Tag Archives: Medicare

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

Rest and Repair: Progressive Dreams and Conservative Nightmares

When last we spoke, the topic was moving from how to stabilize the individual health insurance plan market toward how best to deliver the services and do so without bankrupting American workers. Now we’re in the land of Progressive Dreams and Conservative Nightmares.

Republicans use the expression “patient centered medicine” as code for a system n which the individual (and individual policy holder) is responsible for how much, and what kind, of insurance coverage he or she may have.  This system works in theory, but has severe implications when it collides with reality.  As noted here, and in other analyses, the delivery of health care is not a “market” in the true sense of the term.  A market requires a voluntary transaction, and a diagnosis of a serious illness or the result of an accident aren’t voluntary in the sense of a face life or other form of elective medicine.  Not only is there not a market in the economic sense of the term, but health care is not necessarily an “individual” matter.

Philosophical Review and Reality Check

If I choose not to seek treatment for a communicable disease, perhaps because I don’t feel I can afford the treatment, I am placing my co-workers, neighbors, and heaven only knows who else, in peril.  If I choose not to seek rehabilitation after having an accident causing injury, then I place my own productivity in jeopardy, and reduce the value of my services to my employer and co-workers.  If, for financial reasons, I choose not to have something such basic as an annual physical exam, then I have chosen to ignore the ramifications of this decision on those around me.  My ‘freedom’ places the freedom of others to function in a safe and secure environment in jeopardy.

Arguing that “freedom” requires I accept responsibility for my own health — and health care — in turn requires that everyone else accept the same responsibility even though we have no control over the actions and decisions of others which may impact our own health.  This would be caveat emptor carried to irrational extremes.

If we’ll accept the notion that we are herd animals in our present form, and our socialization requires we not place others in jeopardy willfully or involuntarily, then what options are available within the current system to make sure we are healthy enough to be productive and not ‘infect’ the neighbors?

Dreams and Nightmares

At the risk of inserting more artificiality into this discussion, let’s assume that we maintain our system of paying for medical services with a combination of out of pocket and insurance resources.  What systemic changes can we make to expand the resources to more people in the individual (and employer) markets without changing the fundamental nature of our system?  The options range from tweaks to overhauls.

At the tweak end of the spectrum Senator Claire McCaskill (D-MO) offers a plan to allow residents in areas abandoned by health insurance corporations to purchase insurance offered by companies on the District of Columbia Insurance Exchange.  As discussed yesterday, a more middle of the spectrum suggestion is to revise or renew insurance company options for risk adjustment, risk corridors, and reinsurance to encourage the corporations to remain in rural markets.

The public option model moves us along the spectrum, and is available in legislative form in the text of HR 1307 in the 115th Congress.

“For years beginning with 2018, the Secretary of Health and Human Services (in this subtitle referred to as the ‘Secretary’) shall provide for the offering through Exchanges established under this title of a health benefits plan (in this Act referred to as the ‘public health insurance option’) that ensures choice, competition, and stability of affordable, high-quality coverage throughout the United States in accordance with this section. In designing the option, the Secretary’s primary responsibility is to create a low-cost plan without compromising quality or access to care.”

The public option provides insurance plans which could be restricted to abandoned areas or extended nationwide depending on the final structure of the legislation.

Republicans see a slippery slope in the public option proposal — today the public option tomorrow the single payer plan.  As noted previously, there’s nothing “socialized” about proposals establishing Medicare for all, because the Medicare insurance plan pays for privately delivered services.  However, again, Republicans see any extension of access, with public support, as a step towards nationalized health care.  This makes for intriguing intellectual disputation, but it doesn’t really further the process of making more Americans healthier, or easing the burden of health care insurance from American businesses.  The burden is illuminated by the often quoted:

“For large multinational corporations, footing healthcare costs presents an enormous expense. General Motors, for instance, covers more than 1.1 million employees and former employees, and the company says it spends roughly $5 billion on healthcare expenses annually. GM says healthcare costs add between $1,500 and $2,000 to the sticker price of every automobile it makes.” [CFR]

A pre-ACA Rand study supported the general conclusion that employer sponsored health care insurance combined with rising health care costs was a drag on economic growth:

“The analysts found no significant relationship between the percentage of workers with ESI in the U.S. industries in 1986 and the percentage change in employment in the corresponding Canadian industries over the 19-year study period. The lack of a relationship suggests that excess growth in health care costs does have adverse economic effects and that these effects are more pronounced in industries that have a higher percentage of workers with ESI.”

While the Republicans may envision nightmares of nationalization, some of the industries which provide employer sponsored insurance who support their agenda are simultaneously encumbered with expenses not shouldered by their foreign competitors whose employees are provided with public sponsored health insurance.

Perhaps we could advance our public discourse on health insurance if (1) we would stop discussing the topic as if it were an ethereal scholastic issue in which generalizations and speculations replace hard data and human experience; (2) we would look at a variety of proposals ranging from small technical changes to the Affordable Care Act to technical changes to stabilize the insurance market to full public support for privately delivered health care services.

*H/T to Mark Stufflebeam and @Karoli for suggestions and resources!

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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

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

Medicare Fraud and the Public Images

Loretta Lynch

You go! Attorney General Loretta Lynch’s announcement about Medicare fraud prosecutions isn’t getting the play accorded to more “hot topic” issues, but it’s an important step in doing two things – actually getting fraud out of the Medicare system; and, two dispelling the GOP inference that fraud in social and health care systems is something done by imaginary welfare queens and ne’er do wells.

Who’s getting prosecuted?

U.S. law enforcement officials have charged 301 suspects with trying to defraud Medicare and other federal insurance programs in 2016, marking the “largest takedown” involving health care fraud allegations, the Justice Department said on Wednesday.

The national sweep resulted in charges against doctors, nurses, pharmacists and physical therapists accused of fraud that cost the government $900 million, the department said. The cases involved an array of charges, including conspiracy to commit health care fraud, money laundering and violations of an anti-kickback law. [NatMemo] (emphasis added)

That gives us a general idea that no, the fraudsters weren’t those so often maligned by conservatives as the “undeserving” poor who take advantage of “sacred tax dollars.”  These are professionals, presumably unwilling to settle for professional earnings, income derived professionally.  We can get a bit more specific.

“One group of defendants controlled a network of clinics in Brooklyn that they filled with patients through bribes and kickbacks.  These patients then received medically unnecessary treatment, for which the clinic received over $38 million from Medicare and Medicaid – money that the conspirators subsequently laundered through more than 15 shell companies.” [Lynch DoJ]

How many “undeserving poor” launder money through 15+ shell corporations?

Detroit clinic billed Medicare for more than $36 million, even though it was actually a front for a narcotics diversion scheme.” [Lynch DoJ]

“…another defendant took advantage of his position in a state agency in Georgia by accepting bribes and recommending the approval of unqualified health providers.” [Lynch DoJ]

Lovely.  Another Department of Justice public statement offers a few more details.

“According to court documents, the defendants participated in alleged schemes to submit claims to Medicare and Medicaid for treatments that were medically unnecessary and often never provided.  In many cases, patient recruiters, Medicare beneficiaries and other co-conspirators allegedly were paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could then submit fraudulent bills to Medicare for services that were medically unnecessary or never performed.  Collectively, the doctors, nurses, licensed medical professionals, health care company owners and others charged are accused of conspiring to submit a total of approximately $712 million in fraudulent billing.”  [HCFU DoJ]

What’s been the nature of the Congressional interest in the Health Care Fraud Unit’s efforts?  In 2013 it was to cut funding for Medicare and Medicaid fraud prosecution efforts. [CNBC] [WaPo] We might also want to remember that any additional mandatory funding beyond 2013 levels did not start  until 2015. [HHS]

The notion that “waste, fraud, and abuse” are associated with government employees and the undeserving – is directly challenged by the efforts of the Departments of Health and Human Services and the Department of Justice, and their findings that the fraudsters are among the professional civilian population – ready and willing to line their own pockets with tax dollars.

But don’t necessarily trust me, listen to the Inspector General:

“Health care fraud drives up health care costs, wastes taxpayer money, undermines the Medicare and Medicaid programs, and endangers program beneficiaries,” said Inspector General Levinson.  “Today’s takedown includes perpetrators of prescription drug fraud, home health care fraud, and personal care services fraud, three particularly harmful types of fraud plaguing our health care system.  This record-setting takedown sends a message to would-be perpetrators that health care fraud is a risky way to line your pockets.  Our agents and our law enforcement partners stand ready to protect these vital programs and ensure that those who would steal from federal health care programs ultimately pay for their crimes.” [DoJ]

Health care fraud investigators and prosecutors should be among the nation’s heroes, not castigated as ‘gum’int bureaucrats,’ and should have budget and resource support commensurate with the importance of what they are trying to accomplish.

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Those Wonderous Republicans

Just a quick thought:

Republican Wonder

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Amodei: Not So Mr. Moderate?

Amodei 3Now this is some turn-around!  On April 28, in the year of our Lord 2014, Representative Mark Amodei (R-NV2) was “chiding” Senate Majority Leader Harry Reid (D-NV) for his position on the Bundy Brigands:

The Republican says he disagrees with Senate Majority Leader Harry Reid’s branding of them as “domestic terrorists” and doesn’t think Heller’s labeling of them as “patriots” helps to resolve the dispute over Bundy’s cattle.  Amodei says the issue is the “culture” of U.S. Bureau of Land Management law-enforcement operations in the West. [KOLO]

But wait! On the same day Representative Amodei was heaping praise on the BLM decision to stand down and refuse to offer the ersatz ‘patriots’ a chance to turn the situation in Bunkerville into their own Ruby Ridge, Waco, whatever other fantasy-land re-enactment they’d imagined for themselves.  Those inclined to accept Representative Amodei’s quick-whip-around talking points as evidence of moderation, should look to his recent voting record.

Exhibit One:  The House GOP budget proposal which leaves Pentagon spending unscathed but slashes funding for the Indian Health Service by 18%.  Also under the GOP meat axe, funding for fire fighting on federal lands, again cut by 18%. [HuffPo]  Not only does Rep. Amodei’s district contain a lengthy list of Reservations, but it’s also been known as the site of several recent, and truly large, wild land fires.  Rep. Amodei is fond of referring to his concern for ranchers in the 2nd District, but is apparently not quite so alarmed at the prospect of range fires destroying their grazing lands.

Nor should we miss the fact that the latest incarnation of the House GOP budget included the “Coupon Care” proposal which would eliminate Medicare as we know it, and substitute a voucher plan in its stead. [CBPP]

In case there are any consumers in the 2nd Congressional District, it should be noted that the Ryan Plan would eliminate the provisions of the Dodd Frank Act which requires that Big Banks have a plan in place to wind down operations, and that the FDIC can require the bankers to establish the plans to PREVENT future bailouts.  The ‘plan’ would also put the future of the Consumer Finance Protection Bureau under the guillotine of future Congressional budget cuts. [Hill]

When H.Con. Res. 96 (Ryan Budget) came to a vote on the House floor on April 10, 2014 — Representative Amodei supported it. [Roll Call 177]

Exhibit Two:  Once upon a time there was a mid-level IRS employee in a regional office who was accused of targeting conservative groups by not allowing political organizations to pass themselves off as social welfare institutions.  Truth be told, Lois Lerner acceded to a plan to look for key terms, like “political,” or “party,” on a watch list of sorts to cull the political from the social.  The ultra-right when ballistic.  “Conservatives were Targets of the IRS!”  Not. So. Fast.  Also on the list were terms like “Blue” and “Green Energy” and “occupied territory” organizations. [Wire]

However, this didn’t stop Government Affairs Committee Chr. Issa from claiming that the IRS ultimately “intended” to target more conservative groups, even as it was actually looking for ACORN successor organizations.

Failing to find any solid evidence of IRS targeting, or even of IRS ‘intent’ to increase scrutiny of conservative applicants, the Republican lead House voted anyway to recommend that Lerner be held in ‘contempt of Congress’ for citing her 5th Amendment rights.

This sort of thing happened on Capitol Hill before during the McCarthy Witch Hunt Era.  Lerner joins 10 Hollywood writers, producers, and directors who were voted “in contempt of Congress” for not cooperating with the infamous HUAC.  [Hist]  Rep. Issa may be missing the point that short term theatrical political gains can easily become long term memories of political infamy.

Who joined in the vote to find Lerner in contempt of Congress? None other than Rep. Mark Amodei (R-NV2), and Rep. Joe Heck (R-NV3).  [Roll Call 203]

Aligning oneself with the likes of Hamilton Fish III, Martin Dies, Jr., is not the way to convince most people that you are a proponent of moderation.

 

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Medicaring and the Great Entitlement Fight

Medicare LogoThe great entitlement fight continues, on ground carefully prepared.  Therefore, some basic information should be inserted before launching yet another discussion.

Reviewing the Obvious

The term “entitlements,” which formerly inferred that the benefits were mandated because the individuals had paid for them (Social Security, Medicare), has been folded back into an argument in which Social Security, Medicare, and public assistance programs are lumped together under the umbrella phrase “welfare.”   In one of the latest iterations conservatives have defended the privatization of the Medicare program as a way to “strengthen welfare for those who need it.” [Ryan, TPM]

This oversimplification comes with some ideological baggage.  Representative Ryan continued: “If I could sum up that disagreement in a couple of sentences, I would say this: Our plan is to give seniors the power to deny business to inefficient providers. Their plan is to give government the power to deny care to seniors,” he said, according to prepared remarks.”  [Ryan, TPM]  While this may sound logical when expressed in highly generalized terms, the practical realities are obviously more complex.

The first practical reality is that Medicare is a single payer health insurance program, the participants in which are all 65 years of age are older.  This translates to health care access for approximately 44.6 million Americans. [HHS] While the Department of Health and Human Services administers the programs, the actual implementation of the insurance services are performed by private firms, the most recent contracts for which were announced in 2009.  [HCF] This insurance program works like all others — the bigger the pool, the more manageable the risk, the more manageable the risk, the more sustainable the policies.

The second practical reality is that it takes two to make a market.  It’s all well and good for Representative Ryan to call for the elderly to “deny their business to inefficient providers,” IF there are providers.  Prior to 1965 approximately 50% of Americans over the age of 65 had either NO medical insurance coverage or had coverage woefully inadequate to meet their needs.  [NCM] T’is an actuarial fact that older people require more medical services, thus the more people in the pool the more sustainable the program.   The hard truth is that the elderly and disabled have no leverage to promote efficient providers or deny custom to inefficient providers IF there are no providers, or very few willing providers,  in the first place.

Broadening the Definition of Welfare

One of the more popular recent arguments for the privatization of the Medicare program is that because the elderly are likely to “take out” of the program more than they paid into it some “subsidy” is involved, and if there is a subsidy the program is, by definition, a welfare program.

In the Samuelson version of Medicare as Welfare argument the elderly are getting more affluent, and healthier, therefore there should be means testing for Medicare insurance.  Omitted from Mr. Samuelson’s argument is that one of the prime reasons the elderly have more disposable income in general than they did in 1965 is that they no longer face unaffordable health insurance premium costs.

Samuelson goes on to contend that means testing is “fair” because the elderly survived the Recession in better financial shape than younger people, and that half the nation’s wealth is owned by those 55 and older.   Again, he conveniently omits the fact that this wealth is increasingly accumulated by a smaller percentage of the total population.

The last Profile of Older Americans issued in 2011 (pdf) by HHS reports:

“The median income of older persons in 2010 was $25,704 for males and $15,072 for females. Median money income (after adjusting for inflation) of all households headed by older people fell 1.5% (not statistically significant) from 2009 to 2010. Households containing families headed by persons 65+ reported a median income in 2010 of $45,763.”

A person’s wealth may increase as property values improve, and total wealth nearly always assumes the inclusion of all assets, but the income available for the purchase of health insurance is another matter.  Yes, there may be some people 55 and older who are increasingly affluent — but the majority of the elderly in this country who are a portion of the 99% are not part of Samuelson’s subset of the affluent elderly.

It’s hard to find much sympathy for arguments which assert that because wealthy Americans are called upon to pay into an insurance program for services which support fellow, less affluent, Americans this is necessarily worthy of the pejorative label  “socialism.”   Likewise, to contend that the entire Medicare program should be means tested because a few affluent people have the wherewithal to avoid using it is to impose the interests of the few upon the needs of the many.   Besides, premiums for Medicare Part B are already pegged to income levels.

Destroying the Village to Save It

The prophets of doom and gloom argue that the very solvency of the Medicare program is problematic and therefore only privatization or means testing are the best alternatives to salvage that program.

The means testing argument is perilously close to advocating the creation of a two-tiered health insurance  system for elderly Americans.  One proposal from the Right suggests that the affluent should be “means tested” and thereby receive fewer benefits while the less wealthy should be enrolled in Medicaid-like welfare programs.  [Cowen WaPo] Translation: The wealthy elderly will get the medical care they can pay for while the remainder (perhaps 99%?) will get what the Congress is willing to fund.

The critique of this thinking can be summarized as follows:

“Financing health care through revenues paid into a single, universal risk pool establishes equity by using progressive tax policies, while providing broad political support for a program from which we would all benefit equally. Providing benefit levels inversely related to life-time income might create the appearance of equity, but, in fact, it destroys equity by forcing many of us into a welfare program, impairing access to the health care that we need.”  [PNHP]

The perfect storm for the elderly in America would be a Medicare program in which (1) senior citizens would be driven back to the private markets with little or no guaranteed competition incentivizing health insurance corporations to reduce premium rates or provide more coverage, and (2) a means tested system in which the universal risk pool is divided into segments by income, and (3) the designation of less affluent, or poor, American elderly as “welfare recipients” in a Medicaid program, in which (4) the financial support would be in block grant form to the states and subject to budget cuts any time the Congress was moved to practice Austerity Economics.

The Trouble With Statistics

There are two ways to reduce spending on Medicare (a) increase the eligibility age and  (b) decrease the benefits.  But LOOK! People are living longer, therefore some economies must be made for the health of the system.  This was argued in a recent Reno newspaper LTE:

“That Americans are living longer is a gift, yet programs that serve these older Americans do not reflect critical changes in life expectancy. When Medicare was established in 1965, men had a life expectancy of 67 and women 73. Today, on average, a man reaching age 65 can be expected to live until 83, women until 85.”

Not. So. Fast.  Some care should be taken with those longevity figures.  Not only do we have an income gap widening in the United States, we also have a widening longevity gap.

“In 1980-82, Dr. Singh said, people in the most affluent group could expect to live 2.8 years longer than people in the most deprived group (75.8 versus 73 years). By 1998-2000, the difference in life expectancy had increased to 4.5 years (79.2 versus 74.7 years), and it continues to grow, he said.

After 20 years, the lowest socioeconomic group lagged further behind the most affluent, Dr. Singh said, noting that “life expectancy was higher for the most affluent in 1980 than for the most deprived group in 2000.”  [NYT 2008] see also: [IJE abstract] [NYT 3/2008]

There’s a racial component to these statistics as well, with whites generally having longer life expectancies than African Americans.  [AJPH] If a person is arguing that “life expectancy” is now 78.9 years of age — that’s true — for White Americans nationally.  For African Americans the number is 74. 6.  If a person is a Native American in South Dakota the life expectancy is 68.2. [KFF]

Longevity 1

As we can see from the chart, some caution should be applied to the tendency to over-generalize about the longevity of Americans.  While increasing the eligibility age for White Americans might seem to make sense, it doesn’t hold quite so well for African Americans, and comes nowhere close to securing the argument if one is considering the longevity of Native Americans.  Further, as the income gap continues to grow, and as it is demonstrable that the income disparity informs the longevity tables, could it not be argued that increasing the eligibility age serves only those already reasonably well served?

The Selection of Oxen To Be Gored

The one proposal which has not attracted the attention of the Beltway is the notion that there is another way to improve the solvency of the Medicare program.  It just happens to be the most painful for the 1%’ers.

“Elite anxiety over entitlement-driven budget deficits and accumulating national debt has created a powerful class in the nation’s capital. The agenda of this class is in many respects on a collision course with mounting demands for action by those lower down the ladder to address the threat to government social insurance programs.” [NYT]

This “elite anxiety” puts the blinkers on the obvious solution to many of the financial issues facing both Social Security and Medicare. Raise  or eliminate the income cap.  Failing to eliminate the cap subject to social insurance taxation, at least increasing the current $113,700 to, say, $250,000 would go a long way toward improving the fiscal outlook of Medicare.  What percentage of the U.S. population would be asked to contribute more if the cap were placed at $250,000?

Earning Over Cap 1

It’s remarkable that 1.2% of the total U.S. population has been so successful at promoting reductions in social insurance, and especially Medicare, programs keeping the focus of the media — and thereby the public — on the Cut Side of the ledger and with barely a mention of the revenue increasing alternatives.

And there are alternatives, what would eliminating the cap do?

“According to the Social Security Administration, fully eliminating the cap on taxable earnings would be sufficient to fully close the projected shortfall. If newly-taxed earnings above the taxable maximum were credited toward benefits, eliminating the cap would close most, but not all, of the gap.” [EPI]

If eliminating the cap altogether isn’t acceptable, then perhaps raising and indexing the earnings cap to include 90% of earnings might be considered.  The EPI suggests that this would cut the shortfall by half.

The EPI offered a third alternative:

“A third option would be to split the difference: eliminate the cap on earnings for employer contributions, and raise the cap to cover 90 percent of earnings for employee contributions. With earnings up to the employee cap credited for benefit purposes, this change would reduce the long-term shortfall by about three-fourths.” [EPI]

The objections to the elimination of the cap center on two major points (1) the more Social Security collects the more benefits it will owe, and (2) the elimination or modification of the earnings cap “isn’t fair.”  The first need not apply to Medicare, and the second serves primarily to confirm the unfortunate perception that the wealthiest among us are being “picked on” for the benefit of that amorphous 47%, although it is asserted that those suffering the most would be those immediately above the income cap level.    The problem with the last argument is that this will be the case in any endeavor in which any standard is established.

Meanwhile, the assault on our social insurance programs continues, and 13.1% of the Nevada population which is over 65 may well wonder what happens next.

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Pushing Their Buttons: Then and Now

Socialism Buttons

Watching the Republicans marching carefully in the footprints of their fore-bearers makes for interesting television, and bad governance.   It doesn’t appear to matter to the Anti-New Dealers still among us that Social Security (and cuts thereto) is the Third Rail of American politics, and it’s instructive that the Tea Party Lady held up her sign reading: “Keep the Government Out of My Medicare.”    Their logic is simplicity itself: If it’s about the collective welfare of the United States and its citizens it’s Socialism.  If it’s Socialism then it must be Anti-American.

100% Americanism

Return with us now to the Red Scare — not the McCarthy Era, the first Red Scare.  The groundwork was laid by George Creel, President Wilson’s chairman of the United States Committee on Public Information, who was tasked with encouraging a reluctant nation into World War I.  [PBS] Americans were listening to the Four Minute Men in their movie theaters, some 7,555,190 speeches between April 1917 and November 1918.  They read some 6,000 press releases, and perhaps saw about 200,000 slide shows.  [SW] The Chambers of Commerce were recruited to help distribute the materials, as well as the Boy Scouts and various fraternal societies.  All the speeches, press releases, periodicals, and propagandizing had one point: Hate The Hun.

And then the war ended.  The Russian regime crumbled, and the Communists installed a new government. In the U.S. returning soldiers had trouble finding work, farmers who had been encouraged to plant fence to fence during the war found themselves with surplus crops and declining prices.   During this unstable period Theodore Roosevelt, Jr. and other interested officers formed the American Legion at the “Paris Caucus.” Subsequent organization of the modern version of the Grand Army of the Republic, lead to the adoption of its promotion of 100% Americanism at its 1919 convention.  The events in Centralia, Washington, November 1919, helped change the conversation.

The Centralia American Legion organized a parade for Armistice Day 1919, while members of the IWW worried that their headquarters were going to be raided, as had been the case with other IWW offices since August 1917.  There continues to be controversy about who shot first, who shot whom, and why anyone was shooting at all, but the result was that four people were dead, and the American Legion’s notion of 100% Americanism was attached in popular imagination with anti-IWW sentiment.  In this milieu it didn’t take too much imagination to substitute “Bolsheviks” for “Huns,” and associate Labor with Bolsheviks.  1920 was a turbulent time, with Red Hunting Results:

As a result of the strikes and unrest, the strikers were branded as “Reds” and as being unpatriotic.  Fear of strikes leading to a Communist revolution spread throughout the country.   Hysteria took hold.  “Red hunting” became the national obsession.  Colleges were deemed to be hotbeds of Bolshevism, and professors were labeled as radicals.  The hunt reached down to public secondary schools where many teachers were fired for current or prior membership in even the most mildly of leftist organizations. [UMKC]

That some opinion leaders tried to differentiate between socialism and communism didn’t substantially alter the ideological landscape or still some of the more radical rhetoric.   Anarchy, socialism, communism, even support for organized labor was “Left” and bad, conservatism and the “Right” was 100% American.

Fast forward to the late 20th century, after the enactment of Social Security and Medicare, and we have Rand Paul, then of  Kentucky Taxpayers United, explaining why Social Security is a Ponzi Scheme and Medicare is … (you guessed it) … Socialism. [TPM]

Privatization

Since there are 57,469,232 Social Security beneficiaries as of June 2013, of whom 40,298,999 are retired persons, 6,216,500 are survivors, and 10,953,733 are disabled individuals and their dependents [SSA] it’s no longer politically expedient to speak of repealing Social Security.   The modern opponents instead talk about privatizing the system.  Their “free market” solution to a non-existent problem involves transforming the Social Security program into “private individual accounts” to be invested in Wall Street.   Failing that, the opponents would like very much to have access to the Special Issue securities, which are held in the Social Security Trust Funds and are currently not available to the public.

The last serious attempt at Privatization came in President George W. Bush’s February 5, 2005 State of the Union speech the details of which changed as the President was buffeted by political winds.  The final gasps included private accounts, reduced benefits, clawback provisions, and limited investment in unspecified index funds. [CAP] By the end of 2005 the President’s proposal was DOA.   In fact, as of March 2005 about 58% of our “100% Americans” were opposed to the proposal.  [WaPo]

The privatization of Medicare isn’t meeting with much more enthusiasm, polling conducted in 2011  found 58% of Americans opposed the GOP plan to replace the Medicare program with private health policies for seniors  subsidized with coupons from the federal government.  [TPR]

In short, when faced with a choice of privatization or the “socialism” of the Social Security and Medicare, the American public prefers a little “socialism” in its political mix.

And now we come to the third button.

Republicans did a good job of associating the provisions of the “Obamacare” law with socialism, but perhaps not so much when the actual name of the law is put forward.  A Kaiser Family Foundation tracking poll in March 2013 found a majority favorable rating for the major elements of the Affordable Care Act, except for the individual mandate.   In short, people liked the tax credits for small business owners, closing the infamous dough-nut hole in Medicare Part D, creating insurance exchanges or marketplaces, extending coverage for dependents, subsidy assistance for those purchasing health care insurance, expanding Medicaid, etc… they liked the parts but not the demagogued whole.

The irony is that a minority in the House of Representatives, still held in thrall by the antiquated sloganeering of the early 20th century anti-Left siren songs, could bring down the economic system they purport to espouse — turning their paeans into a eulogy for the free market system.

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