click to enlarge in new window Maureen Shawn Kennedy

Also of special note is the quality improvement report by Ernst and colleagues, which examines how RNs trained to perform lumbar puncture facilitated patient access to care, and Mangels's article on malnutrition in older adults-an oft-hidden problem that must be addressed if the elderly are to live independently.


But while these and other articles deserve to be discussed here in greater depth, my thoughts keep turning to the chaotic quagmire our health care system has become.


As I write this, the federal government has just reopened after a shutdown following yet another Congressional impasse. Thankfully, Congress has agreed to reauthorize funding for the Children's Health Insurance Program (CHIP) for six years (funding had expired in September). CHIP covers about 9 million children whose family incomes are too high to qualify for Medicaid, but who cannot afford private insurance. Historically, CHIP has had bipartisan support, and although it was expected to be refunded without incident, it was used instead as a bargaining chip in Congressional negotiations. Sadly, there were many reports of health care providers, state agencies, and anxious parents scrambling to seek alternatives for children in case CHIP wasn't refunded.


The situation for many other people who have hopes of gaining or maintaining health care coverage is also tenuous, as Medicaid is becoming a target for cutbacks, despite campaign promises to the contrary. In January, the Centers for Medicare and Medicaid Services announced it would allow states to require participation in work or other community service as a condition for continued Medicaid eligibility or coverage. While some people would be exempt (pregnant women, those with chronic illness or disabilities, primary caregivers, the elderly, victims of domestic violence, those in substance abuse treatment), there is concern that since states can set their own parameters for eligibility, some will opt to leave their citizens without coverage. Especially at risk are those in rural areas, where jobs-or transportation-may not be available. Seasonal workers or those in construction may end up going on and off coverage, as will those in low-paying jobs that are often lost in economic downturns. And in some cases, people who work will no longer be eligible for Medicaid but will still be unable to afford private insurance.


And in some states, Medicaid coverage is no guarantee of health care. In Iowa, where Medicaid administration was given over to for-profit private insurers in April 2016, there are harrowing reports of beneficiaries being denied care and being caught up in a cycle of appeals and litigation. In one case, the insurer AmeriHealth cut back twice-daily toileting assistance visits for a 32-year-old disabled man, allowing only five visits a week. According to a report in the Des Moines Register, physician Brian Morley, employed by AmeriHealth, testified, "People have bowel movements every day where they don't completely clean themselves, and we don't fuss over (them) too much[horizontal ellipsis]. You know, I would allow him to be a little dirty for a couple of days." The court sided with the insurance company.


So rather than provide care that allows this man to live independently and with dignity, the system will end up paying for treatment for the inevitable pressure ulcers that will develop and likely become infected as a result of sitting in soiled diapers. Is this the kind of health care we want our government to provide? Is this how Congress would vote for themselves and their families? How can we fix our health care system in a way that's humane and sustainable? Shame on Morley, shame on AmeriHealth, shame on the Iowa court, and shame on all of us if we don't stand up and demand better.