Tag Archives: Medicaid

Incentives? What’s good for Geese and Ganders: Medicaid Work Requirements

We can rest assured the Nevada Policy Research Institute (aka Koch Bros) will be staunchly defending the notion that poor or working Nevadans are so debauched that any form of financial support will cause them to head for the couch and the TV remote, witness their position on work requirements for Medicaid recipients:

“Medicaid is supposed to provide a safety net for those who are unable to help themselves — an admirable goal,” said NPRI policy analyst Daniel Honchariw. “Unfortunately, as the system currently works, it actually encourages many able-bodied adults to stay out of the workforce. As a result, the program isn’t just draining public finances, it’s eroding the self-sufficiency of those it’s purportedly supposed to be trying to help.”  [h/t Nevada Independent]

Dear Lord, I’d hate draining away anyone’s “self sufficiency.”  However, I’m not prone to illusions about innumerable people who for reasons beyond comprehension prefer “getting welfare” to having a job.  But Wait!  Nationally, 42% of those non-SSI, non-elderly with Medicaid health insurance are working full time, another 18% are working at part time jobs.  14% are not working because they are ill or disabled.  12% are caregivers for someone who is ill or disabled.  6% of the enrollees are in school, and 7% give other reasons for not being able to work. [KFF] So, let’s be rid of the Medicaid as Welfare motif — it’s not welfare, it’s a health insurance program.  Further, 60% of the recipients are working full or part time.  So, what are the income requirements for Nevadans in the Medicaid insurance program?

“In addition to the basic Medicaid requirements, petitioners must qualify by earnings. What are the income requirements for Medicaid in Nevada? Nevada Medicaid eligibility requirements pertaining to income are structured around the federal poverty level (FPL). This financial marker of determining Medicaid benefits eligibility considers the size of the family and larger households will have higher income limits. Medicaid can provide health care coverage to households with income up to 138 percent of the FPL. However, children younger than 19 years of age with incomes up to 205 percent of the FPL will also be eligible for medical coverage.” (emphasis added)

Now we come to the Income Trap phase of the argument.  We can’t, dare not, increase the minimum wage from a paltry $7.25 per hour, argue the Conservatives, because to do so would “cost jobs.”  However, if one takes out the plastic brains, punches in the numbers for a person working 40 hours per week at a minimum wage job the conclusion displayed in the little calculator window will be below the 138% FPL line.  Here’s a thought: If the Republicans are bent on removing working people from the Medicaid rolls, how about raising the minimum wage to a living wage?  And, now we continue on to the Geese and Gander finale.

We’ve just survived the enaction of the Republican Tax Cut, Tax-Scam, in which it was argued that if middle and working class Americans would shoulder the burden of supporting the federal government and allow the corporations and hedge fund managers to “keep more of their hard earned money,” then our prosperity will soar, the economy will boom and those hard-working wealth management titans will work even harder at their investment strategies.  So, pay them more and they will work harder, and make their money work harder.  Funny, this principle never seems to apply to working people who drive trucks, serve food, repair fuel injection systems, build houses, landscape properties, clean hotel rooms, sell merchandise, type memos, file records, stock shelves,… you get the idea.

Thus, what is sauce for the Geese (those hard working wealth management, upper 1% of the income earners, etc.) i.e. more benefits and breaks from the government is toxic bilge water for the other 99% Ganders, who if given even the least disincentive in the form of affordable health care will shed their uniforms and work clothes, head for the nearest couch and dissipate into a mere shadow of their former selves as their “self sufficiency” is drained by the system.

Perhaps we should call this out for what it is — yet another attempt to reduce the number of people eligible for assistance with their health care expenses because rich people don’t want to pay for it.  Because they imagine some otherwise healthy soul taking advantage of their fellows merely because the are “unworthy.”  If this sounds selfish, it’s because it is, essentially, a fundamentally selfish argument.  The saddest part of the entire issue is that the Geese having quacked for years about Welfare Queens (non-existent) and Unworthy Lazy Bums have convinced numerous Ganders of the horrors of expending any funds in support of those less fortunate.   There is one last point illustrative of the moral deficiency of the conservative argument.

Opioids.  Remember those 7% who gave other reasons for not working?  Some of them have been laid off from jobs and are seeking new employment, and some others are finding it difficult to secure employment because of opioid addiction.  Just for the record, Medicaid covers about 4 in 10 non-elderly adults with opioid addiction.  13.9% are white non-Hispanic; 6.6% are Black, and another 4.6% are Hispanic.  13.7% are males, 7.3% are females.  [KFF]  If we want to address opioid addiction in this country then we need to be taking care of those who are seeking help with this scourge, and not lecturing them about the wonders of the free market system and healthy lifestyles.

We could use a few less lectures on the Great American Rugged Individual and a few more mentions of our collective responsibility to care for our fellow citizens as we would wish to be cared for by them.

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Filed under health insurance, Medicaid, Politics

Scary Stuff Indeed

Yesterday was an extremely interesting day, replete with all manner of scary stuff compliments of social media platforms and a Special Counsel. However, not all of the frightening items were associated with the Trump Campaign’s eagerness to get the produce of Russian hacking, and Russian assistance.  Here’s some other stuff in the GOP treat basket:

ICE again proves its ultimate heartlessness and horrifying lack of understanding of what it means to “protect” Americans; illustrated by the case of Rosa Maria Hernandez — a ten year old with cerebral palsy undergoing gall bladder surgery.  And, this isn’t the only case — there was the story of parents arrested while their child was having brain surgery, the arrest of an undocumented Iraqi man who was serving as a bone marrow donor for his niece, and a brain tumor patient pulled from a hospital.  ICE thus becomes the ultimate Halloween Scary Story.  Candidates for public office ought to be ask outright how they would assist in the process of getting immigration officials to adhere to their own guidelines on “sensitive locations.’

Nobody in the GOP appears to be all that outraged that the Trump Campaign not only accepted assistance from the Russians, but actively sought to get the goods on Secretary Clinton from Russian sources.  This isn’t normal, or even paranormal — it’s the kind of thing that would make any other campaign (Democratic or Republican) call the FBI if the Russians showed up at the door with treats.  But still, #45 refuses to accept the fact that the Russians at least meddled and at most attacked the US with campaign “assistance” — social media help; opposition research; and, (the part we keep ignoring) attempts to hack into the voting systems of at least 21 and possibly 39 states.  We do need much more attention paid to the last item on the list since the Cult-45 group persists in saying this is a Spook, there’s nothing to see here.

Somehow a tiny company in Montana got a whopper contract, now cancelled, to supply power to the entire island of Puerto Rico.  Nothing puts a place like Whitefish, Montana on the map like having the Secretary of the interior stammering he’s nothing to do with this — and if I believe this then you could easily get me to believe that all the little spookies at the door are Real!

It’s been 30 days since the tragic Las Vegas Shooting, and what has the Congress done to limit high capacity magazines? Bump stocks? Anything?  This month has been a nightmare for the families of the deceased, and the families of the injured.  The nightmare will continue until politicians stop being terrified of the National Rifle Association.

Republicans have been unable to explain away the specter of Opioid Abuse while cutting massive amounts of funding from Medicaid.  The GOP budget calls for cutting some $1.5 trillion from the program over the next decade — while 30% of opioid treatment is covered by Medicaid insurance.   States, already strapped by the crisis will have to either come up with more funding or ration care — speaking of Death Panels…

The Senate of the United States believes that individual Americans are perfectly capable of taking on The Big Banks all by themselves — Super Heroes in Litigation.  So, on October 24, 2017 the Senate voted to dismiss a CFPB rule that would have allowed class action law suits against the Big Banks by ripped off customers; forcing those customers into individual arbitration.  Senator Dean Heller was pleased to vote in favor of this nightmare.

This list seems long enough to send sentient beings into the closet for the Halloween Season, one almost shudders to think what more the Republicans have in mind — like the tax cuts for the 1% and questionable benefits for the rest of the population…

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Filed under anti-immigration, Gun Issues, Immigration, Medicaid, Politics

Senator Heller’s Second Shot at Slashing Medicare and Medicaid

“This morning, the Senate Budget Committee will consider a resolution that instructs lawmakers to find ways to reduce Medicaid spending by $1 trillion (and Medicare spending by $473 billion) over the next decade, according to supporting documentation that Democrats are publicizing.” [WaPo]

Here’s the strategy: “A fast-track “reconciliation” process that would allow for tax cuts costing $1.5 trillion over ten years that require only a simple majority to pass.  The $1.5 trillion cost would not have to be offset by closing tax loopholes or ending unproductive tax breaks, and thus would add to the nation’s deficits, which are already growing as the baby boomers retire.  In addition, the resolution would allow the Senate Finance Committee to cut critical programs under its jurisdiction, including Medicaid, Medicare, and basic assistance for poor seniors and people with disabilities, and then use those savings to make the tax cuts even larger (so that the net cost of the tax cuts and the budget cuts combined equaled $1.5 trillion).  The reconciliation process is the same process that Congress tried to use to repeal the ACA and requires only a simple majority to enact law.”  [CBPP] (emphasis added)

And, there we have it: (1) If it’s a Republican budget, then adding to the federal deficit doesn’t matter; (2) in order to provide for tax cuts to the top 1% of income earners in the United States, the Committee can slash funding for Medicaid, Medicare, basic assistance for senior citizens, and people with disabilities.

The trick is that the Senate Republicans have to pass a “budget” slashing spending for those aforementioned Medicare and Medicaid beneficiaries, elderly people in poverty, and disabled people, in order to create ‘space’ for the “reforms” in their tax legislation.  The buck slashing needs to stop here.

Please contact Senator Dean Heller, and let him know that these are not Nevada priorities.

202-224-6244

702-388-6605

775-686-5770

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Filed under Health Care, Heller, Medicaid, Medicare, Nevada politics, Politics

Demolition Days On End

The television talking heads are talking about today’s sound and fury from the White House as “Demolition Day;” as if every day the mullet-maned moron occupying the Oval Office hasn’t been doing this from day one.

What is buttressing my sanity for the moment is the fact that MMM had a 49.4% approval rating in Nevada as of January 2017 (38.9% disapproval) and dropped to an approval rating of 43.6% in September 2017 and a disapproval rating of 51.2% in the Silver State.  [CNBC]

Much more love from the Republican Congress and the President and Nevada’s going to find itself in a world of hurt.   Case in point:  If the Republicans get their way in the FY 2018 budget 56,044 Nevada families will lose food assistance as of 2023, and 52,613 will lose them as of 2027.   But wait, there’s even more fun … another grand idea in this budget fiasco is to shift $100 billion of SNAP costs to the states.  So, Nevada would have to come up with 10% of the costs by 2020 and this increases to 25% in 2023 and beyond. Just in case lower income, mostly working, families in Nevada aren’t punished enough the GOP plan says states will have more “flexibility” to cut benefit levels to “manage costs.”  Of course Nevada will have to figure out how to get lower income working families basic food items at the local groceries, at state expense.  In case someone’s thinking this makes economic sense (that tired old canard about welfare queens on food stamps with waste and fraud) the actual numbers indicate that for every $5.00 spent on food stamps $9.00 is generated in economic activity. [CBPP] [MJ]

Case in point: The FY 2018 budget calls for cuts in fire-fighting operations.  As if the fires in California weren’t headline news at the moment.  The IAFC isn’t happy  seeing an FY 2017 budget of $2,833,000 for wildland fire management cut to $2,495,058 in FY 2018; or cuts to State Fire Assistance from $78 million down to $69.4 million, and Volunteer Fire Assistance from $15 million to $11.6 million.  And, by the way, the FLAME program (pdf) funding (wildfire reserve suppression fund, large fires) would be eliminated in the GOP budget.  Supposedly, the FY 2018 would sustain current 10 year average costs for fire suppression. [ECO]  The word “supposedly” is used with some caution, because as we experience climate change effects, the cost of fire suppression can be reasonably expected to increase, with a coterminous effect on budgets.   Meanwhile, there’s the matter of expensive fires in Napa and Sonoma counties.

And, then there’s the not-so-small matter of FEMA:

“The president’s budget blueprint calls for FEMA’s budget for state and local grants to be cut by $667 million, saying that these grants are unauthorized or ineffective. The program it explicitly calls out as lacking congressional authorization is the Pre-Disaster Mitigation Grant Program, and a second proposed change would require all preparedness grants to be matched in part by non-federal funds. All of FEMA’s pre-disaster grants are meant to reduce federal spending after disasters, and according to the agency’s website, there’s evidence that $1 in mitigation spending saves $4 in later damages.”  [Newsweek]

There are two points to highlight in this paragraph.  First, the budget cuts are made to grants for disaster mitigation efforts, without saying why the grants are “ineffective,” and we should note that any program can be declared “ineffective” if the standards aren’t reasonable. Secondly, as in the case of food stamps, there’s an upfront economic benefit — for every $1 spent on mitigation we save $4 in subsequent damage costs.   Once more we have a grand example of being penny wise and pound foolish.

Nor are the Republicans keeping their promises not to mess with Social Security and Medicare.

“Not only would it (the FY 2018 budget) cut Medicaid by $1 trillion, it would also cut Medicare by more than $470 billion in order to pay for hundreds of billions in tax breaks to the wealthiest people and most profitable corporations in America. Further, the Republican tax plan this budget calls for would increase the federal deficit by $1.5 trillion over the next decade, which will likely pave the way for savage cuts to Social  Security.”  [SenDem]

Oh, and by the way… let’s sabotage the NAFTA talks, scrap the only treaty containing Iran’s arms aspirations (and tick off all the other European allies who signed on), send a signal to North Korea that our word’s not worth paper on which it’s written, let the health insurance market destabilize into chaos, and withdraw from UNESCO.

And here we sit, not a shining beacon on a hill, but a flickering flame bent to whatever winds happen to be blowing through the head of MMM in the White House.  Not only are programs and services in peril within our own state, but the nation and the world are facing similar dangers emanating from an unraveling White House.

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Filed under Economy, FEMA, Health Care, health insurance, Nevada, Nevada budget, Nevada economy, Nevada politics, Politics, public health, Republicans, Social Security, tax revenue, Taxation

GOP assault on health care in rural Nevada

There’s a tendency to see social needs as an element of urban living in major cities like New York City, Los Angeles and Chicago, and rural poverty as something that happens in Appalachia.  This perspective obfuscates two features of life in Nevada.  For all intents and purposes Nevada is an urban state.  Not only is Nevada “urban” it is getting more so.  In 1970 about 80.9% of Nevada residents lived in urban areas, in 1990 the percentage was 88.3, and as of 2010 the percentage was 94.2% [ISU.edu]

By contrast, New York state as of 2010 was 87.9% urban, and Illinois 88.5% urban, while Nevada is closer to California’s 95% urban population. [ISU.edu]  However, to perceive rural Nevada as a wonderland of “freedom” and rugged individualism is to miss some crucial figures describing life in the “cow counties.”

For example, Pershing County has an 18.3% poverty rate; the US poverty rate is 12.7% [census] but the county does support a critical care hospital with a skilled nursing facility  with a maximum capacity of 25 residents.  The county’s population also includes 11.1% disabled people under the age of 65.   Given these figures, perhaps some politicians would like to explain why slashing Medicaid now and all but eliminating the national program by 2027 would be a good idea for Pershing County, Nevada.

Neighboring Humboldt County has a lower poverty rate, at 9.4% and a lower rate of disabled individuals under the age of 65 at 8.3%, but reducing the Medicaid program would have a deleterious effect on its 53 bed hospital, with an ICU, Obstetric services, and skilled nursing facility for 30 residents.  What effect of cutting Medicaid might be seen in the county’s ability to care for its aging population, including its hospital’s plans to incorporate a “memory care services unit” in its offerings?  [hgh] Recall that some 60% of all skilled nursing home residents get their health insurance coverage from Medicaid.

More populous Elko County has a poverty rate of 9.9% and an 8.4% rate of individuals with disabilities under the age of 65.  The county is home to a short term acute care hospital with 59 beds, and a resident center for 110 people needing skilled nursing care.   Again, if 60% of those SNF residents rely on Medicaid for their insurance coverage then cutting funds in 2027 then 66 families will be under increased pressure to find suitable and appropriate care for elderly family members.

Now, consider that Nevada is an urban state, and that should the Republicans get their wish for a capped Medicaid system of block grants then the state would be tasked with allocating increasingly spare resources to maintain nursing home and hospital facilities statewide.  Given the 2.115 million people in Clark County contrasted with the 52,168 population of Elko County, the 6,650 in Pershing County, and the 16,842 in Humboldt County — where are the monetary resources likely to go?

If Congressman Mark Amodei (R-NV2) and Senator Dean Heller are truly representing the needs of rural Nevada, then offering platitudes about “freedom,” “free enterprise,” and “individual initiative” are a poor substitute for enacting legislation to maintain and improve the health care facilities and the insurance availability to those facilities for northern Nevada rural citizens.

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Filed under Amodei, Health Care, health insurance, Heller, Medicaid, Nevada politics, Politics

GOP: Poor Excuses and Paucity of Empathy

By all accounts the Graham-Cassidy+Heller version of health care destruction would yield a net coverage reduction for 243,000 Nevadans. Overall it would mean a 31% cut in Medicaid for children — that’s right — children.  There’s another 15% cut for services for people with disabilities.  And what’s the rationale for this atrocity?

(1) Because we promised!  This is probably the silliest reason to do anything ever.  I may have promised to offer someone a ride to go shopping, but if there’s a blizzard on the way then it’s downright stupid to “keep the promise.”

(2) Because Obamacare is failing!  And why would that be? Because Republicans refused to make some simple fixes (risk corridors, risk sharing, and reinsurance) and the individual health insurance is unstable.  It’s a classic case of tossing the baby out with the bathwater.  Or, of finding some perfectly “fixable” problems with a law and using those to rationalize pitching the entire thing.  Head UP: They’ll try this same approach with the financial sector reforms in the Dodd Frank Act.

And then there’s the part the Republicans aren’t talking about.

(3) Because they’ve wanted to get rid of Medicaid, Medicare, and to privatize Social Security from time out of mind.

This comment sums up the situation:

“The two keys to the Republican attitude are money and ideology. If you view the modern G.O.P. as basically a mechanism to protect the wealthy, Medicaid is an obvious target for the Party. The program caters to low- and middle-income people, and its recent expansion was financed partly by an increase in taxes on the richest households in the country.”

The concept can’t be articulated more simply or directly.

Then there are the sputtered talking points, common among Republican politicians and supporters to hike around the obvious but unspoken issues they have with the Affordable Care Act.

If we don’t pass this we’ll have socialized medicine.  Please.  Even Single Payer (or Medicare for all) isn’t socialized medicine.  Medicare insurance is used to pay PRIVATE providers for medical treatment.  This obviously isn’t a nationalized medical service plan.  Only by artificially conflating medical insurance with medical services can anyone assert that this is “socialism.”

There are no guarantees in life.  So if a family in Minnesota who has a child with muscular dystrophy may be required to pay higher premiums that’s the way the markets work.  It doesn’t get more morally bankrupt than this — especially since the current system does guarantee coverage for families with chronically ill children.

This issue is long past being a public policy issue, it has devolved into pure politics in which ‘points’ are scored by a party desperately hoping to cut taxes for its most generous donors at the cost of Americans’ health care.

So, every few weeks we’ll have to call our Senators to beg them not to destroy the Affordable Care Act and Medicaid for ourselves, our families, our friends, our neighbors, and our fellow citizens.

Call Senator Heller at his Las Vegas Office 702-388-6605; his Reno Office 775-686-5770; or his DC Office 202-224-6244. 

You may also want to call Senator Cortez-Masto to thank her for her support of health care access for Nevadans. 202-224-3542; 702-388-5020; 775-686-5750.

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Filed under Health Care, health insurance, Heller, nevada health, Nevada politics, Politics

The Moderate Heller Myth: Health Insurance Edition

Senator Dean Heller (R-NV) has cultivated his “moderate” image to the point that this adjective is attached to him with remarkable consistency — when if a person does even a perfunctory piece of research on his actual voting record what emerges is the model of a hard line conservative.  There is a pattern.  The Senator expresses “concerns” with a bill; then announces with ranging degrees of fanfare his opposition to a bill “in its current form,” then when the rubber grinds on the road surface the Senator votes along with the Republican leadership.

Why would anyone seriously believe he would support fixing the Affordable Care Act’s problems and not ultimately support what is now being called the “skinny repeal” version in the Senate based on the following voting record:

In 2007 then Representative Heller voted against the Medicare Prescription Drug Price Negotiation Act (HR 4).  Then on August 1, 2007 he voted against HR 3162, the State Children’s Health Insurance Program reauthorization.  The next day he voted against HR 734, the Prescription Drug Imports bill.  On March 5, 2008 he voted against HR 1424, the Mental Health Coverage bill.  Further into 2008 he voted “no” on HR 5501, the bill to fund programs fighting AIDS, Malaria, and Tuberculosis, and “no” again on the concurrence version of the bill in July.   If he had a ‘flash’ of moderation during this period it happened in the summer of 2008 when he voted in favor of HR 5613 (Medicaid extensions and changes), HR 6631 (Medicare), the latter including a vote to override the President’s veto.  By November 2009 he was back in full Conservative mode.

He voted against HR 3962 (Health Care and Insurance Law amendments) on November 8, 2009, and HR 3961 (Revising Medicare Physician Fee Schedules and re-establishing PAYGO) on November 19, 2009.

In March 2010 Heller voted against HR 4872 (Health Care Reconciliation Act), and HR 3590 (Patient Protection and Affordable Care Act).  He also voted against the concurrence bills.

January 19, 2011 he voted in favor of the Repealing the Health Care bill (HR 2).  He also signaled his stance on Planned Parenthood when he voted in favor of H.Amdt. 95 (Prohibiting the use of Federal funds for Planned Parenthood) on February 18, 2011.    He was in favor of repealing the individual mandate (HR 4), of repealing the Prevention and Public Health Fund (HR 1217).  May 4, 2011 he voted to repeal funding of the construction of school based health centers (HR 1214).

There was another “soft” period in some of his initial Senate votes in 2011, especially concerning the importation of medication from Canada (interesting since many prescription drugs are manufactured in other overseas sites).  See S. Amdt 769, S. Amdt 2111, and S. Amdt 2107 in May 2012.  On March 31, 2014 he voted in favor of HR 4302 (Protecting Access to Medicare).

He was back riding the Republican rails in September 2015, supporting an amendment to defund Planned Parenthood, (S. Amdt 2669) which failed a cloture vote.   Then on December 3, 2015 he voted in favor of another ACA repeal bill (HR 3762).    If we’re looking for patterns in this record they aren’t too difficult to discern. (1) Senator Heller can be relied upon to vote in favor of any legislation which deprives Planned Parenthood of funding for health care services, (2) Senator Heller can be relied upon to vote in favor of repealing the Affordable Care Act, and (3) Senator Heller’s voting record, if it illustrates any ‘moderation’ at all, comes in the form of dealing with prescription drug prices, but even that is a mixed bag of votes.

Thus, when he makes comments like the following:

“Obamacare isn’t the answer, but doing nothing to try to solve the problems it has created isn’t the answer either,” the statement read. “That is why I will vote to move forward and give us a chance to address the unworkable aspects of the law that have left many Nevadans — particularly those living in rural areas — with dwindling or no choices.

“Whether it’s my ideas to protect Nevadans who depend on Medicaid or the Graham-Cassidy proposal that empowers states and repeals the individual and employer mandates, there are commonsense solutions that could improve our health care system and today’s vote gives us the opportunity to fight for them. If the final product isn’t improved for the state of Nevada, then I will not vote for it; if it is improved, I will support it.”

We should examine them with some caution.   If he is referring to rural Nevada voters as ‘victims’ of the Affordable Care Act he might want to note that before the ACA there was one insurer in the northern Nevada rural market and if there is only one now that’s really not much of a change, much less a “nightmare.”  Nor is he mentioning that the proposed cuts to Medicaid will have a profoundly negative effect on rural Nevada hospitals. [DB previous]

That Graham-Cassidy proposal isn’t exactly a winner either:

“The new plan released Thursday morning and written by Republican Sens. Lindsey Graham (S.C.) and Bill Cassidy (La.) would block grant about $500 billion of federal spending to the states over 10 years to either repeal, repair or keep their ObamaCare programs.”

We have no idea if the number is an accurate estimate of what would keep the health care systems of all 50 states afloat — no one seems to want to ‘score’ anything these days.  Additionally, Americans should be aware by now that when Republicans chant “Block Grant” they mean “dump it on the states, wash our hands, and walk away” while the states struggle to keep up with demands to meet needs and provide services, operating on budgets which cannot function on deficits.

Then, there’s that perfectly typical Hellerian comment: “If it is improved, I will support it,” leaving the issue entirely up to Senator Heller’s subjective assessment if “it” has improved his re-election chances enough to go along with it while not upsetting his very conservative base.  Meanwhile, the media persists in repeating the “Moderate Heller” mythology, and we haven’t even begun to speak of his actions to thwart and later repeal any common sense regulations on the financial sector.

 

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Filed under conservatism, Health Care, health insurance, Heller, Medicaid, Medicare, Nevada Test Site, Politics, public health, Republicans, Rural Nevada, SCHIP

Caring for Grandma on the I-80 Corridor

Republican “reforms” of Medicaid, which seem to be composed of stalling funding until the program can be gutted in 2025, could easily have a negative impact on those families trying to find skilled nursing care for elderly relatives along the I-80 corridor in northern Nevada.  As noted in the previous post, health care facilities in northern Nevada have service areas of miles and miles of miles and miles.  The euphemistic term “remote rural” is especially pertinent in this instance.  These may be the “cow counties” but they do include a significant number of individuals over the age of 65.

By The Numbers 

Pershing County (Lovelock) has a total population of 6,560 of which 14.8% are over 65, and 11.1% of those are disabled individuals under the age of 65.  Humboldt County (Winnemucca) population of 16,842 includes 11.9% over 65 and 8.3% under 65 disabled. Lander County (Battle Mountain) has 5,702 people, of whom 13% are over 65 and 6.5% are disabled.  Eureka County (Eureka) is a small entity with 1,917 people of whom 12.9% are over 65, and 6.6% are disabled.  More populous Elko County (Elko) with 52,168 people has an over 65 population of 10.0% and 8.4% disabled individuals.  Churchill County (Fallon) has a population of 24,198 of whom 18.7% are over 65 and 6.5% are disabled.

For the sake of this analysis, let’s assume that the families would like to find skilled nursing facilities for their elderly relatives closer to home than securing similar residences in the Reno/Sparks/Carson City area.  That means finding skilled nursing facilities in the towns listed above.  Elko County has such a unit with room for 110 residents, Fallon has a facility with a capacity for 74 residents.  Lander and Eureka counties are served by a facility in Battle Mountain with a capacity of 18.  Pershing county has one facility with a capacity of 25 residents, and Winnemucca has a skilled nursing facility for up to 26 residents. [Links]  We’re speaking in numbers at present, but it’s important to remember that those numbers are specifically associated with real people, and very real families who are seeking affordable quality care for those individuals.

The cost of skilled nursing care will vary with the level and type of medical or rehabilitative services required, however we can generally assume that the monthly price tag for SNF care in Nevada is about $8,213.  Drilling down a bit deeper, the reported minimum cost per month for Skilled Nursing Care in a semi-private room is about $3,346; the median is $7,128; the maximum is $8,425.  Private rooms come at a minimum of $4,106, a median cost of $8,213, and a maximum cost of $15,452.  [SNF]  At this point another reminder is appropriate — these aren’t price tags, the numbers represent what a family might have to pay for care specific to the needs of their elderly relatives.

And now we return to the numbers.  In the State of Nevada 1 out of every 7 persons over the age of 65 is covered by Medicaid. Medicaid covers 3 out of every 5 nursing home residents. [KFF]  Consider for just a moment what would happen to the fiscal solvency of the residential facilities listed above in the rural counties if Medicaid is cut, then “reformed” into block grants (which can be further cut by Congressional action) and finally all but reformed out of existence by Republican representatives.

Mythology

Let’s work on some of the elements of Republican mythology commonly associated with their efforts to slash the Medicaid program.

(1) It was only originally intended to cover the “really poor.” Republicans have an interesting way of defining “poverty.”  Several reports of recent memory decry the fact that people on various welfare programs have CARS (to get to work) and REFRIGERATORS (which come with most furnished apartments.)  Left to their own devices it’s easy to imagine that unless a person is naked, living rough in the bush, and starved into semi-consciousness the individual wouldn’t qualify as “poor” by some Republican standards.  That said, Medicaid isn’t really a welfare program — it’s essentially a health insurance program.  One way to extend this health insurance coverage was to apply income eligibility standards for publicly subsidized health insurance — for the low income families, for the aged and for the disabled.

(2) The states can do better because they are closer to the problems.   There’s a reason we have a federal system — there are some tasks which the states are not capable of adequately addressing.  Providing health insurance coverage for millions of Americans working at low wage jobs, who have disabled family members, who have aging family members, and have children in need of health care services is one of those objectives best addressed by federal resources.  Imagine if someone said the states can best determine what security is best for them?  Should we block grant the Defense Department budget, send it to the states and let them decide how to fund the elements of their National Guard?  This sounds ridiculous, and doesn’t the Constitution require government prioritization of our mutual defense? Yes, and it also provides that our government provide for our “general welfare.”

(3) We’re really not cutting anything.  No? When the inflation rate for the medical sector exceeds that of the other sectors of the economy, and budgeting or funding proposals don’t meet or exceed that inflation rate the end result is a cut.  It’s not mathematics, it’s just old fashioned arithmetic.  There’s also something disingenuous about continually clamoring for tax cuts (especially at the state level) and then offering that the states should pick up more of “their share” of program expenses.  Finally, it’s always easier to cut funds from “block grants” than it is from specific program budgets.  Yes, the Republicans intend to cut Medicaid; if it’s done slowly or quickly is beside the point — at some date the result will be the same.   Program cuts will affect those real people in those real skilled nursing facilities, both the staff providing the services and the residents who depend on them.

Senator Dean Heller should be aware of these issues, and if he isn’t perhaps he should receive some phone calls this week.  702-388-6605;  775-686-5770; 202-224-6244.

*And we still haven’t discussed the benefits of Medicaid supported home health care programs!

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Filed under Health Care, health insurance, Heller, Medicaid, nevada health, Nevada politics, Politics

Rural Nevada Health Care and the Great Bamboozle AHCA

The state of Nevada consists of 110,567 square miles of miles and miles and miles.  271,985 people live in those miles and miles and miles out of a total population of  2,940,058.  A quick poke at the calculator shows a state in which 93% of the population is urban, while most of the real estate is rural.   This situation poses some easily apparent problems for health care services and the delivery thereof.

Rural health services must literally cover wide spans of territory in which there is a small population.   There is one hospital in Battle Mountain (Lander County, NV) to serve a total population of 5,702.  There is one hospital in Winnemucca (Humboldt County, NV) serving a total population of 16,528.  There is one hospital in Lovelock (Pershing County, NV) with a total population of 6,753.  There is one hospital in Elko (Elko County, NV) serving a population of 48,818.  Two conclusions can be reasonably drawn from this quick view of the northern tier of rural counties: (1) In none of these areas can a hospital draw upon “economies of scale” in terms of hospital services.  The obvious example may be that an expectant mother will usually require the same obstetric services in Battle Mountain, as in Winnemucca, as in Las Vegas or Reno.  (2) These rural hospitals serve populations which are generally not as affluent as in urban areas;  the rural per capita income lagging slightly behind urban areas. [RH] This places the northern tier of counties in a predicament similar to other western states:

“In the rural West, many farmers, ranchers and other agricultural workers are self-employed, so they can’t get coverage through an employer. Hence, a higher percentage of agricultural employees are covered by Medicaid (11 percent) than in non-agricultural industries (8 percent). Before the ACA was enacted in 2010, workers in the agricultural sector had fewer options, so many remained uninsured. But under the Obama-era plan, many states expanded Medicaid, increasing the percentage of those covered. Under the AHCA, that expansion would be significantly scaled back, according to the Joint Economic Committee report.”

Thus, the National Rural Health Association issued this warning:

“Though most rural residents are in non-expansion states, a higher proportion of rural residents are covered by Medicaid (21% vs. 16%). Congress and the states have long recognized that rural is different and thus requires different programs to succeed. Rural payment programs for hospitals and providers are not ‘bonus’ payments, but rather alternative, cost effective and targeted payment formulas that maintain access to care for millions of rural patients and financial stability for thousands of rural providers across the country. Any federal health care reform must protect a state’s ability to protect its rural safety net providers. The federal government must not abdicate its moral, legal, and financial responsibilities to rural, Medicaid eligible populations by ensuring access to care.”

In short,  cuts to the Medicaid program will disproportionately affect rural health care providers serving rural populations.

But, but, but, sputter the advocates of the Republican offering — We’re Giving People A Choice — you can buy what you want!  Not. So. Fast.

“Though some provisions in the modified AHCA bill improve the base bill, NRHA is concerned that the bill still falls woefully short in making health care affordable and accessible to rural Americans. For example, the modified bill contains a decrease in the Medical Expense Deduction threshold from 10% to 5.8% in an attempt to assist Americans between the ages of 50 and 64 who would see their premiums skyrocket under the current plan. However, this deduction is not a credit and therefore would be of little use to low income seniors that are in very low tax brackets or do not pay income tax at all. Additionally, the new amendments to freeze Medicaid expansion enrollment as of Jan. 1, 2018, and reduce the Medicaid per-capita growth rate will disproportionately harm rural Americans.”

Well, that didn’t go well.  What about that “get what you want argument?”  The first question might well be — What can you afford?  The annual earnings of a farm or ranch owner (manager) in Nevada is reported at an annual mean of $91,970.  However, the range runs from 10th percentile $39,850 to 90th percentile $150,410.  The annual mean wage for a farm or ranch worker is $34,520. [BLS]  Nevada’s reported average annual mean for farm and ranch workers is slightly higher at $36,480. [DETR download] Now we have a problem — 138% of the federal poverty level is $16,374 for a single person or $33,534 for a family of four.   Our hypothetical average annual mean earnings for a farm or ranch worker isn’t eligible for Medicaid expansion enrollment, but has an income well below the Nevada average household income average of $52,431, or 63.96% of the annual average household income level.

How to market an insurance policy this hypothetical average family could afford?  Either offer a comprehensive insurance plan and provide premium assistance to make up the difference between what the premium costs and what the family can reasonably afford — or there’s always the Junk Insurance option.   Consumer Reports offered some excellent advice concerning what constitutes Junk Insurance — aka “affordable plans” —  watch out for fixed benefit indemnity plans, and medical discount cards.  Another Consumer Reports bulletin specified the elements of Junk Insurance, your insurance plan could be very hazardous to your physical and financial health if it contains: Limited benefits; Low overall coverage limits; unrealistic “affordable” premiums; No coverage for important health care services; Ceilings on categories of care; No limits on out of pocket costs; Random catches — like covering hospital care after the second day, when it’s known that the first day is usually the most expensive.

The problem at this juncture for rural Nevadans is that those in the agriculture sector may or may not have earnings allowing them to enroll in Medicaid.  If “yes” then a reduction in Medicaid — whether it happens now or just after the 2020 elections — will have a negative impact on many citizens in the northern tier of “cow counties;” similarly, a return to the Bad Old Days pre-ACA makes those who are certainly less than affluent vulnerable to the offerings of Junk Insurance, which is fine as long as they don’t mind paying for a product which will not cover their medical expenses at the time they actually need it.  Exacerbating this issue is the fact that jobs in agriculture (farming and ranching) are listed by Forbes as the 4th most dangerous occupations in the country.

There’s no way to bestow a bright face to the Republican tax cut disguised as a health insurance ‘reform’ bill in terms of what happens to rural Nevadans and their health care providers.  Those it doesn’t cut out completely it leaves vulnerable to incomplete and almost useless “catastrophic coverage” plans — which for too many policy holders leaves them facing health care costs well beyond their ability to pay for out of pocket.  If there were a recipe for increasing the “uncompensated care” costs for local hospitals and clinics this is definitely IT.  Rural hospitals and clinics, already stretched to meet costs, would be especially at greater risk — and we haven’t even touched on the topics of long term care for the aging or home health care services which prevent individuals from having to reside in more expensive residential care facilities in rural areas.

NOW is the time to contact, and continue to contact, our Senators (Heller and Cortez-Masto) and urge their opposition to this assault on medical care for northern Nevada citizens and their health care providers.

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Filed under Health Care, health insurance, Heller, Medicaid, nevada health, Nevada politics, Politics

All Quiet on the Humboldt

When last we heard from Rep. Mark Amodei (R-NV2) it was in early May at which time he smoothly flipped his vote on the disastrous ACA replacement bill, with a convoluted explanation that “it” wouldn’t hurt Nevada…and then came the CBO scoring.  The District 2 Congressional representative has kept his head down like a ground squirrel in his burrow by the side of the highway.  This prevents him from dashing into the roadway, or as constituents might call it — holding an in person town hall meeting.

Tossing statistics about like so much confetti doesn’t remove the cold fact that the bill for which Amodei voted cuts $839 Billion with a B from the Medicaid expansion.  Cue the GOP lament that there are “able bodied” people who benefit from the Medicaid program, a program initially meant to serve the desperately poor.  The expansion aided people who may not be homeless without a tent but who were certainly desperate in terms of their ability to afford health insurance for themselves and their families.  These are the people who waited until the medical situation was so dire expensive emergency room treatment was required; who used the emergency rooms as a form of walk in clinic for the lack of any more available alternative; who went without any medical attention whatsoever — 48,000 who died according to the Harvard study because health insurance was unaffordable.

Representative Amodei may not have believed the ACA replacement bill would have profound impacts on Rural health services, but other politicians from other states have pointed this out with remarkable clarity.

Missouri, for example, refused the Medicaid expansion, and the results aren’t positive, as described by Missouri Senator Claire McCaskill:

“Well, we have, first, more than 2 million Missourians live in rural areas of our state. And 41 percent of our state’s hospitals are in rural areas. We know that they are under particular stress right now, particularly in states like Missouri that have refused the money that has been offered them for their Medicaid program under the Affordable Care Act. We know that there’ve been 78 rural hospitals closed, including three in Missouri. We know that 74 percent of those hospitals were actually in states that refused to accept the Medicaid money that was offered by the federal government back to the federal taxpayers in those states.”

Arkansas which accepted the Medicaid expansion also has some issues related to its rural hospitals:

“The ACA’s crafters essentially made a deal with hospitals: The ACA cut Medicare reimbursements, but the reduction in uncompensated care through the Medicaid expansion helped offset some of those cuts. Without that offsetting boost, some of the state’s smaller rural hospitals might not be able to survive. A hospital like Baxter — the fifth most Medicare-reliant hospital in the nation, according to Moody’s, thanks to the community’s significant proportion of retirees — would be forced to make dramatic cuts in services without the Medicaid offset. “The expansion of Medicaid through Arkansas Works is one of the key components that’s been able to help us through the change in the ACA,” Peterson said. “Not just Baxter, but it helps all of rural Arkansas.”

What is true of Missouri and Arkansas is true for rural health care in general:

Of the more than 11 million people who have gained Medicaid coverage through the ACA expansion, nearly 1.7 million live in rural America, according to new CBPP estimates (see Appendix Table 1).  The expansion population is more rural than the population as a whole: rural residents make up 12.1 percent of the population of expansion states but 14.1 percent of expansion enrollees in these states.  In at least eight expansion states, more than one-third of expansion enrollees live in rural areas: Alaska, Arkansas, Iowa, Kentucky, Montana, New Hampshire, New Mexico, and West Virginia.

The Medicaid expansion has been a lifeline for rural areas in other ways.  The ACA coverage expansions, especially the Medicaid expansion, have substantially reduced hospital uncompensated care costs: uncompensated care costs as a share of hospital operating budgets fell by about half between 2013 and 2015 in expansion states.[8] Reductions in uncompensated care and increases in the share of patients covered by Medicaid have been especially important for rural hospitals.

Nevada hasn’t been immune from the problems associated with a lack of access to affordable health insurance and uncompensated care:

“Rural residents are themselves a public health challenge, as they are generally older, more isolated and less likely to be covered by insurance than their urban counterparts. They’re also more likely to smoke, suffer from obesity and hypertension and die from complications of diabetes.

But preventive care that could head off medical emergencies is hard to come by in many areas. Nevada’s rural and “frontier” counties – a term used for the state’s most-remote and sparsely populated regions – and reservations face severe shortages not just of doctors and primary care services, but also nurses, EMTs, dentists and substance abuse and mental health professionals. And in some areas, the numbers are dwindling, despite efforts to reverse the trend.”

 

And so, there are rural hospitals in Representative Amodei’s district — Elko, Lovelock, Battle Mountain, Yerington, Winnemucca, Ely, Fallon and others — wondering what effects will be felt if the GOP adopts the framework in the House bill for which Amodei voted.   Residents in Tonopah watched as their hospital closed in August 2015, an unfortunate testament to the perils of privatization.  The question which might, and should be raised, to Representative Amodei in some town hall (should he ever emerge) is how does the Republican version of health care insurance “reform” protect rural hospitals from financial pressures endangering rural hospital administration.

Ah, but all this is “old news” now that the Representatives voted on an unscored bill in their haste to get something, anything, done and have tossed the blazing ball into the lap of the Senate — in which we might expect Senator Dean Heller to lament the inadequacies of the measure to the Heavens, and then vote along with Senate leadership for the final (probably dismal) result.

Let’s guess that Senator Heller will announce his ‘profound misgivings and questions’ and then after consultations with some officials, reverse his position and do what he has always done — vote against any augmentation of health insurance affordability for his constituents (see his votes on SCHIP on multiple occasions.)

And so it remains — all quiet on the Humboldt — as Representative Amodei and Senator remain quiet (unless we count Heller’s scripted telephone town hall) on an issue of profound significance to District 2’s health care service providers.

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Filed under Amodei, health insurance, Heller, Medicaid, Medicare, nevada health, Nevada politics, Politics, public health, Rural Nevada