The toll that Zika virus takes on pregnancies appears to be even higher than was previously estimated, with a newly updated study from Brazil suggesting that 42 percent of infants infected in the womb may have significant birth defects.
When the authors factored in stillbirths and miscarriages suffered by women who had been infected with Zika, 46 percent of pregnancies were affected. Microcephaly — a condition in which babies are born with smaller than normal heads — was seen in only about 3 percent of babies in the study.
“Microcephaly is just the tip of the iceberg. It’s definitely not where the focus should be,” said Dr. Karin Nielsen-Saines, the paper’s senior author. “For every case of microcephaly you’re probably going to have 10 cases of other problems that haven’t been recognized.”
In the United States, roughly half of all births are covered by Medicaid. Medicaid and CHIP cover a good number of kids and these two programs cover a disproportionate number of children with significant, expensive life long conditions. We also know that locally transmitted Zika infections will not be uniformly distributed. Alaska will have far fewer proportional Zika infections than Florida. We also know that one of the major policy planks of the Republican trifecta will be to block grant Medicaid on a per capita basis.
We know that treating and caring for an individual with microcephaly will have a lifetime cost of $10 million dollars. Other neurological and cognitive conditions will have lower lifetime incremental costs but these individuals will cost more than their non-Zika effected peers. We know that state Medicaid budgets will cover a high proportion of these individuals. If Zika is not quickly isolated and reduced to a random outbreak here and there and instead is endemic, we have a serious Medicaid financing crisis at hand if the federal funding is transformed into a block grant.
The Medicaid block grant procedures would give states a fixed head payment for each enrollee. It could vary by category of assistance and a few other criteria but the fee would be flat within subgroups by the number of enrollees. From here, the states could have the choice to top-up the Federal match or spend state supplied money in other manners. This is different from the current system where the Feds give the states an open ended funding stream that is a state specific multiple of the state contribution. The block grant removes the variability of the federal spending commitment. In the Ryan plans, it also shrinks in terms of real purchasing power over time so states either spend more money to maintain current level of enrollment and services or cuts to enrollment and services have to occur.
And here is where there is a problem. The capitated payments would be based on average expected costs in year 1 and then get weaker. States with disproportionate clustering of high cost conditions will be significantly worse off. Long run Zika neurological impairments will hit warmer states’ Medicaid budgets much harder and more disproportionally than Zika will hit cold weather states’ Medicaid budgets. This could be adjusted for by having a Zika bump in the block grant calculation much like there could be a diabetes bump or a maternity bump or any other number of risk adjusted bumps to capitation payments. But what happens when there is a new high cost and very concentrated disease that will have major impact on a few states’ Medicaid budgets? The block grant system fails unless there is a side payment of new federal funds. And given the political fights over natural disaster relief bills and the Zika bill, I have a hard time seeing Congress routinely providing multi-billion dollar cash infusions to a few states for new diseases or threatening epidemics.