Medicaid: For Want of an Ostomy Pouch

Gwen B. Turnbull, RN, BS

J ust when state budgets are in desperate need of federal assistance and the number of uninsured Americans has reached an unbelievable high, (at press time) proposals on Congressional tables threaten to drastically cut Medicaid funding. If federal Medicaid cost increases are capped, states will be forced to make difficult decisions about whether to cut Medicaid benefits and eligibility requirements. Indeed, some states have taken such steps. People with an ostomy or patients with wounds who receive their medical supplies through their state’s Medicaid program already are feeling the pinch.

Medicaid is a jointly funded federal and state healthcare program for low-income eligible individuals. Some states are funded 50% by the state and 50% by the federal government and others 60/40 or 70/30. The federal government has established broad program requirements that are further defined at the individual state level, usually by the state Departments of Health. Each state determines what populations (eg, children, families with children, and the elderly) to include in their Medicaid program as well as the benefits and payment levels the program offered (accountability is based solely on ensuring that its program is at least above the minimum federal requirements). Broad federal mandates give each state the autonomy and authority to develop Medicaid programs that meet the unique needs of the particular low-income populations it deems eligible for Medicaid, which explains the vast divergence in payment and coverage policies among state Medicaid programs.

Generally, federal Medicaid guidelines do not mandate coverage of durable medical equipment, medical supplies, orthotics, and prosthetics — including ostomy supplies, wound dressings — other than those provided as part of another Medicaid-covered service (eg, home health or acute care). Until recently, however, many states provided ostomy supplies to their Medicaid recipients even though they were not required to do so.

Still, Medicaid programs are in jeopardy due to our nation’s economic slowdown, increasing numbers of jobless and uninsured individuals and families, the effects of the Balanced Budget Act of 1997, state budget shortfalls, and escalating healthcare costs. As a result, many states, including California, New York, Massachusetts, Florida, Michigan, Texas, and Oregon, significantly reduced the services available from their Medicaid programs and tightened eligibility criteria. Several of these states are considering or have eliminated coverage of medical supplies. Low-income individuals currently enrolled in a Medicaid program in these states may soon be (or have been) forced to purchase their ostomy supplies out-of-pocket, meaning those who can least afford to may have to pay for medical supplies that are absolutely essential to their ability to function in society. This dilemma mirrors the one facing fixed-income Medicare beneficiaries: Do I spend money on my prescriptions or on food this month? Some Medicaid beneficiaries may be soon faced with a similar choice — whether to buy ostomy supplies or food.

The neediest of our country’s needy citizens may have to go without essential medical supplies crucial to their overall health, personal hygiene, and sense of well-being. The United Ostomy Association’s (UOA) Advocacy Committee (www.uoa.org/advocacy) has taken a proactive stance in approaching states where access to ostomy supplies is threatened by cutbacks in their Medicaid programs. Clinicians also have a responsibility to society in general and to their patients in particular to participate in grassroots activist programs. Other efforts to improve low-income ostomates’ access to an adequate supply of quality ostomy supplies may include partnering with local charities or service organizations or organizing a resource or charity program within the local UOA chapter.

In Benjamin Franklin’s time, a man could be lost for want of a horseshoe nail. Today, a person can be lost for want of an ostomy pouch.

For want of an ostomy pouch, the person’s sense of security was lost; for want of security the person’s sense of worth was lost; and for want of a sense of worth, the person was lost, being overtaken and slain by the system – all for want of an ostomy pouch. - OWM

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