Tag Archives: governor bentley

Lend Me Your Ear(mark) and I’ll Sing You a Song? Governor Bentley’s Budget Plan Puts State Mental Illness Care at Risk

As most of my Alabama readers know, our legislature ended the session with no solution to our budget shortfall. We simply do not raise enough money in tax revenue to run the most basic functions of the state. On August 3, our legislature meets in special session to try and solve what couldn’t be solved for months this spring.

Governor Bentley has now released the details of his plan. There is a bit of actual revenue raising, but much of his answer appears to be shuffling money from one insufficient fund to another.

Most alarming is the proposed un-earmarking of nearly $200 million intended for the Special Mental Health Trust Fund—a substantial part of the Department of Mental Health’s budget. Otherwise, the Department depends on General Fund appropriations, which have steadily declined over recent years—the earmarked money is the only secure element. The outcome of poor funding has been dismal, with ever-longer waiting lists for life-saving services. Shane Watkins died this year, because when he needed hospitalization for his severe schizophrenia, there were no beds. Current funding is not acceptable. Level funding for 2016 would not be a victory. Now our governor wants to put mental health funding at even more risk.

Here is an example of the deleted earmarks: “…shall be deposited in the State Treasury to the credit of a special fund which shall be designated the Alabama Special Mental Health Fund and shall be used only for mental health purposes, including the prevention of mental illness, the care and treatment of the mentally ill and the mentally deficient and the acquisition, equipment, operation and maintenance of facilities for mental health purposes.”

Supposedly, we are to believe that money will be taken and then somehow returned afterwards in the subsequent budget process, with a leap of faith reminiscent of the Flying Wallendas. But if these funds are needed to make up a deficit in the General Fund to begin with, how will they be given back? Where will the money come from? If there is money to return to the Department of Mental Health, then why take it away at all? Removing an earmark to solve a General Fund shortfall only makes sense if the earmark is going to an over-funded area. I am not an accountant—I never in my life took a finance class. I still think I can recognize tomfoolery when it is this blatant.

I am aware that our state has an incredible number of earmarks, and I know analysts have said this is a problem. At the same time, I can see why we need them in a state which refuses to fund basic functions on a reliable basis in the annual budget. It’s the Ulysses strategy—we lash our legislators to the budget mast before they pass the Sirens singing at them to drown us in the bathtub.

I strongly recommend that Alabama voters contact their legislators now and advise against un-earmarking these critical funds. Tell them we don’t want circus acts performed with our money.

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Filed under Alabama Legislative Session 2015, mental health

Going Home Another Way– Why We Need to Thank Jan Brewer

Surprise announcement on the healthcare reform front this week—Governor Brewer of Arizona has announced she wants her state to participate in the Medicaid Expansion.  I’m posting a link to the Huffpo article, even though I realize it is not the most unbiased source, because of the comment section.  Scan through it if you have a few minutes because of late work openings from icy roads today! (Hey, give us a break, Yankees—we want to sleep in now and then, and if we have to declare black ice that is almost as imaginary as a Te’o girlfriend, cut us some slack).


Notice a common theme?  Apparently she is doing the “right thing for the wrong reasons.”


I understand what they are saying.  They think she should have a change of heart and do it because she cares about the uninsured poor, not because she wants Arizona’s cut of the money.  But that kind of thinking isn’t helpful.  We have to stop insisting everyone gives us good reasons for actions, as long as there ARE actually good reasons and evidence.  Let her use whatever reasons she needs to use, as long as she does the right thing.


I’m not a believer in using any means to a good end—the path to a goal needs to be as ethical as the goal itself, or something screwy will happen.  The end result will be tainted by what it took to get there.  I’ve seen it happen in person too many times to believe otherwise.  But reasons are not the same as means, even if they make us roll our eyes.


Neurology research points more and more to reason being evolved as an overlay—something may we generate AFTER we decide what we are really going to do.  We crave reasons and can’t avoid making them, but we have to take them with a grain of salt, because we don’t always know where they really came from.  As Pascal said, “the heart has its reasons of which reason knows nothing.”  It might have been a word we didn’t even know we noticed.  We use reasons to persuade each other, so being a skillful reason maker does matter.  What we DO with our reasons matters more.


Why do we need to be more generous in our tolerance for reasons?  Because that’s how we are going to get the good things we need.  People who oppose a good plan and change their minds need to save face—they need to be able to get there another way.  If we have single payer healthcare one day, it will not likely be because all the Tea Party people suddenly become tree huggers—it will be because they have another reason that makes sense to them.  Let it go!  Even better, thank them.  Maybe they’ll return the favor, when our reasons sound flat-out looney to them.


I’m very interested if Governor Bentley will be able to catch this wave.  Our Alabama Medicaid Advisory Committee just announced they are recommending we restructure Medicaid by using Community Care Networks instead of the third party vultures.  I’m not entirely pleased with parts of the plan, but I suspect almost anything would be better than having 15% of our Medicaid budget eaten up by the bad guys.  Although Bentley said he planned to turn down the Expansion, he left himself an out—he said he wouldn’t expand Medicaid in its current form.  Very important words!


Here’s your chance, Governor.  Medicaid will not be in its current form.  Jan Brewer has provided a Red State argument for doing the Expansion.  We could copy them on something good for once!  And fellow Progressives, let’s just clap our hands and get busy with nonpartisan rationales for single payer.  Everybody in, Nobody out—a winner for all reasons.


Filed under Medicaid, Politics

Exchanges, Expansions, and Secessions: Follow the Money

Ever sing the song “one of these things is not like the other” when you were a kid?  Let’s try it with three things Governor Bentley said this week.  First up:  Alabama won’t set up our own health insurance Exchange—we will let the feds handle it.  Second: Alabama won’t participate in the Medicaid Expansion intended to start in 2014—we won’t let the feds help us insure Alabama citizens below the poverty line because after 3 years we would start having to pitch in.  Third: the petition asking permission to peacefully secede from the United States (started by a colorful-sounding dude who got ticked off when his topless carwash got shut down) is, according to our Governor, “silly.”

At first, I thought the third pronouncement didn’t belong with the other two.  By foot-dragging every step of the way, we are engaging in continuous passive-aggressive secession already.  Kind of reminded me of a favorite parents’ book “Get out of my life, but first could you drive me and Cheryl to the mall?” But I think I was wrong.  All of these decisions are about money, and all of them result in the steady upward transfer of funds to those who already have plenty.  Even much of the federal money we receive eventually finds its way to the deepest pockets.

I’m not surprised by us bowing out of the Exchange.  The Exchange, for those of you who don’t know, is supposed to be a central marketplace for health insurance products up and running by 2014.  It will be a tremendous windfall for insurers who get a spot—free advertising, mandatory customers, and big federal subsidy bucks for premiums and out of pocket costs.  Since we are great lovers of both corporate incentives and federal handouts in Alabama, why on earth would Bentley bow out?  Part of it is simple grandstanding and playing to the secessionist base.  Bowing out doesn’t remove the incentives— it just gives Bentley a chance to make his symbolic stand, knowing they’ll get their money anyway. It may pay off for him in 2014.

He also won’t catch his share of the blame when the corporations do what corporations always do—maximize their profit at our expense.

Does it matter?  Alabama Arise thinks we need to talk him out of it.  If you agree, you have time to speak up, because HHS extended the deadline.  They have an easy way for you to get your message to our Governor here.  I’m not sure it will make much difference who runs our Exchange.  Insurers will have the bulk of influence on how things are set up, either way.  At state level, it might be more likely that our currently predominant insurer would continue to have the advantage.  At federal level, all the multi-state players would probably have more traction.  I doubt if the outcome will be much different for people who get stuck with one of these products.

The one qualm I have is the outcome of challenges to federally run exchanges.  Apparently the law was slightly misworded so that subsidies technically can’t be given unless an Exchange is run by the state.  The administration says everybody knows what it was supposed to mean, but some folks are counting on a challenge to be successful.  I haven’t found an article that directly quotes the miswritten section, but I think maybe it is Section 1311 d (1), which says “An Exchange shall be a governmental agency or nonprofit entity that is established by a State.”  Further on in Section 1321, there is a provision that if a state doesn’t do what it is supposed to, the Secretary of HHS will operate the Exchange.  If you know of a different glitch in the wording, let me know.

What about the Expansion?  That surprised me.  When SCOTUS first made their call this past summer, I was horrified at the meanness of finding a way to kick people who are already down.  Then I got reassured by friends who convinced me we would be forced, economically, to take the big federal money that accompanies the Expansion.  I also heard the hospitals were in favor of it.  Right now, hospitals get extra money to help compensate for the expense of caring for patients who can’t pay, but that is being drastically reduced over the next several years to account for the expected decrease in uninsured patients.  So I had expected the hospital lobby to be a strong factor in us getting the Expansion.

Apparently, they have figured out they don’t need this money, if this quote (see third page) from a hospital association representative accurately reflects the hospital lobby’s opinion. They “understand”—no objection in particular.  I would guess this may be the major reason Bentley went ahead with his announcement, along with the chance to look heroic to his topless carwash loving fans.  The formulas are complicated.  I have seen some discussion that no one was completely sure what the effects of not taking the Expansion would be, and that depending on what other states did, hospitals here might get MORE for maintaining a higher level of uncompensated care.  Which would also be in keeping with our tradition of whining about big government while raking in more than our share of federal subsidies.

The stated reasons (rarely the full story) are that he doesn’t agree with Medicaid in general, that we can’t afford it when we have to start putting in our share after three years of a free ride, and that we don’t have enough providers.  I don’t agree with Medicaid in general either and would of course rather see Medicare for All, but it is better than being left in the ditch.  I agree we probably wouldn’t be able to come up with our share in three years, given our history of poor-mouthing to the poor and sweet (incentive)-talking to the rich.

As far as insufficient providers go, we have some alternatives—we could allow independent practice of allied health professionals (I’ll have more about that later).  We could use the federal Expansion money to boost the healthcare economy and increase provider supply.  But there’s a nasty part of this provider shortage that didn’t make it into Bentley’s announcement.  It’s not just that this is like saying we don’t have enough food to feed all the bodies here, so we’ll let some die rather than accept truckloads of money to help grow crops.

It’s that even with the providers we have, too few accept Medicaid, about 68.5% in Alabama according to this study.  That study included specialists.  I would guess the percentage of primary care doctors accepting Medicaid in Alabama is lower, based on what I see locally.  Look here on the Madison County Medical Society page—pull up the number of pediatrician members who are taking new Medicaid patients (15) and then total pediatrician members (23).  Then pull up family medicine doctors taking new Medicaid (8) and total family medicine members (70).  Then internists taking new Medicaid (1) and total internists (30).  That’s only 19% of our primary care doctors here who belong to the county medical society and who are taking new Medicaid patients!  For doctors who see adults, only 16%.  We might not have enough doctors accepting Medicaid to meet the minimal federal standards for provision of care to adults who qualify.

What would fix this?  The even nastier possibility is that money alone might not do it.  In 2013 and 2014, primary care doctors will get paid by Medicaid at rates equal to Medicare rates (a big raise for us), because of the ACA.  I think that might pull more docs into the system, but unless I’m wrong, there will be holdouts.  All the docs who refuse Medicaid participation now could manage at least a small percentage of their practice already, if they really cared about the patients.  It would not kill them or bankrupt them to accept, say, 10 or 20% Medicaid.  When I talk to those doctors, they won’t say outright that they are uncomfortable with poor people.  They say the patients don’t come to appointments or don’t follow instructions, the same as they told this researcher.  They say there is too much paperwork.  But their faces say “I don’t know if I want them in my waiting room.”

We have some wonderful, heroic physicians in Alabama, including our Surgeon General.  But we also have too many who don’t take the Hippocratic Oath seriously. Some just try not to think about it and rationalize their choices.  Others go “concierge” and limit their practices to a small percentage of well-off patients, while they work as hard as they can to prevent other providers like nurse practitioners from filling in the gaps.

Should we push for the Medicaid Expansion?  I have heard Bentley might not be firmly decided.  It is probably worth trying to persuade him.  If the hospital lobby doesn’t find it compelling, I doubt we’ll get it.  Medicaid is better than being uninsured.  Doing the Expansion, while not a cure for health disparity, would give some partial relief to widespread misery.  But people with low incomes will never have real access to quality care unless their insurance cards look the same as those with private insurance.

Medicare for All would go a long way towards decreasing health disparity.  Will failure of the Medicaid Expansion be enough to create pressure for single payer?  Probably not.  The pain of poverty is already great and remains invisible.  Invisible enough so that many liberals celebrated the SCOTUS decision without taking time to mourn over the impact of gutting the Expansion.  Invisible enough so that some were willing to play chicken with Alabama’s Medicaid money for 2013 to make political points.  We will get real healthcare reform only when the middle class finally feels enough personal underinsurance pain to get fed up with being abused.

Is there an option in the meantime?  Maybe.  Is it possible we could persuade the President and Congress to subsidize private insurance coverage on the Exchanges for those who would have qualified for Medicaid, with zero co-pays and deductibles?  Not out of sympathy, but because the insurers would be thrilled to get that extra money and we rarely pass up a chance to support our corporate persons.  Remember that the mandate was dreamed up by the Heritage Foundation—they could come up with a way to make private insurance subsidies sound good, with enough insurer support.  Just call it a voucher—certain groups love that word—but make sure it is enough to cover the product.  It would be more expensive, probably at least 12% more, and that’s probably enough to make this idea a no-go. , and that’s probably enough to make this idea a no-go.  On the Exchange, individual and small group insurers are capped at 20% (edited) overhead and profit, compared to our state Medicaid at 3% overhead. But plans with large risk pools generally can get within 15%, and perhaps we could add regulation requiring 100% subsidized plans to stay within a 15% range.   That would be in line with the roughly 11% higher payouts to privately run Medicare Advantage plans compared to traditional Medicare.

I hate like the dickens to hand over more of our tax money to these corporations.  But I hate even more to see the people who struggle every day to keep their heads above water, the people who deliver our pizza and ring up our purchases and care for our children, be so utterly abandoned. They should at the least be able to access the same inferior products the rest of us can.   If we will not expand Medicaid, and if our doctors will not accept the responsibility to provide care without regard to social status and insurance type, subsidized private insurance is the only moral option until we have achieved real healthcare reform:  Everybody in, Nobody out.


Filed under Healthcare reform, Medicaid

A Surprise Move on Alabama’s Health Insurance Exchange

I learned yesterday that Governor Bentley has decided to throw the job of choosing an Essential Health Benefits package back at the feds.  Very interesting choice and I’m still scratching my head—all I can do is speculate on his motives, but I’ll tell you a couple of possible scenarios.  If you have other ideas, please share.


In his letter, Dr. Bentley does make some good points—there was a link in the Montgomery Advertiser to the actual letter yesterday, which has now been taken down.  I can’t find it elsewhere, but if one of you does, please post the link.  He wrote about the lack of guidance from HHS and their failure to fulfill their responsibilities, and then complains about Health Savings Accounts not being included as an option.  I believe he is wrong to praise Health Savings Accounts, since cost-sharing at the point of service is  an ineffective means of improving healthcare utilization (people do reduce spending but in equal measure on necessary and unnecessary care).  I completely agree with him about HHS abdicating responsibility.


The ACA states that HHS is to make a determination on the items included as Essential Health Benefits (EHB).  EHB are services insurers were supposed to cover without lifetime limits way back in 2010 on non-grandfathered plans, even though they have still not been officially selected by HHS yet.  They will be mandatory on the Exchanges in 2014—Exchanges will offer insurance policies on the state market outside of the typical employer and individual plans, also still in the mix.  Some of the Exchange policies will have government subsidies and out of pocket caps for lower income families above the Medicaid Expansion cutoff (but no subsidies if a family is actually poor, one reason we need the Expansion to happen).  As I’ve discussed previously, the subsidies and out of pocket caps will likely be insufficient to provide adequate coverage, and families may have cards they can’t afford to use—but we at least need to establish the best coverage possible at the beginning.


Even though the ACA did say EHB must reflect “typical” employer-based coverage currently offered, it didn’t specify how HHS was to determine “typical”.  There was some uproar in 2011 when the Institute of Medicine advised the selection of a small group plan instead of a typical large employer plan, since the small group plans tend to be skimpier.  HHS finally settled on punting the decision to states (recall our recent Constitutional Amendment for definition of punting).  States were supposed to select from one of four typical plans to determine the EHB included in our Exchanges.  If you live in a state where one or more of those plans has poor coverage, you could get stuck with poor choices on your Exchange.


Here is the “guidance” from HHS provided to states in 2011, and some interesting commentary.  It’s worth a close read.  The sticking point seems to be that although 10 broad categories of services are supposed to be included, there is a wide variety of ways to apply coverage.  This is particularly true for something called “habilitative” services, which apparently has no consistent definition and was not defined in the ACA itself—these are therapies designed to preserve function or gain function that a person never had initially, rather than recover lost function.  If you have a leg injury that can be overcome with physical therapy, for instance, a plan covering rehabilitative services would help you.  On the other hand, some insurers refuse to cover therapy for maintenance or development of function—for example, with cerebral palsy.   


HHS could have gone a much better route, by selecting coverage from typical large group plans in the country and telling states this is it—this is your EHB, deal with it.  No Congress to fight over the decision, so this can’t be blamed on partisanship.  President Obama, in fact, could have picked up the phone and said do it right.  Instead, a condition like cerebral palsy (which doesn’t actually change upon crossing state lines, go figure) will be potentially eligible for very different levels of service across the nation.  If the purpose of the Exchanges is to make sure people have access to real insurance, not just a card for show, the coverage needs to be meaningful.


You may recall that we had a comment period for our state’s selection process this summer, with very short notice and no press coverage I saw except on Left in Alabama.  Although the general public wasn’t actively encouraged to join in discussion, I know at least one advocacy group was invited to give a recommendation.  We recommended the most comprehensive coverage in the options, the FEHBP plan.  If you look at the comparison chart here, you will see that we had no options where all items were well-covered.  Maybe you think that’s no big deal, but if you or your family happens to come down with a disorder where the treatment or testing involves a non-covered service, you might feel differently.


If a state doesn’t choose, HHS has said that state’s EHB benchmark will be the largest small group policy sold in the state.  That’s the first column in our chart—not the skimpiest, but not the most comprehensive either. 


HHS can change their policy within the loose ACA language, without partisan agreement.  They are already late in choosing EHB, so it isn’t too late to speak your mind to HHS and our President.  Go back, folks, and do your job—set a meaningful, comprehensive EHB package.


Now, why did Governor Bentley take a stand?  I don’t know for sure, but I have a couple of guesses.  First, I don’t know what other advocacy and special interest groups recommended to the Insurance Commissioner for our benchmark plan.   If there was too much conflict between certain influential groups, it might have put Bentley in a political quandary.


Another possibility, maybe more likely—most groups could have selected the more comprehensive choice but interested insurers are pushing the less comprehensive options.  They want to be free to offer poor choices on the Exchange and rake in those federal subsidies without providing good insurance.  Even though plans are not supposed to exclude groups of patients by limiting coverage options, a minimalist EHB permits some sneaky cherry-picking.  Allowing the default to kick in (by appearing to hand the ball back to HHS) is probably the most politically savvy way for our Governor to satisfy the insurance lobby without appearing to do so.  A third possibility—and there could be a mixture of motives—is that the refusal of HHS to provide more specific guidance on items like habilitative services is making it impossible for states to be certain the EHB they choose will pass muster.  I’m not buying the rhetoric about Health Savings Accounts as his primary objection.


Here’s a chance for citizens to speak up.  Push HHS and Obama harder—don’t abandon Alabama to the greedy insurers and state policymakers who can’t or won’t stand up to them.  Our healthcare should not be controlled by political maneuvering.  The best choice—Medicare for All.  In the meantime, being stuck for now with the ACA, the least we can ask is decent coverage for money we will be forced to pay, specified at the federal level.  There is no reason coverage in one state, subsidized by federal money, should be inferior to that in another.  This is not a battle between Republicans and Democrats—it is a battle between citizens and big money, and big money is going to win unless we work harder. 

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Filed under Exchanges, Healthcare reform

Alabama: a Better Pledge to Sign

Tomorrow, our state House of Representatives will debate a budget worse than the worst one we imagined.  I guess $ 400 million for Medicaid is no more impossible than $ 425 million—we were already at a fat-free budget before these cuts began.


Dr. Don Williamson is being straight with us.  Federal rules prevent us from cutting most parts of the program.   He didn’t pull this out of the air for drama—he is just telling the truth.  We would lose all adult pharmacy.  This would render the salvaging of Mental Health meaningless.  What good is it to let people with schizophrenia see the doctor but not give them medicine?  It would also mean pregnant women, who only get Medicaid for the brief duration of pregnancy, would not be able to get medicine for things like pregnancy-induced hypertension and gestational diabetes, thus putting their lives and their babies’ lives at risk.


We would lose hospice.  This would, ironically, increase the cost of dying.  People who had wanted to die at home with their families would not be able to get the pain medication and medical support needed.  They would go to the hospital instead.  And most dramatically, we would be forced to stop dialysis.  As Dr. Williamson said, dialysis patients would die within two weeks. Do we really want our children to see us behave so?


Even after all that, we would still have to cut payments to doctors dramatically.  We would still lose pediatricians who could no longer pay for rent, staff and supplies. 


Dr. Bentley, our Governor, said the proposed budget was irresponsible.  I agree.  What is he willing to do to prevent it?  His initial budget required money to be taken from education, also already underfunded, and made cuts to the Department of Mental Health.  This weekend I read an interview in which he once again implied he might want the legislature to override his veto of any new tax.   He explained it by saying the voters of Alabama no longer trust the government when it says we need more money and that we, the voters, believed it was important to re-examine our funding priorities periodically.  He said if we weren’t willing to cut now, we never would be, as if we need to prove that to ourselves.  He sounded (my friends tell me I’m being overly optimistic) like he was saying he wanted US to “get it”—to send our state lawmakers a clear message—clear enough to make them override his veto—that we have changed our minds and are no longer willing to drown our children and mentally ill in the bathtub along with the government.


In a way, he is right.  Unless we Alabamians, as a people, unite in deciding we value our children and truly understand that the fates of the children of the poor and the children of the rich are intertwined, this kind of budget slashing will be up anew every year and could get worse with every election cycle.  I saw in a recent poll that most of us think the state could cut spending without a bad outcome.  That means we have work to do in our communities, talking to each other, not just calling Montgomery.


On the one hand, I want to believe Governor Bentley is correct—that if we do the right thing now, we will own this budget.  That it could change us at a deep enough level to last at least a few years. 


On the other hand, I do not agree it is safe to risk the lives of our children in a game of chicken.  I set up a Facebook Group last week to get the word out—I made a rule that we would all belong to the “Children’s Party” and avoid partisan criticisms.  You would think everyone could join the Children’s Party.  Indeed, I still believe most of us in this state and enough of our lawmakers can, not just for brownie points but because at their core, they know it is right.  But even a Children’s Party is not without enemies.  It is far too dangerous to let the bodies of our children dangle in their hands.


Our Governor and several legislators have signed a no new tax pledge.  I don’t know if they all realized what that would require of them.  If they are going to do the right thing for children, they must agree to be adults themselves.  Being adults means sometimes they have to admit they have been wrong.  If they are not just adults but also leaders, it means sometimes they have to be the ones to stand up and show us the right path.  Even when it is hard, even when it gives them heartburn, even when they fear for their jobs.  If our leaders can’t do that for us, they have no business in Montgomery.


Fellow Alabamians, we also have work to do.  This problem is too big for one party to solve.  I’m going to pick on the progressives first, since I’m one.  Part of the reason we have lost strength is that we haven’t been willing to see the importance of some conservative values.  We can’t be a state for children without valuing reasonable security and safety from crime.  We can’t go into debt they will have to pay later, without a very good reason. We don’t raise our children by giving them everything they ask for, like sugary cereal for breakfast—we have to understand that in the same way, safety nets can go too far and enable folks to hurt themselves.  We have to stop punishing the children of conservatives for their parents’ decisions, such as by dropping opposition to homeschoolers playing public school sports and looking for other ways to protect our school funding.


Most importantly, if our current leaders make an attempt to go in the right direction, don’t beat them down with snarky comments and say they don’t mean it.  Give them a chance to be good.  When adults go after each other, children are the ones who suffer.


Conservatives, we need you and your children too.  We need you to add a measure of care to your values of fairness, justice, liberty and personal responsibility.  You are the ballast that keeps liberals from overdoing it, but that ballast will fail without the strength of compassion.  Wherever the actions of adults make you justifiably angry, remember that their children are not to blame and do not deserve to be punished.  Remember to do as much for living children as you do to defend the unborn. We need you to understand that you can’t pull the rug out from under those you see as irresponsible without hurting yourselves as well.


Let us ask each other to take a minute this morning to read and sign the Children’s Promise


“I, (your name here), promise to support policies that promote the healthy development of Alabama children into responsible, educated adults.  I will consider the needs of a child in poverty as carefully as the needs of a child in wealth. I will set an example of civilized behavior, and I will not treat any individual or group in a way I would be ashamed to have to explain to a child.  As an adult, I will sacrifice my own self-interest when necessary, for the sake of our children, our future.”


When you have signed it, pass it on.  Ask your friends and neighbors to sign.  And call your legislators and the Governor today.  It’s time to speak plainly, Governor Bentley.  Tell us you know what is right. Renounce your Norquist Pledge, and sign the Children’s Promise.


Filed under Alabama legislative session 2012, Children's Issues

Alabama: No State for Children?

Yesterday, I made the six hour round trip to Alabama’s state capitol, Montgomery, to attend Pediatric Legislative day.  I’ve been many times—it was the largest turnout of docs I’ve seen yet.  This is my personal report, not in my capacity as a state AAP (American Academy of Pediatrics) board member.  In keeping with the several references to Titanic I heard, I am sorry to tell you that we have already hit the iceberg and our ship is in process of sinking.  I do not know if there are enough lifeboats.  Our legislators and Governor are tossing children overboard first.


Those of us who arrived early chatted while drinking coffee, before all the optimism got sucked out of us.  Last month, we got notice that Medicaid provider payments due March 16 were to be delayed and that “a payment date has not been established.”  Many friends in private practice, especially in rural areas where the great majority of their patients have Medicaid, have already forgone their own paychecks.  Many have had to let staff go (one lost 40% of her staff this week) AND take out emergency loans.  Some of the younger docs are already talking about leaving Alabama completely.


A friend in Mobile reported that because of these payment delays, not a single ENT (Ear-Nose-and Throat surgeon) in her county would accept a new child patient with Medicaid.  In Mobile, one of the largest cities in our state, doctors will have to send children out of town for care. Still, while we drank our coffee, we were smiling, hopeful that when our lawmakers heard about this, they would do something.


Once the speakers arrived, the news got worse.  First we heard from some of my personal heroes, those in our Medicaid agency.  These are the people who work day and night to find ways to stretch a dollar for the sake of children.  We heard that there was still no provider payment date set, and that Medicaid was waiting for the Finance office to release funds.  They are anticipating it may be a recurrent problem and are already making contingency plans for a rotating payment schedule.  Some doctors will get paid one month, some the next, etc.  We heard these grim words:  “You are going to see things you’ve never seen before.”


The Alabama House Budget is due in committee today.  We heard there is talk that the Medicaid Budget will be as low as 425 million.  I was told this is far less than the amount that even the corporate Third Party people would consider taking as a managed care contract.  That this would not fund adequate care for children.  That adult pharmacy benefits (serving the disabled poor, including those with serious mental illness like schizophrenia) would have to end.  There will most likely be a significant payment cut to All-Kids doctors (Alabama’s SCHIP program, for children in working families just above the poverty cutoff for Medicaid).


It was hard to watch my heroes try to smile and come up with something hopeful to say.  They looked so tired.


Next came the legislators.  They had big smiles!  Many of them said they personally “got it” and put the blame on Governor Bentley for his signed no new tax pledge, a bizarre Medes and Persians type oath that apparently means more than his oath of office to do his best for our state.  Senator Orr said the idea of having to override Bentley’s promised veto for a tax increase “gives us heartburn.” But the way they were smiling, I have my doubts about the “got it” part.  I sure didn’t see anything that made me want to dig in my purse for an antacid to share.


Speaker Mike Hubbard came in last, also smiling, at first.  He said his philosophy was “never let a good crisis go to waste” and that this was our chance to make Alabama’s government “leaner.”  He said “Medicaid is a black hole”.  I have added and deleted a sentence ten times about why he might have chosen those exact words, because I’m trying to be objective—you decide.  Don’t believe him, by the way—here’s a more accurate description of state spending.


The first question from the floor came from Dr. Marsha Raulerson, a nationally respected pediatrician who has served her poor rural community for decades—a woman who brings her beeper even on vacation and has somehow also managed to perform tremendous leadership and advocacy work.  She asked if Mr. Hubbard realized she was having to let staff go already and if he would consider a tobacco user fee, a $1 a pack fee on cigarettes that would bring us close to the average of other states, improve child health, and raise an estimated 200 million for the General Fund.  He gave the same heartburn sob story.


Around the room, other pediatricians spoke up.  We are usually a polite crowd, and we still were.  There was no name calling or personal criticism, but there was both passion and anguish.  I heard voices with barely held-back tears.  One friend told Hubbard he needed to understand children would die.  He listened to a few of these comments with visibly rising irritation and then said, curtly, “We appreciate your time”, turned on his heel, and walked out.  Dr. Raulerson tried to hand him an information sheet as he left, and he refused to take it.  It was a level of rudeness I have never encountered at our state house.


As we sat in shock, a legislator I didn’t recognize, stuffing his mouth with the lunch sponsored by Children’s Hospital of Alabama, said he had heard doctors were stealing from Medicaid left and right.  He also left.


I looked around the room and saw pediatricians in all stages of grief except denial.  We can no longer deny that this is happening—that our state legislators and Governor will let this ship sink. If the budget is as bad as we are anticipating, we will not be able to fund care at the level required by federal rules.  I didn’t hear anyone mention it, but I was reminded of reports in the media in 2010 that Alabama might drop Medicaid entirely.  After seeing these people smile in the face of child death, I would not be surprised.  The story would be that Alabama tried but just couldn’t comply with “unfunded mandates”.


If nothing is done—and I mean immediately, not just for FY 2013—we will lose pediatricians very quickly.  No matter how much we love our patients, we will not be able to run offices without rent money, staffing or supplies.  Rural areas will go first.  Pediatric residents graduating in June will decide to take jobs elsewhere.  When they leave, they won’t come back.  We will lose the pediatric specialists who can’t pay staff and rent without Medicaid funding.   We will lose our Children’s Hospitals.  There won’t be special hospitals left for children of privately insured parents.  There will be nothing.  It will be like a bad movie called “Alabama: No State for Children.”


What is to be done?  I don’t know what to tell you.  It’s worth a try to make noise now, but it would take real noise, not just a friendly email or phone call.  Dr. Raulerson calls her legislators every day.  If you are a parent or a business owner who employs parents, and you don’t make or hear an uproar, I would be remiss if I didn’t advise you to start making evacuation plans soon.


Filed under Alabama legislative session 2012, Children's Issues

Alabama’s Budget and Healthcare: A Plea for Sanity

Alabama, instead of going for a trickle-down economy, has settled on a suck–the-poor-dry scheme.  We have the lowest overall state taxes but the highest income tax on the poor.  While trying to run our state on the backs of the poor and charitable donations from other states through federal funds, we have also cut money to the essential services that keep the poor afloat enough to continue slaving at their low-paying jobs. 


So now, our Governor says, the well is running dry.  Is it because we have sucked all the water out of an already thirsty ground?  Is it because corporations, many based out of state or even out of country, are hoarding that water in their big tanks?  No, he says!  It is because of tornadoes


Well, I’ll be.  In the face of such drivel, one hardly knows how to respond.   


 Our Governor and Legislature have ruled out many potential solutions on principle.  When principles conflict with reality, it’s time to check out those principles again.


They’ve said they absolutely will not raise taxes.   Even a simple $1 a pack tax on cigarettes, which would bring our state tax on tobacco up to average, would net us an estimated 200 million a year.  That’s the kind of tax they usually love, because it would again hit the poor harder than the rest of us.  True, it could ultimately save poor smokers years of life and money if the tax helped encourage them to quit—oh, maybe that’s why they don’t want it.  Without poor people, whatever would those deserving tobacco companies do?


We could, without raising taxes, end the so-called “incentives” and tax breaks we spend to bring business into the state—especially the ones that pay our workers minimally, provide little or no health insurance, use the labor to create profit for themselves, and return nothing to our state.  Maybe the movie corporations will use our labor and money to film us in our falling-down shacks.


I’ve had a dream for years that when things finally got bad enough, even the most conservative states would have a moment of epiphany—they would say “Oh!  You know, if we had Medicare for All, we could balance our budgets!”  Suddenly, they would find wonderful conservative reasons and manage to make it all look like their idea—fine by me.


I’ve looked at some of the numbers to see if I could get a rough ball-park idea of Alabama’s potential savings under Medicare for All.  First, we appropriated about 1.3 billion dollars of state money to Medicaid in 2011.  This was supplemented heavily with federal matching funds.   For teacher health insurance, we allocated about 899 million dollars total. State employee health insurance (not including teachers) cost us about 359 million dollars.   


If we replaced the teacher health insurance with Medicare for All, at an estimated employer matching (Alabama) cost of 4.75% of payroll, a rough estimate of the cost is 222 million for teachers—this is 25% of what we are paying now.  (See this link for a description of Medicare for All funding sources). That’s a savings of 677 million off current teacher insurance.  I can estimate this because the report lists average teacher salary.  For the other state employees, those numbers are probably out there somewhere, but if I use a cost even as high as half the current private insurance (it is likely far less), Medicare for All’s cost to the state would be 180 million dollars.


So if we just take our 2011 Medicaid appropriations at 1.3 billion, our teacher insurance savings of 677 million, and our underestimated state employee savings of 180 million, we have a savings of 2.15 billion dollars.  That’s still an underestimate, because we should remove the current Medicare employer tax, much of the Department of Mental Health expense, the state contribution to All Kids, and some of public health.


Two billion dollars at a minimum.  Read that again—TWO BILLION DOLLARS.  Woo-hoo!!  We’re in the money!  How many tornado shelters would that buy?


I am not including some peripheral savings that might add up to a lot more.  For instance, I know many people on disability who applied ONLY to get health insurance.  But many want to work—they want to feel part of things and contribute.  How many might be able to do just that (and pay state taxes) without the fear of un-insurance hanging over them? The disability money is federal, but the regained productivity and associated taxes would benefit our state.


We could save money we are now spending to regulate health insurers.  And we would remove the number one cause of bankruptcy and foreclosure—health care costs.


Now, doesn’t that sound like a plan?  First fix our current taxes to get ourselves out of the immediate hole, and then advocate Medicare for All?


Here’s the problem, though.  The people in charge are impervious to evidence and reason.  It will not matter how much money we show them.  They will just keep pushing non-solutions like selling off our cost-effective Medicaid to out-of-state swindlers (yes, it’s on the horizon again), making it easier to carry guns everywhere, chasing immigrants around and torturing women who try to get abortions.  A friend told me if it doesn’t have GGIA in it—God, Guns, Immigration and Abortion—our legislators aren’t interested.  I think he’s right.


If we could prove to our Governor and Legislature that in 2 months, without raising taxes or removing tax breaks, we would have a massive earthquake and all of Alabama would fall into the ocean, even they believed us beyond a shadow of a doubt, here’s what would happen.  They would shrug their shoulders.  They would say it must be because of abortions, gun control, Mexicans or God’s will.  They might even jump into the sea themselves before they would admit they were wrong.


Alabama, listen up.  The well is dry.  We cannot afford these people we have voted upon ourselves. 





Appendix—the numbers


Follow along in this report and tell me if I’m wrong. 


Page 18 History of employer cost for teachers’ and state employees’ health insurance (“employer” here is the state of Alabama)


899 million for PEEHIP (teachers) and 359 million for SEHIP (other state employees)


Page 7, Estimated cost of a teacher unit:  average salary for 2011, $ 46,914


4.75 % estimated employer (Alabama) contribution for Medicare for All–  46,914 X 0.0475 = $2228 per teacher


To estimate the total cost of Medicare for All employer contribution, I used the PEEHIP cost of 9024 per teacher, divided by the 899,261,904 total PEEHIP employer cost, which should be proportional to 2228 per teacher divided by the total Medicare for All employer cost.  This is 222,025,213. 


222 million is about 25% of 899 million. 


I underestimated the other employee Medicare for All cost at 50% of current employer cost to be safe—180 million.


See Medicaid Appropriations on page 68.  Notice how little we contribute from state funds, versus Federal and Local.


Other sad stuff in this report—look at the Rainy Day money, the absent COLA for teachers, the absent funding of teacher supplies.  Look at how much we are sustained by federal money, overall.


Filed under Alabama legislative session 2012, Healthcare reform