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Medicare

Another national publication looks at CD07

Mother Jones, come on down.

Rep. John Culberson

In addition to [Laura] Moser, the top competitors for the March primary are first-time candidates with stories that fit the political moment in different ways. Lizzie Fletcher, a well-connected lawyer at a large downtown firm, got her start in politics as a teenager during the 1992 Republican National Convention, when she volunteered to stand outside abortion clinics blocking Operation Rescue types from chaining themselves to the entrance. Alex Triantaphyllis, who at 33 is the youngest of the bunch, co-founded a mentoring nonprofit for refugees in Houston after spending time at Goldman Sachs and Harvard Law School. Jason Westin, an oncologist and researcher at Houston’s MD Anderson Cancer Center, told me he first thought about running a week after the election, after watching his daughter’s soccer game. She had taken a hard fall and Westin told her to “get back up and get back in the game”—but sitting on the couch later that day, scrolling through Facebook, he decided he was a hypocrite. He decided to enter the race with encouragement from 314 Action, a new political outfit that encourages candidates with scientific backgrounds to run for office. The primary is not until March, but in a sign of the enthusiasm in the district, Culberson’s would-be Democratic challengers have already held two candidate forums.

The 7th District starts just west of downtown Houston, in the upscale enclave of West University Place near Rice University, and stretches west and north through parts of the city and into the suburbs, in the shape of a wrench that has snapped at the handle. It had not given any indication of turning blue before last year. But a large number of voters cast ballots for both Hillary Clinton and Culberson. Moser and Fletcher see that as a sign that Republican women, in particular, are ready to jump ship for the right candidate. In the Texas Legislature, West University Place is represented by Republican Sarah Davis, whose district Clinton carried by 15 points, making it the bluest red seat in the state. Davis is an outlier in another way: She’s the lone pro-choice Republican in the state Legislature and was endorsed by Planned Parenthood Texas Votes in 2016. “To the outside world it looks like a huge swing,” Fletcher says of the November results, “but I think that a more moderate kind of centrist hue is in keeping with the district, so I’m not surprised that people voted for Hillary.”

But whether they’re Sarah Davis Democrats or Hillary Clinton Republicans at heart, those crossover voters still make up just a small percentage of the overall population. Houston is the most diverse metro area in the United States, and a majority of the district is non-white—a fact that’s not reflected in the Democratic candidate field. To win, Democrats will need to lock in their 2016 gains while also broadening their electorate substantially from what it usually is in a midterm election. That means making real inroads with black, Hispanic, and Asian American voters in the district, many of whom may be new to the area since the last round of redistricting. “[The] big thing in the district is getting Hispanic voters out, and nobody knows how to do that,” Moser acknowledges, summing up the problems of Texas Democrats. “If we knew how, we wouldn’t have Ted Cruz.”

[…]

At a recent candidate forum sponsored by a local Indivisible chapter, Westin, the oncologist, warned voters against repeating the mistakes of Georgia. “One of the take-home messages was that a giant pot of money is not alone enough to win,” he said. Westin’s message for Democrats was to go big or go home. While he believes the seven candidates are broadly on the same page in their economic vision and in their opposition to Trump, he urged the party to rally around something bold that it could offer the public if it took back power—in his case, single-payer health care. “We’re behind Luxembourg, we’re behind Malta, we’re behind Cypress and Brunei and Slovenia in terms of our quality of health care,” Westin says. “That is astounding.” Who better to make the case for Medicare-for-all, he believes, than someone in the trenches at one of the world’s most prestigious clinics?

Moser, who likewise backs single-payer, may be even more outspoken about the need to change course. She argues that the Obama years should be a teachable moment for progressives. They let centrists and moderates like former Sens. Joe Lieberman and Max Baucus call the shots for a once-in-a-generation congressional majority, she says, and all they got was a lousy tea party landslide. “I don’t know if we would still have been swept in 2010—probably, because that’s the way it goes—but at least we could have accomplished some stuff in the meantime that we could claim now more forcefully and more proudly,” she says. A missed opportunity from those years she’d like to revisit is a second stimulus bill to rebuild infrastructure in places like Houston, where floods get worse and worse because of a climate Culberson denies is changing.

In Moser’s view, Democrats lose swing districts not because they’re too liberal but because they’re afraid to show it. When DCCC Chairman Ben Ray Luján, a congressman from New Mexico, told The Hill in August that the party would support pro-life Democratic candidates next November on a case-by-case basis (continuing a long-standing policy backed by Nancy Pelosi), Moser penned another article for Vogue condemning the position. “As a first-time Congressional candidate, I’ve been warned not to criticize Ben Ray Luján,” she wrote, but she couldn’t help it. Red states like Texas were not a justification for moderation; they were evidence of its failure. “I have one idea of how to get more Democratic women to polling stations: Stand up for them.”

Fletcher and Triantaphyllis have been more cautious in constructing their platforms. They’d like to keep Obamacare and fix what ails it, but they have, for now, stopped short of the single-player proposal endorsed by most of the House Democratic caucus. “I don’t think anyone has a silver bullet at this point,” Triantaphyllis says. Both emphasize “market-based” or “market-centered” economic policies and the need to win Republican voters with proposals on issues that cut across partisan lines, such as transportation. Houston commutes are notorious, and Culberson, Fletcher notes, has repeatedly blocked funding for new transit options.

Still, the field reflects a general leftward shift in the party over the last decade. All the major candidates oppose the Muslim ban, proposals to defund Planned Parenthood, and Trump’s immigration crackdown. Even in America’s fossil-fuel mecca, every candidate has argued in favor of a renewed commitment to fighting climate change. It is notable that Democratic candidates believe victory lies in loudly opposing the Republican president while defending Barack Obama in a historically Republican part of Texas. But Moser still worries her rivals will fall for the same old trap.

“I just think in this district people say, ‘Oh, but it’s kind of a conservative district,’ [and try] to really be safe and moderate, and I find that the opposite is true,” Moser says. “We just don’t have people showing up to vote. We don’t even know how many Democrats we have in this district because they don’t vote.”

Pretty good article overall. I often get frustrated by stories like this written by reporters with no clue about local or Texas politics, but this one was well done. This one only mentions the four top fundraisers – it came out before Debra Kerner suspended her campaign, so it states there are seven total contenders – with Moser getting the bulk of the attention. It’s one of the first articles I’ve read to give some insight into what these four are saying on the trail. They’re similar enough on the issues that I suspect a lot of the decisions the primary voters make will come down to personality and other intangibles. Don’t ask me who I think is most likely to make it to the runoff, I have no idea.

As for the claims about what will get people out to vote next November, this is an off-year and it’s all about turnout. CD07 is a high turnout district relative to Harris County and the state as a whole, but it fluctuates just like everywhere else. Here’s what the turnout levels look like over the past cycles:


Year    CD07   Harris   Texas
=============================
2002  37.37%   35.01%  36.24%
2004  66.87%   58.03%  56.57%
2006  40.65%   31.59%  33.64%
2008  70.61%   62.81%  59.50%
2010  49.42%   41.67%  37.53%
2012  67.72%   61.99%  58.58%
2014  39.05%   33.65%  33.70%
2016  67.04%   61.33%  59.39%

These figures are from the County Clerk website and not the redistricting one, so the pre-2012 figures are for the old version of CD07. High in relative terms for the off years, but still plenty of room to attract Presidential-year voters. Note by the way that there are about 40,000 more registered voters in CD07 in 2016 compared to 2012; there were 20,000 more votes cast in 2016, but the larger number of voters meant that turnout as a percentage of RVs was down a touch. Job #1 here and everywhere else is to find the Presidential year Democrats and convince them to come out in 2018; job #2 is to keep registering new voters. The candidate who can best do those things is the one I hope makes it on the ballot.

What do our elected officials think about the plan to kill off Medicare?

Hey, remember when this was a major campaign issue?

With all the other things we’ve discussed so far today, I wanted to return to one critical one. It’s not about mights or maybes or fears of what’s to come. It’s about what’s coming just after President-Elect Trump’s inauguration. Paul Ryan has been pushing to phase out Medicare and replace it with private insurance for several years. But now it’s real with unified Republican government. He just said he will try to rush it through early next year while repealing Obamacare.

[…]

I’ve heard a few people say that it’s not 100% clear here that Ryan is calling for Medicare Phase Out. It is 100% clear. Ryan has a standard, openly enunciated position in favor of Medicare Phase Out. It’s on his website. It’s explained explicitly right there.

Ryan says current beneficiaries will be allowed to keep their Medicare. Says. But after the cord is cut between current and future beneficiaries, everything is fair game. For those entering the system, Ryan proposes phasing out Medicare and replacing it private insurance with subsidies to help seniors afford the private insurance. That is unquestionably what it means because that is what Ryan says. So if you’re nearing retirement and looking forward to going on Medicare, good luck. You’re going to get private insurance but you’ll get some subsidies from the government to pay the bill.

Through all the gobbledygook and bamboozlement, you’ll find this line on Ryan’s page: “For younger workers, when they become eligible, Medicare will provide a premium-support payment and a list of guaranteed coverage options – including a traditional fee-for-service option – from which recipients can choose a plan that best suits their needs.”

This means, if you haven’t gone on Medicare yet, when you do, you won’t get Medicare. You’ll get a “premium-support payment” – i.e., a check that will allow you to buy insurance from private insurers. The “support” in the phrase means it won’t cover the whole amount. And in any case, rather than Medicare you’ll have insurance from an insurance company, which everybody should love because haven’t you heard from your parents and grandparents how bummed they were when they had to give up their private insurance for Medicare?

You’ll hear lots of people calling this “reform” and other catchwords. But Medicare is a single payer, universal health care system. Replacing it with private insurance means getting rid of it. Even calling it “privatization” masks what is really afoot.

Every Democrat should be focused and talking about it volubly both as a matter of policy and politics. There isn’t much time.

Yeah, I don’t remember that being a campaign issue, either. Maybe it was discussed in one of those emails that got deleted. But there it is, whether anyone realized it or not. If you need a bit of brush-up on what that means, see here and here.

Now then. The fact that this went basically undiscussed for the last year is unfortunate, but it’s where we are. There’s no time like the present to bring it out from under a rock and shine a little light on it. TPM is on that.

DC journalists tend to think this kind of story evolves in DC. And there’s plenty to follow in Washington. But the real action happens in the states and congressional districts where members of Congress have to sell getting rid of Medicare to their constituents. And that is going to come out in local media, constituent letters, public appearances and so forth. So let us know what you are seeing where you live. In the local paper, on TV, something you hear directly from a representative or senator. Find out where your representative or senator stands on this issue. We want to know.

I’d like to know, too. I live in CD18, and I feel as close to certain as it is possible to be that Rep. Sheila Jackson Lee will not vote to “reform” Medicare. But there are 35 other members of Congress in Texas, most of them Republican. It sure would be nice to know what they think about this, and that includes the Democrats, who may claim to be as in the dark as some Republicans are now claiming to be. So why not give your member of Congress a call and ask them if they support the Ryan plan to privatize Medicare. You might point out to the Republican members that they have voted for it in the past. You might also point out that Trump himself has flipflopped on the issue and now supports it himself. Whatever answer you get, please let me know – kuff@offthekuff.com is the email address. Expect denial, ignorance, and sheer bullshit, but any answer you get is more information than we had before.

No Medicaid expansion for you!

So much for that.

Texas will not expand Medicaid or establish a health insurance exchange, two major tenets of the federal health reform that the U.S. Supreme Court upheld last month, Gov. Rick Perry said in an early morning announcement.

“I stand proudly with the growing chorus of governors who reject the Obamacare power grab,” he said in a statement. “Neither a ‘state’ exchange nor the expansion of Medicaid under this program would result in better ‘patient protection’ or in more ‘affordable care.’ They would only make Texas a mere appendage of the federal government when it comes to health care.”

Perry’s office said he’s sending a letter to U.S. Health and Human Services Secretary Kathleen Sebelius [Monday] morning asserting his opposition, both to accepting more than a hundred million federal dollars to put more poor Texas adults onto Medicaid, and to creating an Orbitz-style online insurance marketplace for consumers.

Of course, opting out of creating a state exchange means that the federal government will create one instead. It does not mean there will be no exchange in Texas. This is why some Republican legislators like Rep. John Zerwas tried to pass a bill to create an exchange, so that it would be implemented by Texas instead of the federal government. The rationale for not implementing the state-run exchange confounds me, but I have never been Rick Perry’s intended audience.

As for the refusal to expand Medicaid, just on Friday the Dallas Morning News reported that Perry was still thinking about it.

Gov. Rick Perry won’t say whether Texas should take or reject the federal largesse that could allow the state’s Medicaid program to cover more poor adults.

But a spokeswoman confirmed Friday that his aides have begun canvassing health care provider groups for their opinions about expanding Medicaid and creating a state health-insurance exchange

Though he’s a staunch opponent of President Barack Obama’s federal health care law, Perry’s reluctance to declare immediate opposition to the Medicaid expansion after the Supreme Court’s ruling last week puts him at odds with several other Republican governors. Some, such as Florida’s Rick Scott, have already vowed to keep their states on the sidelines, taking advantage of the court’s ruling that they can do so without jeopardizing the funds they already receive.

Perry spokeswoman Catherine Frazier played down the calls as routine outreach on a major issue. But several health-care lobbyists and experts said it’s shrewd for Perry to say little because the Supreme Court ruling gives him leverage to negotiate with the Obama administration for tighter Medicaid eligibility rules and leaner benefits before agreeing to the expansion, which would take place starting in 2014.

“It’s smart politics because there’s no need to make a decision at this time, and he and a lot of Republicans are playing for more flexibility within the program,” said Tom Banning, chief executive and executive vice president of the Texas Academy of Family Physicians.

Apparently, he didn’t listen very closely to what the health care providers want, because they have made their preference quite clear.

Getting the Medicaid expansion in place has already become the “number one priority” for the Texas Hospital Association, said John Hawkins, the senior vice president for advocacy and public policy at the organization. “It’s the kind of thing that hits our members right on the margin when they’re trying to digest other payment cuts,” he said.

Twenty-seven percent of working-age Texans, or more than 6.1 million people, were uninsured in 2010, according to the Kaiser Family Foundation. That’s the highest rate in the nation and the second-highest number to California’s 7 million people. Under the Medicaid expansion, 2.5 million Texans would qualify, the Urban Institute estimates.

But Texas Gov. Rick Perry (R) has been a staunch opponent of health care reform and his administration has indicated a willingness to opt out of the Medicaid expansion. For Texas hospitals, which absorbed $4.6 billion in unpaid bills and charity care in 2010, that’s a problem, Hawkins said.

I’m thinking that will provide for some interesting fundraising pitches this fall. My advice to them is to start donating to Democrats now.

So now Rick Perry will take a victory lap on Fox News and bask in the adulation of his cultish supporters. Everyone else will have to deal with the reality of this, starting with county taxpayers.

It's constitutional - deal with it

Unlike many states, Texas does not directly subsidize the cost of caring for the uninsured. Instead, taxpayers in Dallas County and elsewhere help pick up that tab through property taxes that support safety-net hospitals such as Parkland Memorial Hospital.

Last year, Parkland reported that its own cost for delivering uncompensated care was $335 million. Dallas County taxpayers funded $425 million, or 35 percent, of the hospital’s operating budget.

For the average Dallas County homeowner, that created a hospital tax bill of $370.

Some advocates of health reform say the new revenue from Medicaid payments is large enough that hospital districts — whose budgets are controlled by county commissioners — could reduce their tax rates.

[…]

Some experts expect that Texas will eventually accept the Medicaid funding. After all, the federal government would cover the entire cost of the expansion between 2014 and 2016. Hospitals that have struggled to find ways to offset charity care are certain to demand that state lawmakers take the money.

“It really depends on the political pressure they get from the counties and the hospitals that benefit from having these people covered,” said John Holahan, director of the Urban Institute’s Health Policy Center. “To leave all this federal money on the table will create an intense debate.”

The hospitals are big losers as well.

Hospitals regularly get stuck with bills that the uninsured cannot afford to pay. Every year, the American Hospital Association adds all those bills up to calculate the total amount of uncompensated care that its members provide. Every year, the number gets bigger and bigger, hitting $39.3 billion in 2010. Here’s a chart I put together with the AHA data:

Under the health reform law, hospitals will see reductions in some of their Medicare reimbursement rates. They will be forced to deliver higher quality or see financial consequences.

All of that was worth it, in hospitals’ eyes, because of the insurance expansion. That would finally put someone on the hook for the medical bills that have, for decades, gone unpaid.

If states opt-out of the Medicaid expansion, that essentially means there’s no one on the hook for some of the poorest patients. And that explains why Bruce Siegel, president of the National Association of Public Hospitals, calls states opting out a “potentially disastrous outcome” and is urging Congress to come up with a fix. For them, the status quo is the worst possible outcome: One where they have accepted cuts to Medicare, and still get stuck with billions in unpaid bills.

Remember, a part of the Affordable Care Act was a reduction in the federal subsidy for uncompensated care costs because it assumed the expansion of Medicaid would greatly reduce the number of uninsured patients. Unfortunately, no one foresaw the SCOTUS decision striking down the provision that states would lose existing Medicaid funding if they didn’t accept the subsidies to expand it, and so here we are. Just as a reminder, states like Texas that have a lot of uninsured people would have benefited greatly from it as a result. It was a simple case of red state/blue state math.

The deal the federal government is offering states on Medicaid is too good to refuse. And that’s particularly true for the red states. If Mitt Romney loses the election and Republicans lose their chance to repeal the Affordable Care Act, they’re going to end up participating in the law. They can’t afford not to.

Medicaid is jointly administered between states and the federal government, and the states are given considerable leeway to set eligibility rules. Texas covers only working adults up to 26 percent of the poverty line. The poverty line for an individual is $11,170. So, you could be a single person making $3,000 a year and you’re still not poor enough to qualify for Medicaid in Texas. That’s part of the reason Texas has the highest uninsured rate in the nation.

Massachusetts, by contrast, covers working adults up to 133 percent of the poverty line — partly due to a former governor whose name rhymes with Schmitt Schmomney. It’s a big reason it has the lowest uninsured rate in the nation.

The Affordable Care Act wants to make the whole country like Schmitt Schmomney’s Massachusetts. Everyone earning up to 133 percent of the poverty line, which is less than $15,000 for an individual, gets Medicaid. And the way it does that is by telling states the feds will cover 100 percent of the difference between wherever the state is now and where the law wants them to go for the first three years, and 90 percent after 2020.

To get a sense of what an incredibly, astonishingly, unbelievably good deal that is, consider this: The federal government currently pays 57 percent of Medicaid’s costs. States pay the rest. And every state thinks that a sufficiently good deal to participate.

But, somewhat perversely, the states that get the best deal under the law are states like Texas, which have stingy Medicaid programs right now, and where the federal government is thus going to pick up the bill for insuring millions and millions of people. In states like Massachusetts, where the Medicaid program is already generous and the state is shouldering much of the cost, there’s no difference for the federal government to pay.

So if Texas had accepted Medicaid expansion, it would have gotten a vastly better deal than states like New York, California, and Massachusetts. Now that Texas has decided to “send that money back” to Washington, we will subsidizing the Medicaid expansions of New York, California, and Massachusetts, and getting nothing in return. Does that sound like a good idea to you? BOR, Neil, EoW, Juanita, Hair Balls, Ed Kilgore, Sarah Kliff, and Rep. Garnet Coleman have more, and statements from Rep. Jessica Farrar and Sen. Rodney Ellis are beneath the fold.

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What radicals?

I was reading this Patricia Kilday Hart column about how nobody outside Texas paid attention to the sonogram bill until the Virginia brouhaha and the Doonesbury series, which is a good albeit frustrating read, when I came across this bit that was frustrating for an entirely different reason:

In the Texas Legislature, votes like Davis’ – outside party lines – are increasingly rare, according to research conducted by Dr. Mark Jones of Rice University’s Baker Institute.

Jones has data to prove what most of us know by gut instinct: The Texas Legislature has become a more polarized institution in recent decades.

In the past, lawmakers of both parties would overlap on the conservative-liberal spectrum. Now, both parties are dominated by their extremist wings. Moderate Republicans oppose ideologically charged issues like the sonogram bill “at their peril,” Jones says.

Oh, for Pete’s sake. Please, Professor Jones, tell me who these people are that have radicalized the Democratic Party. I mean, I don’t know who you talk to, but I know an awful lot of folks who will laugh in your face if you suggest the Democratic Party has moved appreciably to the left in recent years. Tell me also what positions the Democratic Party has taken that are noticeably more extreme than they used to be, and what legislation they have been pushing to further those radical ends.

These questions are easy to answer for the Republican Party. For who the radicals are, start with Dan Patrick, Debbie Riddle, Wayne Christian, and most of the people that got elected in the 2010 wave. Oh, and Rick Perry, David Dewhurst, Greg Abbott, and now Susan Combs, too. Just compare the David Dewhurst who is running for US Senate to the one who presided over the Texas Senate in 2003, as a for-instance. The GOP as a whole has gone from a position of generally opposing abortion to a full-fledged attack on birth control and family planning, and from a position of generally supporting lower taxes and fewer regulations to opposing any tax increase on anything for any purpose, pushing huge tax cuts for the wealthy, cutting public education, and seeking to end Medicare. There’s quite a bit of polling data to suggest that they are sprinting towards a cliff by embracing these more radicalized stances, but even Republicans with a mostly moderate history are doing so because it’s what their base is demanding and they fear their primaries more than they fear their Novembers.

My point is there’s just no comparison. The Democratic Party has moved left on some things, most notably marriage equality, but it’s been a gradual shift that’s in line with previously held views on civil rights, and more to the point it’s consistent with national polling. The Republicans have moved way, way more to the right, and it’s happened almost entirely in the last two years, despite a plethora of polling evidence that should warn them against it. The “both sides do it” trope is ludicrous on its face. Why is this so hard to recognize?

Tort “reform” is still a scam

I know, I’m as shocked as you are.

A national report released Wednesday says the 2003 Texas law that limited damage awards in malpractice suits has caused health care spending to rise and has not significantly increased the number of doctors in Texas.

[…]

The 24-page report by Public Citizen, “A Failed Experiment,” says that using Texas as a model would benefit doctors and insurers — not residents.

The report claims that Medicare spending in Texas has risen faster than the national average, and so have private health insurance premiums. It also says that, contrary to Perry’s claims, the per capita increase in the number of doctors practicing in the state has been much slower since the state passed the so-called tort reform law than it was before the law.

Organizations that support the 2003 law — the Texas Medical Association and the Texas Alliance for Patient Access — disputed the report’s assertions on the number of physicians who have come to the state. As for health care costs, “we never said consumer costs would go down,” Jon Opelt, the alliance’s executive director, said Wednesday.

You can see the Public Citizen press release here, and the full report here. I wish I had done enough blogging on the 2003 tort “reform” issue to take a crack at evaluating Opelt’s claim that no one promised this would help consumers, but I didn’t so I can’t. It sure sounds bogus to me, and I don’t believe him for a minute. I distinctly remember seeing pro-tort “reform” propaganda in the waiting room of our obstetrician around the time of the vote, and while I can’t remember exactly what it said, I’m sure it promised some benefits to the voting public. Anyway, while I can’t directly judge that claim I can say that the pro-tort “reform” side did make some outlandishly exaggerated promises about insurance rate reductions for doctors that they later tried to walk back. The Public Citizen report notes that insurance costs have eased a bit for doctors since 2003, but not that much. Anyway, check it out for yourself, and if you have any clearer memories – or better yet, evidence you can point to – about what the tort “reform” crowd said would happen if we all gave the insurance lobby a pony, leave a comment and let us know.

Feds may prevent some cuts to Planned Parenthood

Good news, at least potentially.

Stephanie Goodman of the Texas Health and Human Services Commission confirms that the federal Center for Medicare and Medicaid Services sent a bulletin advising state officials that federal rules do not permit states to ban certain health care providers “because they separately provide abortion services.”

The bulletin notes that while federal money cannot be used to pay for abortion services except in extraordinary circumstances like rape or saving the life of the mother, “at the same time, Medicaid programs may not exclude qualified health care provicers — whether an individual provider, a physician group, an outpatient clinic, or a hospital–from providing services under the program because they separately provide abortion services.”

Several states, including Texas, have attempted to restrict funding to Planned Parenthood because legislators suspect that government funds are co-mingled with their abortion services. In the recently-ended regular session of the Texas Legislature, lawmakers considered but failed to adopt a “poison pill” provision banning the state from allowing Planned Parenthood to offer family planning and other women’s health services. But budget writers did include a provision in the state budget prioritizing what types of clinics would receive limited government funds for those services — and listed Planned Parenthood last.

State Rep. Garnet Coleman, D-Houston, said he was inquiring into the bulletin, but believes it could affect the budget rider.

“The argument they make is about (patients having) choice of providers,” he explained. “So I believe one could argue it applies because your choices are limited (under the rider) and that is not what the federal government intended.”

Previously, the feds had informed the state of Indiana that its Medicaid plan, which bans funding to Planned Parenthood, is illegal. I don’t know enough about either state’s bills to be able to make a comparison, but the fact that the Obama administration is taking an aggressive stance in defending Medicaid from state shenanigans is definitely welcome. It also suggests that the Medicaid-related legislation that has been resurrected for the special session is even more likely to be a waste of time. Which, again, is a good thing. In the meantime, be prepared to plug your ears as the inevitable wailing and gnashing of teeth from the “keep government out of our business while we meddle in women’s business” crowd starts in earnest.

From the “Get your government out of my Medicare” files

This ought to be fun.

Across the nation, U.S. House Republicans are getting an earful from their constituents about a GOP budget proposal to overhaul Medicare, the federal health care program that insures the elderly.

The Republican plan, written by Wisconsin Rep. Paul D. Ryan as part of his sweeping budget overhaul, would turn Medicare into a program that subsidizes private health care coverage for seniors instead of directly paying medical costs as it does now. Some Republicans, unnerved by the public reception, have even begun to retreat from it.

But that message hasn’t made its way to Texas, where state lawmakers are moving full speed ahead on their own efforts to take control of — and then restructure — both Medicare and Medicaid, the joint state-federal health care program that primarily serves poor children and the disabled.

Rep. Lois Kolkhorst’s “health care compact” bill, HB 5 — which would effectively ask the federal government to give Texas and other states block grants to run Medicaid and Medicare as they see fit — passed easily out of the House, and was heard in a Senate committee on Tuesday. That’s despite Democrats’ warnings that any effort to redesign Medicare will terrify, or potentially harm, seniors and a failed attempt by Rep. Craig Eiland, D-Galveston, to remove Medicare from the Texas compact bill.

“The reason I offered the amendment is exactly because of what’s going on nationally — it’s an ‘I told you so,’” Eiland said. “Before we start messing with our seniors, let’s try to prove we can run Medicaid.”

Republicans in the state House say they have no intention of curbing services or compromising care for the nearly 3 million Texas seniors on Medicare. But they say the health care compacts under consideration by other states are all written to include Medicare, and that they must align. And they argue there’s no way to get at the country’s escalating medical inflation and spiraling health care costs without addressing overutilization, fraudulent spending and other inefficiencies in Medicare. Medicaid mostly covers children; Medicare’s seniors are far more costly to insure.

First and foremost, I rather doubt that the Obama administration is going to hand over control like this to Texas. Remember, the Bush administration denied Texas’ request for Medicaid waivers before on the grounds that the program the state had in mind wasn’t sufficient in its coverage. I suspect this is more political than anything else. Having said that, the concern in progressive circles is that all the bluster about Medicare at the national level is a smokescreen for an attack on Medicaid, which serves a much less politically powerful group and is thus much more vulnerable. As such, regardless of how the feds may react to HB5, this is worth keeping an eye on. I mean, nobody doubts that the goal here is to slash benefits, right? The point of a block grant is that it’s a fixed sum of money, so if it actually winds up costing more to provide the coverage, that’s just too bad. The state won’t pay anything beyond that. That’s the goal the Republicans are working towards.

Hospital infections

There’s something missing from this story. Do you know what it is?

The most common hospital-contracted malady among older patients in Houston is systemic vascular infections, a problem often caused by unsanitary or improper procedures during their hospital stay, a new study of Medicare claims shows.

Among 46 hospitals within a 50-mile radius of the city of Houston, half reported vascular infections in Medicare patients through catheters, the tubing used for various procedures.

A total of 472 “hospital-acquired conditions” were reported from the 234,200 Medicare discharges from October 2008 through June 2010. That’s two incidents per 1,000 Medicare discharges in Houston.

Allowing the public to see information about mishaps and errors that occur during a patient’s hospital stay has been a contentious issue for hospital personnel, who believe the public could misread it. To date, there’s no universal ranking system for the public to determine the safety of the nation’s hospitals.

The reports released this month by the Centers for Medicare and Medicaid Services is the first to look strictly at how many times bedsores, surgical errors and falls and trauma, for example, occur among Medicare patients.

“We wanted to bring transparency to the fact that patients are exposed to potentially unsafe occurrences at America’s hospitals, said Donald McLeod, a spokesman for the U.S. Department of Health and Human Services. “We hope that by making the data public, we will spur hospitals to work with care providers to reduce — or even eliminate – these hospital-acquired conditions from happening again to even a single patient.”

Have you figured it out yet? Here’s the answer:

Health and Human Services Secretary Kathleen Sebelius on Tuesday pledged “up to $1 billion” for a new “Partnership for Patients.” The initiative aims to reduce preventable hospital infections and patient readmissions after they have been discharged.

“Every time a patient gets an infection in the hospital, or is readmitted because they didn’t get the right follow-up care, our nation’s health care bill goes up,” Sebelius said at a news conference at the National Press Club in Washington, D.C.

The proposal builds on existing rules for Medicare hospital payments, which impose financial penalties against hospitals for patients who experience preventable complications. Among the types of complications hospitals will be asked to examine are those associated with adverse drug reactions, bed sores, childbirth and surgical site infections.

The billion dollars is to come from the Affordable Care Act, last year’s health overhaul. According to HHS, if health care professionals are successful in reaching the goals laid out in the initiative, the initial $1 billion investment could reap as much as $35 billion in savings over the next three years, including $10 billion for Medicare alone.

“As the country’s largest payer for care, Medicare has a powerful ability to be a catalyst for change,” said Sebelius.

Yes, what’s missing from this story is any mention of the Affordable Care Act. One provision of the ACA that went into effect this January was that hospitals will now have to track and report to the Centers for Disease Control and Prevention’s National Healthcare Safety Network when patients get central line associated bloodstream infections (CLABSIs) in intensive care units. The point of this is partly to make this information more transparent to the public, and partly to reduce the incidence and cost of these infections, which represent a huge amount of money being spent and which can be prevented by such simple practices as better hand-washing and more care with catheters. I don’t know why the Affordable Care Act and the role it is playing in reducing hospital-acquired infections and their associated costs weren’t mentioned in this story, but now at least you know they should have been.

Harris County pleads its case to the state

Grits ran into some Harris County officials in Austin the other day and got some information from them about their lobbying efforts with the Lege. Not too surprisingly, it’s mostly focused on mental health services.

Harris Couty is primarily worried that cuts to community supervision, diversion programming and mental health services for adults and children go so deep that the state won’t even qualify to receive federal matching funds. A document from the Harris County Commissioners Court further suggests that, from a fiscal standpoint, state spending for mental health should prioritize funding for the “least expensive services” i.e., community based services, because they are eligible for federal matching funds through either Medicaid or Mental Health Block Grants, or even (in the case of Medicare), fully paid by the feds. Those types of services should be maintained or increased, they argue, while decreasing use of Crisis Services and state mental hospitals, which are not eligible for federal matching funds, through prevention, diversion, and community-based programming.

I’ve been aware for years that the state pays 100% out of general revenue for mental and acute health care for the incarcerated, while indigent people with serious health problems on the outside are typically served through programs either paid for or matched by the feds. That makes a big difference, in aggregate, regarding how much their health care costs in the state budget, especially for the seriously ill. But I hadn’t considered that the same distinction applies to Crisis Services and state mental hospitals. (Half of Texas’ state mental hospital beds are designated as “forensic beds” and there’s already a months-long waiting list to get treatment for defendants who’ve been declared incompetent by the courts to stand trial.)

As always, there’s plenty of detail, so click over and see what’s being said. One point to note, in that recent story about Harris County’s budget for the upcoming year, there was this tidbit:

Because three-quarters of the budget is spent on salaries, deep cuts are almost certain to result in layoffs. Constables, in particular, have warned of hundreds of possible layoffs. Precinct 4 Constable Ron Hickman, under the proposal, would see his budget slashed $3.1 million despite his warning that as many as 100 jobs could be at stake.

And in Grits’ post, we learn this:

Also from ’07-’10: Constables transported 32% more patients in psychiatric crisis from one facility to another,” and “The number of persons in psychiatric crisis that the Constables picked up pursuant to court order (Mental Health Warrant) increased by 55%.

Seems to me that could be a problem. Anyway, check it out.

New flash: Dropping Medicaid would be bad

Don’t take my word for it, take the Texas Department of Health and Human Services’ word for it.

Opting out of federal Medicaid, something Republican leaders have been considering as a method to wipe out Texas’ estimated $25 billion budget shortfall, would create major difficulties, the report states — not just for the millions of poor and vulnerable Texans covered by Medicaid, but for the county governments and public hospitals where much of the financial burden would be shifted.

Up to 2.6 million Texans — many of them children — could become uninsured. And hospitals would still be required by federal law to treat medical emergencies, potentially adding billions of dollars in annual uncompensated care costs funded at the local level. Meanwhile, Texans would continue to pay federal taxes to support other states’ Medicaid spending, the report notes.

Texas would “lose billions each year in federal funds; billions of dollars in indigent health care costs would shift from the state and federal levels to local governments, public hospital districts, medical providers, and the privately insured; and 2.6 million Texas residents could lose health insurance,” the report states.

Still, the escalating Medicaid costs facing the state — up 170 percent in the last 11 years, and accounting for a quarter of the state budget — have far exceeded the growth in state tax revenue, inflation and population, and are unsustainable, the report notes. The HHSC report says the best solution is for the federal government to give states greater responsibility over program costs, allowing them to design their own eligibility systems and benefit packages, and making it easier for them to get waivers. They also recommend reforming the new federal health care law, as well as revising how the federal government calculates the state vs. federal contribution to Medicaid.

“Virtually every state in the nation is facing a severe budget shortfall made worse by rising costs in Medicaid,” the report states. “…Without significant reform at the federal level, states are left facing a no-win dilemma.”

Actually, the best solution, which a number of people have proposed and were pushing during the debate over the Affordable Care Act last year, is a complete federalization of Medicaid. This would be a huge relief for state budgets now and in the future and would ensure a single standard of coverage, so that you don’t have states like Texas which deliberately make it hard to qualify as a way of saving itself a few bucks. Needless to say, this ain’t gonna happen, and if President Obama proposed it you’d see Republicans in Texas and everywhere else tell him to keep his dirty hands off of this beloved program of theirs that they intend to kill if they can get away with it.

The Trib has more here, and Dave Mann notes that what this really constitutes is not an attempt to kill Medicaid, but a move to basically privatize it:

The report concludes that the federal government should allow the state to “incorporate market oriented principles and greater accountability into the Texas Medicaid program.

“Under one waiver proposal, the state would establish consumer-directed medical accounts with sufficient funding to allow a client to purchase an individual or family high-deductible private insurance policy and fund a related health savings account.

“The proposal would empower Medicaid recipients to use health saving accounts for out of pocket health care expenses, job training, child care, or other qualifying purchases.”

This would represent a fundamental shift in how Medicaid functions. In the current model, the government reimburses doctors and other providers for the health care services they offer Medicaid patients.

Under the Perry plan, the government would fork over Medicaid money directly to individuals who would then shop for and purchase a private insurance plan. Instead of one money transfer (government to health care providers), we would have three (government to patient to insurance company to providers). Perry and the report authors pitch the latter system as more efficient, despite the added bureaucracy that would no doubt come along with these added transactions.

I don’t know if it would be more efficient. But it certainly would be a boon for the insurance industry and whatever financial institution would maintain these health savings accounts.

You can read the full report here. Those of you who have been paying attention may notice that this is very similar to the Paul Ryan plan for Medicare, basically by replacing the government as the insurer with vouchers for purchasing private insurance. You then can control costs easily by simply refusing to increase the voucher amounts over time, with predictable results for their purchasing power. One way or another, it all leads to the same end. One more thing from the original story:

HHSC raised eyebrows earlier this year with its big-figure estimates for how much federal health reform was going to cost Texas. The latest agency estimate indicates health reform will cost the state quite a bit less — about $5 billion between 2014 and 2019. This estimate excludes non-mandatory rate increases that were included in the original calculation. And it includes roughly $760 million in state revenue from premium taxes expected to be paid by health plans that cover new Medicaid clients.

I guess now that it’s actually been passed, there’s less point in exaggerating about it. Funny how these things work, isn’t it? A statement from Rep. Garnet Coleman is beneath the fold.

(more…)

We can learn from Indiana’s example

The state of Indiana decided a couple of years ago that it was paying too much for Medicaid, so they created to create a program called Healthy Indiana that provided vouchers for low income people to use to purchase private insurance. How has it worked out for them? About as you might expect, if you had any common sense.

First, many beneficiaries have to pay a lot more out of pocket than they would if they had traditional Medicaid coverage. Nonpayment has been the No. 1 reason for terminating beneficiaries from Healthy Indiana since the program began in 2008, with up to 35 percent of beneficiaries in certain income levels failing to make their first payment.

Second, providers serving Healthy Indiana beneficiaries have indeed been paid more than they would have if the beneficiaries had been covered under Medicaid. However, Healthy Indiana covers only about 44,000 Indiana residents, while more than 830,000 Indianans are uninsured. And in order to pay for the 44,000 Indianans in the Healthy Indiana Plan, the state took $50 million from funds that it uses to help reimburse hospitals for uncompensated care. In other words, 40 percent of the state’s uncompensated care funds were spent on only 5 percent of Indiana’s uninsured population.

But maybe this was still a much better deal for everyone. Maybe most of Indiana’s uninsured population doesn’t need health care, and those who do got a much better deal through the Healthy Indiana Plan than they would have if they’d been in traditional Medicaid.

Unfortunately, neither premise is correct. Healthy Indiana’s waiting list is longer than the number of enrollees it has. And uninsured Indianans, whether eligible for Healthy Indiana or not, continue to need health care. Meanwhile, for those actually in the program, the state paid $75 more per month in 2009 for the healthiest group of Healthy Indiana enrollees than it did for comparable adult Medicaid beneficiaries, even though Healthy Indiana beneficiaries are ineligible for many expensive services, such as maternity care, that Medicaid beneficiaries receive. That doesn’t include the cost that Healthy Indiana beneficiaries must pay out of their own pockets: up to $1,100 per year.

There is no evidence that Healthy Indiana beneficiaries are getting better care than Medicaid beneficiaries. However, the care they are receiving costs more, and leaves less for reimbursing uncompensated care for the remaining 95 percent of the uninsured.

But other than that, it worked great. This is the Republican way – make poor people pay more to get less so that Dan Patrick can get a property tax cut. The same basic ideas of vouchers for private insurance, in this case as a replacement for Medicare, is a cornerstone of Paul Ryan’s blueprint for cutting the national deficit. One must admit, simply not providing a needed service will allow governments to cut their expenditures. Too bad the need for those services doesn’t go away.

UPDATE: Corrected first sentence based on comments from Hope.