Medicaid In Extremis

Three months ago the Republicans opened debate on the FY2012 budget when Rep. Paul Ryan released The Path to Prosperity: Restoring America’s Promise. In that plan, he proposed a remaking of Medicaid that would eviscerate the program’s core purpose: provide health care to the most vulnerable.

Many labor under the misconception that Medicaid is health benefit open to any low-income American. In reality, states are only required to cover impoverished children (including those in foster care), pregnant women, some disabled persons, some adults with dependent children, and the elderly. In fact, more than 2/3 of Medicaid spending pays for services for the disabled and elderly; children consume about 1/5 of the total funds with the rest going to adults.

Childless adults, even those with incomes far below the poverty line are not automatically eligible for Medicaid. Nor are the parents of Medicaid-eligible children automatically eligible for coverage. For example, in Alabama, parents’ incomes cannot exceed 24% of the federal poverty line – less than $5000 a year for a family of three. Eleven other states all have income eligibility well below the FPL.

HHS to Review Health Care Regulations

This morning Deputy Secretary Bill Corr released a statement announcing the Department's plan to retrospectively review existing health care regulations. Regulatory review is about as much fun as filing taxes while undergoing a root canal... an unmedicated root canal. But the Administration's willingness to undertake such a painstaking process is yet another sign of their commitment to providing all Americans with healthcare that is economical, efficient, and, most importantly, effective.

Regulations are the flesh on the bones of law. After Congress passes a law, executive branch agencies are left to formalize specific requirements. For example, the health reform law talked about creating accountable care organizations but the small details were announced late this spring by HHS. How much detail? Try 429 pages of proposed regulations to clearly outline the plethora of requirements for such organizations.

Of particular interest to me is the interplay between Medicare (which typically covers older adults and some persons with disabilities) and Medicaid (which typically covers low-income children and their parents and people in institutional-level care, such as nursing homes). As our population ages, we'll have more people eligible for   Medicare and Medicaid. In theory, whatever isn't covered by Medicare should be paid by Medicaid. In reality, these programs don't always play nicely since what Medicare covers differs from what is covered by Medicaid.

Even more complicated and increasingly common are people who have private insurance or military benefits and are eligible for Medicaid. Trying to coordinate benefits between private insurers, especially those not covered by the complex ERISA rules, and Medicaid is becoming a time suck for states.

The attention to telemedicine is interesting too. Historically, Medicaid and Medicare refused to pay non face-to-face services. In the last few years that has changed and some states are using telemedicine to overcome health care shortages -- an area that is also under exploration as it has been three decades since we first defined "shortage area."

I think it is excellent that the administration is undertaking this project in light of so many regulations to come: final regulations for ACOs, regulations on the basic benefit package, etc. Attention today will prevent confusion and lawsuits later.

FY2012 Budget Battle: The Opening Salvo

This morning Rep. Paul Ryan (R-WI) released a template for the FY2012 Budget Resolution. If The Path to Prosperity is, as the GOP promises, the road to restoring America's promise I encourage you to think about another road.

That is a picture taken during the Dirty Thirties, when our breadbasket crumbled. In the early 30s people turned their faces west. They did find work in California, though mostly as migrant laborers, picking fruit and harvesting lettuce. A few years later FDR would begin his New Deal of recovery, relief, and reform. Three decades on, the Great Society programs would reinforce our social safety net.

Mr. Ryan's budget doesn't even take pains to pretend to leave the safety net in place. Instead, he places all of us in the cradle of laissez-faire economics. The cradle metaphor isn't misplaced here, as it is children who are likely to suffer the most in Mr. Ryan's economic vision.

Food Aid

Mr. Ryan would turn the Supplemental Nutrition Assistance Program (SNAP, formerly known as Food Stamps) into a block grant (more on that in a minute). In 2015, when the economy is once again hale and hearty, benefits will be contingent on either holding a job or enrolling in job training.

This is replay of the 1994-5 debate on welfare reform, which required women to go to work. In general, I have no objection to requiring able-bodied adults to work given proper support. That means child care subsidies, food aid to cover the transition from cash assistance to full employment, transportation and housing subsidies, and so on. If we truly want women – and it is mostly women – to be self-sustaining, we must offer educational opportunities that end in a skilled job with family-supporting wages. How does Mr. Ryan intend to enforce a work or training requirement when very young children are in the home? Or if we have a double-dip recession and unemployment remains high?

Does Mr. Ryan not know that many food aid recipients are employed? They have minimum or low-wage jobs and, assuming a family of three, make less than $1,526 per month -- a couple grand more a year than a full-time, minimum wage worker would earn. Does he not know that increasing numbers of retirees -- again mostly women without pensions and with low Social Security benefits -– rely on SNAP? Will he require the elderly to work? And what about our service men and women who use food aid to make ends meet? Will they too have to get better jobs?

Medicaid

Medicaid is the health insurance program for America's poorest and most needy. The majority of beneficiaries are children and the elderly. I know that will surprise many, who think of it simply as program for the very poor. But Medicaid is much more restrictive than many imagine.

In general, states are only required to cover children (including those in foster care), pregnant women, low-income disabled persons, low-income adults with dependent children, and the elderly who have exhausted their savings and are in nursing homes. Childless adults, even those with incomes far below the poverty line are not automatically eligible for Medicaid.

Mr. Ryan, and Republicans in general, have argued that Medicaid is too expensive. Yes, it is expensive precisely because it is the payer of last resort. Children on Medicaid receive EPSDT services, aimed at preventing health problems. Children on Medicaid are sometimes medically complex and receive SSI income for extreme low birth weight or other serious maladies. Medicaid recipients under 22 or over 65 may be eligible via the need for inpatient mental health care. Elderly in a nursing home who have run through all their savings become eligible; Medicare doesn't cover long-term care. Medicaid is expensive precisely because it operates as a safety net and covers services unavailable via private insurance or Medicare.

Mr. Ryan argues about Medicaid's quality of care, pointing out that the health outcomes of beneficiaries is poor. He must have skipped the public health literature for the last decade or so. Medicaid beneficiaries are poor. Many rely on food aid and while I've save you a retread of Michael Pollan, our agricultural policies mean that healthier food is often more expensive. They are more likely to live in areas with high lead levels. More likely to live in areas too remote or unsafe to exercise. More likely to suffer stress. I recommend he look into the social determinants of health before commenting on Medicaid outcomes. Medicaid is not magic. It cannot heal all comers and then offer a ride home on a unicorn; it is limited medical benefit for people who have concomitant health challenges and outcomes to match.

Yes, Medicaid is straining states' budget and yes, reimbursement is too low to attract enough providers, particularly specialists. But block granting doesn't automatically solve those problems, nor does it solve the GOP favorite claims of fraud, waste and abuse. It just gives states the ability to hold the purse strings.

Mr. Ryan and almost every other R want to convert federal entitlement programs like Medicaid and Medicare to block grants. Block grants are Beltway-speak for bucket of money. Entitlement programs like Medicaid impose requirements and limits on the states to receive money (Rs call this bureaucracy). Do the limits impinge upon states' flexibility? Yes of course. Which is why the federal government allows demonstration projects and waivers – Section 1115, 1915(b) or (c) or some combination thereof, 1915(i). There are optional coverage services to be included or waived.

To simply gut the Medicaid rules that have guaranteed coverage for the most vulnerable citizens and instead hand governors a check is wrong. Mr. Ryan may decry the social safety net, thinking it is becoming a “hammock, lulling able-bodied citizens into lives of complacency and dependency” but I wonder how that image squares with the reality of Medicaid: a child, a pregnant woman, a bed-bound senior, or a disabled adult.

There are other changes in the budget. Ending Medicare for those under 55. Lowering corporate taxes from 35% to 25%. (I'd support that one, if it meant companies actually paid federal taxes.) Cutting federal workers salaries and benefits.

Mr Ryan may pretend that his budget represents some grand vision for America's future. But in truth it is the plan of someone who read too much Horatio Alger and Ayn Rand, of someone who has never lived in Section 8 housing, of someone who does not know hunger, of someone who never had to take their kids to mall to get warm in the winter, of someone who enjoys their comfortable, government-provided chair atop the House Budget Committee.

What a Five-Year-Old Needs to Know About Sex

Last week, after a tempest-in-a-teapot on Twitter that covered birth control, comprehensive sexual education vs. abstinence-only, Title X, CEDAW, and political minorities vis a vis Madison’s Federalist Papers, someone tweeted, “The only thing a 5yrold should need to know about sex is...well...nothing.”

Shortly thereafter, I saw Logan Levkoff debating Peter Sprigg, of the Family Research Council, on Fox News over proposed curriculum changes in Helena, MT.

Did you catch that? Peter Spriggs is all a flutter over the possibility of teaching kindergartners “the names of the male and female sex organs.” In other words, teaching kids the correct names of their own body parts.

Work. Life. Policy.

MamaBee recently opined about her ambivalence about work life policy and her upcoming BlogHer panel with Morra Aarons-Mele on the same.

MamaBee wondered: Wearing my manager hat, I bristle at the idea of government involvement in how I manage my employees.  How can government possibly understand the unique needs of my business and workers?  I’m all for legislating anti-discrimination and family policy — equal pay; affordable, high-quality childcare; and paid family and sick leave, for example.  But I’m having a hard time getting my mind around how the government can practically be involved with flexible work.

I wonder how we can continue without government intervention. I’ve no doubt that MamaBee is a terrific manager but that’s my point: she is one manager. For most U.S. employees, your work life balance, your ability to telecommute, to have flextime or comp time, to have paid time off, or to job share, is only as good (or bad) as your manager, your department head, your unit, and/or your company. Most of us are one job reclassification, downsize, merger, acquisition, or reorganization away from instantaneous disappearance of our work life policies.

Who Doesn't Want More Healthy Moms and Babies?

In light of our abysmal maternal health statistics -- we're 39th in the world, behind Canada, tiny Malta, Croatia, Serbia, and the United Arab Emirates -- the U.S. needs to make every effort to promote and improve maternal health. Knowing that 1.5 trillion text messages were sent in the U.S. in 2008, several groups have teamed up to create text4baby, a mobile messaging service to promote the health of pregnant women, new moms, and their babies.

Yesterday I attended a briefing sponsored by Women’s Policy, Inc., the Congressional Caucus for Women’s Issues, the Office on Women’s Health, and the National Healthy Mothers, Healthy Babies (HMHB) Coalition to promote this terrific new initiative.

Text4baby is a free service that provides thrice-weekly messages to pregnant women and new moms during the first year of their child’s life. The messages focus on health and safety – everything from where to find tobacco cessation services, to appointment reminders, to breastfeeding education, WIC eligibility, safe sleeping, and child care.

Among HMHB's many partners is the Department of Defense Military Health System (yahoo for not overlooking our military families!) and MTV, which is featuring the service on 16 and Pregnant. 

MTV Shows

If you want to sign up (FREE!) just text “BABY” to 511411 (“BEBE” for Spanish).

R.I.P. Dorothy I. Height

Civil rights leader Dorothy Heights passed away early this morning at Howard University Hospital. Ms. Heights was 98 and had served as the president and then chair emeritus of the National Council of Negro Women.

She was supposed to go to Barnard but they'd already accepted two African American students, thereby meeting their quota. Yes, really. She came up with some of the most well-known civil rights leaders, from the Revs. Adam Clayton Powell Sr. and Jr. to the Rev. Dr. Martin Luther King Jr. to Mary McLeod Bethune. A humanitarian and feminist, she was there to see JFK sign the Equal Pay Act in 1963.

I think often of her quote: "If the times aren't ripe, you have to ripen the times."

Please read her amazing obituary.

Maternal health crisis worsening in U.S.

Yesterday the Lancet released a major study highlighting maternal morbidity and mortality in 181 countries from 1990-2008.

The United States ranks 39th with 16.7 deaths per 100,000. We're behind most of the OECD -- behind Canada, tiny Malta, Croatia, Serbia, and the United Arab Emirates. Instead of declining is accordance with Millennium Development Goal 5 -- the target is a 75% reduction in the maternal mortality ratio (MMR) from 1990 to 2015 -- the U.S. saw a 2% increase in MMR from 1990-2008.

I want you to gaze upon these picture for a few minutes:

I know this is hard to read but bear with me: Countries in blue, from very dark to light, have seen a decline in maternal mortality. Notice that the U.S. is in red. That's because instead of declining, our rate has increased. Our company in seeing at least a 1% increase, in descending order: Zimbabwe, Lesotho, Botswana, Swaziland, South Africa, Namibia, Côte d'Ivoire, Mozambique, Malawi, [United States], Cameroon, Denmark, Singapore, Georgia, Nigeria, Afghanistan, Slovenia and Chad.

It Passed the House. Now What?

Now that the Patient Protection and Affordable Care Act (H.R. 3590, a/k/a health reform) and the Health Care and Education Affordability Reconciliation Act of 2010 (H.R. 4872, a/k/a reconciliation) have passed the House, what next?

Well, I'd start by reading summaries of the bill. If you're like most (sane) people, the back-and-forth of parliamentary maneuvering got the best of you. You still tuned into the debate but specific provisions? You have some sort of vague impressions.

Let's fix that.  I'd recommend using the Kaiser Family Foundation's Side-by-Side comparison tool for an easy glance at the provisions across several topic areas. Trust for America's Health has a good summary of the Senate bill too.

The Majority Leader's website has a collection of information too, from ten immediate benefits to the Congressional Budget Office report. Likewise, the Democratic Policy Committee has a slew of press releases and video clips, as well as section-by-section bill analysis and all the fact sheets you ever wanted.

Why the prep work? We must be ready to speak truth to power as the Senate readies for debate on the reconciliation act.

Jane Hamsher on the Why the Sky is Falling (Hint: It Isn't)

Jane Hamsher, she of FireDogLake fame, is shaking her fist at the sky over Steve Hildebrand, Obama's former deputy campaign director, theoretically challenging Rep. Stephanie Herseth Sandlin (D-SD). Apparently, Hildebrand is waiting to see how Herseth Sandlin votes on health care reform. If she votes no, he might challenge her. If she votes yes -- and abandons her pro-choice values -- then she will feel the terrible fury of Jane Hamsher and not! get! another! dime!

It seems to me a lot of hand-wringing for naught. Herseth Sandlin didn't vote yes in November. So the will-she-or-won't-she seems moot, doesn't it? I doubt that she'll vote yes this weekend. Her vote had very little do with choice, I think, and much, much more to do with the fact that she's considering a gubernatorial run and may have a primary challenge from Chris Nelson anyway. So Jane's criticisms of Herseth Sandlin seem like a lot of sound and fury, signifying nothing.

Hamsher then goes on to crack on Rep. Diane DeGette (D-CO), the co-chair the Pro-Choice Caucus (along with Rep. Louise McIntosh Slaughter (D-NY)) using some specious arguments. Sorry Jane, but I'm not going to sit idly by while you paint DeGette as some money grubbing apologist for throwing women under the bus.