When nagging stomach pains finally drove Violet Scales to seek medical help, the 53-year-old Landover woman went to the outpatient clinic at Prince George's General Hospital.
Doctors found and removed a tumor from her stomach. Then, while she convalesced, they discovered another tumor in one of her breasts and removed it. She is recovering from the surgery in a sunny, semiprivate room at the Cheverly Hospital, receiving the same care as any other patient with a health insurance policy.
Scales' only "policy", however, is Medicaid, the state and federally sponsored program for low-income persons on which nearly one out of every 10 Marylanders depends for health care. And Medicaid, critically short of funds in the state, no longer pays hospital charges incurred after the first 20 days of confinement. As of this week, Scales had run up a bill for more than $8,000 in staying more than 20 days past the limit. Scales, whose meager income is what she is paid for caring for an elderly relative, will get a bill for the amount Medicaid does not cover.
Craig Adney, 25, skidded his motorcycle through a barbed-wire fence last month, "and bounced off a couple of trees." The unemployed Suitland construction worker is recovering in Prince George's General from a crushed left knee and a badly broken thigh bone.
Adney will be billed for every day of his care since May 3, when his 20 days expired. Adney will need physical therapy for his leg for up to a year, and has no idea how he will pay the hospital bill.
"If you haven't got any money, you can't pay. You can't get blood out of a rock," he said.
An estimated 5,600 other Medicaid patients share the plight of Scales and Adney -- their illnesses have kept them in the hospital longer than 20 days. And it is a disturbing prospect for all of the 396,000 Marylanders enrolled in the program, including 36,000 in Prince George's County and 19,000 who live in Montgomery County.
It is an equally disturbing prospect for hospitals, which will have to absorb the losses when poor patients cannot pay their bills. Prince George's General has estimated the Medicaid cutbacks will cost the hospital $1.5 million this year alone.
The 20-day cap on hospital stays is the major economy measure imposed by state authorities to make up for an unexpected $51 million shortfall in funds needed to pay Medicaid bills this fiscal year, which ends June 30.
And there is no prospect of relief. Next year's Medicaid budget, as fashioned by Gov. Harry Hughes and the General Assembly, has been pared back to $26 million less than the amount needed to keep services at the level that existed before this year's shortfall. nAnother $23 million is likely to be slashed when the Reagan administration gets around to making reductions in the federal contributions to Medicaid.
State health authorities recently made permanent the 20-day limit and other economy measures. Among these is a requirement that a wide range of surgical procedures, including treatment of simple fractures, vasectomies and removal of lesions, be performed in doctors' offices or outpatient clinics.
These measures will not be enough, however. Medical planners are steeling themselves to make the difficult decisions on what to cut from the Medicaid program.
John Folkemer, who is in charge of program review and planning for the state health department, said "some kind of severe cost containment will have to go into effect by October." The state provides 59 percent of the funds for the Medicaid program.
State health secretary Charles Buck said there are only four areas were economies can be made: in eligibility, by making fewer people entitled to Medicaid; by limiting services, as in the 20-day limit on hospital stays; by cutting out some benefits entirely, or by lowering the fees paid to doctors and hospitals.
Folkemer said cutting eligibility would be cruel, since the maximum income level allowed a family of four already is $367 per month. Some administrators say the wide range of benefits provided on an outpatient basis, including vision care, podiatry, pharmacy and dental care, should be scaled back, but Folkemer said that even as a group these services will not save the necessary money.
Moreover, poor patients are likely to neglect these health programs until they become acute and the patients end up in hospital beds anyway, he said.
An unexpected 12 percent increase in the number of days Medicaid patients spent in the hospital led to the shortage of funds in the $438 million program this year. State officials say they are at a loss to explain the longer hospitalizations, especially since the number of people on the Medicaid rolls has not significantly increased in the last year.
State health officials are fearful of the long-term effects of the cutbacks.
"When a hospital saw a patient in this state, it hasn't in the past made a distinction between a Blue Cross patient or a Medicaid patient. Now with the 20-day cap, it is going to change," said Buck.
The Maryland Hospital Association, a nonprofit organization representing the state's 64 community hospitals, strongly objected to the 20-day limit.
"The problem with the 20-day cap is that it hits the sickest patients," said association spokesman Rick Wade. "Cancer patients, infants in neonatal units, intensive-care patients, elderly patients with hip replacements -- patients who are frail to begin with."
Hospital administrators in Prince George's and Montgomery believe they eventually will be forced to try to raise the rates they charge non-Medicaid patients.
Such a move would have to be approved by the state's Health Services Cost Review Commission, which sets the rates charged by every hospital in the state.
Executive Director Harold Cohen said the commission would review such requests on a case-by-case basis, giving due consideration to the severity of each hospital's need. But he commented that the commission's "authority to tax patients through health insurance premiums should be a last resort. . . It's the legislature's responsibility to decide how much it wants to pay for people the state accepts responsibility for."
Robin Hagaman, chief executive officer at Prince George's General, said the cuts in Medicaid payments "jeopardize the self-sufficiency of the hospital."
Hagaman has appealed to the county government for the $1.5 million he says the Medicaid cap will cost the hospital this year. County Executive Lawrence J. Hogan, however, did not include any operating funds for the hospital in his proposed budget for the next fiscal year.
Hogan aide Irv Smith said the executive believes the hospital's loss estimates were premature. Moreover, Hogan recently signed a lease with the Hospital Corporation of America which, if approved by the County Council, would turn over operation of the county's three hospitals to the private corporation for the next 21 years. Under the agreement, current levels of service would be maintained, and any infusion of county funds would be limited to $500,000 per year.
Several hospital administrators in Montgomery and Prince George's counties stress that they will continue to provide medical care on the basis of need, not the ability to pay.
"We're not going to turn away a patient if they need the care," said Tom Burke of Silver Spring's Holy Cross Hospital. "We can't look at it from the standpoint of dollars."
Hospitals in affluent Montgomery County will feel the impact of Medicaid shortfalls less than those in most jurisdictions. Montgomery has the second lowest percentage of its residents on Medicaid among all counties in the state.
Holy Cross's bad debts, where the cost of serving the medically indigent shows up, are less than 2 percent of all bills for service, compared with nearly 6 percent at Prince George's General.
Buck said state and federal government economizing on health coverage for the poor could mean the return of the separate-and-unequal standards that existed before the advent of Medicaid.
"If we as a society back away from furnishing health care for the poor -- a way that provides them access to mainstream medical care -- we will be participating in the creation of that dual system," he said.