• I must be going soft

    I’ve been reading the Republican Governors Public Policy Committee’s recently released report, A New Medicaid: A Flexible, Innovative and Accountable Future. I was prepared to bring the full snark, sure that this was just another partisan document, completely full of bluster with no actual ideas.

    But I’m not feeling that. Sure, there are elements of crazy, like “Solution #5: Require the federal government to take full responsibility for the uncompensated care costs of treating illegal aliens.” It’s already against federal law for Medicaid to cover undocumented immigrants, so this does nothing  to reduce Medicaid spending whatsoever. But I suppose it makes some people happy to say it again. Others already exist in some form, like “Solution #9: States should be encouraged to develop innovative programs to reduce chronic illnesses and the burden of associated health care costs to individuals and the taxpayers.” And some are just odd, like “Solution #7: Federal and state financial participation in the Medicaid program should be rational, predictable and reasonable.” I assume this is meant to be insulting to current law.

    But it’s not all like that. There are some good ideas in there, too. Here are a few:

    Solution #2: States can create a specific “dashboard” to measure accountability utilizing recognized measures of quality, cost, access and customer satisfaction that reflects the state’s priorities and permits an assessment of program performance over time. Where possible, states will utilize the expertise of state, local and national organizations that have developed appropriate measures. In many cases, states already have developed extensive measures of quality and accountability, including customer satisfaction. These dashboards should utilize those processes instead of recreating onerous administrative burdens for states.

    That seems totally reasonable to me, especially since we’re likely headed somewhere like this for the exchanges in the PPACA. Or course, the devil’s in the details, but that doesn’t mean this couldn’t work.

    Solution #8: If a state can demonstrate budget neutrality, provide states the ability to use state or local funding, now spent as match funding, for certain health services thatwould pay for Medicaid services or health system improvements that are currently not “matchable,” but are cost effective and improve the value of the Medicaid program.This could include Health Information Exchanges, increased benefits for some individuals, improved care management and local care coordination, and pilot programs to test innovations.

    Again, this seems like it could work, with proper safeguards in place.

    Solution #11: Provide states with the flexibility, without requesting waivers or initiating the state plan amendment process, to pay providers based on providers meeting quality care and value-based criteria rather than the current fee-for-service approach. Allow innovative payment methodologies to encourage care coordination for all Medicaid eligibles, without exception. Other options could be capitated payments, shared savings, and incentive arrangements when such payments encourage coordination,reduce cost shifting and improve care delivery.

    I have a hard time fighting against provider payment reforms, especially when they might save money and improve quality. We should be attempting more stuff like this.

    Solution #25: The territories should be treated consistently, fairly and rationally in funding, services and program design.

    That seems like a no-brainer.

    Solution #26: At a state’s discretion, permit states to redesign Medicaid into multiple parts. Medicaid Part A would focus on preventive, acute, chronic and palliative care services; and Part B would focus on long-term supports and services (LTSS). This would enable a state to better manage the different needs between populations who only need LTSS. Eligibility for Part B would be based on income and functional screening of  an individual’s long-term services and LTSS needs.

    I’d need someone to show me why this is a bad idea, especially since this is what we do with Medicare right now.

    Solution #27: Engage in shared savings arrangements for dual eligible members when the state can demonstrate the Medicare program reduced costs as a result of an action by a state Medicaid program.

    That seems only fair. In fact, many of the “Solutions” pitched for LTSS seem totally reasonable.

    You would think I’d be happy. Sure, there are ideas in this document which I don’t agree with, like the notion that block-grants are proven answers to funding issues, or the magical thinking that somehow states could lower costs, increase eligibility, and increase quality if only they were just allowed to. Yes, there are vague areas we’d need specifics for.  But, on the whole, I can’t expect that the Republican Governors Public Policy Committee and I are going to start out in the same place, because we have fundamentally different ideas about how the health care system should function and improve.

    Instead, though, I find myself somewhat sad. I’m feeling that way, because I realize this will go absolutely nowhere. In a rational world, with a functioning government, we would be able to agree on some of these points and disagree on others. We would allow some ideas we don’t favor to be attempted, in exchange for some of our own that others wouldn’t pick first. We’d compromise.

    But there’s no way this will be debated. Opponents of the RGA will pick the pieces they hate the most and focus on them. Supporters will attack those attacks, and this will turn this into a partisan snipe fest for political gain. And we will go absolutely nowhere.

    Of course, I could be wrong. Nothing would please me more.

    • Good news! You’re wrong.

      If the debate proceeds as did the debate over the ACA (and the debt ceiling, for what it’s worth), it will work like this:

      1. Democrats will engage in compromise, embracing some of the GOP’s points.
      2. The Republicans will denounce their own proposals as socialism, tyranny, and hostile to the Constitution.
      3. Republican politicians involved in the crafting of this document will be expelled from the party.
      4. Flourish, exeunt.

    • Dr. Carroll,

      Always enjoy reading your thoughts and hearing your interviews and exchanges on “Stand Up.”

      One of the more telling and problematic signs that compromise is unacceptable is found on the very web page you reference (before you get to the actual document). Point 2 under “Why Join”:

      Grow Our Majority
      And Keep the Democrats On Defense

      There is no reason to include that 2nd sentence. Yet this is the noxious atmosphere that exists. It makes it difficult to view this document as anything other than a war manifesto, not as something that is even being done in the spirit of cooperation or problem-solving.

      Makes this centrist IU graduate who once-upon-a-time worked for the Republican Party as a Ward Chairman quite sad.

    • “I’d need someone to show me why this is a bad idea, especially since this is what we do with Medicare right now.”

      Let’s suppose some politicians were cynical enough to craft health care policy so that it favored one group of people over another just because one group votes more often. Might it then be likely that LTSS keeps getting fully funded while the other parts of Medicaid get cut?


    • One way to save money in the Medicaid program is to encourage more use of the homemaker plan that allows clients to stay in their own homes (for about $1000/month) instead of essentially forcing them into nursing homes (for $10,000/month). I assume nursing homes have more powerful lobbyists than homemaker agencies.
      (I know you wrote thia while ago, but i’ve just found this blog.)