Medicaid and Health Care Reform (Part I)

Feature Article

Medicaid and Health Care Reform (Part I)

Kyle McCammon, DO

Medicaid Eligibility and Regulations

In 1965, Medicaid was established as a jointly funded federal-state entitlement program to pay for the medical services of qualified low-income people. At the federal level, the program is administered by the Health Care Financing Administration (HCFA), an agency within the Department of Health and Human Services (HHS).(1-3)

States are mandated to provide Medicaid coverage to certain population groups, including members of families with dependent children, pregnant women, and persons who are aged, blind or disabled. Mandatory Medicaid eligibility rules include infants in the first year of life born to a Medicaid eligible pregnant woman and children under age six and pregnant women whose family income is at or below 133 percent of the poverty level (with state options to extend coverage to below 185 percent of the federal poverty level). Eligibility has been extended to all children until the age of 19 born after September 30, 1983, so by the year 2002, all children under 19 whose family incomes meet the means-tested guidelines will be covered. States have the option via a "medically needy" program to extend Medicaid eligibility to qualified persons who may have too much income to qualify for mandatory coverage. Some Medicare beneficiaries may also be eligible for certain Medicaid benefits. This "dual eligibility" pertains especially to long-term nursing facility care, prescription drugs and other out-of-pocket medical expenses.(4,5)

States are mandated to provide certain basic medical services for Medicaid recipients and have the option to offer additional services should they choose. The basic services include inpatient and outpatient hospital care, nursing homes, home health, physician services, prescription drugs and state facilities for the mentally retarded.(5)

States are required to reimburse medical providers for their services and to make additional payments to hospitals that serve larger numbers of Medicaid and other low-income patients. Although the states set Medicaid reimbursement rates, they must conform to HCFA guidelines stipulating that rates must be reasonable and adequate and not exceed the "upper payment limit" that Medicare would reimburse for the same service. Because the upper payment limit is applied to the total number of providers within a class, and not individually, states can pay some hospitals more than Medicare would have paid as long as other hospitals are paid less. This regulation is applicable to Medicaid disproportionate share hospital (DSH) payment adjustments, whereby states are required to "take into account the situation of hospitals that serve a disproportionate number of low-income patients with special needs" when setting reimbursement rates for inpatient hospital care. The states determine if a hospital qualifies for DSH payment adjustments.(6-8)

On average, the Medicaid program is financed 57 percent by the federal government and 43 percent by the states. The federal government's individual state share varies from at least 50 percent to no more than 83 percent of that state's Medicaid program expenditures. The amount of a state's federal government contribution, known as the federal medical assistance percentage (FMAP), is determined by a formula that considers a state's average per capita income against the national per capita income. The intended outcome of utilizing the formula is to reduce the differences in state Medicaid expenditures and to more evenly distribute the program's financial burden among the states.(1,2)

Growth in Medicaid Enrollment and Spending

Before 1990, the number of Medicaid recipients to 100 poor persons was generally less than 75. By 1995, these numbers were roughly identical. However, the statistics for individual states were vastly different. For example, the number of Medicaid recipients to 100 poor persons in Alabama was 63, whereas in Tennessee it was 180. The differences among states were due to variations in the extent of expansions in Medicaid entitlements to persons not classified as poor by the Census Bureau. This helps to explain the existence of a weak correlation between the incidence of poverty and Medicaid spending.(9)

In 1995, the national spending per Medicaid recipient was approximately $4,000. These expenditures reflect some degree of waste that exists in a system where recipients have no incentive to economize. Medicaid expenditures are also driven up by the amount of payments that are made to disabled and elderly persons, for whom the per recipient costs tend to be higher (despite the existence of the Medicare program). In fact, only 30 percent of Medicaid expenditures goes for "the ordinary poor" who are neither disabled nor elderly, although spending varies widely between the states. The financial burden of Medicaid has also risen unevenly among the states. From 1980 to 1995, the Medicaid burden on taxpayers increased in West Virginia more than any other state, from $7 of every $1,000 of income to over $36 of every $1,000 of income. Nationally, the average state Medicaid burden to taxpayers doubled over this period of time. Medicaid served approximately 37 million people in 1996 at a cost of $158.5 billion ($92 billion federal funds and $66.5 billion state funds), or about $200 per month for an average family of four. Medicaid spending in 1999 totaled approximately $172.4 billion.(1,5,9)

Currently, the Medicaid program accounts for approximately 6 percent of the federal budget and about 20 percent of state budgets. Medicaid is the third largest social program in the federal budget. Social Security, at a cost of $347 billion, and Medicare, at $191.3 billion, are first and second, respectively.1 In terms of total state spending, Medicaid is the second largest category of state budgets behind only the expenditures for elementary and secondary education. The average state Medicaid expenditures have grown from 10.8 percent in 1988 to 19.6 percent in 1999.(5)

From 1990 to 1992, Medicaid spending increased by 20 to 30 percent each year. Factors that contributed to this growth included new federal mandates and state enrollment expansions to pregnant women and children, the recession of 1990-91 and increased provider reimbursement rates (which made up only 6.4 percent of total Medicaid expenditures in 1991, down from 10 percent in 1975).1,3 The states were induced to maintain provider rates by the need to comply with the Boren Amendment, which required that they reimburse Medicaid providers at rates that were "reasonable and adequate to meet the costs incurred by efficiently and economically operated facilities."(6,7) However, with provider reimbursement rates continuing to stagnate or decline as states struggled to keep up with Medicaid expenditures, the states were able to negotiate a repeal of the Boren Amendment in the Balanced Budget Act (BBA) of 1997.(7)

State Medicaid Funding Schemes

In order to generate funds to pay for the increasing costs of the Medicaid program, states began to utilize financial arrangements such as provider taxes and donations and intergovernmental transfers (IGTs).(2,3,6-8,10,11) These provider-generated revenues were used solely to increase the share of Medicaid costs borne by the federal government. Under the arrangement, states collected taxes and donations from health care providers and then returned the revenue to hospitals as a Medicaid expenditure, whereby states could then claim additional FMAP. These funding schemes allowed states to reduce their state Medicaid contributions, fund other health care needs and supplement general revenue funding at the expense of the federal government and health care providers.

For example, assume a state with a FMAP of 50 percent imposes a tax on all hospitals in the state to collect $1 million. The hospitals pay the tax or donate money to the state. The state immediately returns the money back to the hospitals. The payment back to the hospitals is treated as a Medicaid expenditure and qualifies the state for a federal matching payment of $500,000. The end result is that the state benefits by collecting $500,000 from the federal government at no cost to itself or to the hospitals (except for the hospitals that have received a lower return of their money). IGT arrangements were similar to the provider tax and donation schemes, except that the transfer of funds occurred between government hospitals and the state.(8)

The provider tax and donation schemes created significant financial advantages for states. Each dollar of revenue raised could generate one to four FMAP dollars, depending on the state's federal matching rate. However, in order to earn FMAP dollars, the state had to spend the revenues because federal Medicaid matching funds are based on expenditures.(6) That is, states had to raise the money (through funding schemes or from taxing its citizens), then spend the money (as Medicaid expenditures), in order to get the money (in federal matching dollars).

It was the Medicaid DSH payments that provided the mechanism to spend the tax and donation revenues that were raised in the funding schemes because the DSH payments were not subject to the Medicare "upper payment limit" rule. Therefore, states could make virtually unlimited DSH payments and, in the process, receive more FMAP dollars. As a result, expenditures for DSH payments grew from $1.4 billion in 1990 to $15 billion in 1996.(6)

On the other hand, a state would actually lose revenues if it attempted to be more fiscally responsible and set limits or cut Medicaid funding because it would lose a portion of its federal funding. This was especially true for states that had a higher FMAP. For example, in a state with a 70 percent FMAP, for every $100 million cut in Medicaid spending, the state would save $30 million in state funds and lose $70 million in federal funds. Therefore, the methods that were used to fund the Medicaid program created a perverse incentive for states to drive up Medicaid expenditures to satisfy its dependency on federal matching funds.(10) In effect, states were penalized for reducing dependency and rewarded for allowing Medicaid caseloads to grow.

As a result of the states' Medicaid funding schemes, Congress passed the Medicaid Voluntary Contribution and Provider-Specific Tax Amendments of 1991 to place restrictions (provider-specific caps) on states' use of provider-generated revenues (from provider tax and donation programs) as a source of state matching funds. Provider donations were essentially banned. Under the legislation, the FMAP available to a state was reduced by the total amount of "health care related taxes" that the state imposed, unless the taxes were "broad-based" and "permissible," requiring that the tax contain no "hold-harmless" provisions. This law also placed a cap on state DSH payments at their 1992 levels and limited the national DSH payments to 12 percent of total Medicaid costs.(6)

A tax was judged to be broad-based if it met two criteria; it must apply to all items or services within the same class of providers and it must apply uniformly, meaning that the tax was imposed on all gross revenues of the providers that were subject to it. A tax was deemed to hold providers harmless (and therefore be impermissible) if it in any way guaranteed that providers subject to the tax would not be liable for its true burden.(8,11)

Because the 1991 legislation curtailed DSH payment growth from provider taxes and donations, the major means of generating funding scheme revenues, states were forced to explore other sources of revenue to raise their state Medicaid matching funds. However, the broad-based and hold-harmless criteria caused difficulties for many states because the taxes now had to be a bonafide assessment. Since states are constitutionally prohibited from operating with a deficit, spending cuts, tax increases, budget restructuring and cost containment reform measures became an inevitable response.(3,6) Still, many states looked towards implementing provider taxes that would conform with the new provisions. Many states also turned to IGT programs, which were not restricted in the new legislation, as the means of funding its DSH programs.(6,8)

New Provider Taxes

The Medicaid Voluntary Contribution and Provider-Specific Tax Amendments of 1991 established eight provider classes that could be taxed at the state's discretion in accordance with the new guidelines. The eight provider classes included inpatient and outpatient hospital services, nursing homes, intermediate care facilities for the mentally retarded, physician services, home health, prescription drugs, and health maintenance organizations. The National Governors' Association negotiated a number of other provider classes that could be taxed under the new legislation. These classes included dentistry, podiatry, chiropractic, optometry, psychological, therapeutic, nursing, laboratory and radiology services. The amount of the imposed provider tax could be different for different classes, but they were required to be uniform within each class and cover every provider in that class. The tax would apply to 100 percent of the provider's gross receipts, not just to Medicaid revenues.(11)

Like West Virginia, many other states imposed various applications of provider taxes to generate state matching funds for its Medicaid programs. However, the vast majority of states did not impose these taxes on individual health care providers, but limited them to intermediate care facility services for the mentally retarded, nursing facilities and hospital services. A few state legislatures' chose what they believed to be a less politically costly option and imposed regressive targeted taxes on individual health care providers who were already struggling with the idea of being coerced into providing unexceptionably low reimbursed government-sponsored medical care. As of today, West Virginia and Minnesota are the only states that impose a Medicaid provider tax on physicians and other individual health care providers.

One of the arguments to persuade individual providers that the tax was necessary was to try to convince them that the consequences of not imposing the tax would be more severe, i.e., the threat of deep cuts in Medicaid reimbursement. Supposedly, the revenues generated from the provider taxes (the means by which states could increase FMAP funds) would be used to increase provider reimbursement, expand Medicaid services and cover costs that providers might previously have had to absorb as charity care.(11)

However, since money in state budgets is ultimately fungible, it would be difficult to assess how the revenues from the individual provider taxes were actually being used.(11) One concern was that the provider taxes would also serve as a substitute coffer for state general revenues, as had occurred in prior funding schemes.(6,8,11) In effect, it may serve to replace one fund raising scheme with another. Others argued that provider taxes, particularly on individual providers, would be a shortsighted legislative response to the expansion and escalating costs of a government entitlement program that had no rational method for limiting expense.(10) Although increasing general revenues, re-appropriating funds from other state programs or cutting some Medicaid programs would generate a greater public outcry (possibly at a greater political cost), it would effectively deal head-on with the funding problems. On the other hand, a regressive provider tax would result in price increases to paying users of the health care system. Although the assessment of provider taxes would only postpone the funding issue crisis, it would not cure the funding problems. It would temporarily distract citizens from the main issue of how to responsibly restrain the growth and spending attributed to the Medicaid program. The essence of the problem has been described in the following manner: "The Medicaid truck has a gasoline leak. It's getting worse. Uncle Sam pays for 70 percent of the gas. We pay the rest. We may either continue to pay more and more for gas, or we could refuse and learn to walk more frequently. Neither choice is very good. Either way, we eventually must fix the leak or junk the truck."(10)

The West Virginia Health Care Provider Medicaid Tax

The Health Care Provider Medicaid Tax became effective as law in West Virginia on January 1, 1992. The Health Care Provider Medicaid Tax appears under Article 26, Section 11, of the West Virginia Taxation Code. This article is also referred to as the "West Virginia Health Care Provider Medicaid Enhancement Tax Act of 1991."(12) This legislation imposed a provider tax on individual health care providers.

An explanation of the Legislative findings used to justify the legislation appears under Section 11-26-1. The Legislature attempted to address many concerns within the language of the bill. The Legislative findings included:

1) Medicaid provides access to basic medical care for our citizens who are not physically, mentally or economically able to provide for their own care;

2) Inadequate compensation for health care providers rendering Medicaid services is a barrier to indigent persons seeking access to health care services;

3) Many health care providers are leaving this state due to economic conditions;

4) Without adequate compensation this state cannot attract or retain a sufficient number of health care providers necessary to serve our indigent population;

5) Without additional Medicaid funding this state cannot adequately compensate health care providers for health care services rendered to indigent patients;

6) The Congress of the United States enacted the Omnibus Budget Reconciliation Act of 1990 authorizing state Medicaid agencies to attribute taxes imposed on Medicaid providers as part of the state share;

7) By levying a tax on the Medicaid reimbursements of health care providers for the purpose of meeting state fund matching requirements, federal matching funds will be increased;

8) By dedicating such additional revenue to the Medicaid program, health care provider fees may conform as closely as possible to usual and customary charges; and

9) Moneys generated in accordance with this article are supplementary only and shall not be used to reduce the general financial obligations of the state's medical assistance program as appropriated by the Legislature.(12)

The Health Care Provider Medicaid Tax levied and imposed an excise tax on the gross receipts or gross proceeds derived by all health care providers enrolled in the West Virginia medical assistance program.(12) The provisions of the law were imposed on 16 different provider classes that the state had discretionary authority to tax. The tax rates ranged from 1.75 percent to 5.5 percent. The tax rate imposed on gross receipts for individual physicians is 2.0 percent.(13)

In effect, physicians were now required to pay for the low reimbursed Medicaid care they provided. As Medicaid reimbursement rates continued to lag behind "usual and customary charges" and as new legislation became implemented, the ultimate effect of the provider tax has been to only exacerbate the problems outlined in the Legislative findings of the bill that the provider tax was supposed to have helped ameliorate.

Continued Medicaid Growth and Spending

Because IGTs had not been restricted by legislation, many states expanded IGT funding of DSH programs to public institutions and private hospitals as a means to continue to maximize federal matching dollars without committing its share of matching funds. The success of these new funding schemes was revealed when a 1993 survey of 39 state DSH programs found that 33 percent of DSH allotments were being used for fiscal relief for states' budgets rather than being used to reimburse Medicaid providers.(6)

In response, Congress passed the Omnibus Budget Reconciliation Act of 1993 to place further restrictions (facility-specific caps) on DSH payments. The new federal mandate required that a hospital's Medicaid use had to be at least one percent to qualify for DSH payments. In addition, total DSH payments to any hospital could not exceed the unreimbursed costs incurred from providing care for Medicaid patients and uninsured patients.(6,7)

From 1993 to 1995, the rate of growth of the Medicaid program slowed to an average of 10 percent each year. In 1996, Medicaid growth was only 3.3 percent. In addition to the effects of federal legislation, the slower growth rates occurred because mandated program expansions had become fully phased in and because states had begun to utilize a variety of cost containment measures.(1,5)

For the period between 1996 and 2002, the Congressional Budget Office projected an average annual increase in Medicaid spending of 7.7 percent. One reason for the recurrent growth is higher Medicaid utilization among children through the State Children's Health Insurance Program (SCHIP).(5,14,15) Other factors contributing to recurrent Medicaid growth include the increased use of long-term care services and the rise in pharmaceutical costs.(5)

With the continued growth and expansion of Medicaid, states still have great concerns regarding their capabilities to generate enough revenues to fund the program. To compound states' worries, the BBA of 1997 which set the goal of a balanced budget by 2002, contained the largest reductions in federal Medicaid spending since 1981.(16) The major spending cuts occurred through the establishment of three provisions that reduced reimbursement to Medicaid providers. These provisions included: 1) new limitations on federal matching payments to states' DSH programs, thereby eliminating the DSH allotments established in the Act of 1991; 2) shifting the cost of Medicare premiums, deductibles, and co-insurance requirements to providers by permitting the lower Medicaid reimbursement rates to be the ceiling on Medicare co-payments, thereby eliminating the rule that required Medicaid to pay for Medicare cost-sharing; and, 3) elimination of minimum payment guarantees to certain Medicaid providers which was negotiated into the BBA with the support of the National Governors' Association through the repeal of the Boren Amendment.(6,7,16)

Despite legislation designed to further limit the states' ability to take advantage of federal matching funds and save state dollars, the states still are being accused of fund raising schemes. A recent editorial from The Washington Post was entitled; "How the states are padding Medicaid bills." The article cited a quote from William Roth, the Chairman of the Senate Finance Committee, who said the health care program for the poor has been turned into "a bank account for state projects having nothing to do with health care."(17)

Medicaid currently functions as the nation's largest health "insurer" of children, covering nearly 25 percent of all children; the largest "insurer" of maternal care, covering 40 percent of the nation's births; and the largest "insurer" for nursing home care, paying for more than 50 percent of all nursing home services. A major aspect of this growth is that even though the number of poor people have fallen, the number of Medicaid recipients have risen significantly as increasing numbers of non-poor receive Medicaid benefits.(9) This expansion of Medicaid coverage to many non-poor persons reduces the incentive for working persons to take responsibility for their own health care decisions. The number of people who use private insurance will continue to fall and employers will have greater incentives to drop health care benefits for employees because Medicaid will provide the necessary coverage. This will lead to increased third party involvement in private health care decisions and reduce individual choices in health care. Medicaid program costs have adversely affected other government programs and private sector spending. Medicaid expenses have resulted in undue federal and state fiscal budgetary pressure, limiting government's ability to decrease the tax burden on its citizens.(9,15)

Another concern is that higher Medicaid spending has not resulted in significantly improved health care in terms of better outcomes. Therefore, the degree of success of any particular state's Medicaid program cannot simply be measured in terms of its degree of Medicaid spending. In fact, provided that one could agree on the standards used to measure "success," it is often difficult to determine which Medicaid programs are successful and which programs are not. However, a "good" state Medicaid program should be fiscally responsible and attempt to minimize the burden that it places on taxpayers. A good Medicaid program should strive to have low costs on a per recipient or per capita basis. It should attempt to function as Medicaid was first intended, i.e., to assist poor people. It should not cover a large number of non-poor persons.(9)

Medicaid in West Virginia

Using data from 1980, 1992 and 1995, the Citizens for a Sound Economy Foundation evaluated Medicaid statistics for each state. West Virginia was one of five states that received an "F." West Virginia had the tenth highest ratio of Medicaid recipients to poor persons (1.27) and the seventh greatest rate of increase in this ratio over time (+0.50). West Virginia was the sixth highest in Medicaid payments per $1,000 of personal income. In terms of the rate of increase in payments per $1,000 of income over time, West Virginia ranked first overall.(9) In terms of the actual cost, West Virginia's Medicaid program expenditures increased from $303 million in 1989 to $1.359 billion in 1995. During this time Medicaid health care benefits expanded to cover one out of every five citizens of West Virginia.(18) As a result, Medicaid now finances 55 percent of all births in West Virginia, as compared to the national average of 39 percent.(19) Along with the Medicaid expansions, there has been a commensurate increase in out-of-wedlock births. Of all births in West Virginia, 48 percent occurred out-of-wedlock, as compared to the national average of 33 percent. Only 12.2 percent of the out-of-wedlock births in West Virginia was related to the problem of teen pregnancy.(20)

Another disturbing statistic in West Virginia was discovered in a 1995 internal evaluation of the Department of Health and Human Resources (DHHR). The study found a 16.5 percent policy and procedural error rate in determining Medicaid eligibility when Medicaid services were provided.(21)

In 1995, the West Virginia Medicaid Crisis Panel made various expenditure reduction recommendations. The Panel had not been permitted to recommend reallocating funds from other state programs, nor had they been permitted to recommend a tax increase. The panel's recommendations included: implementing a Medicaid managed care program to create incentives for providers and recipients to use services efficiently and control costs; prioritizing essential over nonessential Medicaid services and eliminating certain services that are not "health care" related to narrow the scope of benefits and eligibility; creating a co-payment system to improve the perceived value of services and encourage appropriate utilization of services by recipients; evaluating the level of reimbursement to providers by focusing on "reasonable costs" and "leveling the playing field" between in state and out-of-state providers; and, implementing effective tort reform measures to decrease the incidence of the practice of "defensive medicine."(18)

Despite the Medicaid Crisis Panel's recommendations and the federal government's legislative actions, the West Virginia Medicaid program has continued to expand and increase spending. For example, the West Virginia SCHIP is an expansion of the Medicaid program that extends eligibility to children below age 19 who live in families with income levels from 150 percent to 200 percent of the federal poverty level.(14) In 1999, West Virginia Medicaid expenditures were 22.3 percent of the total state expenditures. This ranked West Virginia as the tenth highest in percentage of total state Medicaid expenditures. For 2000, the Medicaid spending at 23.8 percent of the total state budget placed West Virginia as the sixth highest in state expenditure percentage for Medicaid.(5) In 2000, West Virginia Medicaid program expenditures were $1.445 billion. For 2001, the total estimated Medicaid expenditures is $1.494 billion. The federal contribution is estimated to be $1.108 billion, a FMAP of 75.3 percent, as compared to the national average of 60.8 percent. Of the total $366 million in state matching funds, $139 million (38 percent) is expected to come from provider taxes.(22)

Part II of this article will discuss the detrimental effects of continued Medicaid expansions on the health care system and how this relates to the problems with employer-based insurance. Part II will provide arguments why the continued movement towards a universal health care system has created frustration and dissatisfaction among patients and physicians and why government-sponsored universal health care should not be the solution to our nation's health care system problems.

Part II will also discuss free market oriented mechanisms of health care reform through restoring equity in the tax system and empowering individuals through widespread availability of rollover flexible spending accounts (FSAs) and MSAs. And finally, the detrimental effects of welfare (entitlements) and its required reform will be discussed as it pertains to health care reform.

References

1. Medicaid. National Association of State Budget Officers. Available at: http://www.nasbo.org/Policy_Resources/Medicaid/medicaid.htm.
2. Medicaid: States Use Illusory Approaches to Shift Program Costs to Federal Government. Report to the Chairman, Subcommittee on Oversight and Investigations, Committee on Energy and Commerce, House of Representatives. Available at: http://frwebgate.access.gpo.gov/cgi-bin/u...e94133.txt&directory=/diskb/wais/data/gao.
3. Iglehart JK. The American Health Care System - Medicaid. New Engl J Med 1993; 328: 896-900. Available at: http://www.nejm.org/content/1993/0328/0012/0896.asp.
4. Medicaid Eligibility. Health Care Financing Administration. Available at: http://www.hcfa.gov/medicaid/meligib.htm.
5. State Expenditure Report: Medicaid. National Association of State Budget Officers. Available at: http://www.nasbo.org/Publications/PDFs/exprpt99.pdf.
6. Coughlin TA, Liska D. The Medicaid Disproportionate Share Hospital Payment Program: Background and Issues. Urban Institute. Available at: http://newfederalism.urban.org/html/anf14.html.
7. Balanced Budget Act of 1997. Reshaping the Health Safety Net for America's Poor: Section III. Available at: http://www.healthlaw.org/pubs/BBAsec3.html.
8. Barker TR. HCFA Questions State Medicaid Financing Techniques. Available at: http://www.bostonbar.org/sc/hl/nl091000.htm.
9. Vedder R, Gallaway L, Lawson R. 50-State Medicaid Report Card. Executive Summary. Citizens for a Sound Economy Foundation. Available at: http://www.csef.org/csefhome/medicaid.htm.
10. Health Policy Brief: State Question 647: Medicaid Provider Taxes, August 1992. Available from: Oklahoma Medical Research Foundation, Center for Health Policy Research, 600 South College Avenue, Tulsa , OK 74104; (918)-582-5607.
11. Verdier JM. State Provider Assessments to Fund Medicaid. National Tax Journal 1993;46:377-383. Available at: http://ntj.tax.org.
12. Health Care Provider Medicaid Tax. West Virginia Taxation Code. Article 26; Section 11: 296-308. Available at: http://www.legis.state.wv.us/scripts/as_web.exe?codeart+D+7352995.
13. Health Care Provider Taxes. State Tax Department. Summary of WV Tax Law Book. Available at: http://www.state.wv.us/taxrev/97taxlaws/97tl_business.pdf.
14. HHS Approves West Virginia Expansion of the State Children's Health Insurance Program. U.S. Department of Health and Human Services. HHS News. Available at: http://www.hhs.gov/news/press/2000pres/20001013.html.
15. Lopez N. Are American Children Being Lured Into Socialized Medicine? Institute for Health Freedom. Available at: http://www.forhealthfreedom.org/Publications/Children/children.html.
16. Schneider A. Overview of Medicaid Provisions in the Balanced Budget Act of 1997, P.L.105-33. Center on Budget and Policy Priorities. Available at: http://www.cbpp.org/908mcaid.htm.
17. How the States are Padding Medicaid Bills. The Washington Post: In the Clarksburg Telegram, Sept 12, 2000. Available from: Clarksburg Publishing Company, PO Box 2000, Clarksburg WV 26301; (304)-626-1410.
18. Medicaid Crisis Panel: Report and Recommendations. Nov. 29,1995. State of West Virginia. Available at: http://www.wvu.edu/~law/clinic/docs/medicaid.pdf.
19. State Health Facts: West Virginia at a Glance. The Kaiser Commission on Medicaid and the Uninsured. The Henry J Kaiser Family Foundation. Available at: http://www.kff.org/docs/states/wv.html.
20. 1998 West Virginia Vital Statistics: Marital Status By Age of Mother. West Virginia Bureau for Public Health. Health Statistics Center. Available at: http://www.wvdhhr.org/bph/oehp/vital98/vs_13.htm.
21. Medicaid: Eligibility Decision Error Rate. Full Performance Evaluation of the Department of Health and Human Resources. State of West Virginia. Available at: http://www.legis.state.wv.us/Joint/perd/medicaid.html.
22. Medicaid Revenues and Expenditures. Department of Health and Human Resources. Bureau of Medical Services. Available at: http://www.wvdhhr.org/secretary/attach%F2001/attach4%2D1.htm.

Dr. McCammon is an emergency medicine physician at United Hospital Center in Clarksburg, WV, a diplomate of the American Board of Emergency Medicine, and a fellow of the American Academy of Emergency Medicine and the American Academy of Family Physicians. His e-mail is [email protected].