Category Archives: Health care

Drinking from a fire hose to set pot rules

Elections, Health care, Legislature, Politics, State government

By Steve Brawner
© 2016 by Steve Brawner Communications, Inc.

When you go to school to be a doctor or a pharmacist or a lawyer, you have to learn how to drink from a fire hose – do a lot of work and absorb a lot of information quickly while bearing important responsibilities.

Good thing that pretty much describes the Arkansas Medical Marijuana Commission, the appointees who will have a little more than a month to create rules for the growers and dispensers authorized by the Medical Marijuana Amendment, which voters passed in November.

The five members of the commission – which includes two doctors, a pharmacist and a lawyer – held their first get-to-know-each-other meeting Dec. 12. About all they otherwise accomplished was electing a chairperson, Dr. Ronda Henry-Tillman, a surgical oncologist, and agreeing to meet again on Dec. 20.

They agreed on that date remarkably fast, which is a good sign because the amendment legalizing medical marijuana doesn’t allow much time for fruitless debate. Rules must be in place 120 days from the Nov. 8 election, which would be March 9. But because a public comment and legislative review are required, the rules must actually be drafted by late January – in other words, a little more than a month from the commission’s next meeting.

Meanwhile, the Department of Health and the Department of Finance and Administration are drinking from their own fire hoses while crafting their own rules and regulations. And when legislators go into session early next year, they’ll be reviewing those rules and passing their own laws to alter the amendment, which they can do with a two-thirds vote. One pre-filed bill by Rep. Doug House, R-North Little Rock, would add 60 days to the timeline. But the Legislature doesn’t go into session until mid-January, and the commission and the affected agencies can’t assume House’s bill will pass.

There’s never been an issue like this in state history. As Gov. Asa Hutchinson’s spokesperson, J.R. Davis, often says, Arkansas is in the process of creating a miniature Food and Drug Administration. And let’s not forget that while marijuana is legal at least medically in 29 states and the District of Columbia, it’s still illegal in the United States of America. The only reason states are passing these laws is the Obama administration made it clear it would look the other way, but President Obama is leaving office next month. President-elect Donald Trump has said he favors medical marijuana, but his pick for attorney general, Sen. Jeff Sessions of Alabama, is a staunch opponent.

So that means that Hutchinson, at one time the head of the federal Drug Enforcement Administration, is leading a state government trying to quickly legalize a drug that’s still completely illegal under federal laws – laws that soon may be enforced again. He’s also trying to administer a program he campaigned and voted against. At least two of the Medical Marijuana Commission members also are known to have voted no.

Eighty-four of the state’s then-135 legislators publicly expressed their opposition prior to the election, though some of them won’t be returning to office. That’s almost two-thirds, and with a two-thirds vote the Legislature can change the amendment so much as to make it virtually meaningless – for example, by tacking on such high fees that few could afford the drug. But that probably won’t happen because there’s another number that will be hard to ignore: 68,505, which is how many more Arkansans voted for the Medical Marijuana Amendment than voted against it.

One other thing that’s kind of interesting about Arkansas’ passage of the amendment: If you look at the map, the states that have legalized marijuana for medical or recreational purposes mostly are on the coasts and along the country’s northern and southern borders. Arkansas is the first Bible Belt state to say yes unless you count Louisiana and Florida, which probably would be a stretch in both cases.

If a conservative state like Arkansas will vote to legalize medical marijuana, then perhaps any state will next. Well, perhaps any state except Utah, home to a large Mormon population, and maybe Alabama, home of Sen. Sessions. He’s soon to be attorney general of the United States, the nation’s top law enforcement official. Did I mention he’s really opposed to marijuana?

Steve Brawner is an independent journalist in Arkansas. Email him at brawnersteve@mac.com. Follow him on Twitter at @stevebrawner.

Private option water torture

Health care, Legislature, Politics, State government

By Steve Brawner
© 2016 by Steve Brawner Communications, Inc.

Voting for the private option was hard for many Arkansas Republican legislators, and every month – every dang month – it becomes harder to keep supporting it.

That’s because every month the number of Arkansans being served by the program continues to rise – past the 250,000 that was originally forecast, and now, as of the end of September, past 324,000 who are either enrolled or have been deemed eligible, or have been placed in traditional Medicaid because they were considered “medically frail.”

The private option is the health care program created by the Legislature in 2013 after the U.S. Supreme Court ruled the Affordable Care Act – that’s Obamacare – was constitutional but that states were not required to expand government-run Medicaid to serve individuals with incomes up to 138 percent of the poverty level. Given the choice, most Republican-leaning states said no to a lot of federal dollars, but Arkansas said yes, with a twist: Instead of simply expanding Medicaid, it bought those folks private insurance.

By many measures, the private option has been a success. Arkansas is a national leader in reducing its uninsured population. Without it, most beneficiaries would not have health insurance, but some still would have health problems, which they would wait to address until they were very sick by showing up at emergency rooms and being treated for free. Meanwhile, the huge pool of private option customers has kept insurers in the state and competing against each other, holding down rates for other individual buyers.

But all that government-paid health care isn’t free. The federal government is sending the state $1.6 billion in taxpayer dollars this year and paying 100 percent of the cost. Starting next year, the state chips in 5 percent, a number that rises to 10 percent by 2020.

For Republicans who have supported the program, it’s been a conundrum. Most if not all would say government benefit programs invariably create ever increasing numbers of beneficiaries – which is exactly what has happened. They went against their own instincts to vote yes because Arkansas is a poor state that needed the money, and local hospitals can’t keep providing all this free emergency room care. Also, frankly, there aren’t a lot of better ideas out there. Health care is hard.

Each legislative session has hinged on whether enough legislators could be found to overcome the objections of diehard opponents. The program barely passed in 2013 and barely passed again in 2014. It survived 2015 because Gov. Asa Hutchinson promised changes in the form of Arkansas Works, his renamed version that requires higher-income recipients to contribute $13 to their monthly premiums and makes other minor changes. Hutchinson wanted more, including a work requirement, but the Obama administration didn’t agree. So he took what he could get hoping the next administration will be more flexible.

Now here we are at 324,000 counting those deemed eligible but not yet enrolled, which is 7,000 more than last month and 16,000 more than the month before that. Department of Human Services Director Cindy Gillespie says there’s still a backlog of applications. Each month, the diehard opponents get a fresh chance to say “I told you so” (without offering much of an alternative), and each month the state draws nearer to when it must pay part of the cost. For Republican supporters, it’s like Chinese water torture: drip, drip, drip.

When the Legislature meets in 2017, those Republican lawmakers will face the same difficult choice they’ve faced every year since 2013: Keep a program that’s growing unsustainably, or … what?

Eventually, those supporters will become opponents unless the next administration gives states more flexibility. For them to keep voting yes, recipients must have more skin in the game. The rules will have to push recipients into jobs, and then into better paying jobs, and eventually out of the program entirely. And if able-bodied recipients don’t move along that path, then they’ll have to lose their benefits.

Of course, doing that – or getting rid of the private option entirely – would put us right back where we were before it existed: sick, uninsured people showing up at the local hospital seeking care, and then what should be done? Treat them for free and then shuffle the costs around, or turn them away because they don’t have insurance?

Did I mention health care is hard?

‘Tis the season for lawsuits

Elections, Health care, Politics, State government

By Steve Brawner
© 2016 by Steve Brawner Communications, Inc.

Every calendar year has four seasons, and so does every campaign year. There’s the filing season, when potential candidates decide to run; the primary season, when the parties choose their nominees; the general election season, which ends in November; and, tucked in its own little spot about now, is a fourth season: the lawsuit season.

Yes, ’tis the season when opponents of various voter-initiated acts and amendments try to remove them from the ballot, or at least keep their votes from being counted, by filing suit in the Arkansas Supreme Court.

This year, four initiatives have qualified for the ballot by gathering enough signatures from registered voters: a constitutional amendment that would legalize marijuana for medical use; an initiated act that would do the same, with some differences; an amendment that would limit attorney fees and jury awards for pain and suffering in medical lawsuits; and an amendment that would authorize casinos in Boone, Washington, and Miller Counties.

All four have drawn legal challenges. Generally speaking, the groups are making the same arguments that are always made about these issues: that the ballot titles are misleading, and that technical violations occurred in the signature collecting process.

These lawsuits are just part of accepted campaign strategy, so both sides know they have to budget for legal fees. The lawsuits almost always happen when issues are this controversial and when someone stands to lose something. For example, the Arkansas Bar Association has filed suit to stop the amendment that would limit attorney fees and jury awards – which, when higher, produce higher fees. The casino amendment faces a lawsuit from a group supported in part by Oaklawn Park and Southland Gaming and Racing, which don’t want the competition.

That last paragraph sounded cynical, didn’t it? Human beings have complicated motivations. For example, the Arkansas Bar Association’s unanimous opposition to the medical lawsuit amendment probably is due partly from a desire to protect an income stream, at least with some members. At the same time, attorneys have a unique appreciation for the importance of why big verdicts sometimes are needed. Moreover, the amendment is being pushed primarily by nursing homes who want to reduce losses from big jury verdicts, some of which might be based on emotion and good lawyering. Can’t blame them for that.

So now the questions go straight to the Arkansas Supreme Court, where the wheels of justice will turn more swiftly than is normal. We’re reaching mid-September. Election Day is Nov. 8. Absentee ballots must be mailed to voters no later than Oct. 14. Early voting begins Oct. 24. That means the Supreme Court must consider arguments and render decisions as soon as possible. Even if it moves quickly, it’s not unusual for the ballot to be littered with proposals that the court has ruled invalid.

At this point, I’m definitely against one of the proposals, leaning against two and wavering on one. Still, my preference is to vote, even if something passes I don’t like.

In a state whose motto is, “The people rule,” it’s probably best if the measures stay on the ballot, if they can. All four were approved – actually, partly rewritten – by the attorney general’s office to comply with state law. All four’s signatures were validated by a small army of full-time and temporary workers with the secretary of state’s office. Should four Supreme Court justices override those efforts?

Also, all four represent the kind of issue for which voters are well-suited to express their will. These aren’t questions of bureaucratic minutiae. They’re big-picture questions about values and about what this state ought to look like. Whether there should be casinos in Arkansas when surrounding states already have them has been debated around many a kitchen table. So has whether marijuana’s clear harm to many means it shouldn’t be available to those it clearly helps. Would limiting a type of jury award help doctors and nursing homes lower costs for all of us, or would they become more negligent? The voters can decide.

If the legal minds on the Supreme Court believe that real problems exist with a ballot title or signature gathering process, then yes, disqualify a proposal. It’s their job to look at the details.

But if it’s in the gray area, let’s hope the Court errs on the side of not disqualifying. In a state whose motto is “The people rule,” the presumption should be to let the people rule.

Insurance hikes coming, fixes not

Health care, Politics, State government

By Steve Brawner
© 2016 by Steve Brawner Communications, Inc.

It’s hard to feel sympathy for a giant health insurance company, but Blue Cross and others will try next year to generate at least some understanding from state legislators, and they’ll probably succeed.

They’ll be doing this after the Arkansas Insurance Department last month required them to lower the rate increases they had requested. Those rates are for private individuals who buy their own insurance or have it bought for them through the state’s private option.

Arkansas Blue Cross Blue Shield asked for a 14.7 percent increase for its 213,955 individual consumers. The state told it to drop the request to 9.7 percent, which it did under protest. In a letter to Insurance Commissioner Allen Kerr, Blue Cross Senior Vice President Lee Douglass noted that the Insurance Department’s own private consulting firm had said the company’s request “appears actuarially reasonable” based on the increasing costs of health care. The company’s reserves have been decreasing for the past three years to $1,265 per insured member by the end of 2015 – not enough to pay for a day of inpatient hospital care.

Douglass added this: “We also believe it is important to increase our efforts and resources so all members of the General Assembly are informed of the costs and issues associated with our state’s health care needs as well as any deficiencies in the filing process.”

Which means Blue Cross will be actively working the halls of the State Capitol looking for allies. It no doubt will be joined by the state’s other health insurers, who also were told to lower their rate requests. Qualchoice had asked for increases of about 24 percent and was told to lop off 10 points. Ambetter asked for 8.1 percent and was approved for 4 percent.

This is the part where you’re going to want me to blame someone, and this being Arkansas, that someone probably is President Obama. The reality is more complicated than that.

Without a doubt, the Affordable Care Act, otherwise known as Obamacare, is part of the reason for the increasing rates. The law required insurance companies to stop turning away sick people, and that’s who in large part is signing up for insurance. Sick people cost a lot to insure, especially when their ailments have been building up for a while, and many of the young, healthy people needed to offset that cost have opted to pay the fine rather than pay more for health insurance.

Furthermore, the Affordable Care Act does not allow for the creation of bare bones health insurance plans that cover only the major illnesses, and it doesn’t give states enough flexibility to experiment with ideas that could lower costs.

On the other hand, other factors are at play – particularly the rising prices of specialty drugs that are wonderful and life-saving and very, very expensive. Long-term trends such as the nation’s aging, overweight population are major contributors to rising costs as well.

The truth is that America’s health care system was unsustainable before Obamacare, and it’s unsustainable now. Obamacare made some things better and some things worse, but it did not create the cost problem, nor solve it. The law’s opponents never solved that problem when they were in power, either.

We can’t just “repeal Obamacare” because it’s now the health care system we live under, and just getting rid of it would be too disruptive for everyone. Besides, who would want to go back to the days when insurance companies turned away patients because of pre-existing conditions or dropped coverage when their illnesses became too expensive?

What should happen now is that policymakers should try to fix the system, calling it whatever they must. They should do next year what they should have done in 2009 – engage in a multi-year, bipartisan process that addresses access and cost. A solution should be created that includes ideas and buy-in from Democrats, Republicans, the medical community, insurers like Blue Cross, and average Americans. And then we should try to make it work rather than half of us trying to make it fail.

Unfortunately, America’s political system is too unhealthy to engage in that kind of productive advancement. So next year, at the state level, the insurance companies will ask for higher rates that probably are justified, and they probably will succeed because that’s the kind of “fix” the political system can handle.

And bigger, bipartisan solutions? Those will probably have to wait until the system is healthier – someday.