Category Archives: Health care

Cynicism, watchfulness, the presidential campaign and Arkansas Works

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

Watchfulness is a cornerstone of a free society. Cynicism leads to the decay of it. There’s a huge difference between them, but not much distance.

What’s the difference? Watchfulness means being aware that people are sinful and selfish, that we seek our own glory and power and riches, and that we abuse and misuse other people and institutions. But it also takes into account that people make choices, and often the right ones. So it does the hard thing: It gathers facts about each individual situation and then makes a determination of what is happening, knowing that it’s probably neither all bad nor all good.

Cynicism sees bad qualities in others but often doesn’t see it in the mirror. Instead of gathering many facts to form a belief, it takes the lazy shortcut of forcing a few facts into a predetermined belief. It substitutes mockery for joy, and it builds its own worth on the shaky foundation of other people’s flaws.

Cynicism leads to inaction. Because cynicism says that nothing can be fixed, then there’s no reason to try. That’s why everyone who ever did anything great was optimistic about something. Worse, cynicism can lead to scorn, and scorn can lead to blaming, and blaming can lead to dehumanizing, and dehumanizing can lead to a lot of terrible things.

The challenge with watchfulness, on the other hand, is that it requires a delicate and difficult balance. Tip too far in one direction, and it falls into naivete. Tip too far in the other direction, and it leads to cynicism. There’s a huge difference between the two, but not much distance.

So let’s try to look, not on the bright side, but on the true side. It is true that the presidential race includes four candidates who for many people elicit strong negative emotions: Donald Trump, Sen. Ted Cruz, Secretary Hillary Clinton, and Sen. Bernie Sanders. (I wish Gov. John Kasich would elicit some negative emotions, too, but alas.) It would be easy to watch what has happened in this campaign and become cynical. Very easy.

But remember that watchfulness doesn’t take that easy route. It looks at the whole picture. So while it can be dismayed that the system isn’t working as well it should, it doesn’t ignore that the system is working much better than it could. For all the system’s flaws, we can be virtually certain there will be an orderly transfer of power come next January, and that’s a pretty uncommon thing in world history. The next president of the United States, far from seizing power with a sword, is traversing the country begging little ole’ you and me to vote for him or her and, to some degree, listening to our concerns. Yes, the watchful person says, money has far too much influence. On the other hand, Jeb Bush had a lot of it.

Closer to home, legislators during the next month will be engaged in a fierce debate about extending the private option, the program that uses federal dollars through Obamacare to purchase private health insurance for Arkansans with incomes up to 138 percent of the federal poverty line. It serves about a quarter of a million Arkansans. It expires at the end of this year, but Gov. Asa Hutchinson is trying to save it by making some changes and calling it “Arkansas Works.”

It’s a very divisive issue. Democrats unanimously support it; Republicans are split. Cynicism from one direction says it’s all part of a movement to nationalize the health care system. Cynicism from the other direction says some people don’t care enough about the poor or simply oppose whatever President Obama supports. There are elements of truth to all those charges, and they should not be ignored.

But the rest of the truth is that a legitimate debate is occurring about the role of government in imperfectly addressing a problem that can’t be perfectly solved. Health care is hard. It’s a product we naturally think should be cheap and limitless, and that’s just not possible. So we try to find that delicate balance between spending enough and spending too little, and doing it the right way.

Where is that balance? No one knows. But we’ll come a lot closer to finding it by being watchful than we will by being cynical.

Related: What exactly is Arkansas Works?

Arkansas Works and the private option: What’s all the fuss about?

Gov. Asa Hutchinson

Gov. Asa Hutchinson

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

This next month, legislators will debate whether or not the private option should continue as Gov. Asa Hutchinson’s version, Arkansas Works.

What’s all the fuss about? I’ll try to answer your questions.

What exactly is the private option?

Let’s start with the background. The Affordable Care Act, which created Obamacare, expanded the number of Americans eligible for Medicaid, the program that pays for medical care for poor people. Americans with incomes up to 138 percent of the federal poverty level became eligible. Meanwhile, the act cut the federal government’s reimbursements to hospitals that serve a high number of uninsured patients, who often don’t pay for their own care. The assumption was those people would be on Medicaid.

But then the Supreme Court ruled that states could choose whether or not to participate in the Medicaid part. Most Republican-leaning states said no, but their hospitals’ reimbursements are still to be cut. Arkansas in 2013 said “Yes, but.” Instead of putting people on Medicaid, a government program, it used those dollars to purchase private insurance. Republican legislators and Gov. Mike Beebe’s administration created it, and the federal government approved it.

What have been the results?

As of the end of January, 267,590 Arkansans had qualified. A Gallup poll last year found Arkansas’ adult uninsured rate had dropped from 22.5 percent in 2013 to 9.1 percent in 2015 – the country’s biggest improvement. Hospitals are treating fewer patients who don’t pay.

Other states that turned down the Medicaid money have faced consequences. Rural hospitals have closed. Oklahoma this week proposed cutting what Medicaid pays doctors and hospitals by 25 percent. That’s huge because Medicaid already doesn’t pay much, which is why many doctors won’t treat Medicaid patients. Louisiana, which first said no to Medicaid expansion under a Republican governor, recently elected a Democrat who promised to take the money.

What do opponents say?

The private option as it currently exists would cost $1.63 billion in 2017. Currently, the federal government pays for almost all of it, but next year the state starts picking up 5 percent, which increases to 10 percent by 2020 – assuming Congress doesn’t change the rules and make the state pay more. So the state will have to find that money.

Some legislators have a major philosophical problem with the private option. They say it’s a health care entitlement with roots in Obamacare that increases government dependency and adds to the national debt. Those federal dollars aren’t a gift; they come from American taxpayers, current and future.

So what’s Arkansas Works?

Last year, Hutchinson convinced legislators to approve the private option through the end of 2016 while the state figured out what to do next. In the meantime, he’s proposed Arkansas Works, which changes the program in a few ways. Beneficiaries with incomes from 100 to 138 percent of the federal poverty level would pay up to 2 percent of their income for insurance premiums – about $19 a month. Private option recipients would be referred to work and work training opportunities, though they wouldn’t be required to take advantage of them. Hutchinson would like to do more in that area, but the Obama administration won’t let him.

Is it really that different from the private option?

No.

Why does the Republican governor support government-funded health care?

He says he opposed and still opposes Obamacare, but he inherited this situation. If Arkansas does nothing, the private option would go away at the end of this year, and then all those people would lose their health insurance, and hospitals would have to go back to providing all that uncompensated care. Also, losing those federal dollars would blow a $100 million hole in the state budget.

What does the next month look like?

Legislators are meeting starting April 6 in a special session to vote on Arkansas Works. Then starting April 13, legislators meet in the fiscal session that occurs every even-numbered year. Because Arkansas Works will cost money, it requires a three-fourths vote in both the House and Senate. In other words, 26 representatives or nine senators could kill it.

What’s the vote count look like?

Hutchinson doesn’t have a three-fourths majority yet in either the House or the Senate. But he’s trying.

What will the outcome be?

I don’t know.

Related: The private option ink blot.

Less government, not no government

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

At the State Capitol this week, a high-profile Republican talked about reforming an important but imperfect government service, rather than complain about it being there.

Lt. Governor Tim Griffin recently completed an extensive review for Gov. Asa Hutchinson of the Department of Human Services, the sprawling state agency that handles human needs such as health care for Arkansans with low incomes or disabilities, paying for nursing home residents, and serving foster children.

Meeting with reporters in his office, Griffin said he found an agency that’s poorly organized into divisions that don’t communicate with each other, leading to waste, inefficiency and less effective services. An Arkansan served by more than one division must talk to each separately, with little help.

Griffin, who previously served four years as Arkansas’ 2nd District congressman, said this kind of organization exists in other agencies. Addressing it in DHS is most critical because it serves what he said are “vulnerable” Arkansans.

The presentation was completely constructive. He offered solutions. He was genuine in wanting better services for DHS clients. He didn’t dismiss the department as another example of hapless government. He didn’t blame anybody.

Griffin’s presentation was not the only example this week of Arkansas Republicans trying to make government work better and smarter, when it would be easier to just criticize it. On Monday, the Republican-dominated Health Reform Legislative Task Force voted to endorse Republican Gov. Asa Hutchinson’s Arkansas Works program, which is a continuation of the private option, which was created largely by Republican legislators.

The private option uses federal Medicaid dollars to purchase private health insurance for Arkansans with incomes up to 138 percent of the federal poverty line. It now provides insurance for 200,000 people.

It unquestionably is a government expansion, so many Republicans understandably don’t support it. Republicans who do are trying to make government work at the state level to address problems not being fixed at the federal level or through the private sector. It’s a tough call, and the Legislature may yet choose to end it. However, Louisiana at first said no to the Medicaid money, and now it’s changing its mind.

Republicans have long been more comfortable with government at the state and local levels than at the federal level. State and local governments are closer to the people. In Little Rock, constructive work does get done.

But the party’s rhetoric often doesn’t reflect that, at any level. While it’s the party of less government, it often sounds like it’s the party of no government.

Unfortunately, it’s painting itself in a box. The GOP says it wants to cut or end government programs it can’t cut or end. That means it breaks a lot of promises and disappoints a lot of people. Meanwhile, its base includes a lot of people age 60-plus who depend on government or soon will. So what does the GOP do with that?

So here’s where we are. One party says it wants to cut government unrealistically. The other party too often wants to grow government. What’s not being said enough is that government is sometimes the best bad answer we have, but that it should be smaller and that it should work better. Instead of ending government, or growing it, there should be more talk about reforming it. What Griffin did at DHS should be done everywhere.

In the presidential race, you know who’s sort of filling that niche now? Donald Trump. He doesn’t seem to have a well developed political philosophy, but he’s talking about bringing his supposed business competence to government. He certainly doesn’t talk much about cutting government, aside from repealing Obamacare. He doesn’t want to cut Social Security or Medicare. He wants to build up the military and enact tariffs on Chinese goods. He wants to build a wall along the border funded by Mexico, which can’t afford it, so American taxpayers would pick up the tab.

This election may have been an eye-opener for the GOP. It opposes government, but its voters are nominating a candidate who doesn’t.

Maybe, somewhere in our political discourse, there’s room for responsible candidates to talk knowledgeably about smaller, cheaper, smarter government – reforming it, in other words, because sometimes that’s the best an imperfect society can do.

That’s not pro-government. It’s pro-honesty, and it can happen, even in politics.

Hutchinson’s ham and egg election

Gov. Asa Hutchinson

Gov. Asa Hutchinson

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

You know that old saying about the difference between ham and eggs? The chicken is involved but the pig is committed. Gov. Asa Hutchinson was both during this year’s primary elections.

With the presidential race, he was merely involved. He endorsed Sen. Marco Rubio for president eight days before the vote. He made a couple of appearances and a TV commercial. Donald Trump won Arkansas. Rubio was third, which he was going to be anyway.

Hutchinson, however, was committed in the state legislative races, where his political action committee, ASA PAC, donated money to eight Republican candidates who had Republican opponents.

This happened because the eight he supported also support, or at least would consider supporting, Hutchinson’s Arkansas Works. That’s the continuation of the private option, the state program that uses federal Medicaid dollars through Obamacare to purchase private insurance for adults with incomes up to 138 percent of the federal poverty level.

Created in 2013 by Republican legislators and Gov. Mike Beebe’s administration, it now covers 200,000 Arkansans. It brings a billion dollars in federal money to the state’s economy annually and has saved hospitals from providing millions of dollars in uncompensated care. But some Republicans are opposed because of its association with Obamacare, because it’s another government entitlement, and because they say neither the state nor the country can afford it.

Because it involves spending money, it requires a three-fourths vote for passage every year, which means nine senators can kill it. It barely reached three-fourths in 2013 and in 2014.

In 2015, Hutchinson persuaded legislators to accept a truce: Fund the private option through 2016, when it would end, and he and a task force would look into creating something else. That alternative is Arkansas Works, which is like the private option except that it requires a bit more personal responsibility on the part of beneficiaries. He says it’s a real change. Opponents say it’s cosmetic.

Hutchinson says Arkansas needs it. His budget depends on it. He doesn’t want to take insurance from 200,000 people. He needs $50 million in extra money for highways so the state will be eligible for $200 million in matching federal dollars. Take away the private option, or Arkansas Works, and that money’s hard to find without a tax increase, which isn’t happening.

On April 6, legislators will meet in special session to vote on Arkansas Works, or something. It can pass with a simple majority, which isn’t that high a bar. Then they’ll meet in the fiscal session, which occurs every even-numbered year, to vote on funding. And because a three-fourths majority will be needed, that session could be a doozy.

Arkansas Works was a central issue in those eight Republican primaries, which left Hutchinson a choice: Do nothing so as not to offend the potential winners; get involved like the chicken; or be committed like the pig. He was committed. He openly supported candidates. He held a press conference defending them. His political action committee gave each of them $5,400.

His job would have become much harder had those candidates lost. While the winning candidates would not take office before the special session, the current legislators would see Arkansas Works as a losing bet. Then Hutchinson next year would be dealing with as many as eight new legislators he’d worked to defeat.

Instead, six of the eight won, including all three in the Senate, where Hutchinson has no votes to spare. On the House side, three of his five candidates won, and one who lost was challenging an incumbent, Rep. Josh Miller, R-Heber Springs. Miller was already in the House, so Hutchinson’s situation didn’t change there.

The next day, Hutchinson addressed the Political Animals Club at the Governor’s Mansion. His mood was not quite jubilant, but it was definitely somewhat north of relieved.

“I think everybody in this room knows that if those three state senators had lost their race, it would not be a pleasant day for me in this room,” he said. “I would have to be explaining. It would have been considered a referendum on me and my leadership.”

Yes, it would have been, in a way that the presidential race was not. He was merely involved with Rubio for eight days, but he’s staking a big chunk of his first term as governor on Arkansas Works. That’s commitment.

Related: Coming health care debate a “cage fight,” says leading legislator.

Priorities and the Hogs

Football on tee - transparentBy Steve Brawner
© 2016 by Steve Brawner Communications, Inc.

Merriam-Webster’s online dictionary defines “juxtaposition” as “the act or an instance of placing two or more things side by side.” On January 27, an interesting one occurred at a University of Arkansas System Board of Trustees meeting.

The trustees were led on a tour of the University of Arkansas for Medical Sciences hospital campus in Little Rock. While parts are new and gleaming, what once was the main hospital needs $13 million just to become fire code-compliant, and even then it would be badly outdated and inefficient. UAMS would like $97 million to spruce up that building and other facilities, all for administrative space. Tearing the building down and replacing it would cost $250 million.

Board members later heard from the University of Arkansas at Pine Bluff. Students there enjoy a new science and technology building and a new fitness center, but in the middle of campus is an unused old multistory facility with weeds growing from the roof, and not as part of a science experiment. The campus security headquarters is an aging house, which can’t be reassuring to parents, and after a good rain, parts of the campus are underwater. UAPB would like money, too.

Then came the University of Arkansas Athletic Department, which seeks a $160 million expansion of its football stadium that would include 3,200 premium seats along with other amenities, such as a video board. The project would be funded through $40 million in donations and a $120 million bond issue repaid through higher ticket prices, paid mostly by fans not sitting in those 3,200 premium seats.

The trustees gave Athletic Director Jeff Long their blessing to continue gathering information, but not before former Sen. David Pryor had questions and abstained from voting. He said he was not necessarily opposed, but priorities should be discussed. This would be, he said, “the largest single bond issue in the history of higher education in the state of Arkansas.” He asked who would benefit, and how much of the costs students would bear.

“A bond issue is a debt of the University of Arkansas,” he said. “It is a debt of the people of Arkansas, and ultimately if something goes wrong, who’s responsible? And that’s the people.”

This is where the columnist perches in his ivory white tower and wags his finger at the trustees, right? Well, not necessarily. Pryor had it right. A discussion is needed.

True, it was quite a juxtaposition to see the state’s teaching hospital and one of its universities asking for money that’s currently not available for boring but necessary stuff like medical administration and drainage, which was then followed by a mostly celebrated $160 million request for football seats used six or seven times a year by rich people, along with other amenities.

However, the needs UAMS and UAPB are seeking to fill would be met partly by tax dollars that haven’t yet come from the Legislature. Moreover, it should never be assumed that public entities are spending the money they already have as efficiently as can be expected (or that they’re not).

Long, in contrast, was asking to pursue money paid voluntarily by donors and fans who, if they don’t like the higher ticket prices, could choose to watch the games on TV, which is what I do. The UA Athletic Department is one of the nation’s few big time college programs that turns a profit and is self-sustaining. In fact, it’s given money back to the university for academics for the newly built Champions Hall.

Finally, at what point do the Razorbacks add to the university, and at what point do they distract from it? The head football coach, Bret Bielema, is by far the highest paid state employee, including the doctors saving lives at UAMS. That seems like a misplaced priority. On the other hand, the Razorbacks are the university’s best marketing tool and a tie that binds the state together. And on the third hand, does all this send a message to young people that while we adults tell them to hit the books hard so they can become doctors, what we really value is how hard the Razorbacks hit the opposing players in the SEC?

It’s a complicated discussion, and it’s worth having before letting people spend $160 million of their own money on a football stadium, and making taxpayers responsible if something goes wrong.