Tag Archives: Health Care

Myths and Legends: The Medicaid Issue in Nevada

There was a Republican politician on my television screen this morning telling me, or trying to tell me, that Medicaid was “meant for mothers, children, and those who couldn’t work…” This is outdated. Then, he tried to convince me that Medicaid was being “abused” by those who work and ‘game the system,’ while spouting platitudes about the Free Market and the Joys of Competition.  Let’s start at the very beginning.

This is the explanation of Medicaid as reported by Nevada’s Division of Health Care Financing and Policy (pdf)

“Medicaid is the nation’s main public health insurance program for people with low incomes and the single largest source of health coverage in the U.S.”

The program is meant to help people with low incomes.

“The PPACA extended coverage to many of the non-elderly uninsured people nationwide. The June 2012 Supreme Court Ruling made Medicaid expansion optional for states, and Nevada elected to join the expansion and maximize federal dollars. Effective January 1, 2014, this move broadened Medicaid eligibility to nearly all adults under age 65 with income at or below 138% of the Federal Poverty Level (FPL). At the end of SFY 2014 that meant that there were an additional 125,989 new enrollees in Nevada Medicaid, and increased expenditures of $154,816,777.00. These new expenditures are 100% federally funded.” [NV med pdf]

Medicaid expansion added those working Americans who were earning 138% of the poverty line and below, (pdf) and more specifically: (1) Those between the ages of 19 and 64 who are earning less than 138% of the FPL. (2) Pregnant women in homes earning less than 165% of the FPL. (3) Children from birth to 19 years of age in homes wherein the earnings are at or below 205% of the FPL, with a small premium required in some cases. Translated into real people with real levels of low income earned, this means a family of four would be eligible for Medicaid in Nevada if the family earnings are less than $2795 per month; for pregnant women if the earnings are at or less than $3341 per month; and families are eligible for the kids’ Check Up program if family earnings are less than $4151 per month.

If we calculate annual earnings, then monthly earnings of $2795 mean an annual income  of $33,540. At $3341 annual earnings of $40,092, and at $4151 annual income of $41,630. Nevada’s median income is $52,431 (2015). To put these numbers in perspective, the average weekly wages of a person working in a private restaurant in this state are $382, or $1528 per month ($18,336 yearly). [DETR] The average rent for a 2 bedroom apartment in Las Vegas, the obvious site for most private restaurants, is $932 per month. [RJ] In short, not only are wages not all that generous in Nevada, the benefits available for Nevada families aren’t all that generous either.

Republicans, however, strenuously oppose benefits for adults capable of working. This would make infinitely more sense IF and ONLY IF they were willing to support a living wage for all employees. One really doesn’t get to have it both ways.  Either you want a reduction in benefits that most working people can afford to purchase on their own because they have the financial resources to do so, or you want lower wages which mean that individuals and families cannot afford those things, like health insurance, and the public benefits are required to make up the difference.  However, at this point we slam into another GOP myth.

Free market competition will make health insurance affordable for everyone, even those who are working in low wage jobs.  Good luck with that. Personally, I have yet to hear anyone explain with any specificity why health insurance corporations will be flocking to Clark, Washoe, or even Esmeralda counties because there is more “free market” applied to the situation. If the insurance companies weren’t wildly excited about selling individual and family health insurance before the enaction of the ACA, why would they do so now? Unless, of course…

They could sell policies that didn’t cover all that much? That cost more for those between the ages of 50 and 64?  That didn’t cover maternity expenses? That didn’t cover preventative care? That didn’t cover drug rehabilitation and mental health services in parity with physical treatments? That only covered the items required in those states with the least consumer protections? And, even then all we have to look to is the situation in Nevada when insurance corporations were free to offer what they were pleased to call comprehensive policies.  Again, if they weren’t interested in selling a plethora of individual and family policies then why believe they would be now?

And that Free Marketeering? It doesn’t work in the health care industry:

“In a free market, goods and services are allocated through transactions based on mutual consent. No one is forced to buy from a particular supplier. No one is forced to engage in any transaction at all. In a free market, no transactions occur if a price cannot be agreed.

The medical industry exists almost entirely to serve people who have been rendered incapable of representing their own interests in an adversarial transaction. When I need health services I often need them in a way that is quite different from my desire for a good quality television or a fine automobile. As I lie unconscious under a bus, I am in no position to shop for the best provider of ambulance services at the most reasonable price. All personal volition is lost. Whatever happens next, it will not be a market transaction.” [Forbes]

The only thing I can say with any certainty is that the Republicans have little idea exactly what constitutes a Free Market, and instead are waving it like a banner crovering their underlying desire to be free from the moral requirements compelling us to be our brother’s keepers.  The range of misanthropic explications are appalling, from “we need not do anything because the poor will always be with us anyway,” to “when Jesus told us to provide for one another he only meant fellow Christians.”

The Repeal and Replace campaign is as void of humanity as it is of understanding of the reality of most family economics, and of the comprehension of what the term ‘free market’ actually means.


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Filed under Economy, Health Care, health insurance, Politics

The Not Quite So Better Way

Nevada’s two Republican representatives to the 115th Congress, Senator Dean Heller, and Representative Mark Amodei (R-NV2) are now proposing not to have town hall style sessions with constituents until they have something to say.  We might assume this applies to the threats to repeal the Affordable Care Act, without having something concrete to say to the  voters.  Representative Paul Ryan is touting the GOP “Better Way” (pdf download) as a set of talking points for Republican members of the 115th.

First, there isn’t anything really new here. It’s the same proposal a person might have downloaded last June (June 22, 2016).  The foundation is Unleashing the power of choice and competition is the best way to lower health care costs and improve quality. One way to immediately empower Americans and put them in the driver’s seat of their health care decisions is to expand consumer-driven health care. Consumer-driven health care allows individuals and families to control their utilization of health care by providing incentives to shop around. This ultimately lowers costs and increases quality.”

Problem: “Consumer-driven health care” makes for lovely free market rhetoric,  but it boils down to the same old High Deductible Health Policy/Health Savings Account proposal the GOP has rolled out since time out of mind.

“This insurance arrangement— in which a person is protected against catastrophic expenses,  can pay out-of-pocket costs using tax-free dollars, and in turn takes responsibility for day-to-day health care expenses—is an excellent option for consumers. HSAs tied to HDHPs are popular tools that lower costs and empower individuals and families. This type of coverage also helps patients understand the true cost of care, allows them to decide how much to spend, and provides them with the freedom to seek treatment at a place of their choosing.” (page 13)

This is an elegant way to tell people (1) you’re on your own; (2) that you might expect some tax credits, but the expenses are going to come immediately out of your pocket; (3) and you’ll be able to address ‘catastrophic’ illness or injury expenses out of what you’ve put into an HSA.  Good luck with that.  Health Savings Accounts are great for the healthy and wealthy, for everyone else – not so much.

Worried about those expenses out of your pocket? Well there are HRA’s on offer and more “defined benefit” possibilities.   In short, instead of having several comprehensive health care plans to choose from, a person could also ‘choose’ to be involved in HDHP/HSAs and HRAs and other privatization schemes. 

Question for Congressional Representatives:  What in this plan insures that the health care insurance will be truly comprehensive? Affordable? Affordable for those families having Nevada’s median income around $50,000 per year?

Secondly, there is still the question of what portability means in practical terms.

“…our proposal is like a health care “backpack” that provides every American access to financial support for an insurance plan chosen by the individual and can be taken with them job-to-job, home to start a small business or raise a family, and even into retirement years.”

ProblemWhat’s going to be “portable?”  If a health care plan is to be truly national, then does this mean that there will be a lowest common denominator for all health care insurance plans?  Will the plan acceptable in a state with little or no oversight and consumer protections become the national standard? And, if not, then what IS the standard supposed to be?

Another problem: What elements of a health insurance policy must be included for the plan to be acceptable?  One of the advantages of the ACA requirements is that some coverages (mental health, pregnancy, etc.) don’t apply to all consumers – however, if we start cutting out elements of comprehensive coverage where does it end?

Questions for Congressional Representatives:

(1) If a health care plan is portable across state lines, then do the consumer protections in place remain enforceable?

(2) If a health care plan is considered “junk insurance” in one state can it be enforced in another state with higher consumer standards?

Third, there’s the Medicare, Medicaid issue.

Depending on who is doing the talking from the Republican side these programs are either failed or failing.  Neither is true.  However, nothing is preventing Speaker Ryan from offering Coupon Care in place of the Medicare program, and from proposing turning the Medicaid support into a block grant program with formulaic funding.

Questions for the Congressional Representative:

(1) The ACA actually extended the viability of the Medicare program, what in the GOP plan will insure this viability is extended?

(2) If funding for Medicaid is turned into a block grant program what provisions in your plan would prevent this funding from being cut?

Senator Heller and Representative Amodei may be waiting for the GOP to come up with a rational and comprehensive plan to replace the ACA and Patient’s Bill of Rights – I’d advise them not to withhold breathing.  Or, if they are assuming there’s nothing on offer from the GOP side since June 2016 – sort of a budget without numbers in health care terms – they may never have to have anything to say to their constituents. 

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Filed under Amodei, Health Care, Heath Insurance, Heller, Nevada politics, Politics

St. Paul (Laxalt) and the ACA: NV joins anti-choice case

birth control pills Heaven help us. Paul Laxalt, Attorney General of the State of Nevada, has proudly announced he’s filed an amicus brief in the U.S. Supreme Court in Little Sisters of the Poor v. Burwell

“Little Sisters of the Poor is an organization of Roman Catholic women dedicated to serving the poor. The Little Sisters and co-petitioners sued the U.S. Department of Health and Human Services in response to the Affordable Care Act’s contraceptive mandate. The mandate requires religious nonprofits such as the Little Sisters to provide employees with all available forms of contraception at no cost. Facing hefty fines for non-compliance, a number of these groups have sought U.S. Supreme Court review of their case.

    “Religious organizations serve our communities in countless ways, and their contributions should be supported, not impeded by the government,” said Laxalt. “These organizations should not be fined for living in accordance with their sincerely held religious convictions. This brief encourages the Supreme Court to take the necessary steps toward ensuring that our government and our courts do not force people of faith to violate their religious beliefs.” [Laxalt]

    Here’s what he’s jumping into:

    “On July 14, 2014, the 10th Circuit Court of Appeals issued a decision denying the Little Sisters of the Poor and other religiously affiliated nonprofits’ request for a stay. The Court found: “The accommodation relieves Plaintiffs from complying with the Mandate and guarantees they will not have to provide, pay for, or facilitate contraceptive coverage. Plaintiffs do not “trigger” or otherwise cause contraceptive coverage because federal law, not the act of opting out, entitles plan participants and beneficiaries to coverage. Although Plaintiffs allege the administrative tasks required to opt out of the Mandate make them complicit in the overall delivery scheme, opting out instead relieves them from complicity. Furthermore, these de minimis administrative tasks do not substantially burden religious exercise for the purposes of RFRA.” In July 2015, the plaintiffs appealed this case to the Supreme Court.” [KFF.org]

    In short, the Little Sisters have a Church Plan. The Church Plan doesn’t cover contraception. This is accommodated under the exemptions to the Affordable Care Act.  Their plan does not have to “provide, pay for or otherwise facilitate contraceptive coverage.”  What’s the question?  They can opt out of the ACA provisions – but, they argue the mere act of opting out makes them “party to the scheme?”

    This gets even better – because entangled in the case is the question of whether or not the Little Sisters of the Poor (or the Christian Brothers) can prevent their employees from getting insurance covering contraception from a third party. [AU]

    The Kaiser Foundation offers this handy chart on the exemptions from the provisions of the Affordable Care Act:

    Religious Freedom Court Chart

    Thus far the provisions of the ACA have been upheld. Contrary to the anti-contraceptionists, the courts have held that the law doesn’t unduly burden anyone, and they can opt out by requesting an exemption. Period. Of course, that didn’t prevent the Little Sisters from availing themselves of the funding and efforts of the arch-conservative Becket Fund.

    Making this entire case even more incredible is the fact that as of August 2014, the government provided a second accommodation for religious non-profit organizations which as of that date only needed to “write a letter to the government in order to be relieved of any obligation to provide contraceptive coverage.” [AU]  A letter.  One single letter.

    So that an exempt religious organization doesn’t have to write one single, one paragraph letter,  the Attorney General of the state of Nevada signed on to an exceptionally spurious, often downright illogical amicus brief with his fellow Tea Party, Radical Right, Ultra-Right Wing anti-contraception amigos.

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    Filed under Health Care, health insurance, nevada health, Nevada politics, Women's Issues, Womens' Rights

    The Problem with Socialism

    Economic Theory BookThe critics of the Affordable Care Act are relentless in their characterization of the law as “socialist.”  And, socialism, of course means the End of America! The death spiral of the Nation! Or at the very least the ultimate diminution of our Freedom and Liberty.   The problem with all this palaver is that socialism is one of those amorphous intellectual creatures which comes in at least as many flavors as might be manufactured by an upscale ice cream factory.

    Econ 101

    For the sake of those who get their information from chain e-mails let’s start out as simply as possible.   There are three basic economic activities: (1) The production of goods and services; (2) The distribution of goods and services; and (3) The exchange of goods and services.   Production includes growing, mining, manufacturing, or providing goods and services. Distribution in a material sense concerns the transport or shipping of goods, or the provision of off site services.  Speaking more theoretically, distribution refers to the way in which total output (or income or wealth) is distributed among individuals or among the the “Factors of Production,” i.e. land, labor and capital.  Exchange means exactly what it sounds like — a rational exchange is the act  in which the product or service is transferred to a consumer for compensation.

    Econ 101a

    Now for the benefit of those who get their infotainment from Faux News, we might want to get a bit more nuanced.

    If we take the simplest definition of socialism we would describe it as an economic system in which there is collective ownership of the means of production and co-operative management of the economy.  At this point things start getting fuzzy.  What might a person mean by “collective ownership?”   Here come the first different flavors.

    If by using the terms collective or social ownership do we mean cooperatives? For example, is a farmer’s market, owned and operated by its members with the profits shared by those members, a socialist economic enterprise?  Is it “common ownership?”  In this format the enterprise’s assets are owned by individual members in common.  At the other end of the spectrum socialism might be defined by state ownership.

    Once we’ve figured out what definition of social ownership is being applied, it’s time to tackle what might be meant by “co-operative management.”

    Econ 101b

    Since we’re speaking in very broad terms let’s generalize the “co-operative management” into the concept of a mixed economy.  Now things get sticky.

    “There is not one single definition for a mixed economy, but the definitions always involve a degree of private economic freedom mixed with a degree of government regulation of markets. The relative strength or weakness of each component in the national economy can vary greatly between countries. For some states, there is not a consensus on whether they are capitalist, socialist, or mixed economies.” [PrincetonEdu]

    This explication is just about broad enough to include every national economy on the planet.   A person could be talking about an economy in which the means of production, distribution, and exchange are almost completely nationalized, to an economy in which there is precious little regulation of economic activities.  To an extreme “social libertarian” of the classic archetype ANY regulation which infringes on free association and free exchange would be on the socialist side of the spectrum of mixed economies.

    It’s difficult to determine what some people might mean when they are telling us “Obamacare is Socialist,” but the charge does tell us where they are on the range of definitions of a mixed economy.  If the facilitation of the purchase of health insurance policies from private health care corporations is “socialist” then the person is informing us that he or she believes government should not interfere in any way with the production, distribution, or exchange of goods and services — even if the “interference” is intended to encourage participation in the market for private health care policies.

    Political Science 101

    There’s always another possibility — that the individual slapping the socialist label on various and sundry ideas, be they regulatory or promotional, is merely parroting talking points on offer from political leaders and opinion manufacturers.  At this point some obvious logical inconsistencies emerge.

    One cannot logically be in favor of “pro-business” policies which seek to promote business by means of trade representation, start up financing for entrepreneurs, or the compilation of consumer statistics, while at the same time proposing that government has no “right” to interfere with such things as child labor.  Like lunches, there really is no such thing as a completely free market in the real world.

    I am not free to manufacture highly flammable pajamas for infants. I cannot hire 10 year old boys to sort coal from slate in my mine.   I am not free to  use floor sweepings in the production of my sausage.   There are some topics in which there is a general acceptance that public safety, health, and welfare must not be sacrificed on the altar of a completely free market unrestrained by anything but the tragic consequences of avarice.   The result? A mixed economy.

    Of course, there’s always another explanation — The one which proposes that extremely low information individuals, who rigidly adhere to simplified talking points fed to them by other individuals who have “skin in the game,” apply the socialist label to anything they are told not to like?”

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    Filed under Economy, Politics

    Nevada’s Mental Health Services: Choose between safety and services?

    Nevada Legislature BuildingInteresting thing:  There are politicians among us who never tire of telling their audiences how important it is to Cut Taxes.  How important it is to curb government spending. How important it is to put more ‘bureaucrats’ off the public trough and out to pasture.  Until reality kicks in.

    So Nevada pared its budgets down, and left positions unfilled in various parts of government… until the Sacramento Bee published this on page A1, April 14, 2013:

    “In recent years, as Nevada has slashed funding for mental health services, the number of mentally ill patients being bused out of southern Nevada has steadily risen, growing 66 percent from 2009 to 2012. During that same period, the hospital has dispersed those patients to an ever-increasing number of states.

    By last year, Rawson-Neal bused out patients at a pace of well over one per day, shipping nearly 400 patients to a total of 176 cities and 45 states across the nation.”

    At this point the glossy generalizations met the unburnished realities of providing public health services.   What might we have expected when in 2009 Nevada allocated $226 million for mental health care services and in 2011 $186.8.  A cut of  $39.2 million, or 17.3%?  [NAMI pdf]   This might have been understandable if the number of people seeking mental health care services and treatment had been reduced.  It wasn’t.

    There were 2,997 people treated in Nevada hospitals for mental illness in 2007, in 2009 there were 3,103 receiving hospital mental health treatment. [NAMI pdf]   In short, we knew — before the 2011 budget was developed — that we were treating an increasing number of patients.

    We knew, or should have known, that in 2007 some 28,513 Nevadans were treated by the State Mental Health Authority in its several forms. By 2009 that number increased to 32,035, an addition of 3,522.  [NAMI pdf]  The number of individuals needing treatment went up, while our budget allocations went down.

    If we were waiting for the federal reinforcements to show up in the form of federal funding — don’t restrain the breathing:

    “The House and Senate have pieced together two distinctly different Labor, Health and Human Services (HHS) and Education FY 2013 Appropriations bills. The House version (no bill number yet) would gut funding for public health agencies, including a whopping 10 percent cut to the Substance Abuse and Mental Health Services Administration (SAMHSA) – a crippling, irreversible cut that would take years to recover. Whereas, the Senate version (S. 3295) provides a funding increase of $20 million each for both the Mental Health Block Grant and the Substance Abuse Block Grant, as well as a $100 million increase for the National Institutes of Health.” [MHA]

    On August 6, 2013 the Nevada Legislature’s Interim Finance Committee authorized $2.1 million in emergency funding to address problems at the Rawson-Neal facility.  However, the financial juggling act was on stage yet again:

    “Lawmakers tabled a second proposal to renovate an old psychiatric hospital in Las Vegas to relieve Rawson-Neal and Lake’s Crossing for consideration later this month. Legislators worried that approving the proposed renovation would divert $3 million in funds now earmarked for other Lake’s Crossing projects deemed critical for patient safety.” [LVRJ]

    There was a reason for that decision. The meeting materials (pdf) explain the expenditures for the Lake’s Crossing facility were to upgrade the fire alarm system, the sprinklers, replace or repair metal doors, the upgrading of smoke barriers and safe walls, and the upgrading of exit lighting.   In simpler terms, the Interim Finance Committee was called upon to juggle the necessity of ameliorating the conditions which created the “patient dumping” solution at Rawson-Neal with the necessity of fixing the “fire trap” situation for patients and staff at the northern Nevada facility.   This is not a decision which should be faced by anyone.  One Assemblywoman summed up the morass:

    “It’s going to take a whole evaluation of the system” to get Rawson-Neal back on track, said Assemblywoman Maggie Carlton, D-Las Vegas. If the state wants a good mental health system, then it has to pay for a good mental health system, she added. [LVRJ]

    It’s going to take an evaluation of the entire system, and the funding thereof, in order to satisfy investigations and actions from several directions.  First, the federal government:

    “The U.S. Health and Human Services Department agency warned the hospital in April that it was in violation of Medicare rules governing discharge of patients and gave the facility until May 6 to come up with a remedy.

    “We’ll continue to inspect the hospital until we’re convinced that it’s in full compliance with Medicare rules that protect the health and safety of patients,” said Jack Cheevers, spokesman for the Medicare and Medicaid Centers. “If the hospital fails to comply, it could lose its federal funding.” [KELO May 24’13]

    Next, the city of San Francisco, which totaled up the costs for dealing with 500 patients dumped in California, 24 of whom ended up in San Francisco.  City Attorney warned what was to come:

    Herrera wrote that San Francisco has spent nearly $500,000 on medical care and housing for those patients, all of whom were homeless and suffering from mental illnesses.

    He wrote that the busing practices were “inhumane and unacceptable,” noting that they were allegedly transported without escorts, without adequate medication or food and without arrangements for someone to receive them at their destination. [SFAppeal]

    By September 10, 2013 Herrara made good on his promised litigation:

    “San Francisco City Attorney Dennis Herrera today filed a class action against the State of Nevada on behalf of California local governments to which indigent patients were improperly bused from the state-run Rawson-Neal Hospital in Las Vegas.  The lawsuit filed in San Francisco Superior Court this morning seeks a court-ordered injunction barring Nevada from similar patient discharge practices in the future, and reimbursement for San Francisco’s costs to provide care to the patients bused there.” [SFBJ]

    Nevada pushed back in correspondence from the Attorney General’s office indicating that Herrara’s suit lacked sufficient evidence to substantiate the claims, and did not specify how the 20 patients were identified. [LVRJ]

    Dumped patients form a third element reacting to the practices at Rawson-Neal.

    “The complaint filed Tuesday in U.S. District Court in Las Vegas seeks class-action status for Brown and as many as 1,500 people his lawyers claim were bused since 2008 from Nevada to almost every state in the U.S.

    Brown is the only named plaintiff. The lawsuit that makes nine claims, including negligence and breach of fiduciary duty. It seeks an immediate court order to stop Nevada from sending psychiatric patients out of state, unspecified damages for Brown and others, and a declaration that patients’ civil rights were violated. […] Defendants are six state agencies including the Nevada Department of Health and Human Services, the Division of Mental Health and Development Services and the Bureau of Health Care Quality and Compliance, plus eight individual hospital and state agency administrators.” [KTVU, June 24’13]

    What did we get for our parsimony with funds for mental health care services?  More stringent federal oversight, litigation from the patients, and more litigation from California — the site of many “deposited” patients.

    What we have not gotten is a full evaluation of the adequacy, much less the quality, of our mental health and substance abuse treatment in Nevada.   And, what we have not yet achieved is a system in which we adequately address the numbers of adults and children in the Silver State who are in need of mental health or substance abuse treatment — we know the number who are in waiting for treatment in the community (see the working papers from IFC), we know the numbers in Emergency Rooms, but do we have a firm grip on the numbers who need assistance and find it unavailable on a timely basis?

    What we have not gotten is a system in which we don’t have to choose between understaffed services in one region and unsafe conditions for patients and staff in another.

    Assemblywoman Carlton is correct — we will get what we are willing to pay for.

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    Filed under Health Care, nevada health, Nevada politics