To some, it was a straight-up issue: Spend a little state money and get twice that much from the federal Medicaid program to provide expanded coverage for treatment of breast and cervical cancer.
But that proposal from Gov. Tony Knowles didn't get resolved until the final day of the four-month legislative session.
When it seemed stuck, U.S. Sen. Frank Murkowski, in a rare move, sent a letter to all 60 legislators urging them to act. They did, but it took a House-Senate conference committee to resolve differences just hours before adjournment on May 8.
A breast cancer survivor was at the center of the storm. Sen. Lyda Green, a Matanuska-Susitna Republican, held up the bill in her Health, Education & Social Services Committee, concerned about the precedent of raising the income eligibility cap only for specific illnesses.
Although Green finally moved the bill out and voted for it on the Senate floor, she maintains it was a bad policy call.
"If we're going to start paying for Medicaid by diagnosis, let's do it for all our friends," she said in an interview this week. "I don't think it's a good public policy direction."
The issue will spark a careful review of the entire Medicaid budget, Green said.
And in committee hearings before the 2002 session, she said she'll look at whether self-insurance plans should be taxed to better fund an existing state program for catastrophic health coverage for the uninsured. "I have no problem helping people with health care. I just don't want it to be through Medicaid."
On Jan. 12, Knowles unveiled the cancer legislation. It's based on recent congressional action extending coverage to women who have earned too much for conventional Medicaid but not enough to buy their own health insurance.
The income limit is 250 percent of the federal poverty rate, a near-doubling of the previous income cap.
Green complains that there's no assets test - a part of determining financial eligibility - further removing the program from the original Medicaid goal of providing coverage for the poor. To be eligible, women must have had their cancer diagnosed through a specific federal program for early detection, a limitation Green says is arbitrary.
Kate Coleman of Juneau could have been helped by the cancer bill, if she hadn't already been treated. Coleman, a widow who appeared at a Knowles news conference, said that she wasn't eligible for regular Medicaid for breast cancer treatment because Social Security survivor's benefits pushed her above the income limit, even if she didn't accept them.
The Knowles administration says the state's investment of $175,000 will leverage $413,000 in federal money to help an estimated 42 women annually.
Green said, based on her own cancer treatment bills, that she's skeptical the state cost will be that low, and said the state will be on the hook for even more if Congress lowers the federal contribution.
The bill sat in Green's committee for two months. She said during that time she was absorbed by the issue of delaying the high school exit exam.
In mid-April, Knowles identified the cancer bill as "must-have" legislation. Senate Democrats held their own hearing. Coleman and other advocates handed out pink ribbons to legislators.
Then Murkowski, a Republican, weighed in, calling the bill "a very important priority for me." While acknowledging "concerns about creating disease-specific Medicaid eligibility categories," he said the pending bill "deals with a thoroughly unique set of circumstances."
Green's committee then moved the bill, but with two amendments that enraged supporters. One called for a report on behavioral risk factors, which Green said was aimed at finding out why there's a breast cancer epidemic in Alaska. The other was a two-year sunset provision.
The first was seen by some as an invasion of privacy, although an amendment approved during heated debate on the Senate floor was aimed at guaranteeing anonymity for women in the program. Critics maintained that automatically ending the program would cut women off in the middle of treatment.
After the Senate passed the bill, Knowles called on the House to reject the Senate version, which it did on a 40-0 vote. A conference committee quickly met and changed the bill to clarify that women enrolled before the two-year repeal would continue their treatment, at 100 percent state expense if necessary.
"It was unbelievable drama," Coleman said.
Karen Perdue, state commissioner of health and social services, says she's open to a continuing examination of Medicaid policy but wasn't willing to wait on the bill. "I'm used to the fact that we have to do incremental reform. ... What's the alternative? Wait until we have the perfect system?"
Green said she wants to examine why the Medicaid budget has had "incredible increases."
Next year's budget has $405.5 million in federal money and $156.6 million from the state general fund. Since 1994, the state share of Medicaid has increased only 3.4 percent annually, while federal funds have gone up an average of 22.7 percent a year, said Janet Clarke, a state health official.
Bill McAllister can be reached at firstname.lastname@example.org.
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