I hope you’ve read my posts earlier this week, explaining why even a short term cut or delay in Medicaid payments would cause years of damage to our healthcare system in Alabama. If that hasn’t convinced you to vote Yes next Tuesday, here are a few more things to consider.
First of all, most people in the loop don’t believe our legislature will totally axe Medicaid or cut it so badly they might as well have—but even those folks aren’t quite certain. There are some Legislators who have actually said things like “Medicaid is going to be unaffordable soon anyway, so we might as well go ahead and end it.” That’s right, they think we can get along with various free clinics already overloaded and understaffed, and I guess they are going to hastily build some free nursing homes, free hospitals, and free mental health centers. Don’t know what they are smoking, but we’ll all probably want some if they get their way.
I have a lobbyist friend who has worked the hallways in Montgomery for years. He told me he had never seen anything like it—he would go in a room and think he knew what the intentions were, then come back a half hour later and everything would have changed. Every time I saw him last spring, he would shrug his shoulders and throw his hands up, because he had no idea what this group would end up with.
After three and a half months of time to make a realistic budget last spring, they couldn’t come to an agreement. They waited until the last few hours to put a poorly thought-out plan together. Now they have thrown this mess in our laps. The same people who did that last spring are still with us, and I don’t think they are any more likely to agree on a good plan than before, although there’s always the possibility of something worse. To borrow a friend’s words, “If you didn’t have the time to do it right the first time, how are you gonna have the time to do it over?” If any of you think they were just hoping for 12 days at the end of September to pull out the real fix, you are also smoking something.
Most likely, they won’t kill Medicaid outright. But whatever they do instead, it won’t likely get done in 12 days. Once October 1 gets here, without the assurance of adequate funding for the year, Medicaid will have to operate on the stripped down budget, followed by probably a federal takeover but accompanied by the loss of participating doctors. If we lose the doctors, it doesn’t matter how much we put back into Medicaid later. The program will be dead. Or, there’s what Dr. Don Williamson is calling the “drunken sailor” option—spend it all up, knowing it will run out by August, in hopes the state will figure out something else by then. There are people quoting this and changing it to us “not feeling the pinch” until August, but that’s grossly misleading—a pinched budget and slap out of money are different, and Dr. Williamson appears to have been trying to get that point across by using the words “drunken sailor.” Hint, hint, he means it would only sound like a good idea if you’d taken leave of your faculties.
Some of you have said, ok, that’s terrible, but we’re tired of this continual incompetence. Let it happen, let there go ahead and be that suffering and even death. It isn’t our fault, it’s theirs, and when people see their children and elderly suffer, they’ll know who to blame. Not hardly. First of all, it is very difficult for me to believe my friends are willing to risk that scenario—even a 1% risk—when there are innocent children involved. Second, you are forgetting who some of our voters are. People who deny global warming, deny evolution, and believe God takes sides in football games. People who think doctors are happy to get paid in chickens. People who believe there’s enough hidden money in the education budget and that teachers are paid too much or get too much in health insurance and retirement. Will they look around at the resulting suffering and say “Oh, we get it—we should not elect people like this!”? Hell, no, they’ll say “More Cowbell.”
So what are the funding options, if this amendment fails? Despite the bewildering and conflicting statements from Governor Bentley over the summer, no one I know seriously thinks there is any chance we will get a tobacco tax or any other tax in the short term, and there is probably not time to bring in other new revenue. We could try to run that program again this spring, with the same code—unless someone can demonstrate to me opinions have substantially changed, why is that worth leaping into the void with a no vote? Our state legislators are not going to legalize marijuana or quit incarcerating non-violent offenders to save money in the prisons. They are not going to quit prosecuting the death penalty, which is many times more expensive than life without parole. They are not going to undo any of the corporate incentives they’ve handed out.
Governor Bentley wanted to cut into the education money before but couldn’t get the support— it is hard to tell if enough would have changed since then to open that back up, but that doesn’t mean he and his supporters won’t try—which means they would try to block other options, just like everyone did last spring with ideas not their own. What about bingo? Stan Pate has thrown that hat openly in the ring and says he’s putting his money on it. The history of electronic gaming politics in our state is OMG complicated, and there is all sort of maneuvering around with the current law already. I concede that in terms of predicting this Legislature, all bets are off. But unless someone can give me a vote count on legislators who say they will support bringing in funds from gambling and a reason this is a stable platform to land on when we jump off the cliff, bet your play money and not my patients’ health insurance.
When you hear any of our legislators who are advocating a no vote next week, call them on the carpet and insist they not only propose a better solution but give you names of colleagues who will back their plan. And for those who say they’ll pull a rabbit out of the hat, a new plan, on September 19 if the amendment fails, ask yourself why they won’t spit it out now. If it’s something that would require such delicate finesse and strategizing that they can’t go public today, is it really that likely to succeed?
I’ve seen comments that people don’t trust this crowd. The amendment sends money to the General Fund, and it doesn’t specifically earmark which program gets what—that’s in the budget itself, and only for 2013. People are saying they could do anything they want to with the money—put it into prisons, for instance. For this year, they’d have to re-do the main budget, but sure, I suppose that could happen. Earmarking in the amendment would NOT help that problem, because the money going to various parts of government, including Medicaid, is only part of the overall budget. If it were earmarked and they wanted to undo that, all the legislature would have to do is pass a cut to the rest of the Medicaid budget in the amount provided by the amendment. I don’t trust them any more than you do, but the only way you could make certain money is used the way they say they will, with or without the amendment, is if the entire budget had to be passed by referendum.
You don’t believe them when they say they will pay the money back to the Alabama Trust Fund, because that isn’t in the amendment itself. Fine, I don’t think they will either. Remember that old rule of Dear Abby—don’t lend money to friends, just make a gift? I’m not thinking of this as a loan from the Trust Fund. It’s a transfer. That could cause problems down the road, but not as severe and hard to repair as cuts to Medicaid now.
A politically savvy friend of mine told me I should mention constitutional reform, even though I haven’t heard much chatter about that lately on this particular amendment. But just in case, I know there is a group who decided to vote No to every amendment, no matter what it was, to force our state to go ahead already and replace our awful Constitution. My friend made an excellent point. He told me to ask you if you really want the people now in office, Americans United for Life, ALEC, and Karl Rove to rewrite our Constitution. This is not the time. We need to wait until people with good sense are in charge.
Some of you think a No vote will send a message. Again, you are forgetting that you are a small group in the general voting Alabama public. I’m working so hard to convince you because I know you do get out and vote and the turnout might be small, but that doesn’t mean a failed amendment will send the message you think it will. Some of the Democratic legislators are pushing a No vote, even when they voted to let you have this referendum. Why? Because it is safe for them—they think they aren’t going to be blamed for the outcome of this budget. They just don’t realize that even if they come back into majority in 2014, they will not be able to overcome the damage for years. They will be blamed, and I’m here to do it.
I hope you don’t get to see the spin that would be put on a No vote. It would be all about how people want less government and more cuts. Don’t encourage them.
There are definitely times to send messages. There’s no point, though, if there are so many reasons from the opposition for a no vote that your message will get drowned out. A third party candidate in an election or a write-in can be a message, although I prefer to see it as a building process. A public protest is a message, and we did that successfully last spring over the ultrasound bill. Whenever possible, I would strenuously avoid the strategy of taking the lesser of two evils. To do that, though, you have to have a viable alternative or a way to build momentum for the future. In this case, there is no alternative we want on the table, and I’m just not going to count secret plans behind door #3. We would get damage to hurt better legislators in 2014 and after, damage to children that can’t be undone, and a door left open to unpredictable wild schemes this spring. I know you don’t want those things.
Some of you think I am assuming incompetence and that our legislators can’t pull it together if we help “focus” them with a no vote. I don’t think they are incompetent, and I do want to say I believe there are genuinely good and smart people in both parties, just not enough of them. What I think is that they are so much at cross-purposes that they are not going to be able to function effectively on this issue. The Republican party is divided into factions with different leaders and they are gearing up for their next primary season. Neither side wants to support the opposition’s plan in case it makes the other side look good. This is not a good recipe for compromise or long-term solutions, any more than it was last spring. Each side will try to hold out the longest so the other will feel forced to cave in, and if they miscalculate so that Medicaid money falters… I’ve given you that scenario. Now they want you to let them at it again, at our expense. Make them find something else to play tug of war with, or poker or chicken, whatever it is they are playing. If they are sorry now they gave us a chance to end their game, too bad.
In all fairness, I need to tell you I could be biased. Even though I’ve tried to remove myself from the partisan arena, I still have employment that depends on Alabama’s budget. Most comes from the education budget, and some comes from the money generated by seeing patients that goes to my employer, mostly from Medicaid. I’m salaried, and you know state employees haven’t gotten raises in years. So no matter what gets cut, Medicaid or education, my job could go on the chopping block. I’ve worked in other settings, including owning a solo practice, so I guess I’d figure it out, but I don’t know. I prefer employment to running a business, because I want to spend all my work time on patient care and teaching, not ordering supplies and figuring out paychecks. We’re close enough to Tennessee that if Alabama can’t employ me, I might go north. Or heck, Vermont’s looking pretty good right now. I could go cry on Bernie Sanders’ shoulder.
I’m going to close with a metaphor. I’ve told you before our budget is like a person with bad anemia that needs a cash transfusion, not a Band-Aid. This fall, it is even worse. Our budget is like a person with bad anemia whom our legislators and Governor have placed teetering on the edge of a cliff. They had some rope to save it from falling, but instead they’ve tossed it to us. If we use that rope wisely, we’ll haul our ailing budget back from the edge. It will still need a real transfusion soon, but if we let it fall based on promises of a net we can’t see, it could be too injured to save. Whose fault will it be if that happens? Their fault, for the anemia. Their fault, for the teetering on the cliff’s edge. Their fault, for not using the rope themselves. Our fault, if we don’t use the rope now.
Case closed. I’m voting Yes next week. Yes to save our Medicaid program, Yes for the children in our state, Yes for my job. I’ll send the rest of my message loud and clear in 2014, when I say Yes to candidates who can behave more responsibly. Please say Yes with me.