The West Virginia legislature recently gave the thumbs up to a radical experiment in health care: doctor-run pay-in-advance plans that provide a family unlimited primary and urgent care for $125 a month. No insurance coverage is involved. The primary care physicians are, in effect, providing the insurance of coverage and access to it-- which is why the legislature was urged to act. Insurance companies and regulators were concerned that patients might forgo comprehensive health coverage or get ripped off by an unscrupulous doctor who might take the prepaid fees and fail to provide service. With the passage of the law permitting pilot programs for three years, several insurance companies are looking into products that would complement the prepaid plans.


With Medicaid enrollment declining for the first time in nearly a decade, health care analysts suggest that two factors are driving the phenomenon. One is a sign of recent good times: Lower unemployment has meant fewer people signing up for assistance. The other is more of an administrative tangle: New documentation requirements have been causing significant delays in processing applications. Medicaid spending also is growing more slowly than usual. That is due, in part, to the decline in enrollment but also to the transition of prescription drug costs for dual eligibles from Medicaid to Medicare. States don't expect the enrollment decline or spending slowdown to continue.


Florida's dramatic Medicaid reform was much in the news under former Governor Jeb Bush. In an effort to save money and improve care, Bush wanted to move the state's 2.3 million Medicaid recipients into private, HMO-style health plans. The legislature resisted and insisted that the program first be run as a pilot in three counties. A year into that pilot, the state's first major evaluation of the program found that the new system was difficult for Medicaid recipients to parse. Many with complex illnesses used up drug coverage and were left without coverage. The report recommended that expansions be delayed until the flaws are corrected.