There's a certain audacity to Governor Carcieri's drive to put a global Medicaid waiver in place in Rhode Island — mostly because the General Assembly, which faces a January 15 deadline if it wants to scrap the effort, would have to make up $67 million in budgeted savings if it rejects the initiative.

Meanwhile, the sharply divergent descriptions of how the waiver might affect the state and some of its most vulnerable citizens underscore the disputed nature of its ultimate impact.

Carcieri has said his plan will save an estimated $358 million over five years while reducing program costs and "ensuring access to the right services, at the right time, and in the right setting," according to a fact sheet prepared by the administration.

In a ProJo story on Tuesday, House Finance Committee chairman Steven M. Costantino, suggested the possibility that the legislature, if it doesn't reject the waiver, might subsequently seek to build health-care protections.

Yet the state's Congressional delegation, which first wrote to Carcieri about the Medicaid waiver in August, renewed its serious concerns in a letter sent that day to the governor.

"Despite numerous public briefings held in Rhode Island, a detailed plan and justification are still not public and accessible," reads the letter from Senators Jack Reed and Sheldon Whitehouse, and US Representatives Patrick Kennedy and James Langevin. "Collectively and individually, we have made repeated requests for specific information, but we are still awaiting key details. For example, the State has not provided data on the impact on beneficiaries, nor has it provided projections of state spending, savings, or assumptions and methodologies on which such projections are based. Absent such basic information, it is extremely difficult for us to make an informed and responsible evaluation of the waiver.

"From the information we have, one aspect of the waiver seems quite clear. The aggregate cap on spending could leave the State up to $842 million short of its projected obligations over five years. This is because the cap is based on national projections in the President's Budget, and does not factor in Rhode Island's specific circumstances — including a significant aging population and skyrocketing unemployment. While the President's Budget and the waiver assume an unemployment rate of only 4.9 percent, Rhode Island's unemployment rate is currently 9.3 percent. By the State's own estimates — which understate the problem by assuming a maximum unemployment rate of 8.0 percent — 53,433 people will become eligible for Medicaid due to increased unemployment. Because of the cap, the federal share of the costs of enrollees above the cap is at stake."

According to Carcieri spokeswoman Amy Kempe, "The governor has offered to brief the delegation, here in RI or to fly to DC, on the waiver, and has extended the offer for his staff to brief their staff." In terms of the cap, Kempe writes via e-mail, the House fiscal staff and other knowledgeable sources "all agree, after extensive and careful analysis of potential future growth, that the State will NOT exceed the cap."

In a November response to an earlier letter from Reed, Carcieri characterized his drive for the global Medicaid waiver as an effort to continue Rhode Island's status as a state that has been "out in front" on health-care.

"In proposing the Global Compact Waiver, I am committed to doing no less . . ." the governor wrote. "The critical factor here is what the State stands to gain from taking this risk: the flexibility required to transform Rhode Island Medicaid into a sustainable, cost-effective program capable of adapting to the changing needs of beneficiaries."

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