Seniors, Guns and Money

OP-ED by Paul Krugman in the New York Times
This has to be one of the funniest political stories of recent weeks: On Tuesday, 42 freshmen Republican members of Congress sent a letter urging President Obama to stop Democrats from engaging in “Mediscare” tactics — that is, to stop saying that the Republican budget plan released early last month, which would end Medicare as we know it, is a plan to end Medicare as we know it.

Now, you may recall that the people who signed that letter got their current jobs largely by engaging in “Mediscare” tactics of their own. And bear in mind that what Democrats are saying now is entirely true, while what Republicans were saying last year was completely false. Death panels!
Well, it’s time, said the signatories, to “wipe the slate clean.” How very convenient — and how very pathetic.

Anyway, the truth is that older Americans really should fear Republican budget ideas — and not just because of that plan to dismantle Medicare. Given the realities of the federal budget, a party insisting that tax increases of any kind are off the table — as John Boehner, the speaker of the House, says they are — is, necessarily, a party demanding savage cuts in programs that serve older Americans.

To explain why, let me answer a rhetorical question posed by Professor John Taylor of Stanford University in a recent op-ed article in The Wall Street Journal. He asked, “If government agencies and programs functioned with 19% to 20% of G.D.P. in 2007” — that is, just before the Great Recession — “why is it so hard for them to function with that percentage in 2021?”

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Saving the American Dream: The Heritage Plan to Fix the Debt, Cut Spending, and Restore Prosperity

The conservative Heritage Foundation released a budget plan Tuesday that balances the federal budget far sooner than the House 2012 budget resolution, in part by cutting benefits for current seniors.

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GOP Unveils Medicaid Flexibility Bill

By Sam Baker


Congressional Republicans' bill to let states cut their Medicaid rolls would save the federal government nearly $3 billion over the next five years, according to a preliminary estimate from the Congressional Budget Office (CBO).


A group of House and Senate Republicans on Tuesday outlined their bill to repeal the Medicaid "maintenance of effort" provisions in the new healthcare law. The law expands Medicaid beginning in 2014, and the federal government will initially foot the bill for the new beneficiaries. In the meantime, states are prohibited from reducing their eligibility levels.
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NEJM - Remaking Health Care

The April 28th issue of the New England Journal of Medicine contains a series of papers on Health System Reform:

Consensus and Conflict in Health System Reform — The Republican Budget Plan and the ACA
Timothy Stoltzfus Jost, J.D.

The “Roadmap for America’s Future,”1 put forward by Representative Paul Ryan (R-WI) and adopted in principle as the Republican budget proposal for 2012, offers a vision of the role of government and the nature of a good society that contrasts sharply with the vision inherent in the Affordable Care Act (ACA). Nevertheless, the Roadmap and the ACA have much in common, suggesting that there is a growing consensus regarding the way in which the U.S. health care system should be structured. The Republicans have borrowed ideas from the ACA, and the ACA drew heavily on earlier Republican proposals. Exploring the shared elements of the two plans (see Similarities and Differences between the Affordable Care Act and the Ryan Plan) to clarify the extent to which consensus has emerged in U.S. health policy may enable us to begin addressing the serious conflicts that remain.

Reforming Medicare — Toward a Modified Ryan Plan
Gail R. Wilensky, Ph.D.

Medicare reform, an issue that is rarely out of the political spotlight for long, has once again achieved a position of prominence. The current focus is primarily on the role that Medicare and other entitlement programs play in driving up the deficit, but the need to reform Medicare long predates the economic collapse of 2008.

High-Risk Pools — Merely a Stopgap Reform
Linda J. Blumberg, Ph.D.

A central goal of health care reform is to ensure that everyone, regardless of health status, has access to adequate, affordable insurance coverage and medical care. The Affordable Care Act (ACA) aims to achieve this goal by prohibiting insurers from engaging in practices that discriminate against the sick and requiring that the vast majority of Americans have insurance coverage — allowing the costs of care for people with substantial health care needs to be shared broadly by the whole population. Because most people are healthy at any given time, the sharing of expected health care costs should mean only small increases in premiums for the healthy and large savings for people who may incur disproportionately high medical expenses. However, these broad-based reforms will not be implemented until January 1, 2014.

Medicaid at a Crossroads
John K. Iglehart

Approximately 68 million Americans were enrolled in Medicaid at some point during 2010, when the program spent $406 billion on acute and long-term care services for its beneficiaries.1 Another 16 million people are slated to gain Medicaid eligibility through the Patient Protection and Affordable Care Act (ACA), which would make the federal–state program responsible for financing services for more than one in four Americans. Enacted in 1965 as an afterthought to Medicare, Medicaid has become a vast public enterprise that underscores the limits of the private insurance market even as it squeezes state budgets already stretched by the recession. These realities, along with the fact that an increasingly conservative electorate has given Republicans control of the U.S. House of Representatives, raise a fundamental question for policymakers: What level of support should government provide to people who can’t afford private insurance and are not offered employer-sponsored coverage?

How Not to Reform Medicare 
Henry J. Aaron, Ph.D.

Medicare reform has become a hot political issue. The program is wildly popular but expensive. It is the principal source of projected increases in budget deficits. With deficits increasingly seen as a mortal economic threat, many believe that now is the time for Medicare reform.

The reform flavor of the day is “premium support.” What is it? What are its strengths and weaknesses?


The ACO Regulations — Some Answers, More Questions
John K. Iglehart

Recognizing that physicians allocate most of our health care resources, Congress and the Obama administration challenged doctors in the Affordable Care Act (ACA) to develop more accountable, quality-driven health care delivery systems, promising performance bonuses for those who succeed. The vehicle that Congress created for tackling this task is the accountable care organization (ACO), which is built on a strong foundation of primary care.1 To qualify as an ACO, a group of health care providers must have the capacity to deliver the full continuum of care to at least 5000 Medicare beneficiaries and to be held accountable for the costs and quality of their care. Although the law links ACOs to Medicare, the administration has encouraged private health plans to contract with these new organizations as well. With the launch of ACOs, the reform law raises new issues that are certain to roil relations between primary care physicians and specialists. Managing care utilization more efficiently could require a rewiring of long-standing referral and hospital relationships. And conflicts may well arise over how to divide ACO savings, with primary care doctors, whose incomes are appreciably lower than those of most specialists, striving to reduce that differential. The implications for hospitals could also prove profound, given the complex new equation for calculating shared savings under the ACA.

New Flexibility for States to Improve Medicaid and Implement Innovative Practices

The U.S. Department of Health and Human Services (HHS) today announced four initiatives to give states more flexibility to adopt innovative new practices and provide better, more coordinated care for people with Medicaid and Medicare while helping reduce costs for states and families. The initiatives support the Obama administration’s work to make Medicaid more flexible and efficient and to address long-term cost growth. Several of the announcements also help implement provisions of the Affordable Care Act. Today HHS announced:

•Fifteen states will receive federal funding to develop better ways to coordinate care for people with Medicare and Medicaid coverage, also known as dual eligibles, who often have complex and costly health care needs.

•All states will receive increased flexibility to provide home and community-based services for more people living with disabilities.

•All states are eligible to receive more money to develop simpler and more efficient information technology (IT) systems to modernize Medicaid enrollment.

•A proposal by the state of New Jersey for flexibility to expand health coverage for nearly 70,000 low-income residents has been approved.

“Medicaid programs provide health coverage for millions of low-income Americans who otherwise would lack access to health care,” said HHS Secretary Kathleen Sebelius. “With these new resources and flexibilities, states will have new options to make their Medicaid programs work better for the people they serve, while helping lower their costs.”

Coordinated Care for People with Medicare and Medicaid

Under a new initiative funded by the Affordable Care Act, 15 states will receive up to $1 million each to develop new ways to meet the often complex and costly medical needs of the approximately nine million Americans who are eligible for both the Medicare and Medicaid programs, known as “dual eligibles.” The goal of the program is to eliminate duplication of services for these patients, expand access to needed care and improve the lives of dual eligibles, while lowering costs. The new Federal Coordinated Health Care Office, or the Duels Office, at the Centers for Medicare & Medicaid Services (CMS), was created by the Affordable Care Act to improve care for dual eligibles and will work with the states to implement the top strategies to coordinate primary, acute, behavioral and long-term supports and services for dual eligibles, improving quality and lowering costs.

The 15 states that will receive these funds are California , Colorado , Connecticut , Massachusetts , Michigan , Minnesota , New York , North Carolina , Oklahoma , Oregon , South Carolina , Tennessee , Vermont , Washington and Wisconsin .

“Beneficiaries who are in both Medicare and Medicaid can face different benefit plans, different rules for how to get those benefits and potential conflicts in care plans among providers who do not coordinate with each other,” said Donald M. Berwick, M.D., administrator of CMS. “This can be disastrous for those beneficiaries who are most vulnerable and in need of help.”

Helping People with Disabilities Live in their Communities

CMS proposed new rules today giving states new flexibility for their programs to help people with disabilities choose to live in their communities rather than in institutions. The proposed rules reduce administrative barriers for states seeking to help multiple populations, which may include seniors and/or people with different types of disabilities. They will also allow individuals to participate in the design of their own array of services and supports, including such things as personal care and respite services for caregivers.

“These long awaited rules will help people living with disabilities realize the promise of the ADA to live in the least restrictive environments possible for them—like their own homes,” said Henry Claypool, director of the Office on Disability at HHS. “With these new tools as well as incentives included in the Affordable Care Act, states, working closely with advocacy groups, beneficiaries, and other stakeholders, can more easily develop effective plans to improve options for people with disabilities. We hope states will take advantage of this new flexibility.”

The proposed rule, CMS-2296-P, can be found at www.ofr.gov/inspection.aspx.

Developing and Upgrading Medicaid IT Enrollment Systems

New rules issued today will provide 90-percent of the cost for states to develop and upgrade their IT systems to help people enroll in Medicaid or the Children’s Health Insurance Program (CHIP) – and

75-percent of ongoing operational costs. This increase over the previous federal matching rate of

50-percent will help states prepare for the Medicaid improvements and expansion that will come in 2014 from the Affordable Care Act, when many more Americans will be eligible for these programs, and to coordinate enrollment with the Exchanges. The rules establish performance standards for the improved eligibility systems to promote greater efficiency and a more consumer-friendly enrollment process.

The final regulation, CMS-2346-F, can be found at www.ofr.gov/inspection.aspx.

Expanding Health Coverage in New Jersey

HHS Secretary Kathleen Sebelius today approved a Section 1115 demonstration for New Jersey that will expand health coverage to nearly 70,000 uninsured, low-income people through the Work First New Jersey program. In addition, the state will increase care coordination to improve health outcomes for participants in the program.

“This demonstration is yet another example of the many flexibilities states have to adapt their Medicaid programs to better serve their residents,” said Secretary Sebelius. “I want to commend New Jersey for expanding coverage to people in need.”

For more information about these announcements, visit www.cms.gov/apps/media/fact_sheets.asp.

Proposed Medicaid Cuts Could Be Devastating to Utah

By PATTY HENETZ-The Salt Lake Tribune

Advocates for elders and low-income residents in Utah see Republican plans for cutting Medicare and Medicaid costs as an unfair approach that could mean the loss of billions of dollars to Utah.

The proposal released last week by House Budget Chairman Rep. Paul Ryan, R-Wisc., would repeal key provisions in the year-old Affordable Care Act, privatize Medicare and cut $1 trillion from Medicaid funding for states. The states would get set amounts, which would cap spending rather than adjusting it for changing needs and new enrollees. Congress is expected to vote on the proposal Friday.

The plan could translate to a $554 million cut in federal Medicaid supports to the Beehive State, say officials with the Utah Health Policy Project, who used reports by the Congressional Budget Office and the Center on Budget and Policy Priorities for their own state-level study.

UHPP says losses over a 10-year period could include:

• $3.2 billion in business activity, as seniors and others spend more on care and less on other goods and services produced in the state;

• 30,369 in related jobs;

• $1.1 billion in worker earnings associated with those job losses.

The cuts could also mean nearly 76,000 more people will be uninsured in Utah, mostly low-income children, seniors and people with disabilities, who together make up 73 percent of the state’s Medicaid recipients.

Story Continues

Elders and Obama's Speech

by Ronni Bennett

Did you watch President Obama's speech yesterday afternoon? Whew! It was better than I feared it would be. Kinda busy today (Wednesday) so mostly I'll stick to the major points affecting elders.

If you will recall, Paul Ryan's deficit reduction plan, widely praised by Republicans, would turn Medicare into a voucher program which, as the president said, “would end Medicare as we know it.”

“It says that ten years from now, if you’re a 65 year old who’s eligible for Medicare, you should have to pay nearly $6,400 more than you would today,” said Obama. “It says instead of guaranteed health care, you will get a voucher. And if that voucher isn’t worth enough to buy insurance, tough luck – you’re on your own...”

“They want to give people like me a two hundred thousand dollar tax cut that’s paid for by asking thirty three seniors to each pay six thousand dollars more in health costs? That’s not right, and it’s not going to happen as long as I’m President.” [emphasis is mine]

Write that down, everyone. Paste it on your desk and as the debate on the budget continues in Washington, let's not let him back down.

One of the biggest budget busters in Medicare is the prescription drug plan. Rammed through Congress during the Bush II administration by a Louisiana legislator, Billy Tauzin, who almost immediately left Congress for a $2 million per year job as head of the pharmaceutical industry lobby, the bill specifically denies Medicare the right to negotiate drug prices as the Veterans Administration does.

Yesterday, Obama sounded like he wants to rescind this horrendously expensive giveaway to big pharma:

“We will cut spending on prescription drugs by using Medicare’s purchasing power to drive greater efficiency and speed generic brands of medicine onto the market.”

Medicare is the largest purchaser of prescription drugs in the country and allowing negotiation would go a long way toward reducing Medicare costs. I'm pretty sure the board rooms of drug companies are going ballistic this morning while planning their assault on Congress members to reject this idea.

Referring to Medicare and Medicaid, Obama said he would reform these programs, “but we will not abandon the fundamental commitment this country has kept for generations.”

”That includes, by the way, our commitment to Social Security,” he continued. “While Social Security is not the cause of our deficit, it faces real long-term challenges in a country that is growing older...

“[B]oth parties should work together now to strengthen Social Security for future generations. But we must do it without putting at risk current retirees, the most vulnerable, or people with disabilities; without slashing benefits for future generations; and without subjecting Americans’ guaranteed retirement income to the whims of the stock market.”

Okay, he rejected privatization of Social Security. That's good. He wants to protect current beneficiaries and not “slash” benefits for younger people. That's sort of good. Unfortunately, he left the door wide open for some kind of cuts for people younger than 55, for smaller cost-of-living adjustments and made no reference to maintaining the current retirement age.

And there was no mention, either, of raising the salary cap which, if it were to be eliminated, would fix almost all the Social Security shortfall for the next 75 years. So, there are still some red flags to Obama's commitment that we need to keep our eyes on.

Those are the big points relating to elders. I like it when Obama gets all warm and gooey about what America is (or should be), as in this passage of his speech:

”The America I know is generous and compassionate; a land of opportunity and optimism. We take responsibility for ourselves and each other; for the country we want and the future we share.

“We are the nation that built a railroad across a continent and brought light to communities shrouded in darkness. We sent a generation to college on the GI bill and saved millions of seniors from poverty with Social Security and Medicare.

“We have led the world in scientific research and technological breakthroughs that have transformed millions of lives.

“This is who we are. This is the America I know. We don’t have to choose between a future of spiraling debt and one where we forfeit investments in our people and our country. To meet our fiscal challenge, we will need to make reforms.

“We will all need to make sacrifices. But we do not have to sacrifice the America we believe in. And as long as I’m President, we won’t.”

Nevertheless, I was struck by the president's offhand acknowledgment of a sad truth about you and me and everyone who is not rich. While enumerating the many things wrong with the Ryan budget proposal, Obama said,

“There’s nothing serious about a plan that claims to reduce the deficit by spending a trillion dollars on tax cuts for millionaires and billionaires. There’s nothing courageous about asking for sacrifice from those who can least afford it and don’t have any clout on Capitol Hill. [emphasis is mine]

That's the president saying out loud that if you're not rich, you don't have a say in government which implies that any benefits for the middle class and poor are left to the largesse of the corporate controlled government. Oy vey. What an admission.

If you missed the speech, the full text is here.

TIME GOES BY | The Fight of Our Lifetimes

by Ronni Bennett

After last week's budget battle, the lines are drawn. Two factions are in control of the debate for the future of the United States:

• The religious zealots who intend to make their ignorance the law of the land
• The corporatocracy who intend to bleed every last dollar from the rest of us for their personal use

Aside from a small number of sane pundits dismissed by the other two groups as leftwing or socialists (horrors!) and a few Congress members (of whom only Bernie Sanders and Harry Reid regularly speak up) hardly anyone, including President Obama, speaks for the people.

The budget debate last week, devolving into an abortion argument over funding of Planned Parenthood, got so stupid I wanted to fire everyone. Crazy, ignorant legislators in Congress apparently never heard of the Hyde Amendment which has banned federal funding of abortions since 1976.

Having defeated the president (who weirdly claimed a win), the zealots were all over the media telling us what we are in store for. Following on Senator Paul Ryan's draconian and fraudulent deficit reduction plan, they made no secret of what's next.

Here is House Majority Leader Eric Cantor (R-Va) talking on Fox News Sunday about a proposed $750 billion in cuts to Medicare and Medicaid (transcript via ThinkProgress – my emphasis):

CANTOR: We are in a situation where we have a safety net in place in this country for people who frankly don’t need one. We have to focus on making sure we have a safety net for those who need it.

WALLACE: The Medicaid people — you’re going to cut that by $750 billion.

CANTOR: The Medicaid reductions are off the baseline. So what we’re saying is allow states to have the flexibility to deal with their populations, their indigent populations and the healthcare needs the way they know how to deal with them. Not to impose some mandate from a bureaucrat in Washington.

WALLACE: But you are giving them less money to do it.

CANTOR: In terms of the baseline, that is correct…What we’re saying is there is so much imposition of a mandate that doesn’t relate to the actual quality of care. We believe if you put in place the mechanism that allow for personal choice as far as Medicare is concerned, as well as the programs in Medicaid, that we can actually get to a better resolve and do what most Americans are learning how to do, which is to do more with less.

”Most Americans.” Except for rich people, of course. And don't forget that Social Security is in their sights too. Eric Cantor, again, in March:

“If we want America to be what WE want America to be”?

Which “we” would that be? I sure don't want the America he describes.

It's not just Republicans who are pushing for an increased transfer of wealth from the poor and middle class.

David Plouffe, a White House senior adviser, also made the chat show rounds (emphasis mine):

"'We can't take a machete,' Plouffe said on ABC's This Week. 'We have to take a scalpel, and we're going to have to cut, we're going to have to look carefully.'”


[According to AP, Plouffe also] “said Obama was committed to finding ways for the nation to spend within its means, including reducing Medicare and Medicaid, the government's chief health care programs for seniors and the poor.”

Why in the world are the Democrats – the White House in particular – selling out elders to the zealots and corporations? Perhaps they are counting on support in the 2012 election from the growing number of old Americans who increasingly vote against their own and their offsprings' interest.

Here is another possible reason: The current New York magazine has a graphic showing the previous employment of 14 high-ranking White House advisers. Seven of them, half, are former executives of Goldman Sachs. The rest were hired from Lehman, Citi, UBS, Hartford Financial and JPMorganChase.

These are the people who already stole an estimated $2 trillion in life savings from the people of the United States, an additional $3 trillion in home values through fraudulent mortgage practices, have sent millions of jobs overseas and who pay lower tax rates than you and I.

Now that corporations can contribute unlimited, unreported money to candidates, do you really expect them NOT to do everything else in their vast power to grab all the money that now goes to Medicare, Medicaid and Social Security?

With a list like these 14 talking to the President Obama every day, do you really expect him NOT to bow to their demands?

Tomorrow, he will deliver that speech about deficit reduction. I am frightened for us and for all future elders. Obama's past record is not good. He has capitulated to the zealots and corporatocracy at every opportunity and although I hope David Plouffe will be proved wrong, I am not expecting that to be so.

It looks like we are in for the fight of our lifetimes. I don't know if we can win, but there is no choice except to try.

Health Overhaul Could Double Community Health Centers' Caseload - Kaiser Health News

By Michelle Andrews

Community health centers serve 20 million people every year, and that number is expected to double by 2015, thanks to an $11 billion infusion from the health-care overhaul and $2 billion in federal stimulus funds.

If you're a middle-income worker with health insurance through your job, chances are these centers have been under your radar, since their target clients are low-income and uninsured people. But as the number of uninsured has risen to 50 million, more people than ever are struggling to get and pay for health care, and community health centers are an affordable option. As they expand, they're adding new services and new locations nationwide.

Although their mission is to provide a primary-care safety net for people in underserved areas, no one is ever turned away from a community health center. People with incomes up to 200 percent of the federal poverty level ($44,700 for a family of four in 2011) pay on a sliding scale; uninsured people with higher incomes pay the full cost of care, which is generally comparable to costs in the private sector. The centers accept Medicaid and Medicare in addition to many private insurance plans.

The new health care law is full of incentives to encourage doctors to provide "medical homes" for their patients, with coordinated care and close patient monitoring to stay on top of necessary preventive services. But community health centers have always taken this approach, say experts.

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Economists Oppose Plans to Convert Medicaid to Block Grant

Dear Speaker Boehner, Minority Leader Pelosi, Majority Leader Reid, and Minority Leader McConnell,

We write this letter to oppose plans to convert Medicaid to a block grant and to cut Medicaid benefits.

These changes would do nothing to improve quality but would ration care to millions of America’s most vulnerable citizens.

Medicaid supports health care for nearly 60 million people, including 30 million children. Two-thirds of Medicaid expenditures support services for impoverished people who are elderly or who suffer from disabilities. By spreading the cost of care between federal and state budgets, Medicaid helps state governments maintain services during economic downturns.

Looming budget deficits have led some to propose capping federal spending by converting Medicaid into a blockgrant program. We recognize the challenges posed by budget deficits. Actions must be taken to close those deficits.

Yet block granting Medicaid is both unfair and unwise. During economic downturns it would expose states to the full costs of increasing enrollments just when their revenues are falling. The inevitable result would be curtailed services, reduced eligibility, and increased charges that many low-income patients would be unable to pay, forcing them to forego care or placing burdens for uncompensated care on hospitals and physicians.

Furthermore, a decision to tie the block grant to an economic index (the Consumer Price Index adjusted for population growth) that grows more slowly than medical care spending or actual Medicaid expenditures would cause steady erosion in all of these dimensions.

The only effective and equitable way to curb total health care spending, and the only way to address the fiscal burdens of that care, is to support systemic health reform. The best current hope for doing so is the Affordable Care Act, which should be implemented with vigor.

List of Economists Who Signed the Letter

Gay Couples Closer to Receiving Medicaid Spousal Protections - NYTimes.com

By TARA SIEGEL BERNARD

Same-sex couples are one step closer to receiving protections that heterosexual married couples get when they receive long-term care through Medicaid — that is, the healthy partner will be able to keep some of the ailing partner’s money and remain in their home.

At least, that’s the goal. Right now, only opposite-sex married couples receive those rights because the federal government doesn’t recognize same-sex marriage.

To qualify for long-term care through Medicaid, individuals generally have to spend their money until it’s practically depleted. But married couples can keep more money so that healthy spouses don’t have to impoverish themselves to qualify the sick spouse for care. Nor do they have to worry about giving up their home to raise money to pay back Medicaid for its services after their spouse dies. They can stay put for the rest of their lives.

As a work-around, the Obama administration is close to notifying the state-run Medicaid programs about how they can replicate these protections for same-sex domestic partners, according to the Centers for Medicare and Medicaid Services.

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Medicine-On-Time Shown To Reduce Likelihood Of Nursing Home Admission By 66 Percent

In a new study published in The American Journal of Geriatric Pharmacotherapy, researchers from the University of South Carolina School of Public Health found that the use of the Medicine-On-Time medication delivery technology reduced the likelihood of nursing home admission by 66 percent.


The study assessed the impact of a medication adherence management program on nursing home admissions. Medicine-On-Time's medication management system helps ensure that medications are taken properly through the use of patient-specific customized packaging.


This study found that the pharmacy-based calendar card dispensing system and coordinating service, which was designed to facilitate medication adherence, can reduce medication management issues, address problems as they arise, and reduce nursing home admissions of community dwelling, nursing home-eligible patients. With nearly 1.5 million residents in nursing homes, the widespread implementation of a medication management system could potentially save the healthcare system billions of dollars per year by avoiding unnecessary nursing home admissions.

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stevegoldada: Attacking Medicaid - Myths and Some Realities.

By Steve Gold 

Aldttacking Medicaid - Myths and Some Realities. Information Bulletin # 320 (4/2011)

There have been a lot of articles and speeches attacking Medicaid: “GOP Governors Seek Leeway to Cut Medicaid,” “Fiscal Health Hinges on Containing Costs of Care.”

Now comes Rep. Ron Paul plan to change Medicaid.....

From article to article to political speech, the drum beat is the same: “Block Grant” Medicaid so states can set their own rules and achieve, hear the drum roll, “flexibility.”

Block grants are allocate federal funds based on the total number of people or the number of low-income people, or some other criteria. Under block grants, States would decide who will be eligible and which “medically necessary” conditions to cover. States would receive a dollar grant to spend as they wish. If you think politicians, lobbyists, and pressure groups are active now, just wait if there are block grants and no federal standards or requirements.

There are a number of reasons for the current activity.

First and probably the most important reason, this is a backdoor attack against the 2010 Health Care Reform Act. Last year, Congress, for the first time in our history, enacted that all low-income people - below 133% of the poverty level - will be eligible for Medicaid in 2014. That’s an addition 16 million low-income Americans.

In the past, Medicaid eligibility was federally based primarily on categories, so that two people with the same income but different sources of income were treated differently. The Health Care Reform Act ensures that two people in the same or different states with the same income and same impairments will not be treated differently.

When you hear Medicaid Block Grants, think “eligibility.” As David Wessel wrote in the Wall Street Journal, “The argument is that with ‘flexibility,’ states can do more with less. But the biggest ‘flexibility’ that states now lack - given that many already rely heavily on managed care and low provider fees - is the authority to reduce the rolls. That leaves them to do less with less.”

What’s fascinating about this conservative attack is that they do not articulate who currently on Medicaid does not need or does not “deserve” to receive health care. What’s at stake is the answer to the question “If a low-income American needs health care, should they receive it?”

Second, States presently have a lot of authority to control their Medicaid costs. Medicaid costs can be contained under the present system, but it does take some political backbone. Despite the drum roll of “out of control” Medicaid costs, these costs can be and have been in some instances controlled. For example, between 2000 and 2005, Medicaid reimbursements for drugs increased by 95.9%. To counter that, States took control and by 2009, reduced Medicaid’s drugs expenditures by 44%.

Another example of States controlling Medicaid costs should focus on why 17.4% of all Medicaid nationally in FY 2009 went to keep people with disabilities institutionalized. States control this. Yes, States throughout the country spent more on nursing homes and institutions for persons with development disabilities than they spent on in-patient hospitalization and drugs! The federal government did not make States do this. Medicaid did not make the States do this! Moreover, many of these institutions provide at most custodial care; they’re the 21st century’s poorhouses and homeless shelters paid for by Medicaid.

Again, as David Wessel wrote in another column, regarding “often overlooked facts.... Medicaid pays 43% of America’s long-term care bill, including bills for about 60% of nursing-home residents.” He correctly points out that right now, without any changes in Medicaid, States could “keep the elderly and disabled out of nursing homes by helping them pay for home or community-based care... It’s cheaper and often preferred by the individual. That push has been under way for years. It’s now at risk as states scramble to save money, and eye cuts to home and community-based care.”

Cheaper, preferred? Why is it not happening? States control this and have decided to buckle under to the nursing home lobby! Ask your State’s nursing home lobby how much they contributed to your Governor’s campaign. It’s not the present Medicaid statute.

Third, presently States pay with State general revenue funds at most 50% of Medicaid costs, and the federal government matches States expenditures. About 36 states receive more than 50% from the federal government depending on the state’s per capita income. The poorer the State the more federal match. Don’t be fooled that the push for “Block Grants” is to help States financial situation. The feds pay an enormous share of Medicaid.

Right now, the Medicaid standard is that only “medically necessary” services and treatment are required. Let the Block Grant proponents identify and list which specific “medically necessary” services should not be paid for.

It’s critical that advocates for disabled older and younger Americans get into the fray. Our lives and the lives of brothers, sisters, neighbors, friends and all low-income people depend on it.

stevegoldada: Attacking Medicaid - Myths and Some Realities.

TIME GOES BY | Note to Elder Republicans: Suckers!

by Ronni Bennett

In the 2010 midterm elections, elders voted Republican 58 to 39 percent. As Paul Krugman said on his blog Monday:

”Oh, and for all those older Americans who voted GOP last year because those nasty Democrats were going to cut Medicare, I have just one word: suckers!”

No kidding.

Yesterday, chairman of the House Budget Committee, Representative Paul Ryan of Wisconsin, presented his budget proposal for fiscal year 2012. It is, basically, a blueprint to destroy Medicare and Medicaid.

Oh, and there is this stunner: a cut in the top income tax rate for individuals and businesses from 35 percent to 25 percent.

But back to Medicaid and Medicare. Here is a short version of Ryan's plan as it affects these two programs:

Medicaid would be eliminated by changing it into a block grant program without federal guidelines that would allow states to spend the lump sum grants as they choose. Oh, yeah, that will work out well for poor people.

Medicare under this plan would be privatized. Beginning in 2021, the current program would be replaced with a federal voucher system under which elders would purchase health coverage on the open market.

Oh, sure - try to find an insurance company when you're old and sick. At 64 and healthy, I couldn't find coverage at any price so I lived on a wing and a prayer until I qualified for Medicare. Had I been hit by a truck or had a serious illness during that time, I now would be among the elder bankruptcy statistics.

And get this about the Ryan Medicare plan, the vouchers are designed NOT to keep up with expected increases in health care costs and, therefore, premiums would quickly grow far beyond the amount of the vouchers leaving elders under-insured or without coverage at all.

(If you want more details and commentary on these plans, just google “paul ryan budget proposal.” There are already a zillion stories.)

Keep in mind that these changes would affect only people 54 and younger. (For a frightening take on this generational divide-and-conquer gambit, check out Matt Yglesias.)

Paul Ryan's draconian proposal has almost no chance of getting anywhere in Congress. It is so extreme that it makes the Simpson/Bowles plan look almost progressive - and that is the real danger: Stating the unthinkable moves the starting point of the debate much further to the right.

If Medicaid and Medicare are substantially destroyed, it will be all those elder Republican voters who sentenced their own children and grandchildren to an old age of poverty, sickness and earlier death.

Krugman, I think, gets it wrong about “suckers.” It seems to me that for those 65 and older Republican voters, it was more a matter of, I've got mine and screw you, my child. Sometimes I'm ashamed to be an old person.

Ryan Budget Pulls the Rug Out from Under Seniors, People with Disabilities, and Struggling Families

Community Catalyst Press Release
Contact: Kathy Melley  Office: 617/275-2861  Mobile: 617/791-0708  kmelley@communitycatalyst.org

Joint Statement of Robert Restuccia, Executive Director, Community Catalyst, and Rev. Heyward Wiggins, Co-Chair PICO National Network Steering Committee, on the House Republican budget plan


(BOSTON AND WASHINGTON, DC) - "The House Republican 2012 budget plan released today is a blueprint for disaster. Rather than prioritizing cuts, it seeks to balance the budget on the backs of those who can least afford it - seniors, people with disabilities and struggling families - while asking too little of those who can most afford to sacrifice. Today Medicare and Medicaid work in tandem to help people stay healthy as they age, become disabled, or face hard times. Block grants, privatization and vouchers would take away the health care security that all Americans have relied on since 1965.

"As consumer and faith-based organizations representing millions of American families, we find it abhorrent that people would be made to suffer needlessly or die prematurely because they could not afford to get the care they need. The House plan to gut Medicaid and Medicare will roll back sixty years of social progress in the United States and decimate programs that are a critical part of the safety-net and the backbone of our health care system.

"Block granting Medicaid shifts costs to already financially overburdened states during this recession leads to dramatic cuts in benefits and eligibility for seniors, people with disabilities, children, pregnant women, and working parents, just when people need them most. Families that rely on Medicaid to cover long-term or nursing home care could face enormous financial strain in trying to care for loved ones when their health care costs are no longer picked up by Medicaid.

"Privatizing Medicare is a hand-out to insurance companies, driving up deductibles and co-payments for seniors on Medicare today, and doing nothing to contain health care costs. By 2021, Medicare as we know it would be gone, replaced by a voucher program that would require seniors to buy private insurance. Vouchers lead to rationed health care. As health care costs rise, vouchers would be too small to buy adequate coverage. Many seniors would find they couldn't afford coverage at all and end up uninsured.

"Instead of taking an ax to programs that provide health and economic security to millions of people, federal policy makers should build on the cost containment framework that is already part of the Affordable Care Act and focus on reducing excessive insurance premiums, giving people the care they need to stay out of hospitals and nursing homes, and investing in public health measures to reduce heart disease, diabetes and other chronic illnesses that lead to higher health care costs.

"The savings produced by the House plan come at a great human cost and take our health care system in the wrong direction. We ask Members of Congress to reject this radical proposal to take Medicaid and Medicare away from those who need it most."
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About Community Catalyst

Community Catalyst is a national non-profit advocacy organization dedicated to quality affordable health care for all. Since 1997, Community Catalyst has been working to build the consumer and community leadership required to transform the American health system. With the belief that this transformation will happen when consumers are fully engaged and have an organized voice, Community Catalyst works in partnership with national, state and local consumer organizations, policymakers, and foundations, providing leadership and support to change the health care system so it serves everyone - especially vulnerable members of society. For more information, visit www.communitycatalyst.org.

PICO National Network is a national network of faith-based community organizations working to expand health care coverage and improve communities in 17 states. www.piconetwork.org

Medicaid and Access to the Courts | Health Policy and Reform

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by Sara Rosenbaum, J.D. in New England Journal of Medicine

The Medicaid program is grounded in a statute that is one of the most complex of all federal laws. An insurer of more than 60 million people — and poised to begin serving 16 million more by 2019 — Medicaid will be reexamined this year, in all its legal complexities, by the U.S. Supreme Court, which has agreed to hear California’s appeal in the case Maxwell-Jolly v. Independent Living Center of Southern California. The Court’s ruling could fundamentally alter states’ accountability to beneficiaries and providers when their official conduct allegedly violates Medicaid’s essential federal requirements.

The Maxwell-Jolly case was precipitated by a series of deep cuts to provider payments that were enacted by the California legislature and aimed at services used predominantly by the state’s most severely disabled beneficiaries. The payment reductions were halted by the U.S. Court of Appeals for the Ninth Circuit, but this action by no means ended the dispute. Indeed, the question before the Supreme Court is of far greater consequence than that of specific provider payments: it is whether beneficiaries and providers have the right to seek judicial redress when they allege that state conduct abridges federal law and threatens health and safety.
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In Republicans' 2012 Budget Plan, Rep. Ryan Gives Social Security a Pass - TheHill.com

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By Erik Wasson

House Budget Committee Chairman Paul Ryan (R-Wis.) will largely give Social Security a pass in his highly anticipated budget while proposing a significant overhaul of Medicare and Medicaid, according to sources briefed on the plan.

The 2012 budget resolution, which committee Republicans are still finalizing, is scheduled to be unveiled on Tuesday. It will not back specific benefit cuts to Social Security or suggest raising the retirement age, sources said.

Instead, it will lay out the problems with the program and suggest authorizing committees tackle the specifics. It also will propose “trigger” thresholds for Social Security that, once reached, would ask the president to propose a way to fix the program.

Ryan is also not planning to include a proposal that would allow recipients to invest their Social Security payroll taxes, something Democrats have attacked as a “privatization” of Social Security. Such attacks doomed a 2005 effort by then-President George W. Bush to reform the system.
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MEDICAID Improving Responsiveness of Federal Assistance to States during Economic Downturns

What GAO Found

Past recessions hampered states’ ability to fund increased Medicaid enrollment and maintain existing services. Both the 2001 and 2007 recessions resulted in increased Medicaid enrollment and decreased revenues, though states’ experiences varied. During the 2007 recession, total state tax revenues declined by 10.2 percent from the fourth quarter of 2007 to the second quarter of 2009, with individual state experiences varying. For example, North Dakota had a revenue increase of 6.9 percent while Arizona had a decline of 23.1 percent. In addition, the effect of increased Medicaid enrollment and decreased revenues persisted after the recessions ended, causing states to further adjust their Medicaid programs.

The increased FMAP funds provided by the Recovery Act were more responsive to state Medicaid needs than were funds provided after the 2001 recession. Overall, the Recovery Act funds were timed for state Medicaid funding needs. Assistance began during the recession while nearly all states were experiencing Medicaid enrollment increases as indicated by rising unemployment and revenue decreases as indicated by declining wages and salaries. The FMAP funds were targeted for Medicaid enrollment growth, but did not distinguish among states with varying degrees of reduced revenue in the allocation of assistance. The increased FMAP following the 2001 recession was provided well after the recession ended and was not targeted for state Medicaid needs.

Past recessions offer options for improving the responsiveness of temporary FMAP increases to state Medicaid program needs. More responsive assistance can aid states in addressing increased Medicaid enrollment resulting from a national recession, as well as addressing decreases in states’ revenues. GAO has revised a prototype formula for temporary FMAP increases it developed in 2006. The revised formula would address the timing and targeting of funds, and further improve the responsiveness of the increased FMAP funding. In particular, these revisions (1) use an automatic trigger to start the assistance program closer to the onset of a national recession, (2) add several quarters of transitional assistance before ending the increased FMAP assistance, and (3) target assistance by calculating the increased funding needed on the basis of the economic conditions of each state.

In commenting on a draft of this report, the Department of Health and Human Services (HHS) agreed with the analysis and goals of the report while emphasizing that changes to the FMAP formula must be authorized by statute. HHS also stated that it is critical to align changes in the FMAP formula to individual state circumstances in order to avoid unintended consequences for beneficiaries as well as provide budget planning stability for states. GAO agrees that statutory changes would be necessary to implement any adjustments to the FMAP, but does not make recommendations regarding particular actions in this report.

Full Report

Employment-Supportive Personal Assistance Services (E-PAS) Facilitate Employment of Persons with Serious Physical and Mental Disabilities - Disability.gov

By Raymond E. Glazier, Ph.D., Director of the Abt Associates Center for the Advancement of Rehabilitation and Disability Services and Member of the MA Work Without Limits Initiative in Disability.gov

Persons like me with serious physical, intellectual or psychiatric disabilities often can’t function productively in the workplace without some form of assistance. This is not to say that we can’t perform, quite capably, the essential functions of many jobs. Instead these, oftentimes, very simple accommodations (such as personal assistance services) help us go about our daily routines more efficiently.

What Are Employment-Supportive Personal Assistance Services (E-PAS)?

Personal assistance services (PAS) are defined as assistance with everyday tasks that a person would typically perform for him/herself, were it not for the disability (ODEP, 2006). These services can include in-home assistance with bathing, grooming and dressing to get ready for the workday. In the employment context, PAS does not include routinely performing the employee’s essential job functions.

Employment-Supportive Personal Assistance Services, or E-PAS, supports people with disabilities engaging in competitive employment. E-PAS can involve personal care services performed at a workplace – for example, help eating a meal, preparing for the workday and/or getting to and from the workplace. It may also encompass job coaching, which is not always thought of as PAS.

For a worker with quadriplegia, the assistance needs might include personal care tasks like feeding or toileting at the worksite, as well as help with traveling to and from the job and task-related assistance with copying documents and perhaps, filing and retrieving papers.

For an employee with cognitive limitations, needs might include assistance with organizing work tasks, becoming acclimated to a work schedule and learning one’s way around the workplace.

For a worker with serious mental health issues, there could be a need for cueing services like medication reminders, guidance in relating appropriately to co-workers or help with interacting with supervisors.

Medicaid as a PAS/E-PAS Funding Source

Most persons with significant disabilities are in no position to pay privately for PAS, and neither Medicare nor private health insurance will cover it – even for vital personal care needs like in-home assistance with transfers, bathing, toileting and dressing, not to mention cueing services for persons with mental health issues or workplace PAS services. The only funding sources for personal care PAS are Medicaid (which goes by different names in different states) and the Veterans Administration for those with military service-connected disabilities.

Medicaid is a joint federal-state health care program that funds services for eligible low-income/low resource individuals and families. While there is a federally mandated set of basic core services, eligibility rules and additional optional services vary from state to state. Coverage for personal care services is a state plan option that is offered by two thirds of states and does not always extend to cueing services (even though the Centers for Medicare and Medicaid Services has reimbursed them for many years.)

Several states have explicit Medicaid E-PAS programs designed to facilitate competitive employment for persons with disabilities. California, Connecticut, Kansas, New Jersey, Nebraska and Wisconsin come to mind; Utah also has a remarkable E-PAS program targeting consumers with mental health issues.

Ordinarily, working individuals have incomes that put them over the usual income threshold for Medicaid eligibility. However, most states have a Medicaid Buy-In program that allows working persons with disabilities to become eligible for the broad array of Medicaid services by paying a monthly premium. Again, there is much variability state to state as to the minimum required work effort, services covered, premium rate structures, etc.

Other Types of E-PAS and Who Pays for What

Certain E-PAS items, like job coaching, are the province of the state operated, state/federally funded Vocational Rehabilitation (VR) programs, which also have income and asset limits for eligibility. The state VR programs have finite funding that limits the number of consumers they can serve in a given fiscal year. Therefore, the federal Rehabilitation Services Administration (RSA) requires that they serve persons with ‘most significant disabilities’ first.

While Medicaid may cover travel to and from the workplace, as well as on-site personal care services like feeding and toileting needed during the workday, employers are required by Title I of the Americans with Disabilities Act (ADA) of 1990, as amended, to fund personal care services during work-related company travel. And importantly, ADA ‘reasonable accommodations’ required of employers also extend to task-related PAS with non-essential job functions like copying, mailing, filing, etc.

The following table summarizes the three main areas of E-PAS and who funds them. Obviously there are gray areas, and the distinctions between each category and responsible party are not always clear-cut.

Three Categories of Workplace PAS/Three Funding Sources
Medicaid-funded Personal Care PAS: Help getting to/from worksite, personal care (mobility, feeding, toileting) at the worksite, cueing services for those with serious mental health issues.	Employer Reasonable Accommodation PAS (per ADA): Task assistance, e.g., ASL inter-preter, filing help, scribe; personal care only for job-related travel.	Vocational Rehabilitation PAS: Job Coach (helps organize tasks and processes; advocates for worker)/Supportive Employment.

How to Identify E-PAS Resources Available to You

Your VR counselor or Club House are likely sources for assistance in determining your needed employment supports and how to obtain what E-PAS you require in order to achieve competitive employment.

You can also visit the websites of the Center for Personal Assistance Services, the Job Accommodation Network or Disability.gov to learn more about personal assistance services and other types of workplace accommodations.

Raymond E. Glazier, Ph.D., Director of the Abt Associates Center for the Advancement of Rehabilitation and Disability Services in Cambridge, MA receives in-home PAS through the MA Medicaid Buy-In; his employer provides additional service hours at the same wages for two of his home PAS workers to provide task-related E-PAS at the office.

Older Adults Not Getting Recommended Preventive Services

Critical gaps exist between older Americans who receive potentially lifesaving preventive services and those who do not, according to a new report from agencies of the U.S. Department of Health and Human Services.

Clinical prevention services examined in the report include vaccinations that protect against influenza and pneumococcal disease (e.g., bloodstream infections, meningitis, and pneumonia), screenings for the early detection of breast cancer, colorectal cancer, diabetes, lipid disorders, and osteoporosis, and smoking cessation counseling.

The report was published by the Centers for Disease Control and Prevention, in partnership with HHS' Administration on Aging, Agency for Healthcare Research and Quality, and Centers for Medicare and Medicaid Services.

The document, "Enhancing Use of Clinical Preventive Services Among Older Adults: Closing the Gap," highlights the need to promote preventive services for adults age 65 and older, especially among minorities.

"Millions of Americans are not getting proven clinical preventive services that we know can prevent disease and improve quality of life," said Lynda Anderson, Ph.D., director of the Healthy Aging Program at CDC and one of the primary authors. "The report takes stock of current levels of recommended services by older adults, and it becomes obvious that many of these services are woefully underutilized."

About 10,000 Americans turn 65 every day; by 2030, about 1 in 5 Americans will be 65 older.

"We know prevention is critical to healthy living and independence," said Kathy Greenlee, assistant secretary for aging. "It is important that we continue our efforts at the community level to reach all older Americans. We want to ensure that they are aware of the preventive benefits which are available to them, including those made possible by the Affordable Care Act."

The report also addresses the use of preventive services by diverse populations. It says 49 percent of Asian/Pacific Islanders and 47 percent of Hispanics reported not being screened for colorectal cancer, in comparison to 34 percent of whites. More than 50 percent of Hispanics, 47 percent of blacks and Asian/Pacific Islanders, and 36 percent of whites report never receiving a pneumococcal vaccination.

According to the report, challenges underlying these disparities are complex and reach beyond the traditional health care arena of patient-provider interactions. Older adults may not be aware of the services recommended for their age group or may not know that the services are covered by Medicare, the report said.

"The section of the report titled `Making a Difference' features innovative strategies applied at the local, state, and national levels to increase the use of preventive services in underserved communities," said Wayne Giles, M.D., M.S., director, Division of Adult and Community Health at CDC. "By putting into practice effective community and clinical strategies, we can dramatically reduce the gaps highlighted in this report."

The showcased activities include: promotion of policies to increase community access, making services available in convenient community settings, such as providing influenza vaccinations at polling places on election days, and building awareness through media.

Non-federal organizations contributing to the report include AARP, American Medical Association, Association of State and Territorial Health Officials, Gerontological Society of America, National Association of Area Agencies on Aging, National Association of Chronic Disease Directors, National Association of County and City Health Officials, and National Association of States United for Aging and Disabilities.

"Giving Americans access to quality, proven preventive services in their communities is a crucial part of improving the health of Americans and lowering their health care costs in the long run," said AARP board member Catherine Georges, R.N., Ed.D.

Contributors to and supporters of this report agree that the use of such services should be a high priority of community and health systems alike. While the benefit of expanded insurance coverage is substantial, it is also important that older adults take advantage of preventive services on a regular basis to ensure good health.

"If we can help patients age 65 and older get the recommended preventive screenings and regular immunizations, we could significantly reduce unnecessary illness," said Edward Langston, M.D., an American Medical Association board member.

To view the full report and for more information about CDC′s health aging activities visit here.

Source:
U.S. Department of Health and Human Services