Poop Happens: New Rules for Alabama Medicaid

In the ongoing effort to squeeze more juice out of the budget turnip, Alabama’s Medicaid office has revised pharmacy benefits.  There are new limits on the number of prescriptions per month for adults, and for all ages, the program will no longer cover any over the counter medications as of October 1.


Were you aware our Medicaid program covered some (not all) OTC medications if prescribed?  After all, most private insurances do not, and neither does Medicare.  This is an optional coverage by states—we don’t have to do it, and now we won’t.


 Most of the OTCs I prescribe for kids are fairly cheap—for instance, 1% hydrocortisone for mild eczema is under $5 a tube.  Others are a little pricier—polyethylene glycol for constipation is about $12 to $36 for a one month supply depending on the dose.  For most of us, that’s still less than the typical pharmacy co-pay anyway, so what’s the big deal?


You’d be surprised how many families tell me, as they are leaving the office, that they can’t even afford to buy ibuprofen to give their children pain relief, or a thermometer, or a bulb syringe to suction a baby’s nose.  Children with Medicaid live at the very lowest income levels, so sometimes there really isn’t $5 or $10 for an OTC medicine.  Sometimes, maybe there is—maybe the household budget is out of line and maybe that $5 was spent on something you might judge wasteful or frivolous.  The problem for the kids is that whether their parents could budget differently or not, many will simply not get their medications unless Medicaid covers them. 


I wasn’t the only pediatrician who thought the change sounded like a problem.  Several of us made lists of the most commonly used OTC medications for which there is no good or inexpensive prescription substitute.  The list was submitted by an advocacy organization to our Medicaid agency, along with an explanation of our request to have an exception for these limited items.  A few days ago we got our answer—no.


We are told this is because of federal rebates for prescription drugs, not available for prescribed OTCs.  I understand how that would work in general, but not for everything.  1% hydrocortisone, for instance, can be used sparingly on the face for eczema (along with a thick moisturizer).  Stronger prescription steroids are not a great idea on the face for extended use.  So our next step up from the $5 OTC is… pimecrolimus or tacrolimus, priced online at $150 or more.  I don’t know what Medicaid pays and gets back as a rebate, but I’d be surprised if it isn’t a money loser by comparison to the $5 product.


One of my friends out of state suggested the decision may also be related to Medicaid’s possible switch to Pharmacy Benefit Managers.  If we go with third party, for-profit PBMs, they make their profit on our prescriptions and would likely object to any coverage of OTC meds.  I’ve asked around and have not been able to find out if PBMs are a factor.


Now I’m going to talk about poop, so if you are eating or squeamish, skip to the end.  Pediatricians are bad about poop talk in front of nonmedical people, even at parties.


Constipation is a common problem in babies and children—hard stools that not only hurt but can even tear the anus.  I’m talking blood.  Children are scared to poop afterwards—they expect pain and they hold back, resulting in more stool buildup and more pain the next time.  Eventually, this pain/holding cycle can lead to encopresis—large amounts of hard stool in the now dilated rectum with thinner, liquid stool leaking around it and out into the underwear.


Parents may think their children are not wiping or are having accidents.  The kids are embarrassed.  It smells bad.  They get called names.  Whenever I see “train tracks” in a child’s underwear, I know I need to do a rectal exam and see what’s up in there.  After diagnosing and explaining the problem, I outline a course of treatment in which we need to get the poop cleaned out and then keep it very soft, like pudding, for several months to avoid new tears and recurrent buildup.


Treatment is almost always successful.  OTC polyethylene glycol, PEG, (aka, Miralax is the best thing going for encopresis—both for the initial cleanout and for maintenance.  It isn’t absorbed into the body—it pulls water into the stool to soften it.  When I was in training, we had mineral oil—a chore to coax children to drink even with heavy flavoring, and there were cases of aspiration pneumonia when the oil got into their lungs.  Then we had lactulose—better accepted than mineral oil but not quite as effective as PEG and rarely with significant side effects, including obstruction of the bowel.  We had various fiber supplements, which helped inconsistently.  For cleanouts, we often had to resort to milk and molasses enemas.  Finally we started using PEG.  Kids will drink it, it works most of the time, and there are minimal side effects.  Life for constipated kids got much better. 


Now, depending on the dose needed, families may have to spend as much as $36 a month to keep treatment going.  Some will manage to do it, and others will not.  Say whatever you want about what the parents “should” do—if it doesn’t happen, it doesn’t happen, and the kid will be the one with a bleeding bottom.  Or in the ER for abdominal pain.  The number one cause of abdominal pain in children who visit the ER is constipation.  Untreated constipation can lead to urinary tract infections.  It can lead to CT scans and repeated radiation exposures in the ER.  Sometimes we have to admit children for cleanouts, with PEG dripped through a nasogastric tube.  I have had kids who got so constipated they vomited fecal material, but not since we’ve been using PEG.


I know some of you by now are asking why we are using medication for constipation at all.  Isn’t it a crutch?  Why not fix the diet, try juice, prunes, coconut oil, stop all the dairy products, or whatever your favorite home remedy is.  We do!  If you have been in my office with your child and we haven’t talked about diet, one of us has had memory loss.  The problem is sometimes the same as with the cost of the PEG—reality.  The children are not buying their own food.  And to be fair, some parents really do provide healthy food and the constipation remains.


Whatever your thoughts about how children ought to be eating, when they get painful constipation or encopresis, OTC PEG gets them out of misery.  And coverage for it is going away for many of our patients on October 1.


I don’t know if our Medicaid will track ER visits for constipation or complications like UTI to see if costs go up. Will we save money on medications only to spend extra elsewhere?  I doubt it will take very long for us to see problems in our practices.   I plan to let the state know if I do.


 I want the Medicaid money to stretch as far as it can, so that no one goes without needed care.  I appreciate the state’s creative efforts to work the budget.  This particular change is probably not going to be as bad as the limit on prescriptions for adults, which will land some in the hospital (what do we skip this month—the diabetes medicine, the blood pressure medicine, the heart rhythm medicine?), but it will cause some definite problems.  No matter what insurance system we have, even if we had single payer, we would have to think about this type of decision.  



Filed under Children's Issues, Medicaid

5 responses to “Poop Happens: New Rules for Alabama Medicaid

  1. Barbara Power

    Many excellent points and, once again, an increasingly sad trajectory.in pedi care for those who are poor. Also, quite correct in your assertion that “no matter what insurance system we have, even if we had single payer, we would have to think about this type of decision.”

    I am all over the map, it seems, when I face stories such as this or when I see it in my own work. We seem ever closer to a time when medical care and medicines did not exist at all, and one went to see a “doc” only as a desperate measure. Suffering existed, people died much earlier in life, and very few had a list of 6 to 16 Rx meds to sort through. Always, of course, this was different for the wealthy.

    Then I think of the “due diligence” suggested regarding runaway spending for healthcare in this era of a health care “arms” race where we are guilty of spending one trillion or 17% of GDP (whichever metric pleases you). So we tell ourselves that a dose of rational thinking is required because we should not just spend wildly on unnecessary care. Yes and no.

    That is, rational as in ration.

    I think this arms race is tragic. It is predatory and based on greed. The expense of health care in the US is revenue to large corporations of many types in the US and for global corps who sell meds or med devices.

    Not one corporation receiving revenue and profits related to health care spending truly wants it to stop rolling in. All talk of this is false. We will ration , but only to the poor, and continue the obscene spending for those who are rich and, at least for a few more years, for those who still believe they actually have affordable insurance.

    Are we going to ration defense spending? Are we going to ration corporate subsidies (which dwarf spending on social needs)? Are we going to ration tax loopholes for corporations and wealthy individuals?

    Will we guiltily prescribe Miralax as our tax dollars are, as we speak, being spent to gear up for another military action (whether it’s approved by congress or not, the gearing up is happening and our taxes are paying for it)? But no meds for kids who are poor.

    Should our citizens do a better job of caring for their health by doing all the “right” things? Yes, that would be good and we could, perhaps, spend less on MD visits, Dx tests, and meds. But then we all know it can be difficult or impossible when one is poor to purchase quality food – even if it is available in poor urban or rural locales. It can be dangerous to be outside to exercise in many urban settings.

    So we WILL watch as Medicaid is cut. We WILL watch as the tobacco industry gains a greater foothold after 2 decades of diminished market share in the US. We WILL watch as agribusiness wins once again and pours corn syrup (paid for by subsidies) on every possible “food” substance marketed to us and our children. We WILL watch as the inequity grows in this wealthy country.

    It is no accident that these trade-offs are happening as corporations rule and own our elected officials.

  2. Autismmomx4

    Basically one of the problems with out healthcare system is that cost is NOT a factor. The ultimate question is, is it in the contact. If not, you don’t get it. Even if it is cost effective. Case in point, my husband just got a staph infection in his residual limb….coupled with a blood clot in his lungs. He now has an open wound on his limb which is packed wet to dry. It’s swollen and irritated. And it hurts to pack it. He has RA so his hands don’t work well and he’s slow. Due to the blood clot he’s on blood thinners so you need to move fast to pack this wound. Our “private” Medicare policy will only pay for 5 days of home healthcare for the packing. If he can’t do it himself within 5 days, he has to go to a rehab facility until he can….both the home health and the rehab facility are fully covered. Does any of this make sense?

  3. I am one of the adults on Alabama Medicaid. I just got turned down by all the prescription assistance programs because of course I have Medicaid already–but they won’t pay for my Meds! So, I have 13 or so prescriptions a month, a lot I know, but I have everything all at once, from GERD from a bad stomach operation to high blood pressure, to chronic pain from 3 failed back surgeries and allergies and high cholesterol.. and on and on.. 13 or so pills a month. Now, my doctor was great trying to get me into assistance programs, but nobody is having me… now what. Just not take my pills? Some I have been on since 1990 (Prozac) and I should quit abruptly? Or should it be the high blood pressure pills? The doc took my BP after talking about the Medicaid changes and my BP was up to 205/180 (that’s WITH meds) and everyday my body is getting worse because I’m trying to quit pills because on SSI I only make $710 a month, after rent that’s shot… so I can’t afford $70 to $500 in medicine a month. What am I supposed to do? Nobody will help. I can’t get anyone to even care. So… I am an adult and I need prescription help. If I were under 21 they would be paid for. I guess children are more valuable than I am? Why don’t they just put me out of my suffering and just kill off the older folks… it would be better than a slow death by lack of medications.

  4. Barbara Power

    Dear Karla,

    I tried, via testimony to multiple state forums and legislators where I live, to protect adults on Medicaid – well, more accurately– to approve Medicaid Expansion to adults in my state. We Lost on ALL fronts. I had hoped that either logic or compassion would prevail in the face of such obvious need and suffering. Not to be. Unfortunately, my state is regressive and mean-spirited.

    Your story and that of many others, when knit together, represents what we all know with increasing angst: without personal funds those with medical needs will suffer.

    This truth is ignored every minute of every day in the US health “care” system, as it is in many “Less-Developed-Countries” all over the world. It’s just that the USA in the context of equality and medical care, can no longer be classified as a Developed Country. This has become an unassailable fact in my opinion, especially evident in 2013. So, the truth is out.

    When I hear advertisements (cloaked as charitable giving e.g., Medtronic, Eli Lilly, Novo Nordisk, etc) I now insert the words: “if you have the money to pay.” When I hear new medical recommendations from lauded institutions such as the IOM, I now insert the words: “if you have the money.
    I see Billboards on highways touting breast cancer treatment in yet another oh-so-caring hospital and I now add the words: “if you have the money.”

    Pippa may have noted a recent blanket recommendation from medical pundits that in the world of statins (cholesterol medications), the numbers no longer matter. The recommendation is to prescribe statins for anyone with a family history of high cholesterol, anyone who is obese, anyone with either type 1 or type 2 diabetes, anyone with high blood pressure, and on it goes.

    What wasn’t in this new formalized recommendation is the message: “if you have the money.” Statins For All will even affect some pediatric patients in their teens who may already have a bit of high blood pressure or who are overweight. Their cholesterol numbers may be perfect but the new guidelines are to Prescribe statin meds. (Again, the unspoken caveat here is ‘if you have the money.’

    The message in the US is this: we really care…….buuutttt only if you have the money.”

    I realize this is a harsh message but I believe my newly evolved understanding of the truth in the US is valid.

    yours in solidarity,

  5. turtlegirl

    I am in desperate need of Medicaid. I was sent there by marketplace and found out that we have basically been cast aside. I am asthmatic, need an inhaler and need an epi pen desperately. So sad that our cells like we don’t matter. I’ve worked my whole life, i just don’t make enough for insurance. *sigh*

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