Category Archives: Health care

Executive orders, congressional disorder

U.S. Capitol for blogBy Steve Brawner
© 2016 by Steve Brawner Communications, Inc.

This past week saw two big news events that weren’t actually very “new”: President Obama’s announcement that he is issuing yet another executive order, this one related to gun restrictions, and Republicans in Congress voting to repeal Obamacare.

Obama’s executive order, which attempts among other things to close the gun show loophole, doesn’t seem to be that significant a policy move or even a bad proposal. Sellers should all play by the same rules, and I’m not opposed to there being one less avenue for crazy people, convicted felons and terrorists-in-waiting to be able to purchase military-grade weapons.

The problem is the process. Congress has not voted to accomplish what Obama wants to accomplish. More concerning, executive orders are becoming a habit of his, the most obvious example being his attempt to completely bypass Congress on immigration policy. That effort is now being tied up in court, where it should be. And I write that despite the fact that, as with the gun show issue, I agree with Obama in principle that the United States should focus on deporting dangerous illegal immigrants while finding a path to legalization for those who have been here awhile and are otherwise obeying the law.

But that’s another column. This is about misusing the presidency’s powers.

I guess this is the part where I’m supposed to write about Obama in hysterical, apocalyptic terms. Let’s instead have a calm, rational discussion, shall we? President Obama is exceeding his constitutional authority. He should stop doing that.

Actually, Obama is doing exactly what the Founding Fathers anticipated a chief executive would do, which is try to exercise power. They knew that was a bad thing, even if the president’s goals were agreeable.

So they included in the Constitution a system of checks and balances to keep that from happening. Congress makes the law; the president enforces the law; the judiciary interprets the law.

Unfortunately, Congress is failing to check and balance the president, and it’s time for congressional Democrats to step up.

Members of Congress are supposed to place their branch above their political parties – which, by the way, are not even mentioned in the Constitution. Throughout American history, senators and representatives have stood up to presidents who have tried to usurp their role. Instead, with exceptions, congressional Democrats today too often are behaving as if this is a British parliamentary system, where a prime minister leads the government and most everybody falls in line most of the time.

Because I’m determined to offend everyone in this column, congressional Republicans share blame as well. The system is supposed to work through a system of checks and balances, not unending dysfunction. Republicans made a political decision from the beginning of Obama’s presidency to make him fail, no matter what. It’s worked for them – politically. They’ve made huge gains in Congress, in governor’s offices, and in state legislatures. But a more constructive approach would have been better for the country.

Now we’ve had yet another vote to repeal Obamacare – one that actually will make its way to Obama’s desk, where he will veto it.

This is happening because Republicans believe it will help them in November prove once again that President Obama supports Obamacare, along with Democrats, as if there were any doubt about all that. Meanwhile, Republicans still haven’t coalesced behind a plan to replace the system they would repeal. The bill they sent to his desk would give policymakers a couple of years to create an alternative, but if they don’t, or can’t, would we all go back to the days when insurance companies denied coverage to people because of pre-existing conditions, or cut them off when they became too expensive to cover? At the moment, I guess we would.

No one’s the hero, and no one is the villain. What’s happening is that a lot of officeholders are caught up in the big game up there, which is one reason why Obama’s approval ratings are only 45 percent, according to Gallup, while Congress’ are at 13.

Anyway, it’s 2016, and time for us regular folks to vote. If we do our jobs better, maybe they will too.

Next year’s health care ‘cage fight’

CapitolBy Steve Brawner
© 2015 by Steve Brawner Communications, Inc.

In mid-December, I wrote that legislators would decide how to reform health care in Arkansas by the end of the month. As the TV character Maxwell Smart used to say, “Missed it by THAT MUCH.”

What legislators actually did was give Gov. Asa Hutchinson a few months to negotiate with the federal government – and then sometime next year they’ll decide how to reform health care. It will be a “cage fight,” in the words of Sen. Jim Hendren, R-Sulphur Springs, chairman of the Health Reform Legislative Task Force (and Hutchinson’s nephew).

The task force was created last year to determine what to do about Medicaid and the private option. Medicaid is the health care program for the poor, the aged and disabled. The private option is the Medicaid program that buys private insurance for Arkansans with incomes up to 138 percent of the federal poverty level. The private option, which was created in 2013, currently is funded entirely by the federal government, but Arkansas begins paying 5 percent in 2017 and 10 percent by 2020.

The private option provides health insurance for about 200,000 Arkansans. It is the primary reason the state has cut in half its number of uninsured residents, lessening the unpaid care provided by hospitals. But critics believe it is an unacceptable concession to Obamacare that eventually will cost the state a lot of money. It must pass with 75 percent support from each house in the Legislature each year, which means nine senators can kill it.

Hutchinson, who wants to keep it, persuaded lawmakers this year to fund it through the end of 2016 while his administration and the task force create an alternative. He’s proposed a sequel, “Arkansas Works,” that like many sequels looks a lot like the original. It would, however, involve more personal responsibility on the part of beneficiaries, including requiring those with higher incomes to shoulder part of the cost for what is now essentially free health care.

Those changes will require a waiver from the federal government that Hutchinson has already started seeking. In January, he’ll meet with Sylvia Burwell, secretary of the Department of Health and Human Services. He’ll probably get part of what he wants because Burwell will know the private option is on shaky ground. But he already knows he won’t get everything he’d like.

He requested and received the task force’s blessing to proceed. During a voice vote on a motion supporting his efforts Dec. 16, zero legislators voted no.

But legislators weren’t necessarily endorsing Hutchinson’s overall goals. Sen. Cecille Bledsoe, R-Rogers, a private option opponent who had led the task force in applauding Hutchinson the day before, didn’t vote at all. She’s not opposed to seeking waivers because it can’t hurt to ask. But she remains deeply concerned about the program, whatever it’s called. Among her fears is that the federal government won’t hold up its end of the bargain of paying 90 percent, forcing Arkansas to pay more.

The next few months will be eventful. Hutchinson will request and then await the waiver. On March 1, Arkansas’ party primary elections could reduce the number of pro-private option lawmakers, though the new officials won’t take office until January 2016. There will be a fiscal session after the primaries and then a special session regarding health care that could be a doozy.

Somewhat surprisingly, the biggest debate for now is not about the private option but about adopting a managed care model where a private company would be contracted to manage parts of Medicaid. Even the Arkansas Department of Human Services’ director, John Selig, says private companies could better manage some services than DHS can.

But DHS’ record on contracts has been disappointing lately – the most notable example being a computer system for tracking Medicaid re-enrollments that is $100 million over budget. And not everyone supports managed care, anyway. Opponents include a group of mostly Republican legislators who make their livings in health care and believe Arkansas would be better served expanding the reforms it’s already undertaken. So the same day the task force gave Hutchinson its blessing on the waiver, it also instructed its consultant, The Stephen Group, to see if it could find enough savings over five years using the current model to cover the state’s 10 percent in 2020. Then lawmakers will decide if that route is better than managed care.

So changes are still coming to Arkansas health care. It’s just the cage fight will be next year, not this past one.

***

For additional reading: Is health care a commodity or an entitlement? Neither.

For legislators, The Stephen Group report was an ink blot test.

Reforming health care – next week

By Steve Brawner
© 2015 by Steve Brawner Communications, Inc.

Next week – Dec. 15-17, to be precise – a legislative task force will try to reform health care in Arkansas while deciding what to do about the state’s most contentious issue in years. That’s all.

Here’s the background. After the passage of Obamacare and then a U.S. Supreme Court decision on the matter, states could choose whether or not to expand Medicaid, which provides health care to poor Americans and others. Blue states said yes to the expansion. Most red states like Arkansas said no.

Arkansas said, “Yes, but …” Instead of expanding Medicaid, it would use that money to buy private insurance for Arkansans with incomes up to 138 percent of the federal poverty level.

The program has insured 250,000 Arkansans at its height. In fact, Arkansas has led the nation in reducing its uninsured population. Several states have followed its lead and adopted or considered their own versions. However, some legislators are opposed because the state is scheduled to begin paying part of the cost in 2017, and because this is Obamacare, and because it contributes to the national debt.

The private option barely passed in 2013 and barely was reauthorized in 2014. Because money is being spent, passage requires a three-fourths majority, which means nine senators can block it.

Instead of having yet another political battle this year, Gov. Asa Hutchinson asked legislators to fund it through 2016 and, in the meantime, reform it along with the overall Medicaid program. To accomplish that task, a Health Reform Legislative Task Force has been meeting this year and will make its report by the end of this month. Their big meeting is scheduled for Dec. 15-17. Then there will be a special session next year where the full Legislature will vote.

The task force was composed of about half private option supporters and half opponents. It hired a national consultant, The Stephen Group, that offered suggestions for changes but certainly didn’t advocate scrapping it.

Hutchinson has offered his own reforms, similar to The Stephen Group’s, that he’s calling “Arkansas Works.” Speaking to a health care group this week, he insisted the private option would end on Dec. 31, 2016. But while Arkansas Works clearly changes the private option, it’s not radically different. The government still would pay for poor people’s private health insurance.

The changes instead would make it less of a welfare program. Beneficiaries who work would be required to be insured through their employer when available rather than through the private option, with the state chipping in to help with costs. Those who don’t work would be required to obtain work training. Recipients earning at least 100 percent of the federal poverty level – and maybe some making less – would be required to pay part of the costs for what is now free health care. Those who don’t pay would lose their health insurance and be locked out of the system for a period of time. Hutchinson also floated the idea of a lifetime cap, meaning a person can’t stay on the private option forever.

Hutchinson said the program must cut costs, explaining, “We have to have the savings if we’re going to do what I believe is our responsibility, and that is to cover that expanded population.”

Note that Hutchinson said covering those people “is our responsibility.” It’s been clear since his 2014 campaign that while he might want to change the private option, he doesn’t favor replacing it with nothing.

Nor do that many legislators. There are some, but even many of those who originally opposed it now would keep something in its place. Otherwise, many Arkansans would lose their health insurance and go back to waiting until they are really sick and then accessing the health care system without insurance – and their local doctors and hospitals would eat the cost. If that happens, hospitals will close. It’s happened in other states.

Actually, the private option isn’t the biggest controversy now. The big debate is about whether the state should adopt a managed care model where parts of the Medicaid system would be run by a private company and not the state. Supporters say it would create efficiencies. Opponents say managed care companies will take taxpayer dollars and skimp on care and on payments to providers. Several Republican legislators – generally they work in health care somehow – are among the opponents.

That debate is worth more space, but I only have 750 words to talk about health care. The task force, meanwhile, has one more week to reform it.

Is health care a commodity or an entitlement? Neither.

By Steve Brawner
© 2015 by Steve Brawner Communications, Inc.

The first question that must be answered about health care is about what it is: a commodity, an entitlement, or something else.

If health care is a commodity, then it must be treated as such. The price of health care should be what the market will bear, which, for someone in a life-or-death situation, is a lot. If someone is a poor negotiator, or if circumstances such as a ruptured artery make them unable to negotiate, then they might pay more. If they can’t afford it, then they can’t buy it, and the rest of us should feel no more remorse than if they can’t afford a pickup truck. They should have made better economic choices before they went shopping at the hospital.

Very few of us see health care this way. So if it’s not a commodity, then what is it? The opposite would be an entitlement – a service the government bestows. That’s how it works in a lot of European social democracies and in Canada.

Americans don’t like that either. The idea of the government having the power to give and take away free stuff, particularly something as important as health care, typically makes us uneasy (unless we can figure out some way of justifying it when we personally benefit, of course).

If health care isn’t a commodity, and it’s not an entitlement, then it’s something in between – a partial responsibility for middle- and upper-class individuals under age 65. That’s the messy middle ground Americans have selected, and the way it’s implemented is through insurance.

All of this is relevant because it’s time for Americans to once again sign up for health insurance. It’s now mandatory, of course, and this time, the fine for not paying is $695, which is enough to sting a little.

You can bet that Republicans will use this fact to score political points, even though this part of Obamacare was a conservative idea not long ago.

Insurance’s purpose is to insure us against unforeseeable costs we cannot pay. We pay thousands to the insurance companies today so we’ll be assured of receiving much more expensive care if we need it tomorrow.

For that system to function properly, most of us must lose money on this deal. And it only works fairly if all of us who can afford it pay in. The 23-year-old with money who doesn’t buy insurance will still be allowed to access the system if he crashes his motorcycle, because in that moment his life is so precious that it cannot be commodified. But somebody has to pay for saving that life, and because he didn’t, his health care will be subsidized by the rest of us. That makes it an entitlement.

One of the problems with this middle ground is that it doesn’t contain enough cost controls. If health care were a commodity, care would be rationed by the market. If it were an entitlement, care would be rationed by the government. As insurance exists now, buyers pay most of their health care costs upfront and have few incentives to shop around. Sellers therefore have few incentives to provide the cheapest deal possible.

The United States spends about 18 percent of its gross domestic product on health care, far more than the rest of the world, and the costs still are rising at unsustainable rates. If you’re wondering why you haven’t received a raise in a while, the truth is that you have: Your employer is paying more for your insurance every year rather than increasing your salary.

This can’t continue. In any economy, costs must be controlled by something, and if nothing else will do it, eventually the government will. So the buzzword these days is “consumer-driven health care” – making health care a little more of a commodity, but within the current system. Policymakers who are interested in solving problems are considering how to incentivize consumers to make more informed economic choices. Making them spend more of their own money, but not a crippling amount, through higher deductibles is one imperfect way of doing this.

This will be messy, it will be hard to figure out, and there will be a lot of yelling. So far, the United States has foregone the more cut-and-dried choices – making health care either a commodity or an entitlement – because of those choices’ problems. In other words, we still have a majority consensus about what health care is not. Now we just have to figure out what it is.

The private option ink blot

By Steve Brawner
© 2015 by Steve Brawner Communications, Inc.

You know those tests where therapists ask clients to describe an ink blot because people see what they’re inclined to see? This week, legislators were given a 450-page one.

That would be the report by The Stephen Group, the consulting firm hired by the Health Reform Legislative Task Force to help it decide what to do about the private option in particular and Medicaid in general.

Here’s the ink blot part: Legislators who support the private option can be encouraged by the report because it recommends changing it but not ending it. Meanwhile, opponents can point to a finding that 43,000 people served by Medicaid and the private option may not live in Arkansas, while the programs combined enroll 500 people who are deceased.

Here’s the background. Medicaid is the government health program serving the poor, the disabled, and the aged who live in nursing homes. It’s mostly but not entirely funded by the federal government and mostly administered by states. The Affordable Care Act, which created Obamacare, expanded Medicaid in all the states to cover more lower-income people. In 2012, the Supreme Court ruled that Obamacare is constitutional but that the Medicaid expansion must be only voluntary. Many states said no.

Arkansas created the private option. Instead of expanding Medicaid, it uses those dollars to buy private health insurance for Arkansans not covered by Medicaid and having incomes of no more than 138 percent of the federal poverty level. Republican legislators had the idea and worked with then-Gov. Mike Beebe, a Democrat, to implement it.

In some ways, it’s been a success. It’s currently serving about 200,000 Arkansans, give or take tens of thousands because the state is in the process of redetermining eligibility. According to a Gallup poll, the state’s uninsured rate fell from 22.5 percent in 2013 to 9.1 percent during the first half of 2015. That’s the best in the country, and the private option was a big reason why. Without the private option, hospitals would provide $1 billion in uncompensated care from 2017-21, according to the report. The private option is bringing $1 billion in federal funds to the Arkansas economy every year.

But that’s still a billion dollars in taxpayer money, opponents say, which increases the national debt. While the feds are paying for all of it now, Arkansas will be responsible for 10 percent of the cost in the next few years. It was supposed to serve the working poor, but 40 percent of its beneficiaries had no income last year, so it’s still a health care entitlement program. It’s still Obamacare.

The private option was created in 2013. It must be approved by 75 percent of legislators each year. It barely passed the first time and barely survived in 2014. We can’t keep doing this. So this year, Gov. Asa Hutchinson asked legislators to extend the private option through 2016 while it created the task force to decide what to do next.

Back to the ink blot. The small consulting firm found what the state’s huge Department of Human Services could not: 42,891 Medicaid and private option beneficiaries whose best addresses appear to be located out of state, including 3,220 whose best addresses are in California. Almost 500 on the rolls were dead before they even became a part of the program.

It’s unknown how much of this represents waste and abuse. It’s unclear how many actual dollars are going to the wrong places. A program this big will have challenges with its mailing list. Some people with California addresses may have moved to Arkansas recently.

Still, private option opponents can point to this report and say they were right all along, that government can’t do anything correctly, and the private option should be scrapped.

But the report didn’t recommend that. Instead, it said the private option should be retooled to become more of a transitional program that encourages work and personal responsibility – which, supporters would say, was the plan all along. Participants should look for work and meet health and wellness goals. Legislators might consider limiting participation in the private option to a few years. Meanwhile, the state should create an office that monitors the eligibility of all Arkansans seeking state services, including the private option.

Members of the task force must make their own recommendation by the end of this year. Will they vote to end the private option, or change it? It depends on what they see in the ink blot.