Tag Archives: Medicaid

Those Pesky Facts

One of my earliest research projects when I entered academia focused on an element of the “Personal Responsibility and Work Opportunity Reconciliation Act of 1996,”  (PRWORA) aka welfare reform. I looked at the consequences of the measure’s invitation to (undefined) Faith-Based Organizations to help government agencies provide welfare services.

Needless to say, the “armies of compassion” envisioned by George W. Bush failed to materialize, since the invitation was based largely on fanciful–indeed, “faith-based”–beliefs about the capacities of the invitees.

I mention this in order to explain my heightened interest in a recent “spat” between Peter the Citizen and Arthur Brooks.

In “The Dignity Deficit: Reclaiming Americans’ Sense of Purpose,” Arthur Brooks, president of the American Enterprise Institute (AEI), emphasizes the importance of work requirements for welfare programs and suggests that the 1996 welfare reform law provides a model for other safety net programs:

Putting more people to work must also become an explicit aim of the social safety net. Arguably, the greatest innovation in social policy in recent history was the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. The PRWORA, which became synonymous with the phrase “welfare reform,” made several major changes to federal policy. It devolved greater flexibility to the states but established new constraints, such as a limit on how long someone could receive federal welfare benefits and a work requirement for most able-bodied adults.

As Peter points out, PRWORA changed a number of programs, but what Brooks is lauding is TANF (Temporary Assistance for Needy Families). Peter, like Brooks, is a political conservative; he was a  former member of the Reagan Administration whose “portfolio” was welfare programs.
And he begs to differ.

For the past two years, I have been writing papers as a citizen to highlight TANF’s many problems. My hope is that conservatives will adopt more “rigor” in their assessment of the 1996 law and use evidence rather than ideology in developing reform proposals.

Brooks claims that TANF reduced poverty, and that its “lessons” about “the dignity of work” should be extended to other poverty programs. Peter convincingly demolishes the first assertion, and provides copious data to prove his point. Although he clearly agrees that there are “lessons” to be learned,  the content of those lessons differs significantly from what Brooks suggests.  I really encourage readers to click through and read the entire paper. The exchange illustrates the difference between ideology and intellectual integrity–between seeing what you want to see and seeing what the evidence shows.

What really caught my eye, however, were the following observations (emphasis mine):

TANF’s block grant structure creates a situation in which states don’t have the resources to run meaningful welfare-to-work programs, as the amount is not adjusted for inflation or demographic changes. This problem is exacerbated when state politicians divert scarce funds to plug budget holes….

In fiscal year (FY) 2015, just 25 percent of TANF funds were used to provide basic cash assistance and just 7 percent were for work-related activities, despite the fact that the number of poor families with children was higher in 2015 than in 1996. In many states, TANF has become a slush fund used to supplant state spending and fill budget holes…

Since TANF’s inception, states have used tens of billions of federal TANF dollars to simply replace existing state spending. For example, Jon Peacock of the Wisconsin Budget Project explains how “a significant portion of the federal funding for … assistance is being siphoned off for use elsewhere in the budget, to the detriment of the Wisconsin Works (W-2) program and child care subsidies for low-income working families.” It would be one thing if poverty had declined in Wisconsin since TANF’s enactment, but the poverty rate for children in Wisconsin grew from 14.3 percent in 1997 to 18.4 percent in 2011. If the supplanted funds were used to fund other programs for poor families, the practice would be less harmful, but that doesn’t seem to be what happens in Wisconsin. According to Peacock, “That shell game uses TANF funds to free up state funds [general purpose revenue] (GPR) to use for other purposes, such as the proposed income tax cuts.”

Trump’s budget–which combines utter fantasy with gratuitous cruelty (eliminating Meals on Wheels!?)– contains deep cuts to Medicaid and proposes to  fund what’s left through block grants, facilitating–and probably ensuring– precisely the sort of “shell game” that the states have played with TANF.

Anyone who thinks that the monies sent to the states via Medicaid block grants would all be applied to the costs of providing medical care for poor people is smoking something, and it’s hallucinogenic.

 

 

 

The Unarguable Benefits of Universal Healthcare

As political posturing over the Affordable Care Act (aka “Obamacare”) continues, the fiscal and social benefits of expanded access to healthcare become steadily more obvious.

The journal Health Affairs recently reported an 8 percent increase per year in the number of early-stage colorectal cancer diagnoses since passage of the ACA. Extrapolated across the country, the researchers estimate the ACA led to approximately 8,400 additional early-stage colorectal cancer diagnoses among seniors between 2011 and 2013.

A 2015 study published in JAMA found that the ACA had increased the number of early-stage cervical cancer diagnoses in women aged 21 to 25.

Early diagnosis doesn’t just increase the likelihood of successful medical intervention; it significantly reduces healthcare costs. When cancer is caught earlier, it is cheaper to treat.

America’s healthcare costs have long been far higher–and our outcomes considerably worse-– than in countries with universal systems. The lobbying clout of Big Pharma and Big Insurance continue to make a cost-effective “Medicare for All” politically impossible, but even with its problems, the ACA has vastly increased the number of Americans who are insured while significantly slowing the rise of healthcare spending; last June, Fortune Magazine reported

The United States will save about $2.6 trillion on health care expenses over a five-year period compared to initial projections made right after the passage of the Affordable Care Act.

While health spending spiked briefly in 2014, evidence shows that it has once again slowed down and will help save Americans trillions between 2014 and 2019, according to a new study by the Urban Institute and Robert Wood Johnson Foundation.

Spending declines will happen across both private health insurance as well as Medicare and Medicaid. Centers for Medicare and Medicaid Services actuaries predicted that total Medicare spending between 2014 and 2019 would be $455 billion lower than the ACA baseline forecast. Projected Medicaid spending over the same time period is expected to be $1.05 billion lower than previous ACA estimates, while private insurance spending projections declined by $664 billion.

I simply do not understand the Republicans’ hysterical opposition to the ACA. Both health outcomes and cost controls have improved, and problems with the program can be fixed with relatively minimal tweaking. The program’s popularity has also improved. (According to survey research, approximately half of those who do remain unhappy with Obamacare complain that it doesn’t go far enough–they would prefer a single-payer system.)

It isn’t just the ACA. Paul Ryan and the GOP are threatening to dismantle both Medicaid and Medicare–programs with low overhead and proven effectiveness– and they are intent on defunding Planned Parenthood, which delivers critical medical services to millions of poor women.

It isn’t as though a free market system could work for healthcare. Market transactions require a willing buyer and a willing seller, both of whom are in possession of all information relevant to the transaction. Equal bargaining power doesn’t describe real-world doctor-patient relationships. In that real world, insurance companies have virtually total control over the options available to those fortunate enough to have coverage.

It seems inconceivable that Ryan, et al, simply do not see the multiple fiscal and social benefits of universal–or at least expanded–access to healthcare. So what accounts for their persistent hostility to programs that have proven their effectiveness? Why are they intent upon substituting block grants for Medicaid, turning Medicare into a “voucher” system, destroying Planned Parenthood and eviscerating the ACA?

If the answer to that question is what I think it is– slashing social programs that benefit millions of Americans will allow them to subsidize the insurance and pharmaceutical industries even more generously and deliver more tax cuts to their wealthy patrons–I wonder how they sleep at night.

If There is a Hell….

Yesterday, I wondered just how venal and despicable our politicians and plutocrats will be allowed to get  before they trigger an inevitable revolt.

Rick Scott, the obscenely rich and demonstrably corrupt Governor of Florida, is evidently trying to push those limits.

The Miami Herald obtained thousands of pages of health department documents under the state’s public records law, including nearly 800 emails and hundreds of memos and reports that detailed the state’s plan to “restructure” CMS. They show that the elimination of children from CMS was the result of a plan to slash spending on sick kids at a time when Florida had a $635.4 million surplus. For the legislative session that begins next month, Gov. Rick Scott has proposed $1 billion in new tax cuts. The spending plan would eliminate an additional 718 health department positions. […]

The parents of one Palm Beach County infant learned on the eve of a critical craniofacial surgery that their 6-month-old son had been “screened out” of CMS. The little boy is profoundly disabled, records show, having been born deaf, without eyes, and with a disfiguring cleft palate. The child’s mother called CMS in preparation for the surgery, only to be told “the screening is showing ‘NO,’ so they would not do anything.”

A post at DailyKos explained the program and summed up the situation:

This program—for Medicaid-qualified children and for those whose parents make too much for Medicaid coverage but not enough for private insurance—provides more intervention with specialists and care devised for kids with special medical needs. Some of the activities of the CMS, like “providing care coordinators to help parents access therapy and medication, and organizing one-stop clinics for kids with sickle cell disease, HIV or cleft palates,” just doesn’t happen with Medicaid.

But there was too much need in the state for the program. It was getting too many enrollees and it became too expensive to treat these kids, so the state had some options. Not having $1 billion in new tax cuts was not among the options. Dropping 9,000 kids was what they settled on.

Rick Scott’s priorities. Excuse me while I take a long shower….

Dollars and Sense

This morning, I was scheduled to participate in a statehouse rally intended to urge the Governor and General Assembly to exhibit rational behavior, also known as Medicaid expansion under the Affordable Care Act. (Of course, this is Indiana, where rational political behavior can be pretty rare.)

The weather required organizers to reschedule, but I’m posting my prepared remarks, which centered on dollars and sense.

___________________

Many of us have just wished our friends and loved ones a healthy, happy and prosperous New Year. In Indiana, those are going to be elusive goals.

According to a report issued in December by the respected Kaiser Family Foundation, Indiana stands to forego17.3 billion dollars between 2013 and 2022 because we are refusing to follow the lead of surrounding states (including those governed by Republicans) and implementing the ACA’s Medicaid expansion.

Indiana is refusing to accept the federal dollars that would pay for expansion of Medicaid despite the fact that over half a million Hoosiers have lost employer-sponsored coverage since 2000, and despite the fact that Indiana has seen the nation’s largest loss of health insurance coverage for children. More than eighteen percent of Indiana children have lost coverage since 2000.

Let’s talk dollars and sense.

Under the ACA, the federal government will pay 100% of the costs of expanded Medicaid for the first three years and 90% thereafter. Expansion would actually save Hoosier taxpayers money, since some of those federal dollars would pay for services we currently provide.

Since there is no rational reason to forego billions of dollars and deny a quarter of a million Hoosiers access to affordable coverage, some Indiana officeholders have resorted to deliberately misleading their constituents. One legislator recently sent out a survey seeking “input on legislative topics”.  The Medicaid question read as follows:

 “Currently, one out of six Indiana residents is on Medicaid, or about 1.1 million Hoosiers. Medicaid makes up about 14 percent of the state’s budget. Under the Affordable Care Act (or Obamacare), Indiana can expand Medicaid to cover more uninsured Hoosiers at a projected cost to taxpayers of more than $1.4 billion by 2020. This expansion would allow one in four Indiana residents to enroll in the program. Do you support full Medicaid expansion for Indiana under Obamacare guidelines?”

The question clearly–and dishonestly–implies that Indiana taxpayers would foot the bill for expansion. (Of course, he might get an answer he doesn’t want if he explained that new federal dollars would cover the costs.)

The question we need to ask our Senators and Representatives is pretty simple: Why are you refusing to allow the federal government to pay the entire cost of expanded coverage for three years and 90% thereafter—especially when those dollars you are rejecting would create an estimated 30,000 Hoosier jobs and, according to health economists, would reduce premiums paid by those of us who do have private insurance?

The only response I’ve heard is weak and highly speculative: the federal government might stop paying the full 90% at some future time. But if the feds cut payments, we could cut services, so that excuse just doesn’t pass the smell test.

It’s hard to escape the conclusion that Indiana is leaving 17 billion dollars on the table, leaving more of our citizens uninsured, costing Hoosiers who are insured more money, and refusing to cover Indiana’s most vulnerable children simply because our governor and state legislative leaders will oppose anything and everything proposed by this President, no matter how that opposition affects the citizens they were elected to serve.

Here’s a news flash: you don’t have to like this President—and you don’t have to like the Affordable Care Act—in order to accept billions of federal dollars that will save lives and money and create jobs for the people of Indiana.

Thanks to Governor Pence’s refusal to implement  Medicaid expansion, Hoosiers will pay higher state taxes, higher health insurance premiums and higher out-of-pocket expenses. And those costs will fall most heavily on those who can least afford them.

Our politicians may be aiming at President Obama, but the people they are hurting are the Hoosiers who elected them.

 

Our Own Desert Island

Later today–between I:00 and 2:00 pm– there will be a rally at the Indiana Statehouse on behalf of the nearly 400,000 Hoosiers who find themselves marooned on Indiana–the island of the uninsured.

States surrounding us, Republican and Democrat, have opted to take advantage of the new federal incentives and expand Medicaid. Not Indiana. Our Governor has decided that political posturing trumps the health needs of Indiana citizens who work in retail, education, home health, child care and other low-wage jobs without benefits. These are the people who are caught in the middle, who are too poor to use the new exchanges but  too “rich” to qualify for Indiana’s existing medical programs.

It’s pretty obvious that refusing to expand Medicaid effectively screws over these  400,000 Hoosiers. What is less obvious–and even more maddening–is how that refusal screws over the rest of us.

  • If a state expands its Medicaid coverage, the federal government will pay 100% of the costs for the first three years and 90% thereafter. Indiana is forgoing approximately twenty-six billion dollars between now and 2020–dollars that would create an estimated 30,000 sorely needed new jobs in our state.
  • The American Academy of Actuaries says that private insurance costs will rise in non-expansion states like Indiana. Local media has reported that Hoosiers are already seeing rates higher than the rates in states that surround our “island.”
  • The federal money we are turning down would offset expenses for indigent care and prison health care that are currently being covered by Indiana taxpayers.

Medicaid expansion would save money while saving lives and improving the health of our citizens. It would provide access to preventative care to those who are currently uninsured, reducing the tab for healthcare costs overall, including those that we taxpayers are now paying.

I know you’ll all be shocked to discover that Indiana currently ranks near the bottom of all states for most health indicators. In a sane world, we would jump at the opportunity to improve Indiana’s health and its economy.

Governor Pence’s refusal to expand Medicaid has already forced significant layoffs by Indiana hospitals, which have argued forcefully–but thus far unsuccessfully–for expansion. Other states with Republican governors have done the math and decided that the good of their citizens should trump their hatred of the President.

This should be a no-brainer.

I’ll forego the obvious pun.