Yesterday's celebration comes amid calls for the state-run health plan to include coverage for dental care.

01:00 AM EST on Tuesday, December 7, 2004

BY FELICE J. FREYER
Journal Medical Writer

PROVIDENCE -- When state officials first dreamed up the idea of overhauling health care for low-income families, advocates for the poor were up in arms.

The plan called for enrolling tens of thousands of Medicaid recipients, mostly children and their mothers, in HMOs. That meant "managed care" -- and as far as the advocates were concerned, managed care meant less care.

One of those advocates, Marti Rosenberg, recalls meeting in 1993 with Dr. Barbara A. DeBuono, who was then the director of the state Health Department. DeBuono didn't mince words. "This is going to happen," she told the advocates; they would be wise to stop fighting it and, instead, work to make it better.

Yesterday, 10 years after the experiment known as RIte Care started, Rosenberg joined some 200 political and health-care leaders at the Marriott for a luncheon celebrating the state-run health plan.

Rosenberg, director of Ocean State Action, was there to accept an award for her work on behalf of RIte Care enrollees. And she was there -- like everyone else -- to sing the praises of the program she once fought, which now enrolls 119,000 Rhode Islanders.

"RIte Care has been a tremendous success," Rosenberg said.

No one is disputing that statement. And plenty of numbers are backing it up. At yesterday's luncheon, Rhode Island Kids Count, another advocacy group and the luncheon's sponsor, provided a sampling:

The percentage of uninsured children in Rhode Island dropped from 10.9 percent in 1995 to 4.8 percent in 2003.

Emergency-room visits and hospital use have declined more than one-third since RIte Care began.

The percentage of women who get timely prenatal care increased from 56 percent in 1993 to 72 percent in 2002, the highest rate in the nation.

Infant mortality among publicly insured infants declined by 36 percent in the 1990s. The decline for publicly insured babies aged 1 month to 12 months was 58 percent.

"RIte Care insures almost one-third of the kids in the state. That's a phenomenal figure," said Christopher F. Koller, chief executive officer of Neighborhood Health Plan of Rhode Island, an HMO that was founded to serve the RIte Care populations. "It means that we really helped kind of weave it into the fabric of the state."

Yesterday's celebration came amid calls for improvements -- especially coverage for dental care -- and warnings that RIte Care could be undone by federal cutbacks, because the federal government pays more than half the cost.

But mostly the talk focused on RIte Care's success.

It originated, in part, from that pivotal meeting between DeBuono and the angry advocates. The advocates, and Medicaid enrollees, took their place at the table along with hospitals, doctors, legislators and the HMOs to craft a program that would work.

"Everyone owns RIte Care," said Tricia Leddy, the longtime RIte Care administrator.

The RIte Care Consumer Advisory Committee, which Rosenberg has co-chaired for all 10 years, made sure that the HMOs understood, for example, that RIte Care enrollees could not get access to care unless they had transportation to the doctor's office -- and unless someone in the doctor's office spoke their language.

Another driver of RIte Care's success lies in the numbers that Kids Count highlighted yesterday -- the fact that the state even bothered to collect such data.

"They committed themselves early on to documenting the impact of the program," Robert E. Hurley, professor of health administration at Virginia Commonwealth University, in Richmond, said in a phone interview. "You can see quite early and quite convincingly that beneficiaries are better off. The state is more aware of what it's buying. You build into the program a culture of improvement."

Hurley has studied Medicaid managed-care programs around the country, and he confirmed that the luncheon crowd yesterday was not just patting itself on the back -- RIte Care is considered a national model. Leddy, he said, is well-known and widely admired around the country for her stewardship of the program. (She was recently honored by Governing magazine as one of the 2004 Public Officials of the Year.)

"I think people in Rhode Island should be very proud of what RIte Care has accomplished," agreed Alan Weil, executive director and president of the National Academy for State Health Policy, in Portland, Maine. "I think it's safe to say you have a really innovative and effective program."

The data gathering also demonstrated that the goal was not just to save money but to provide better health care.

Everyone involved, said Christine C. Ferguson, Rhode Island's former director of human services, was "really working together to make sure that this was in truth managed care, as opposed to managed price. . . .

"We were able to focus on what it was we were trying to achieve in terms of health outcomes and how it would affect long-term cost," Ferguson, now the Massachusetts public health commissioner, said in a phone interview yesterday.

Speakers at yesterday's luncheon recalled why the care under Medicaid, before RIte Care, so badly needed improvement. Medicaid paid providers so little that most would not accept people covered by the plan. Without access to doctors, Medicaid recipients often didn't get care until their illnesses became severe and more expensive to treat, or they went to the emergency room, the most expensive setting for care.

Bernadette Hicks, of Warren, who has cared for many foster children over the years and adopted six, recalls that before RIte Care, "it was almost impossible to get a doctor."

When one of her children got sick, she told the gathering, she would have to wait three or four hours for care in the emergency room, or "weather the storm at home."

Now, under RIte Care, her children have doctors.

Dr. Michael D. Fine, a family practitioner, said he used to beg his friends who were specialists to treat his Medicaid patients.

"For Rhode Island primary-care physicians, RIte Care meant the end of the tin cup era," he said.

But even though RIte Care pays better than the old system, doctors who treat RIte Care patients still often get paid less for them than they do for people with commercial insurance, Fine said. Much of the program's success has come at those doctors' expense, he said.

Several people called for RIte Care to encompass dental care, which is now extremely difficult for poor people to get. Hicks said that when her daughter got a toothache recently, she called 53 dentists trying to find care. Most were not accepting Medicaid; others had months-long waits.

While other states are looking at cutting or even dismantling their Medicaid managed-care programs, Rhode Island's legislature has not attempted to curtail RIte Care in years.

But clouds are gathering in Washington, where the federal deficit and the cost of the war in Iraq have prompted reconsideration of Medicaid funding.

RIte Care depends on an open-ended commitment from the federal government, which pays back to the states more than half of every dollar spent on Medicaid, including RIte Care. This helps states sustain such programs during economic downturns when more people are eligible for coverage and state budgets get tight.

Now, the Bush administration is considering capping the federal contribution to Medicaid.

"State leaders are going to have to be very strong to hold on to this program," U.S. Sen. Jack Reed told the group yesterday. "I can't underestimate the challenge ahead in keeping this program going."