Senator Eliot Shapleigh - El Paso, Texas

AUSTIN — A desire by the U.S. Congress to cut $10 billion in medical coverage for low-income people worries some San Antonio leaders that such reductions would mean higher local taxes or less health care.

Congressional Republican leaders are eyeing budget cuts in the range of $35 billion to $50 billion over the next five years and are looking to squeeze at least $10 billion of those cuts from Medicaid, the 40-year-old health care program for the poor.

Critics contend the budget cuts will harm the most vulnerable at the expense of the wealthy, who would benefit from new tax cuts, including a permanent repeal of the estate tax.

"When they say they're going to cut Medicaid, what they are saying in the same breath — but under their breath where nobody can hear — is that they are raising taxes at the local level," Bexar County Judge Nelson Wolff said. "It doesn't cut anything. It's a shell game."

San Antonio's public hospital, University Hospital, must provide care "to anyone who shows up at our door," Wolff said.

Medicaid cuts could result in less health care coverage, more indigent patients and higher local taxes to cover the difference, he said.

Nearly 205,000 residents of Bexar County receive Medicaid coverage, including 135,188 children.

Adults who get Medicaid help generally are low-income pregnant women, those with disabilities and others in nursing homes.

House GOP leaders are pushing for larger Medicaid cuts than the Senate has approved. Two key House committees are expected to take action this week on budget cuts, and Medicaid is expected to absorb a big chunk of those reductions.

The positions of San Antonio's two Republican members of Congress are unclear. U.S. Rep. Henry Bonilla did not return phone calls, and U.S. Rep. Lamar Smith said it's too early to assess the impact.

"At this time, no legislation has been introduced in the House of Representatives to reduce Medicaid's funding levels," Smith said. "I think it would be premature to speculate on cuts to the federal budget that have yet to be determined or voted on."

Impact is uncertain

A precise impact of the proposed Medicaid budgets on San Antonio and Texas cannot be assessed until Congress acts.

"But it's going to affect all kinds of people that most Texans know — seven of every 10 nursing home residents are getting support from Medicaid, so it has an enormous impact," Anne Dunkelberg said.

She is a health care expert and assistant director at the Center for Public Policy Priorities, an Austin-based research organization that tracks issues affecting lower-income Texans.

However, some believe Medicaid spending is out of control.

A $10 billion cut from a $300 billion program is "really a drop in the bucket," said Mary Katherine Stout, a health care expert at the Texas Public Policy Foundation, an Austin-based research group that advocates for limited government.

Congress' proposed Medicaid cuts "probably are not as aggressive as we need," she said.

Medicaid must undergo major reform, Stout said: "We need to end entitlements and give states flexibility to run a Medicaid program that best fits their needs.

"Medicaid should be a safety net for the most needy citizens, not a long-term insurance alternative," she said.

But there are so many low-income families who need health care, and children who get medical attention stand a better chance of escaping serious and more costly treatment later, San Antonio pediatrician Dr. Dianna Burns said.

"It's just disheartening that that's where we have to take our monies from," she said of proposed Medicaid cuts.

"Medicaid should be a program that provides health care for those who need it," Burns said. "The richest country in the world should provide some kind of minimal health care for all of its citizens."

More than 5 million Texans carry no health insurance, according to the Texas Legislative Budget Board. No state has a higher uninsured rate than Texas' 23.5 percent. State lawmakers slashed health and human services budgets two years ago to close a $10 billion shortfall.

'Absolutely horrific'

Medicaid cutbacks at the federal level "would exacerbate all the problems that we already have," said state Sen. Judith Zaffirini, D-Laredo, one of the Legislature's health care experts.

"It's absolutely horrific," she said. "It's outrageous to even consider such cuts."

Cutting Medicaid spending in Washington won't reduce the number of sick people or low-income elderly who require nursing home care, said Zaffirini, who represents part of San Antonio.

"There will not be a change in the number of people who need medical attention, so if one level of government doesn't provide the services, the next lower level of government has to pick up the burden," she said.

And that's what bothers the county judge.

"They are not saving any money. They're just transferring the burden to local communities, and that's typical of what has happened in the last few years," Wolff said.

Texas could lose $600 million over the next five years, if the proposed $10 billion Medicaid cut is applied proportionately across the country, said Dunkelberg of the Center for Public Policy Priorities.

"Medicaid is an integral part of our health care safety net and helps pay for everybody's public hospital and everybody's trauma center that everybody has to rely on," she said.

Dunkelberg speculated that the proposed cuts would make it more difficult for older adults to get nursing home care through Medicaid and also force families to spend savings as they pay a larger share for nursing home services.

Seniors with disabilities get $600 a month in living expense and could be asked to pay higher copayments for prescription drugs, Dunkelberg said.

Those with chronic diseases, she said, don't have "a lot of room with that $600 a month budget to pay for things like that."

The problem facing the uninsured should be addressed by expanding private insurance coverage, said Stout from the Texas Public Policy Foundation.

"We continue to try to address our problems of the uninsured with expanded Medicaid, but we are not making a significant dent in our uninsured population," she said. "Medicaid is not the answer. We have been pumping more money into a Medicaid program that is failing to address the uninsured."

Decision for doctors

Dr. John Holcomb, a San Antonio lung specialist, said Medicaid budget cuts would create "a hard business decision" for physicians — especially for those whose patient mix is top-heavy with Medicaid clients.

"It probably will cause them to leave the community where they have 60, 70, 80 percent Medicaid loads because they won't be able to make it on the 20 percent (of non-Medicaid patients)," said Holcomb, whose own patient mix includes only 8 percent of Medicaid clients.

"We're discouraged. We're not sure what we can do about it. I think most of us will just vote with our feet," Holcomb said.

The problem is especially acute in border communities where high poverty concentrations typically mean large Medicaid patient mixes for doctors, he said.

Texas physicians took a 2.5 percent cut in Medicaid rate reimbursement when state lawmakers slashed budgets two years ago. Most Medicaid patient office visits pay Texas physicians less than $30 — about half of what private insurance plans pay.

The evacuation of hundreds of thousands of evacuees from Hurricane Katrina will put extra pressures on the state's Medicaid program, said Rep. Carlos Uresti, D-San Antonio, former chairman of the House Human Services Committee.

But children and low-income populations don't carry political clout, he said.

"It's the poor and the elderly and the frail that always seem to get beat up the most," Uresti said. "You can kick them while they're down and what can they do about it?"

While aiming to cut social spending by at least $35 billion, Congress also wants to perpetuate tax cuts worth $70 billion.

Congress appears to be following the Texas model, said state Sen. Eliot Shapleigh, D-El Paso, the only senator who voted against the current state budget.

"In Texas, radicals cut the estate tax, then hiked tuition on college students," he said.

"Last session, the same leaders cut $10 billon in the budget on the backs of CHIP (Children's Health Insurance Program) and Medicaid kids. Here's how it works: tax cuts for millionaires are paid with budget cuts in programs critical to middle- and low-income families."