Tag Archives: Medicaid funding

It’s A National Emergency, we think…

Since his attempt to revive Nancy Reagan’s “Just Say No” campaign in the face of a crisis in the increased addiction to opioid drugs in this country fell flat,  Dear Leader appeared to suggest the problem is a matter of law enforcement — a major mistake.  The genesis of the issue comes from the over-prescribing and over use of opioid medication once advertised as “virtually addiction free.”  Indeed, Purdue Pharma is still facing litigation from the state of New Hampshire over its advertising of Oxycontin. This, in addition to the 2007 guilty plea from the corporation for mislabeling the drug, and the payment of  $634.5 million to resolve a DoJ investigation.  Meanwhile, Nevada holds its unfortunate position in the top ten states when counting opioid death rates.  There were 224 overdose deaths in 2014, another 259 in 2015 [CDC] related to natural and semi-synthetic opioids; Nevada’s statistics were more bleak citing some 465 opioid related deaths in 2015.

Since we probably can’t arrest our way out of this mess, in Nevada or anywhere else, the answer in the long run is prevention (better guidance for physicians and tracking, combined with better public education on the nature of opioid addiction) and treatment.  And, for treatment, people have to have a way to afford it.

Medicaid has been a Godsend for many suffering through an opioid addiction.

“The authors of the report (Urban Institute) draw a parallel between the Affordable Care Act’s Medicaid expansion and spending on addiction medications, saying it has brought addiction treatment to previously underserved populations.

“What we saw was this gigantic, rapid, ongoing expansion in treatment,” says co-author Lisa Clemans-Cope. “It was particularly fast after 2014 when the big Medicaid expansion came into play. There’s definitely an effect of people getting access to treatment. That’s the primary driver of growth of spending.”

So, Medicaid spent more on treatment after 2014 – because more people were in a position to afford the treatment programs available to them.  Therefore, the next time a Republican politician stands before us with plans to slash Medicaid spending, and turn the Medicaid program into a block grant lottery for the states, we might well ask:  What does your proposal do to assist the states, like Nevada, deal with the treatment expenses of individuals trying to cope with opioid addiction and who are seeking assistance to make that treatment affordable.

Gee, the states are supposed to “benefit” from greater flexibility?  Would that be the flexibility to choose between supporting special education children with speech and physical therapy and opiate addicts?  Or choosing between the needs of the families of opiate addicts and the severely disabled?  Or choosing between the needs of opiate addicts seeking treatment and women seeking mammograms and other cancer screenings?  Santa doesn’t come without some expense.

Somehow the Republicans have managed to entangle themselves in their own rhetoric.  We can cut taxes, expand the military, all by cutting social safety net programs, and still have money for fighting opioid addiction in this country!  Santa will bring us tax cuts and another Santa will keep Granny in the skilled nursing facility, help cousin Elwood find a job in a new industry, make sure the family can get immunizations, cancer screenings, treatment for acute and chronic medical conditions, and insure that the Interstate Highway System is continually maintained.

It’s Jude Wanniski’s Two Santa Theory — a position only definable as something coming from an opiate induced delusion:

“Unfortunately, Mr. Wanniski opened Pandora’s box when he let loose the two-Santa theory. Republicans are now bound to it, whether they know it or not. As Keynes once put it, “Madmen in authority, who hear voices in the air, are distilling their frenzy from some academic scribbler of a few years back.”

**For more information: See the following excellent articles in the Nevada Independent — “Another side of the opioid heroin crisis,” “For Many Governors…” “As Out of Control opioid epidemic rages..”

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Filed under Economy, health insurance, Medicaid, nevada health, Nevada politics, Politics

Republican YOYO Home Economics: Medicaid Slashed, Other Support Burned

Former President Clinton advised the delegates to the 2012 Democratic Convention to listen carefully to what the Republicans were offering in regard to Medicaid, and those of us in Nevada should be “listening with both ears.”  Here’s the description of the Medicaid program as stated by the Nevada Department of Health and Human Services, the program:

“Provides health care coverage for many people including low income families with children whose family income is at or below 133% percent of poverty, Supplemental Security Income (SSI) recipients, certain Medicare beneficiaries, and recipients of adoption assistance, foster care and some children aging out of foster care. The DHCFP also operates five Home or Community-Based Services waivers offered to certain persons throughout the state. The Division of Welfare and Supportive Services (DWSS) determines eligibility for the Medicaid program.”

Listing those categories focuses on the aims of the program — it is to serve (1) low income families with children; (2) elderly Nevadans; (3) low income Nevadans over 65 years of age; (4) families receiving assistance for adopted children; (5) children in foster care.  Who was enrolled in Nevada’s Medicaid program as of fiscal year 2009:

What services were provided to those enrolled in Nevada’s Medicaid program?

During fiscal year 2010, 68.1% of the spending from the Medicaid program went for acute care, 25.6% was allocated for long term care, and 6.3% was used for “disproportionate care – hospital payments.”

The spending for long term care breaks down as illustrated in the following chart:

11.1% of the long term care funding was allocated to facilities for the intellectually disabled, 2.9% went to services for the mentally ill — and notice — 86% was used to provide home health & personal care, and nursing facility care.  In other words, 86% of Nevada’s Medicaid expenses for long term care went toward serving those least able to care for themselves.  The other 14% was used to provide intermediate and long term care for those unable to care for themselves because of intellectual limits or mental illness.

Here is exactly why President Clinton told his audience to “listen up:”

My view is get the federal government out of Medicaid, get it out of health care. Return it to the states.” – Romney, South Carolina GOP Primary Debate, Jan. 20, 2012.

In case anyone is remotely confused about what that statement from the former Massachusetts Governor means, he’s speaking about transforming the Medicaid program into Block Grants.

More specifically, the former Governor is adopting the block grant proposal for Medicaid set forth in his running mate’s “Path to Prosperity” budget plan:

“The plan also would repeal health system reform law provisions that will expand Medicaid coverage starting in 2014. Instead, states would receive block grants, which would free states “to tailor their Medicaid programs to the unique needs of their own populations,” the budget says.”  [AMA]

The tailoring is to be done with less cloth:

The Ryan budget would cut $2.4 trillion from Medicaid and other health programs. Reduced spending would increase the number of uninsured dramatically, Park* said. “Those who retain coverage will have benefits scaled back and have higher cost-sharing.” [AMA] (emphasis added)

We can drill down further into what Governor Romney and Representative Ryan have in mind for the Medicaid program by looking at the Congressional Budget Office’s analysis of the Ryan position:  Medicaid and the Children’s Health Insurance Program (CHIP)—from 2 percent of GDP in 2011 to 1¼ percent in 2030 and 1 percent in 2050.

Now is the moment to recall that 58% of those who receive Medicaid assistance for their health care needs in Nevada are children, and the AAP isn’t thrilled at cuts to that constituency:

“American Academy of Pediatrics President Robert W. Block, MD, said the proposal would undo investments in health programs for children. More than half of Medicaid recipients are children, but their care accounts for up to only one-quarter of the program’s costs.

“Whether considering fiscal year 2013 federal spending bills or reviewing long-term budget proposals, Congress must seize this opportunity to invest in the future of our country by protecting children’s health,” Dr. Block said.” [AMA]

Dr. Block has reason to be concerned, if we return to the Congressional Budget Office’s analysis we can see why.  In two paragraphs from their analysis of the Ryan “Path” the non-partisan office explains why the proposal would make deep cuts, and place greater burdens on the states:

“The specified path (Ryan Plan) would cause federal spending on Medicaid and CHIP to decline relative to GDP in coming decades, rather than to rise sharply as in the other policy scenarios that CBO has analyzed, and would include no exchange subsidies (see Figure 3). As a result, by 2050, such spending would be 76 percent below what would occur for Medicaid, CHIP, and exchange subsidies under the baseline scenario and 78 percent below what would occur under the alternative fiscal scenario. Because spending on CHIP and exchange subsidies represents a relatively small share of the amounts in the baseline and alternative fiscal scenarios, most of the reduction would have to come from the Medicaid program.” [CBO] (emphasis added)

The Republicans do, indeed seem serious about eliminating Medicaid as a federal program and shifting the expenses for health care access to low income elderly, the disabled, the intellectually disabled, elders in nursing facilities, and children in poverty to the states.  The CBO explains the nature of this shift:

The responses of the states would be of particular importance. If states were given additional flexibility to allocate federal funds for Medicaid and CHIP according to their own priorities, they might be able to improve the efficiency of those programs in delivering health care to low-income populations. Nevertheless, even with significant efficiency gains, the magnitude of the reduction in spending relative to such spending in the other scenarios means that states would need to increase their spending on these programs, make considerable cutbacks in them, or both. Cutbacks might involve reduced eligibility for Medicaid and CHIP, coverage of fewer services, lower payments to providers, or increased cost-sharing by beneficiaries—all of which would reduce access to care. (emphasis added)

Translation: Even if the states were able to achieve all the vaunted efficiencies a “flexible” plan might provide — the cuts proposed are so deep and so drastic that citizens in the United States who are lower income elderly or the disabled in nursing homes, and those who are low income and living in foster care, or families in poverty — would have reduced access to care. Period.

These aren’t generic numbers and pie in the sky statistics we’re talking about, we’re speaking of 25,841 elderly Nevadans, 40,898 disabled Nevadans, 55,626 adult Nevadans – mostly women, and 168,070 Nevada children.

So, here’s a question for Governor Romney and Representative Ryan — If no matter how much efficiency the state of Nevada squeezes from your block grants for Medicaid, Nevada and the other states will still have to either appropriate significantly more revenue, or drastically reduce services — how is your plan anything other than a proposal to shift the burden of health care costs, for the least able among us, from the federal treasury to the state treasuries and the pockets of low income Americans?

Where, Governor Romney and Representative Ryan, does the Nevada Legislature start cutting? From the acute care services for adopted or foster children? From the acute care for pregnant women? From acute care for children in poverty who have asthma, autism, broken arms, or sprained ligaments?  From the long term care for the elderly who need home health care services and personal care to avoid institutional living?  From the long term care for the indigent mentally ill?  From elderly residents of nursing facilities?  From disabled children who need home health care? Where?

Perhaps cuts aren’t the only option. Must the Nevada government raise the eligibility standards such that only those living at “25%” of the official federal poverty level can receive assistance?  Here are the 2012 guidelines from the Department of Health and Human Services —

How much more should a family of four living on $1,920.83 per month  have to pay for basic health care?  How much more should a young man and his pregnant wife living on $1,260.83 per month have to pay for pre-natal care, and expenses associated with the birth of their first child?  For a political party which lauds its “Pro-Life” stance — asking low income families to dig deeper to pay for health care to make up for federal and state budget issues (while proposing more tax cuts for the top 1% of American income earners), makes it sound as though the GOP is the Pro-Birth, not Pro-Life party.

How much more should a young family have to pay for health care before the cost of health care begins to impinge on the capacity to put a roof over their heads?

Or their ability to put food on the table?  It’s likely going to cost our young family with two children under the ages of 19 approximately $366.40 to $578.40 per month to keep everyone fed. [USDA] Our hypothetical family might be lucky to have $764.43 per month remaining after housing and food for utilities, clothing, transportation costs (auto payments or bus fare) — that $764.43 translates to about $25.48 per day to cover ALL the basic family needs listed previously… including Health Care.  But wait, the Romney/Ryan budget cuts nutrition assistance too, drawing fire from the U.S. Conference of Catholic Bishops:

“Cuts to nutrition programs such as the Supplemental Nutrition Assistance Program (SNAP) will hurt hungry children, poor families, vulnerable seniors and workers who cannot find employment. These cuts are unjustified and wrong.” [The Hill]

And what other program do the Republicans fantasize about turning into a Block Grant Program and then cutting?  Housing subsidies. [TO.org]  There was some discussion of the Ryan proposal on this topic at the March 21, 2012 House Budget Committee hearing:

“Rep. David Price (D-NC) asked Donovan what the implication of the Ryan budget cuts would be on HUD programs such as public housing, Choice Neighborhoods, HOME and others.  Donovan responded that, under the proposed Ryan budget, approximately one million households could lose their housing.  Of the one million households at risk under the Ryan budget, Donovan estimated that 585 thousand would come from the Housing Choice Voucher Program, 425 thousand from the Project-Based Voucher Program, and 110-180 thousand from homeless assistance programs.  He also mentioned that an estimated 17 thousand jobs would be lost from CDBG, and cuts to the HOME program would mean tens of thousands of new affordable housing units would not be built.”  [CLPHA] (emphasis added)

So, no help for financially fragile families for health care, or housing, or food — or anything, but tax payers in the top 1% of all our income brackets will get more, yet more generous, tax breaks.  Little wonder the Bishops were annoyed.  Less wonder Sister Simone Campbell from Nuns on the Bus received a standing ovation at the Democratic National Convention.

A person doesn’t have to be Roman Catholic to find the Republican proposals supported by Governor Romney and created by Representative Ryan astonishing in their parsimony and appalling in their avarice.

Perhaps one has to be incited by the fact that a family in Las Vegas might have an air-conditioner, or a DVD player, or a functional motor vehicle — “Look,” cry the miserly, “They have nice stuff, and they got it by doing nothing.” Not. So. Fast.   As of 2010 not that many Nevadans were receiving public  assistance. [Census] In fact, about 3% of Nevadans were receiving public assistance. [Census pdf]

Thus much for the Miserly Myth that “They’re all sitting around collecting welfare, and learning to be dependent on Guv’mint.”  Perhaps we should add the usual follow up, “and they’re doing it on my hard earned tax dollars.”  The latter portion is correct, we do pay taxes which support assistance programs for fragile families.  However, the Grinches among us appear to believe they are the only ones chipping in.

S’cuse me Mr. Grinch, but I really don’t mind paying a fractional portion of my income to insure NO child goes to bed hungry, NO elderly person with dementia is left alone, NO foster child is left with an untreated case of pneumonia, NO pregnant woman is without pre-natal care, NO family is homeless, NO mentally ill person is abandoned, NO disabled child is without care.

This is what Democrats mean when we say, “Just Say No.”

References and Resources:  * Edwin Park, CBPP.  Congressional Budget Office, Ryan’s Specified Paths, March 2012. (pdf) “House Republican Budget Seeks to Slow Medicare, Slash Medicaid,” American Medical Association, April 2, 2012.   Kaiser Family Foundation, State Health Facts, Database.  “Public Assistance Relief,” Census, Department of Commerce, pdf.  “HUD Secretary Defends FY13 Budget Before House Appropriators,” CLHPA.   “Four Ways Romney and Ryan Would Roll Back the 20th Century ,” Jake Blumgart, AlterNet, September 5, 2012.  “What Paul Ryan’s Budget Actually Cuts,” Brad Plumer, Washington Post, August 12, 2012.  USDA, Cost of Food Plans, Center for Nutrition Policy and Promotion, May 2011 (pdf).  ASPE, Department of Health and Human Services, HHS Poverty Guidelines 2012. Congressional Budget Office, “The Long-Term Budgetary Impact of Paths for Federal Revenues and Spending Specified by Chairman Ryan,” March 2012, pdf.   Kaiser Family Foundation, link to interactive database for state health care statistics.

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Filed under 2012 election, Economy, family issues, Health Care, health insurance, Medicaid, Nevada budget, Nevada child welfare, nevada health, Nevada politics, Politics, public health, Republicans, Romney

A Romney-Obama White Board on Medicaid

Read More (and references)  Republican Medicaid Plan, New York Times.   Obamacare Medicaid Expansion, Washington Post.  GOP plan transforms Medicaid, NJ.Com.

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Filed under 2012 election, Health Care, health insurance, Medicaid, Republicans, Romney

Bedeviling Daniel Webster: The American Community Survey

Very little in this world better illustrates the fevered world of the Tea Party GOP than Rep. Daniel Webster’s (R-FL) assault on the Census Bureau, and specifically on the American Community Survey.   Webster was joined by Nevada Representatives Heck (R-NV3) and Amodei (R-NV2).  [May 9, roll call 232] In fact, the House Republicans passed an amendment to H.R. 5326 to prohibit funding for the Census Bureau’s American Community Survey because it’s “unconstitutional and intrusive.”

“This is a program that intrudes on people’s lives, just like the Environmental Protection Agency or the bank regulators,” said Daniel Webster, a first-term Republican congressman from Florida who sponsored the relevant legislation.”

“We’re spending $70 per person to fill this out. That’s just not cost effective,” he continued, “especially since in the end this is not a scientific survey. It’s a random survey.” [NYT]

There are both public and private sector reasons why this just might qualify as the Dumbest Vote of the Session.

Structurally Deficient: First, we might think that a Representative such as Webster with a degree in engineering may have taken enough math classes somewhere along the way to comprehend the structure of a random survey.  We could also surmise that Representative Webster and his cohorts Amodei and Heck have utilized ‘random sample surveys’ during their political campaigns.  A properly structured random sampling IS scientific.

Governmental Incomprehensibility:  Secondly, the ACS is used to determine how approximately $400 billion in federal funding is distributed to states and local governments.

In FY2008, 184 federal domestic assistance programs used ACS-related datasets to help guide the distribution of $416 billion, 29 percent of all federal assistance. ACS-guided grants accounted for $389.2 billion, 69 percent of all federal grant funding.

Medicaid alone accounts for 63 percent of ACS-guided funding. In general, ACS-guided funding is highly concentrated in a small number of programs, recipients (states), departments, and budget functions.

The ACS facilitates the distribution of federal assistance largely by serving as the basis for six other federal datasets. Most important of these are the Bureau of Economic Analysis’ per capita income series and the Census Bureau’s population estimates. The ACS itself is directly used to guide the distribution of about a fifth of the $416 billion in assistance.

State per capita ACS-guided funding is positively related to income inequality (high annual pay, high poverty), Medicaid income limits, and the percent of the population that is rural. The higher any of these measures, the higher per capita funding tends to be.  [Brookings]

Hey, here’s a way to eliminate Medicaid and other federal programs! Just make it impossible to calculate how the federal funds should be distributed…  So how much funding should Nevada’s Medicaid program for those in poverty receive?  Who would know?   How many Nevada schools are eligible for funding to provide for at-risk students? Who would know? How should funding for law enforcement efforts at curtailing methamphetamine use be distributed?  Who would know, because law enforcement agencies rely on datasets from the ACS to make predictive calculations.

And, if Representatives Webster, Heck, and Amodei had their way no one could find out how any of the medical care, education, or law enforcement funds should be allocated, including the people who were tasked with distributing them.

Knocking the props out from under the private sector:   There are some private data firms that provide demographic information for advertising and marketing purposes, but none so far have the capacity — or perhaps the interest — in developing data which is national in scope and comprehensive in nature.  Private data is expensive.  There are also important instances in which private data collection is predicated on parameters established by government datasets.   Where to locate a store? A factory? A Telemarketing office? These, and similar questions can be answered in no small part by information from the ACS. [Census]

Little wonder the U.S. Chamber of Commerce, the National Retail Federation, and the National Association of Home Builders are “up in arms” over this House folly. [NYT]

The Chamber was opposed to the Lankford-Webster amendment because as their spokesperson said:

“The Chamber of Commerce, for example, strongly advocates funding them, since its members rely so much on the information they provide on basic things such as household spending, per capita income, and population estimates. The ACS is of particular value to them, says Martin Regalia, Commerce’s chief economist. “It is especially important to some of our bigger members for trying to understand geographic distinctions and other granularity in the economy.” [BusinessWeek]

Business economists weren’t thrilled with the deletion of funding for the ACS either:

” Tom Beers, executive director of the National Association of Business Economists, says that without good economic data, businesses would be “flying blind.” He adds: “You end up in a guessing game about what’s going on in the economy. The types of losses that result are far worse than what you end up spending to fund these surveys.” [BusinessWeek]

Economic Idiocy:   We need economic information even when the news isn’t good — especially when the news isn’t good, as one data analysis CEO explained:

“Knowing what’s happening in our economy is so desperately important to keeping our economy functioning smoothly,” said Maurine Haver, the chief executive and founder of Haver Analytics, a data analysis company. “The reason the Great Recession did not become another Great Depression is because of the more current economic data we have today that we didn’t have in the 1930s.”

She added that having good data about the state of the economy was one of America’s primary competitive advantages. “The Chinese are probably watching all this with glee,” she said, noting that the Chinese government has also opted not to publish economic data on occasion, generally when the news wasn’t good.”  [NYT]

There seems to be at least one point at which conservative think tanks like the Cato Institute and the AEI agree with their liberal counterparts — we can’t Fly Blind.

“… economists at conservative think tanks Cato Institute, American Enterprise Institute, and the Heritage Foundation all expressed support for the data-gathering agencies since all three rely heavily on the statistics they produce to study the economy. “Those agencies are essential,” says Phillip Swagel, an economist and nonresident scholar at AEI. “The data they provide really tell us what’s going on in the economy. This shouldn’t be a political issue.”  [BusinessWeek]

It shouldn’t have been a political issue but it was.  Worse still the arguments in favor of de-funding the American Community Survey were grounded in ideological fervor rather than on principles of  rational economics and governance.  Webster implored, “What really promotes business in this country is liberty,” he said, “not demand for information.” [NYT] Huh?

How is a business helped when it cannot get accurate data on the location of potential workers? On the best placement of a retail store based on the demographic trends in a given region?  On the likelihood that particular areas have more growth potential than others?  How is a business to know when and how to market its products or cater to the tastes of various demographic communities if there is no trustworthy data available? Extrapolating Webster’s assertion to its conclusion we’d have to conjecture that by his lights a business should be “free” to blunder about blindly as it tries to plan for its future.

But then, “There are none so blind as those who will not see.”  Perhaps Representatives Heck and Amodei would care to explain to Nevada’s educational, law enforcement, medical, and business communities why they voted to de-fund the ACS?  Representative Berkley (D-NV1) need make no such amends, she had the good sense to vote against the Willful Blindness Amendment.

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Filed under Amodei, Berkley, Heck, House of Representatives, Medicaid, Politics, Republicans