Health cuts: Will Washington end up a lot like Arizona on transplants?

Cutting the state's Basic Health Plan, as Gov. Gregoire suggests, might leave some potential transplant recipients in a position that wouldn't be all that different from Arizona's.

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Cutting the state's Basic Health Plan, as Gov. Gregoire suggests, might leave some potential transplant recipients in a position that wouldn't be all that different from Arizona's.

It's hard to think of any political similarities between Washington’s Democratic Gov. Chris Gregoire and Arizona's Republican Gov. Jan Brewer. But there is one. Both governors want to cut off funding that affects people needing transplant operations.

Brewer caused a national furor last month when she defended her state's budget-saving termination of Medicaid coverage for certain types of transplant operations, which has placed about 100 patients on transplant waiting lists at risk of imminent death. Critics have called it Brewercare, the real-life version of the bogus death panels dreamed up by foes of President Obama's health reform legislation. Even some Arizona Republicans — though not Brewer — have begun backing away from the transplant cuts.

Now, Gregoire, an advocate of universal health coverage, has proposed eliminating the state’s 17-year-old Basic Health Plan, an affordable health insurance program for working-poor families with incomes at 133-200 percent of the federal poverty level. Zeroing out the program as of March 1 would save $219 million over the next two years, as part of her proposal last week to slash nearly $4 billion in spending and close the state’s huge budget deficit.

The proposed termination of the Basic Health Plan (BHP) came as a shock to a man I’ll call Jim, a 34-year-old Spokane electrician and father of seven whose kidneys are failing. I’m not using his real name because his unemployment benefits could be jeopardized if the state learns he can't work due to poor health. Jim’s BHP coverage will end if the Legislature approves the governor’s plan, which appears likely. As a result, he may not receive the kidney transplant he’s waiting for at Providence Sacred Heart Medical Center. And his wife, who’s also on BHP, wouldn’t be able to afford the care involved in donating a kidney to him.

"Gregoire proposed that?” Jim said when I talked with him last month. "I don't even know why they would try to do something like that. It would leave a lot of people in a lot of hurt. I’m a union worker. I voted for her."

A kidney transplant costs tens of thousands of dollars for the operation and the anti-rejection drugs, which must be taken for years after the surgery. Like other transplant centers, Sacred Heart won’t perform transplant operations on patients who don’t have the means to pay for the operation and the drugs, because kidneys and other organs for transplant are scarce resources.

“Our purpose is providing patients access to life-saving transplants,” says Dr. Okechukwu Ojojho, the surgical and program director at Sacred Heart’s kidney transplant program. “But they have to be able to afford the medications which help keep the body from rejecting the new transplant. So financial issues will have to be a consideration in deciding whether to transplant (Jim).”

Jim is not the only Washington resident who may lose access to a transplant if Gregoire’s budget passes. BHP paid for eight transplant operations in 2009 — a kidney, a liver, two lungs, two bone marrow grafts, one heart, and a liver/intestinal transplant. While state officials couldn’t say how many BHP patients currently are waiting for transplants, Dr. Ojojho says Sacred Heart has at least a couple of other BHP patients waiting for kidneys. Another hospital official said Sacred Heart does four to five heart and kidney transplants each year on BHP patients.

State officials are well aware of the harsh impact that terminating the program would have on patients in need of transplants. And, of course, it also would have major consequences for the rest of the 66,000 BHP enrollees who may have serious if less critical health care needs —not to mention the 138,000 people on the program’s waiting list. “We understand and shared those impacts with the executive and the Legislature,” said Preston Cody, BHP’s director. “If the program is eliminated, we’ll make every effort to communicate with the entire population and send them information on other resources to see what their other options are.”

But the cold reality is that many of these patients have no other viable options. The BHP transplant patients are people who surely would be rejected by private insurers. They generally wouldn’t qualify for the state Medicaid program for the poor, have medical costs that are too high for the limited-benefit Washington Health state insurance program, and couldn’t afford the stiff premiums in the state high-risk insurance pool, said Jim Stevenson, a spokesman for the state Health Care Authority, which runs BHP.

Jim was diagnosed with Focal Segmental Glomerulosclerosis (FSGS), an unexplained scarring of the kidneys, six years ago. But he worked regularly as an electrician on construction projects until being laid off a year ago. He relied on BHP for years because his employers either didn’t offer coverage or made him wait six months for coverage after he started the job. He felt fortunate to have the state coverage, because he has needed a lot of expensive care related to his failing kidneys, including two recent fistula operations and lots of medications.

Two months ago, when his kidney function fell below 20 percent, Sacred Heart put him on the transplant waiting list. This past month, his wife, a nursing home aide, insisted she wanted to donate one of her kidneys to him. He had resisted the idea for months because he wants her to stay healthy to take care of their children, ages 4 to 17 (the older three are from his wife’s previous marriage). But if tests determine she’s a suitable donor, that would expedite his transplant operation.

Dr. Ojojho says if all goes well, Jim could undergo the operation within two months. He considers Jim a “great” candidate for transplantation. There’s a 50-70 percent chance he would experience no recurrence of FSGS, in which case he would have a very good long-term prognosis, particularly with a kidney from a living donor. Sacred Heart reports a three-year survival rate for kidney transplant patients of 92 percent, according to the
national Scientific Registry of Transplant Recipients.

The alternative to the transplant would be for Jim to wait until he goes into kidney failure, then start receiving kidney dialysis three days a week for the rest of his life. That probably would be paid for by Medicare.

But Dr. Ojojho says a transplant is far preferable because Jim’s quality of life and functional status would be much better, and he may even be able to return to work. “We want to put medical necessity ahead of politics and balancing the budget,” the surgeon says. “His life would be incredibly enhanced by getting the transplant.”

Jim says the thought of dialysis three days a week, five hours a day, is “pretty grim.” He probably wouldn’t be able to work. “Once I get the transplant, I’m going back to work and paying taxes,” he says. “If I’m on dialysis, it’s very expensive and the government would be paying. Wouldn’t everyone would be better off with me having a kidney?”

Stevenson says that if BHP is terminated, there’s a chance — but no certainty — that Jim and his wife could qualify for state coverage under Medicaid’s Temporary Assistance to Needy Families program (their kids are already covered under the state’s Apple Health program). If they could wait until 2014, when the new health reform law’s insurance protections and subsidies begin, they would have no worries. But getting alternative coverage any time soon is a big if, and Jim won’t get his transplant unless he has guaranteed financing now.

Karina Shagren, a Gregoire spokeswoman, says she’s not familiar with the Arizona transplant crisis or whether something similar will happen here. “But it’s critically important to remind people,” she says, “that there are very few options to filling our $4.6 billion budget gap.” The governor’s proposal, she added, “maintains some protection for our most vulnerable while still reflecting the economic realities of today.”

“I hate my budget,” Gov. Gregoire said last month as she unveiled her austerity plan. “I hate it because in some places I don’t even think it’s moral. Who’d have ever thought that I would be doing this?”

Who indeed? Certainly not Jim. “I don’t want to say anything mean,” he says. “But I think it would be devastating to Washington to drop Basic Health. There are a lot of people who depend on it."


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