A recent court decision on the interpretation of federal Medicaid law sounds an ominous note on the rationing front. The 11th Circuit Court has ruled that even though Medicaid is supposed to provide all "medically necessary" treatment, this phrase can be interpreted by the states (since states contribute to Medicaid) using cost-containment considerations to limit utilization. In other words, "medically necessary" doesn't really mean "medically necessary." It also can include completely non-medical considerations. Said the 11th Circuit,
While it is true that, after the 1989 amendments to the Medicaid Act, the state must fund any medically necessary treatment that Anna C.Moore requires, Pittman v. Department of Health and Rehabilitative Services, 998 F.2d 887, 891-92 (11th Cir. 1993), it does not follow that the state is wholly excluded from the process of determining what treatment is necessary. Instead, both the state and Moore’s physician have roles in determining what medical measures are necessary to “correct or ameliorate” Moore’s medical conditions. Rush v. Parham, 625 F.2d 1150, 1155 (5th Cir. 1980);1 42 C.F.R. § 440.230 (“(d) The agency may place appropriate limits on a service based on such criteria as medical necessity or on utilization control procedures.”); see 42 U.S.C. § 1396d(r)(5). A private physician’s word on medical necessity is not dispositive. [My emphasis]
You get that? "Medically necessary" includes "utilization control procedures" as well as determinations of what is, you know, medically necessary.
Wesley J. Smith notes that this decision is unpublished. As far as I can gather (legal eagles, correct me if I'm wrong), this means that lower courts will not officially regard themselves as required to follow this interpretation of the law as precedent. On the other hand, three states didn't join in appealing this case for nothing when a lower court ruled in favor of Mrs. Moore. Clearly, they regard this as a "precedent" in some sense: They believe that they can now limit Medicaid outlays based on something other than medical necessity even though the law says they are supposed to use only medical necessity.
P.S. The term "fair" in my title comes from this analysis by Jeffrey Emanuel, who says,
However, Georgia officials argued Callie’s care was subject to rationing, as the state bureaucrats’ need to ensure Medicaid resources were allocated “fairly” superseded her doctor’s care prescription or her personal medical needs.HT Secondhand Smoke