Some states have capped enrollment, cut benefits and slashed services that aren’t specifically required by the federal government, such as home care for the disabled and vision and dental care. Others such as Nevada, with already-lean Medicaid programs, have resorted to across-the-board cuts in payments to hospitals and doctors. As it stands now, the stimulus legislation would require states to retain or restore Medicaid eligibility levels to those of July 1, 2008, but it wouldn’t prevent states from making benefit or provider cuts.

Even before the financial crisis, Nevada’s Medicaid spending was the lowest in the country per beneficiary — $472 compared with a national average of $1,015, according to a 2006 survey. In September, Nevada cut Medicaid payments to hospitals by 5% across the board, and some physicians, especially pediatricians specializing in orthopedics, urology and cancer, saw their payments reduced by 41%. Still, the state faces a revenue shortfall of more than $2.3 billion in the next two fiscal years as gambling and sales-tax revenues have plummeted.

Nevada Gov. Jim Gibbons in his State of the State speech this month proposed increasing Medicaid spending by $206.6 million to $2.8 billion. But he also proposed eliminating Medicaid coverage for low-income pregnant mothers.

The state has already reduced personal-care assistance to the elderly and disabled, which led to complaints and some 200 hearings, said Charles Duarte, the state’s Medicaid administrator. The state also capped dental benefits for its State Children’s Health Insurance Program, or Schip, at $600 a year, and eliminated orthodontics and vision coverage. Gov. Gibbons plans to cap enrollment at 25,000 for the state’s Schip program, which already has 23,000 enrollees and pending applications for 7,000 children. “We don’t have money,” Mr. Duarte said. “We try to look at things that will have the least impact.”

The cuts meant $21 million less in Medicaid funding for the area’s only public hospital, the University Medical Center of Southern Nevada in Las Vegas, said Chief Executive Kathy Silver. That came at a bad time for the hospital: Even before the cuts, it was expected to lose $51 million, about 10% of the hospital’s net revenue, to uncompensated care.

The hospital, which treats most of the Medicaid and uninsured patients in the area, eliminated some services. By early November, it stopped accepting new patients at the outpatient oncology clinic, and then canceled a contract for outpatient dialysis, saving $2.5 million a year. It also ended routine prenatal care, leaving 600 women to find other providers, and it discouraged women with high-risk pregnancies from using the hospital by closing a unit that was losing more than $2 million a year, Ms. Silver said.

The transition hasn’t been without risks, especially for the uninsured who can’t afford costly oncology drugs. For undocumented immigrants, she said the hospital is working with the Mexican consulate in Las Vegas to “try to get them treatment or send them to Mexico, if they want.”

Officials at the local Mexican consulate declined to comment.

Meanwhile, some doctors — especially specialty pediatricians — have stopped seeing Medicaid patients. Mark Barry, an orthopedic pediatrician at Desert Orthopaedic Center in Las Vegas, said he stopped accepting patients after Medicaid slashed reimbursement rates 41%. “It’s extremely troubling,” Dr. Barry said. “There’s nothing more I want to do than provide care.”

Health clinics and doctors’ offices that still accept Medicaid are overcrowded, and some patients are looking for care out of state. “We are almost creating medical refugees out of the Las Vegas area,” said Stacey Gross, community-programs manager in southern Nevada for Susan G. Komen for the Cure, a nonprofit dedicated to fighting breast cancer. “Only a small fraction of people are actually securing any amount of charity care.”

As the economy worsens and job losses mount at casinos and elsewhere, some fear patients will eventually flood emergency rooms when their conditions worsen. “I feel like this is a tsunami coming,” said University Medical Center’s Ms. Silver.

If Nevada’s state legislature approves the governor’s budget, Mr. Duarte said hospitals will get another 5% payment cut on July 1 this year.

A particularly knowledgeable Nevadan responded with this letter to the editor:

Dear Ms. Zhan,

In your January 28, 2009 WSJ article, States Take Aim At Medicaid you stated, “[e]ven before the financial crisis, Nevada’s Medicaid spending was the lowest in the country per beneficiary — $472 compared with a national average of $1,015, according to a 2006 survey.” You don’t state the source of this data but it is clearly erroneous. Your article states Nevada’s Medicaid spending per beneficiary is only $472. You have probably confused per beneficiary spending with per resident spending. According to the Kaiser Foundation’s web site Nevada’s 2006 Medicaid spending was $1,177,644,552 and according to the Nevada State Demographer Nevada’s total population in 2006 was 2,495,529. This would result in per capita Medicaid spending of $472. Obviously not every resident in Nevada is on Medicaid so this figure does not represent per beneficiary spending.

The purpose of citing this statistic was apparently to prove that Nevada is under funding Medicaid as compared to other states. Quite obviously the amount Nevada (or any other state) spends per resident has nothing to do with the adequacy of its Medicaid funding. The more relevant fact would be Medicaid spending per enrollee since this would tell the average amount each beneficiary receives. In fact your article incorrectly states it is referencing spending per beneficiary not per resident. If a state were prosperous enough to have only 5% of its population qualify for Medicaid it could spend substantially more per beneficiary than a depressed state that had 15% of its population qualify for Medicaid. The more prosperous state would in fact be more generous in its spending per Medicaid beneficiary but still spend less per resident than the less prosperous state. The Kaiser Foundation’s Statehealthfacts.org website has a calculation of per enrollee spending by state, and Nevada ranks 18th not dead last as you reported. In fact Nevada’s per enrollee spending, per the Kaiser Foundation website is 65% higher than its neighbor state of California and 46% higher than Arizona. But those facts apparently didn’t work into your story line.

I apologize if this e-mail seems overly critical but I grow tired of the endless stream of articles that misrepresent Nevada’s spending on Medicaid, Education and other public services. Thank you for your consideration of my views. I am a long time subscriber to your paper and enjoy the articles and particularly the editorials.

This generated this correction from the Wall Street Journal on 2/3. Sure wish all newspapers were as willing to note their errors!

It sure does seem like if you ask the government to do something, the largest possible percentage always gets skimmed off the top.

Here’s the website for Nevada’s food stamp fraud police.

Here is their recent study ranking Nevada 40th in terms of Medicaid spending.

Another Medicaid expansion advocate, the Kaiser Foundation, finds Nevada’s overall Medicaid spending per enrollee ranks us 37th.

Eligibility for this program was confused when the federal government expanded Medicare pharmaceutical coverage in the mid-2000’s. Consequently, this program has no waiting list.

Here is Senior RX’s homepage.

The federal taxes pays two-thirds of the cost while state taxes pay one-third of the cost. Families who participate pay a small (average $25 per month for all children in the family) premium with no co-pays, deductibles or limits.

Plan benefits are better than many private insurance plans, offering vision, dental, chiropractic, mental health and full prescription drug coverage.

After the first two years, so few people actually signed up that state bureaucrats were assigned to “to investigate new methods, including advertising, to locate more recipients.”

Nevada’s program is called “Nevada Checkup” and its administrators are quite aware of the political sensitivity of its program – as you can see, its homepage urges recipients to register to vote in order to rally political support to its side.

In 2007, Washington held a vote to expand the S-CHIP program. After President Bush vetoed the expansion, his opponents turned the spotlight on a 12-year-old who captured the nation’s attention with his story about how S-CHIP had repaired his shattered body after a car accident. Later, it was revealed that his family was not poor and that he and his sister both attended a private school.