Category Archives: State government

Health care reforms: These would be easy

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

Health care reform is difficult, in large part because it’s so hard to achieve consensus on many issues related to it. Repeal Obamacare, or amend it? Keep the private option, or replace it?

So maybe more attention should be paid to reforms where agreement is possible. For starters, here are two.

One would be for hospitals to make fewer people sick. According to the federal Centers for Disease Control and Prevention, 648,000 Americans contracted infections while in an acute care hospital in 2011, and 75,000 of them died while a patient, though not necessarily from the infection. One in 25 hospital patients is infected during their stay.

Not all of those infections were the hospitals’ fault, of course. Many patients have weakened immune systems. But many infections are preventable if hospitals follow simple procedures. Sometimes it’s as simple as making sure physicians and nurses wash their hands.

That’s one of the practices at Unity Health in Searcy, one of nine hospitals in the country and the only one in Arkansas given a top rating for infection control by Consumer Reports.

The magazine recently rated 3,000 hospitals based on five infections: clostridium difficile, or C. diff, which develops in 290,000 patients each year and contributes to the death of at least 27,000; methicillin-resistant staphylococcus aureus, or MRSA, which contributes to more than 8,000 deaths annually; catheter-associated urinary tract infections; central-line associated bloodstream infections; and surgical-site infections.

Unity Health staff members told me there’s no magic bullet. Instead, they just follow nationally recognized guidelines, such as using a bleach-based cleaning procedure to combat C. diff infections. They avoid unnecessary catheterization. The housecleaning staff keeps the rooms clean.

How can more hospitals be encouraged to follow Unity Health’s lead? One way is to continue changing the perverse incentives surrounding health care. Medical providers traditionally have been paid by insurance companies and government payers under a “fee for service” model. They bill for each service they provide, so if a patient is infected while in the hospital, the hospital gets paid for treating that infection. That doesn’t mean hospitals are purposely careless, but it does give them less reason to be extremely careful.

Arkansas is a national leader in creating an “episodes of care” payment model based on appropriate costs for select procedures, such as knee and hip replacements, from the beginning to the end of treatment. If average costs for all such patients fall below a certain threshold, medical providers are paid a bonus, and they face a penalty if costs are too high. So if enough patients contract an infection, the hospital’s bottom line will suffer.

The model was created with input from government agencies, insurance companies and medical providers. In other words, consensus was created. The state started with five episodes and has been increasing the number. The federal Medicare program is experimenting with the model as well.

Makes sense, doesn’t it? If health care is to remain a free market entity, then providers should face the same expectations as other businesses: If I hire you to fix something, you don’t get paid more if you break something else.

Another health care reform where consensus should be possible is increasing the number of medical professionals.

Recently, 214 physicians completed their residency training at UAMS and are ready to practice medicine. Unfortunately, that’s only a drop in a bucket with a hole in it. According to a 2015 study sponsored by the Association of American Medical Colleges (AAMC), the United States faces a shortage of between 46,000 and 90,000 physicians by 2025.

A medical education is costly. According to the AAMC, 84 percent of 2014 medical school graduates had education debt, with a median debt of $180,000 – and that comes after many years of school, long after law school graduates are making money suing doctors.

Gov. Asa Hutchinson has made increasing the number of high school students with computer coding skills a top priority. How about an effort to produce future doctors? Could we agree on that? If Arkansas can award more than 168,000 lottery scholarships, many to students who aren’t particularly focused or directed, can it reallocate resources to qualified medical school students?

More doctors are needed, and hospitals shouldn’t make people sick. Solving those problems won’t be easy, but coming to a consensus will be easier than it’s been with Obamacare and the private option. So can we talk about the easy stuff more often, and fight about the hard stuff a little less?

Private option: It’s all about the paperwork now

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

As of the beginning of this month, 31,501 Arkansans no longer have insurance through the private option, mostly because there’s a problem with their paperwork.

The state is redetermining eligibility for 600,000 Arkansans who receive health insurance through the private option or traditional Medicaid. Medicaid serves the poor, the disabled and others. The private option uses federal dollars to buy private insurance for lower-income Arkansans who previously wouldn’t have qualified for Medicaid.

The redetermination process, required by the federal government, has been a mess, beset by costly computer glitches. Now the state is trying to make up for lost time. Recipients whose incomes appear to have changed 10 percent are sent a Department of Human Services letter warning that they must verify their income within 10 days or they’ll lose their benefits.

If you count both the Medicaid and private option recipients, and both July and the upcoming August terminations, about 48,000 Arkansans will be off the rolls – 97 percent of them because they didn’t meet the deadline.

Some of that is because the state is overwhelmed. Some recipients have claimed to have submitted their incomes and then been told they’ve lost their benefits anyway. On Tuesday, Hutchinson announced a two-week pause in sending out the warning letters while DHS scrambles to find staff to process all the paperwork.

Why aren’t the others responding? Maybe they never realized they were on the private option, or they moved and never received the letter, or they read the letter and tossed it because they’re not sick right now. Some mistakenly sent verification to their local DHS office instead of the address required by the letter.

And some may have misunderstood the letter’s meaning or importance. Using bureaucratic language, it tells the recipient to verify their income or “your case will be closed and you will have to reapply” – not “or you will lose your insurance.” The envelope isn’t marked with anything that would communicate that it’s more important than all the other mass-produced envelopes in the recipient’s mailbox. Here’s the verification letter.

Asked if he might throw away an impersonal mass mailing, Gov. Asa Hutchinson, who personally selected that 10-day timeline, said, “If I were a recipient of Medicaid from DHS, and I get a letter from DHS, I would presume it’d be a responsibility to open that letter.”

He’s right that recipients of a very generous government health benefit have at least that responsibility. But the private option serves many lower-income people who, for whatever reason, haven’t previously qualified for Medicaid and often haven’t had health insurance, government or private. Many have jobs but just don’t have experience working the system.

Hutchinson also pointed out that recipients actually have much more than 10 days. Counting a grace period and then a 90-day appeal process where medical bills will be paid retroactively, recipients actually have three or four months before they are completely off the rolls. Before losing their benefits, they are told through another bureaucratic-sounding termination letter that their ”case will be closed.” Also, the insurance companies who provide private option recipients their coverage were alerted that they were about to lose their government-funded ratepayers, so they had a big incentive to try to contact them as well.

Seems like there should be a better way to verify who should receive a government benefit, and who shouldn’t. The state will pay to kick people off the private option, and then pay to put them right back on it when their pharmacist can’t fill their prescription.

The backstory behind this process is the controversy over the private option itself. Created as an outgrowth of the Affordable Care Act (Obamacare) it barely passed in 2013 and barely was reauthorized in 2014. The Legislature cut the private option’s marketing budget in 2014, which might could have paid for the ink to print on those envelopes, “Urgent: Respond within 10 days or you’ll lose your insurance.” The private option survived 2015 only because Hutchinson convinced legislators to give him a couple of years while he and a legislative task force create something better by the end of 2016. One by one, private option supporters are losing elections or drawing primary opponents.

So part of what’s happening is that we’re all trying to prove that we can get tough on the private option, right before we close the case on it and reapply with something else.

The real Common Core conflict

Common Core cover cutoutBy Steve Brawner
© 2015 by Steve Brawner Communications, Inc.

The Governor’s Council on Common Core Review didn’t drop any bombshells when it announced its recommendations July 30. It had already made its mark when it pre-recommended in June that Arkansas join the many states exiting the year-end PARCC exam, which Arkansas has since done.

But while the Council may have calmed the waters, which was part of its purpose, the conflict will continue. That’s because the Common Core debate isn’t just about what schools teach, which would be important enough. It also reflects the country’s fundamental divisions.

The Common Core is a set of math and language standards adopted by most states – standards meaning “what students should know” but supposedly not “how teachers should teach.” It was originally proposed by the National Governors Association and the Council of Chief State School Officers as a way to create consistency and comparability among the nation’s schools. The State Board of Education adopted the standards in Arkansas in 2010 without much public discussion, which is part of the problem.

The Common Core partly was a reaction to No Child Left Behind, signed by President George W. Bush in 2002. That law gave the federal government the ability to punish schools if their students weren’t proficient but then let states create their own definitions of proficiency – and their own tests. Because states had a financial interest in their students being “proficient,” the result was a wide variety of standards that often weren’t very rigorous.

The 17-member Council, chaired by Lt. Gov. Tim Griffin, commendably held more than 40 hours of hearings and also hosted public meetings in nine cities. It eventually produced six pages of findings and recommendations. Among the council’s assertions is that “a significant majority of educators generally approve” of the Common Core and that educators “are almost unanimous” in the belief that the Common Core is better than Arkansas’ previous standards.

So what are the problems? Among them are a lack of communication between policymakers and the public, and uneven implementation among the state’s school districts. The Council reported that common criticisms of the standards ranged from “well-founded to completely baseless” and often pertained to issues not actually mandated by the Common Core. For example, those weird math problems that have frustrated so many parents are part of a teaching method that complies with Common Core but isn’t required by it.

Among the Council’s recommendations is that the Department of Education continue studying the issue, which it was already doing, that the standards remain under Arkansas’ control, and that they be fluid and changeable.

Will 40 hours of hearings, nine public meetings, and the slaying of PARCC turn down the heat on this issue? Probably some. A public discussion finally has been had. The longer these are the standards, the more entrenched they will become.

On the other hand, the Common Core controversy isn’t just about the Common Core. Instead, the controversy is really about the country’s division, dysfunction and distrust. These days, any national policy effort, even one originating outside the federal government, will be treated skeptically by many. That’s understandable because power tends to centralize. What begins as a voluntary effort by states could become a federal government mandate.

So the divide over Common Core is about educational standards, but it’s also about Obamacare and President Obama, who had little to do with the Common Core until he expressed support for it and his Department of Education unfortunately started handing out grants to encourage it. It’s about the Confederate flag and Bruce/Caitlyn Jenner and all the other things we’re fighting about. Really, if there’s been a federal school takeover, it happened when Bush signed No Child Left Behind. But that occurred early in his administration, a few months after the September 11 attacks, when the country was relatively unified and its attention focused on external enemies.

The Council has finished its work. We still have the Common Core standards, which are probably better than what we had. We have a less intrusive year-end test. We still have a lot of distrust.

And we still have educators trying to do their jobs in the midst of an ongoing education controversy that’s about a lot more than education. School starts this month.

Is having more choices at the ballot box worth all the trouble?

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

The unspoken question in Judge James Moody’s Eastern District courtroom Monday was, how much trouble should the election process undergo to accommodate candidates who aren’t going to win anyway, and also to accommodate Arkansans who want to vote for them?

The case, Moore v. Martin, involves two Marks. One is Mark Moore of Pea Ridge, an independent candidate – not a member of any party – who collected 39 percent of the vote in a two-person state legislative race in 2012 and wanted to run for lieutenant governor in 2014. The other is Mark Martin, who as secretary of state is the official in charge of elections, thereby making him the defendant.

The case concerns Act 1356 of 2013, which requires independent candidates to submit their required number of signatures when they file for election. In 2014, that meant they had to qualify by March 3, two months before the Republicans and Democrats held their primaries to choose their candidates. Under previous law, independents could file and then had until May 1 to collect their signatures – 3 percent of qualified voters with a maximum of 10,000 in state races and 2,000 in others. Because the Legislature moved the 2016 primary elections to March, independents this time must collect signatures by November. That’s November 2015, for an election that will occur in November 2016.

Moore says Act 1356 is unfair and unconstitutional. In non-2016 years, independent candidates must collect signatures door to door long before the election in the dead of winter. As a result, argued his attorney, James Linger of Tulsa, the number of independent legislative candidates dropped from seven in 2012 to one in 2014. Court precedent is largely on Moore’s side. In 1976, a three-judge district panel ruled in another Arkansas case, Lendall v. Jernigan, that an April signature deadline for independents was unconstitutional. That decision was affirmed by the U.S. Supreme Court.

Martin’s attorney, A.J. Kelly, argued that Moore doesn’t have standing – he can’t sue – because he didn’t try to collect signatures in 2014. He pointed out that one legislative candidate did qualify, so the law doesn’t restrict access for those who really want it. Finally, he said an early deadline is justified because it takes time to review signatures to make sure overseas Arkansans can be mailed a ballot before the election.

Watching the proceedings were the chairmen of the Libertarian Party and the Constitution Party. Act 1356 also gives third parties early deadlines. The Libertarians already have submitted their signatures and plan to hold their convention in November to nominate candidates – again, for an election that won’t occur until the next November.

Judge Moody said he’ll render a decision within a couple of weeks. If he bases it on the merits, it’s hard to see how Moore loses. There’s too much court precedent on his side, and there’s no reason to have such an early deadline for submitting signatures. According to Richard Winger, publisher of Ballot Access News, between 1891 and 1955, Arkansas independent candidates needed only 50 signatures for any office, and the petition deadline was 20 days before the general election. I don’t know why legislators voted for Act 1356, but the practical effect is to reduce the chances of anyone challenging their two big parties. But Moody could decide for Martin based on a procedural or technical matter.

A Gallup poll released in July found that 46 percent of Americans consider themselves to be independents. However, the reality is that many who say they are independent reliably vote for one party or the other. Even though the Constitution doesn’t mention political parties, for many structural and psychological reasons, our system gravitates toward having two of them. And so this case is about opening up the process for candidates who probably aren’t going to win.

On the other hand, at one time, the United States had two major political parties, and the Republican Party wasn’t one of them. Our society values giving people choices, in letting ideas flourish, in freedom of speech, and in giving the little guy a chance. Some candidates want to run as neither Republicans nor Democrats. Some voters would like the chance to vote for them. In a nation where consumers have dozens of choices in the cereal aisle, why pass laws that reduce the choices at the ballot box?

So is having more candidates and a more robust debate worth the trouble? We ought to lean toward saying yes, regardless of what a judge decides in this particular case.

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

Talking religion and politics

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

You know that old saying, “Don’t talk about religion or politics in polite company?” It would be hard to agree to that as a columnist after these past couple of weeks, when so much has happened involving both.

Start with gay marriage. The Supreme Court’s declaration that it’s now the law of the land hasn’t completely settled things in Arkansas. One county clerk resigned rather than issue licenses, and one pledged to fight but then changed her mind. Meanwhile, the issue has created a division between Gov. Asa Hutchinson, who says the Court’s ruling is final, and others, particularly Sen. Jason Rapart, R-Conway, who say it’s not.

It is. Gay marriage will remain legal. It’s not just the Supreme Court that has spoken in this case, but popular opinion. Six out of 10 Americans support it. Support is even higher among younger Americans, who, as time passes, will compose more and more of the other four.

Instead, the real issue is the tension between two government aims that are competing in this case: preventing discrimination and protecting religious liberty. In Oregon, a baker who declined to participate in a gay marriage ceremony was ordered to pay the offended couple $135,000. In Kentucky, a t-shirt company that declined to promote a gay pride event won its case because the judge ruled it acted on the basis of the owner’s beliefs, not because of discrimination.

This is going to be a big argument, it’s going to be heated, and it’s going to last a while.

Meanwhile, another religious controversy arose this week over the Legislature’s decision, with the governor’s signature, to erect a monument to the 10 Commandments on the Capitol grounds. Extremely predictably, other groups, including Satanists, say they also might want monuments. Asked about the controversy, Hutchinson said everybody can’t have a monument and that the 10 Commandments are historically relevant to Arkansas in a way that other groups’ monuments would not be.

Finally, Hutchinson on Tuesday announced that a multi-faith statewide summit will happen this August in Little Rock to call houses of worship to act in two areas – finding foster homes for the 1,900 Arkansas children who have no place to stay, and helping the 6,000 inmates who will leave prison this year reintegrate into society. A steering committee composed mostly of Christians but also of two Jewish rabbis and a Muslim imam has been planning the event,

Asked by reporters, Hutchinson, an attorney, acknowledged that a partnership between churches and state is involved. Yes, he said, people of faith will have a faith-based motivation for participating. Yes, he said, state resources are being used to help organize and promote faith-based activities.

It’s early, but so far, no one has really complained. Maybe we’re too busy fighting over other things. Maybe all but the most hard-core among us recognize that the needs are so great that they’re willing to accept a little church-state partnering in order to provide homes for those kids and a second chance for those inmates. Some things are more important than our political arguments. So proceed with caution, Governor, but please proceed.

A chasm is widening between Americans who see the world very differently. What a person believes about legal issues like gay marriage often depends on how they personally feel about homosexuality or about Christians.

That is not how the Constitution is supposed to be interpreted. The real question should be, what is the role of government in enforcing social norms and in controlling behaviors and beliefs?

And the answer in a free society should be, as small a role as possible. Really, it’s best for all of us if we live and let live, and try to avoid using judges, law enforcement and the IRS to try to make people believe what we want them to believe.

It could be argued persuasively that this widening chasm is good for religion, which grows stale when it’s too acceptable. It’s definitely bad for politics, which in a country like ours requires people from different backgrounds to meet in the middle. The next president will have an impossible job.

Oh, well. Maybe sometimes we should just talk about the weather in polite company. There’s an old saying about it, too. In Arkansas, if you don’t like it, just wait, because it will change.

As do other things.