Category Archives: Health care

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what once was the main hospital needs $13 million just to become fire code-compliant, and even then it would be badly outdated and inefficient.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.

Reducing debt and cures for cancer

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

During the president’s State of the Union address Tuesday, there was an elephant in the room, and I’m not talking about the Republican Party, whose mascot is the pachyderm.

The elephant would be the $19 trillion national debt, ignored by President Obama during an hour-long speech, which was otherwise pretty good, and alluded to a couple of times by South Carolina Gov. Nikki Haley in her Republican response, which was also pretty good.

What was good about the State of the Union speech was its optimistic tone and its call for reason on issues both at home and abroad. The United States should identify and respond to threats, not inflate them so that it makes bad decisions out of fear. Its politics should be messy, not ugly.

However, the president’s only referral to the government’s red ink was to say that annual budget deficits have been reduced amidst other aspects of an improving economy.

That’s true, but while deficits have decreased, they’re still occurring each year, and still adding to the national debt. At the tail end of the Bush administration and the first half of Obama’s, the United States government was spending more than $1 trillion more than it collected each year – more than $3,000 per American per year, and at its worst, $4,000. According to the Congressional Budget Office, the deficit for fiscal year 2015 was $439 billion, or almost $1,400 per American.

Yes, that’s an improvement. We’re adding to the debt less quickly than we were before.

But during this prolonged period of economic growth, policymakers have failed to act to reduce future deficits. They haven’t make changes to the government’s retirement and health care programs that soon will help drive those annual deficits back to $1 trillion levels. They’ve failed to reform a tax code to juice the economy by, if nothing else, reducing the time we all spend doing our taxes. They haven’t created a sustainable method to fund the country’s infrastructure.

The economy is much better than it was in the midst of the Great Recession. Unfortunately, it remains dependent on debt – and worse, the kind caused by in-and-out spending, not investment.

That’s why potentially one of the most important paragraphs in Obama’s speech was tucked in the middle, when he said the United States should cure cancer.

That’s exactly the kind of investment that can make life better for Americans and help reduce all that red ink described earlier in this column. According to the National Institutes of Health, cancer cost the health care system $124.6 billion in 2010 and will cost $158 billion in 2010 dollars in 2020 – and that’s not including the impact of each invaluable life lost, nor the financial and emotional losses suffered by cancer patients and their loved ones. The disease often strikes people during their most productive years, or before they’ve even reached those years. All those things slow the economy, cost taxpayer dollars, and add to the debt.

At the same time we’re spending that kind of money to treat the disease, Congress recently appropriated $5.2 billion for cancer research this fiscal year, which is actually a raise from the previous $4.9 billion. That’s pretty good, but we could do better.

Since 2009, the national discussion over heath care has been about bureaucracies – what kind and how much. At some point, it would be helpful to talk about health care when we’re talking about health care. Curing the various types of cancer would be one of the greatest investments America could ever undertake. It would increase Americans’ ability to enjoy their inalienable rights of life, liberty and the pursuit of happiness. It would be a far greater service to the world than many of the things we’ve been doing since 2001. It would be a wonderful gift to future generations and sort of make up for the debt we’re passing down to them.

The research must take into account not only medical effectiveness, but cost-effectiveness. The NIH assumes in its analysis that new technologies and treatments will cost more, not less. So not only must cures be found, but costs must be affordable – both for Americans and for poorer countries.

We can do it. Americans put a man on the moon. Let’s find cures for cancer next.

Related: Who gets first dibs on Uncle Sam’s money? Its creditors, of course.

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.