Policymakers Cannot Deny What Medicaid Expansion Means to Survival

It is never easy to absorb unpleasant information.

And when I was a policymaker, if someone told me that my decisions were going to cost innocent people their lives, then I usually chalked it up either to hyper-sensationalism or hyperbole. 

After all, would passing a small increase in a business tax really force an employer to imperil workers by cutting corners on safety?  Would gun registration really leave a homeowner defenseless in the case of a break-in? Would cutting back welfare a few dollars actually result in a choice between eating or heating in the winter?

In most instances, it was hard to see the direct connection.

But the more I learned about health issues, the more I understood that there really were some decisions that were a matter of life and death.  These were the issues that taught me humility.  These were the issues that taught me that I needed to set aside my political ideology and embrace both theology and hard data whenever they stared me in the face together.

One of those issues was Medicaid. 

Back in the late 1970s, I saw Medicaid as a safety net program for seniors and people with developmental disabilities to help pay for skilled nursing or intermediate care.

And so when Ronald Reagan and, later, George Bush agreed to expand the program to cover children and families, I admit I was skeptical.  Wouldn’t it burden taxpayers who were already paying far more for Medicaid than they ever expected?  Wasn’t private insurance enough? And what would happen if we did not go along – would anyone die without the expansion?

That was always the billion dollar question – who dies without the help of government?

We knew that people caught in fires, victimized by criminals, or trapped by natural disasters died.  We also knew that those who couldn’t get into hospitals, who couldn’t get emergency services, and who were given substandard care in institutions also died as a result.  But we did not know how Medicaid fit into this.

Fortunately, we voted to expand Medicaid anyway, taking it mostly on faith that it was the humanitarian thing to do.  And now we know the result.  We saved a lot of lives, just as if we had disarmed potential killers or rescued people from fires burning out of control,

We do not have to assert this as a matter of faith anymore.  We also have compelling hard data.

I wrote about this in February 2013 in a column I provocatively entitled Failure to Expand Medicaid: Just another Death Penalty?   If you are interested, you can read the full column by clicking on the title, but the essential point was this: Based on a study published in the highly-respected New England Journal of Medicine, it did not take a rocket scientist to calculate that as many as 36,000 lives nationwide hung in the balance of the Medicaid expansion. 

It may not be hard for a policymaker to dismiss the results of a single study; I did it myself in my day.

But it is not quite so easy to dismiss two.  

And there was a second study, conducted by the prestigious RAND Corporation, published by the equally reputable Health Affairs in June of 2013.  I wrote about it in another column entitled Grim Numbers Result from Failure to Expand Medicaid.  By then, we could all come up with a first set of estimates of the numbers of people who would die in just those states that failed to expand Medicaid last year – up to 19,000.

But last year’s sessions were over by the time people saw the report.  And so they likely threw it into the bottom of the circular file and forgot about it.

But can similar evidence be denied a third time – much as Peter denied knowing Christ?

Health Affairs blog published a new report just days ago, entitled Opting Out of Medicaid Expansion: The Health and Financial Impacts.  It found that up to 17,000 lives still hang in the balance in states that have refused to expand Medicaid.

As Health News Florida pointed out: “More than 1,100 Floridians will die prematurely if the state Legislature continues to refuse to expand Medicaid.” As will more than 1,800 in Texas, 500 in Georgia, 400 in North Carolina, 350 in Pennsylvania, and 200 in Missouri, Alabama, Virginia, Louisiana, Tennessee, South Carolina, and Indiana.

Policymakers in those states – and others – can continue to vote against Medicaid expansion, but they had better be willing to embrace what they are doing.  They are sentencing innocent people to death, and they will own this forever.   

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

Race Does Matter

On August 7, 2012, Allen Daniel Hicks, Sr., died of a stroke.  The Hillsborough County FL resident was 51 years old.  At the time of his death, he was coaching Little Leaguers.

It is a tragedy to lose someone so young to a stroke, but it is not uncommon.  And race matters with strokes.

According to the Office of Minority Health at the Department of Health and Human Services, African Americans are 60 percent more likely to have a stroke than their white counterparts.  And African American men like Mr. Hicks are also 60 percent more likely to die from a stroke than are white men.

But Allen Hicks’s death was especially tragic because the circumstances surrounding it eerily echo those surrounding the death of a young black woman named Anna Brown a year earlier and 1000 miles away.

Both died from blood clots.  Mr. Hicks’ was in his brain; Ms. Brown’s was in her lungs.  Both died young and left children behind.  Both suffered from pain and paralysis before they died.  And both deaths could have been prevented with prompt treatment.

But here’s what really ties these two tragedies tightly together.  Both Allen Hicks and Anna Brown were taken to jail when they were taken ill, and both lay there without treatment while they suffered.

I wrote about Anna Brown’s horrifying death last year.  You can read the full column here, so I won’t rehash those details again.

But Allen Hicks’ story is also worth telling, because, along with Anna Brown’s, it raises too many questions for us to ignore.

A headline in Health News Florida directs you to the Tampa Bay Times for the details.  According to the Times, when Allen Hicks suffered the stroke in May 2012 that led to his death he was driving along a highway.  Despite experiencing sudden partial paralysis that caused him to swerve and hit a guard rail, he managed to avoid other vehicles and stop his car on the side of the road.  While he waited, witnesses called 911.

The newspaper account noted the extent of his stroke at that time, when it reported that Hicks was “speaking incoherently and unable to move his left arm” when the officers arrived.  And what was their response when faced with such classic symptoms of a stroke?  In a scene absurdly reminiscent of the movie Meet the Fockers, “Hicks was arrested on a charge of obstructing a law enforcement officer when he did not respond to commands to exit his car.”

Then it got worse.  His left side paralyzed, Hicks was brought to a jail, where he was apparently given no medical screening.  He was placed face down on the floor of a cell.  “From time to time his right limbs twitched,” the newspaper reported, as he apparently tried to crawl to help using the non-paralyzed side of his body.

He waited three hours for a medical evaluation.  The conclusion?  His stroke went unnoticed, but it was recommended that he receive a psychiatric evaluation.

Two hours later, he was transferred to another jail (this is how we often treat psychosis in America – jails are our de facto psychiatric holding facilities), but did not even receive his unnecessary psychiatric evaluation until noon the next day.  He was found to be “delusional with a poor memory.”

As the old saying goes, if all you have is a hammer, everything looks like a nail.

By then, he was past the time period during which “clot buster” drugs can save the brains of stroke victims, and so his brain was probably already permanently damaged.  But his jailers did not notice this.  He was not transported to Tampa General Hospital until twelve hours later, almost 36 hours after he suffered his stroke.

He held on for three months before he died.

The Hillsborough County Sheriff’s Office gave the following statement to the Tampa Bay Times:  "It is clear that mistakes were made by Hillsborough County Sheriff's Office employees and contracted medical staff employed by Armor Correctional Health Services."

The two parties reportedly paid a million dollar settlement to the family.  I doubt that this will make their pain go away.

Nor will it resolve all the troubling questions this story raises.

How could first responders and jailers fail to recognize obvious symptoms of stroke?

When did incoherent speech and paralysis become synonymous with mental illness?

And – at a time when so many wonder if there is a different standard for whites and blacks – why were Anna Brown and Allen Hicks brought to jail in the first place?

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

The Medicaid Elephant in the Supreme Court Room

States’ Medicaid elephants are being dragged into the courts this year.  States had better be careful, or they just might get trampled under the weight of people they’ve failed to enroll.

Last week, CT News Junkie reported the story of a class action lawsuit filed on behalf of almost 7,000 potential Medicaid recipients in Connecticut as of November 2011 whose applications were not processed within the 45 days mandated by federal law.  

And Health News Florida, among others, reported that Florida’s Attorney General Pam Bondi filed a brief with the Supreme Court on behalf of twenty-six states (Connecticut is not one of them) alleging that Congress exceeds its authority when it “coerces states into accepting onerous conditions” of participation in the Medicaid program –even when it pays 90-100% of the costs of those provisions. 

The two battles raise similar questions about how states avoid Medicaid costs today.

The Supreme Court brief is supposed to be an argument against the Affordable Care Act-mandated Medicaid expansion to cover everyone up to 133% of poverty beginning in 2014.

Bondi builds her argument around a simple point.  States depend so heavily on Medicaid money from the federal government that they can’t afford to drop out of the program.

And the ACA-mandated expansion, she argues, will cost Florida almost $1 billion.

But then there’s a stunning revelation in her brief.

Most of the costs she cites have nothing to do with ACA.  They represent the cost of enrolling currently eligible people in the Medicaid program, not those who will become eligible as a result of the Affordable Care Act. 

On page 17 of the brief, she writes that “Florida anticipates spending approximately $351 million on its share of the cost for newly eligible program participants who are presently uninsured and $574 million on the currently eligible but unenrolled.”

In other words, 62% of the costs she’s claiming will result from ACA are actually costs the state should be paying today, but avoids by failing to enroll Medicaid-eligible residents.

The Connecticut class action suit attacks essentially the same issue – failure to enroll currently eligible people.

In paragraph 25 of the complaint, the plaintiffs allege that Connecticut “has set up a system to circumvent the federal timeliness requirements by making it appear that the applicant has failed to provide required documentation.” 

Throughout the nation, these practices result in the avoidance of billions of dollars of costs at the expense of elders, low income children, and people with chronic diseases and conditions – and the health and mental health providers who serve them.

Bondi’s brief suggests that new Medicaid enrollments could cost Indiana about $2 billion over ten years, Arizona and Louisiana over $7 billion, and Texas close to $25 billion.  But these numbers all appear to include the currently eligible populations.

States understandably and justifiably want to contain their Medicaid costs.  But they cross the line when they do it by turning away literally millions of people who already belong on the program.

Bondi works hard to make the currently eligible group relevant to the Affordable Care Act by stretching a silken thread of the individual mandate around them. 

She writes that “the considerable cost for the [currently eligible group] reflects the fact that, unlike for the newly eligible, Congress has not increased federal funding for those newly enrolled (but previously eligible) by virtue of the ACA’s individual mandate.  As a result, the States will continue to pay for up to half of the costs generated by the latter group’s now mandatory enrollment.”

But she stretches the thread to the breaking point.  The individual mandate doesn’t apply to the group of people currently eligible for Medicaid.  Their Medicaid enrollment is “mandatory” by virtue of existing state and federal laws that pre-date ACA.

So what happens when the Supreme Court makes its ruling this spring?

If the Court finds the Medicaid expansion constitutional, then the states will have to implement it in 2014 – and also enroll those currently eligible without further delay. 

But even if it doesn’t, the currently eligible group isn’t going away – and we now know what they will cost.  Florida will still owe at least $574 million and Connecticut will still have to enroll up to 7,000 more eligible people.

That’s the best case scenario.  The worst is that such a ruling could induce the federal government to reduce its role in the Medicaid program to avoid the “coercion” argument in the future.  Then states might have to provide coverage and care to the poor and elderly all by themselves.  

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Florida's $11 Billion Medicaid Gamble

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Treating the public policy arena like a casino is never a good idea.

Florida is placing an $11 billion bet on Medicaid this year.  If the state loses, we’ll all be emptying our pockets for lower services.

The bet involves moving all Medicaid recipients to managed care.  As reported in an article by Jim Saunders in Health News Florida last week, passage of this legislation this year is as close to a sure thing as there is in government.

Florida hopes to save $1 billion the first year, and $2 billion by 2013 – nearly 10% of the total State Medicaid budget.

There are three problems with this calculation.

The first is that the projected savings from moving to managed care might be too high.  In a 2009 report prepared for America’s Health Insurance Plans, the Lewin Group found that savings in 24 different state Medicaid plans ranged from half of one percent to 20% after a switch to managed care.  Savings tended to be low at first, and most were still in the single digits after several years.

The second is that the savings will be offset by lost federal revenues, because the federal government will reimburse at least 55% of Florida’s Medicaid costs the next two years.  The actual savings to taxpayers is under $1 billion in FY2013, less than half of what the Governor and legislators are claiming.

The third problem is that to achieve these savings, Florida has to include elders and people with disabilities – who together account for 70% of Medicaid expenditures – in managed care.

To many people, “managed care” means the same thing as “care delayed or denied.” If $700 million of Florida’s Medicaid savings come from denying care to nursing home residents, cutting back on treatment services to people with mental illness, and delaying care for people with mental retardation, legislators fighting Medicaid growth won’t exactly be hailed as conquering heroes.

Together, these factors leave at most $300 million in savings associated with the non-long term care Medicaid program.

But the savings may not be even that high.

The reality is that Florida had a much slower growth rate in its Medicaid program from 2004 through 2009 than did the nation as a whole. The cumulative savings in Florida over this period was 10% compared to Medicaid spending in the nation as a whole.  Florida may have already squeezed the savings from Medicaid without resorting to managed care. 

Also, there is a new cost associated with turning the program over to the private managed care companies.  Unlike the state, these companies have to make money, which has to be added into the cost calculation.

Finally, reports authored by Jack Hoadley and Joan Alker of the Georgetown Health Policy Institute and released yesterday by the Jessie Ball DuPont Fund suggest that Florida’s own Medicaid managed care pilot program has disrupted care for Medicaid recipients while saving little or no money. 

In the face of all this evidence, saving even $300 million in Medicaid non-long term care is a long shot. 

So on what is Florida wagering $11 billion? 

Senator Joe Negron, the Senate legislation’s sponsor, says that Florida will drop out of the Medicaid program if the Federal Government refuses to go along with Florida’s managed care plan.

That’s an $11 billion gamble – the annual Federal reimbursement that Senator Negron says Florida will give up if the federal government doesn’t let it switch to managed care.      

Obtaining federal approval for unpopular Medicaid changes which could disproportionately and adversely affect elders is no sure thing.     

If Florida drops out of Medicaid, 3 million Medicaid recipients will become uninsured.  This will bring the total number of uninsured people in Florida to close to 7 million – more than 35% of the population.

Hospitals, nursing homes, independent physicians, community health centers, mental health centers, and other providers do not have the capacity to absorb care for 7 million uninsured people. 

Instead, Florida would have to create and fund a new plan to pay for the care of all 7 million people.  To do this, it would have 9 billion state Medicaid dollars with which to work. 

$9 billion – or $1,300 per person – may seem like a lot of money to provide care for these 7 million people.  But they aren’t young and healthy – remember, 70% of the Medicaid dollars go to long term care – and one nursing home bed alone can cost fifty times this amount.

$9 billion could disappear in a matter of weeks.

Florida can’t afford the gamble.  If saving $300 million in the Medicaid non long-term care program is the state’s goal, it should either find out in advance if the federal government is willing to approve or find another way to do it.   

After all, Florida’s not playing with house money, but ours.      

Making People with Mental Illness Pay the Price

Isn’t it worth a few dollars to preserve essential mental health services?  It would appear that many state legislators would say no.

According to the National Alliance on Mental Illness, states have cut a total of $1.6 billion for mental health services over the past three years.

That was just the teaser. 

This year, states around the country are making people with mental illness pay the price for tax cuts and deficits.

NAMI state-by-state data show that the State of Florida spends no more for mental health services than it did in 2009.  But Health News Florida reports that the Florida Senate has proposed millions of dollars of cuts to mental health. 

Next week, its Appropriations Committee will vote whether to cut $137 million from adult mental health services, 57% of the total outpatient budget.  Anyone who thinks these services aren’t essential should think again.

On a single day this spring, in addition to offering its full array of group counseling, AA, NA, and individual support services, the only full-time peer drop-in center operated by MHA of Palm Beach County dealt with the death from natural causes of a middle-aged client (people with mental illness die 25 years earlier than normal), a former client’s suicide, a hospital patient discharged to the center for follow-up services, and a person with a traumatic brain injury who had no other place to go.

“Days like this are now common,” commented MHAPBC CEO Pam Gionfriddo, “and will become even more so if policymakers keep cutting.”

 Over 5,300 people in central Texas alone will lose services, according to the Austin American Statesman, if a proposed 20% cut in outpatient mental health services goes through.  The CEO of Austin’s major service provider said this would add to the suffering of families, and Lynn Lasky Clark, President of Mental Health America of Texas added that those affected would be “devastated.”

Texas already spends 3% less on mental health services than it did in 2009. 

Nevada spends 17% less on mental health services than it did in 2009.

But, according to the Las Vegas Sun, the Governor’s proposed budget includes millions of dollars of additional service cuts, including cuts to triage centers in Las Vegas and Reno and to outpatient counseling services.

Sen. Sheila Leslie termed the cuts “a mental health catastrophe.”

Tennessee already spends 10% less on mental health services than it did in 2009.

Now, Tennessee is proposing to cut $31 million more from mental health services, affecting all areas of the state.

The northeast is not immune.  New Hampshire has cut mental health funding by 8% in the last two years.  This year, the state is considering eliminating all services for two-thirds of the 20,000 people for whom it has responsibility. 

Ditto the northwest.  Oregon actually added 23% to its state mental health budget the past two years.  However, Disability Rights Oregon reports that the state is now proposing cutting mental health services by 30%, costing 45,000 Oregonians access to care.

Let’s call this exactly what it is – public officials across the country pummeling people who are the least able to defend themselves.

The bad economy is a phony excuse. 

Even in the Great Depression, state policy makers increased mental health services to meet increased needs.  The census of patients served in mental hospitals – the only care option available at the time – grew from 272,252 on January 1, 1929 in 1929 to 321,824 on January 1, 1934, and the number of first admissions – a signal that new needs were being met – rose from 60,500 on January 1, 1929 to 69,368 on January 1, 1933.

Do policymakers really think times are tougher today than they were then?

Most legislators pray to God for enlightenment and compassion at the opening of each session.  Here is an excerpt from a Florida Senate prayer this year, offered on March 16^th by Monsignor Thomas Skindeleski of Delray Beach:

“Open our minds to better understand the needs of those who have chosen us to serve them. Teach us how to craft laws that will better the lives of millions of people who are counting on our efforts to serve them well.  Let justice and peace be foremost in our minds as we endeavor to legislate in ways that will benefit the lives of our people. Direct our efforts to preserve the life and liberty of the most vulnerable members of our society.”

It’s a powerful prayer.  I hope our leaders listened. 

Don’t smirk.  When was the last time we told our own elected officials that we willing to pay taxes to provide services to people with mental illness?  Today – before it’s too late – is the day to call, email, or forward this column to a policy leader.

We must add our voices to those of the mental health advocates speaking up for some of the most vulnerable members of our society.

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The Brick Walls in the Battle Against Health Reform

States battling to repeal new health reform mandates have settled on two issues that may well turn out to be political brick walls. 

One issue is the requirement beginning in 2014 that individuals purchase insurance or pay an income tax surcharge, the so-called “individual mandate.”  The other is the federal expansion of the Medicaid program. 

The battle is being joined in the courts, the Congress, and state legislatures.

Most of the action so far has been in the courts. 

Florida has filed a suit challenging both the individual mandate and Medicaid expansion.  CNN calls it the “highest profile” lawsuit of many, and 19 other states have joined it.

Florida argues that the individual mandate is unconstitutional, contending that it’s unconstitutional for the federal government to require individuals to purchase health insurance by taxing them if they don’t.  As of last week, federal judges in both Michigan and Virginia have ruled against this position in other cases, but these decisions will be appealed. 

Florida’s argument against expanding the Medicaid program is more about public policy than the constitution. The Medicaid expansion will add 17 million uninsured people nationwide to Medicaid beginning in 2014.  This will cost a lot of money, and that’s the basis of the objection. 

However, for the first few years the federal government will pick up the entire cost of the expansion.  This means that states and localities initially will actually save millions of dollars they’ve been using to pay for care for the uninsured.

Also, the federal government doesn’t require states to participate in the Medicaid program.  Medicaid is not administered as one big federal program, but as fifty different state programs.

Why don’t states simply opt out?  When Governor Rick Perry of Texas floated the idea earlier this year, his own Health Commissioner quickly shot it down.  It’s because the Medicaid program draws down billions of federal dollars.  These pay not only for health care for poor people, but also for nursing home and home health care for seniors and intermediate care for people with disabilities.

A state opting out of Medicaid would be between a rock and a hard place.  It would bankrupt and alienate seniors and people with disabilities, while killing off some hospitals, nursing homes, and home health agencies that rely on these payments.  Or it could pay the whole bill itself, and its political leaders would have to preside over the biggest tax increase in state history.

Still, today’s court cases are only the opening volleys in this battle.  Even though they raise issues that seem today to create losing scenarios for the states, at least one case – perhaps Florida’s – will eventually reach the Supreme Court.  Health reforms will have been in place for years by then, and no one can say what the Court will focus on, what it will decide, or what the political landscape will be.

How will the other two battlefronts play out for states this coming year?  They’ll be noisy at times, but little ground will be gained or lost.

First, some members of Congress will try to choke off some funding to slow down reform implementation while introducing bills aimed at paving the way for more state challenges to reform.

Senator Roger Wicker (R-Mississippi) is introducing one of these this week.  They’ll argue “states’ rights,” noting that states – not the federal government – should determine how best to protect the health and well-being of their citizens.  None of these measures will pass, but they will give some cover to politicians trying to appease angry voters.

Second, state legislators will introduce and pass legislation that will be carefully crafted not to do too much too soon. 

Florida’s legislature is already working on its plan.  As Jim Saunders reported in Health News Florida on November 23^rd, Florida legislators are reviving a proposed constitutional amendment giving Florida residents the right to opt out of purchasing health insurance.  Voters may eventually get the chance to air their frustration by voting for the amendment, but even if it passes, it won’t affect anyone until 2014. 

By then, many of the crusading legislators will be out of office, and the Courts will all have ruled.  If they find the individual mandate constitutional, will anyone refusing to buy insurance want be the first one who refuses to pay the federal income tax surcharge?   That fight will be a lonely battle against the IRS, and not one the individual is likely to win.