Health Care Reform

Research & Thoughts

A joint report from the Robert Wood Johnson Foundation and the Urban Institute projects that, over the next 10 years, the state will leave $66.1 billion in Medicaid funding on the table by not approving the expansion included in the Affordable Care Act to cover individuals with income up to 138 percent of the federal poverty level.That will mean more than 1 million uninsured state residents will not qualify for health care coverage, the report said.Over the next decade, Florida’s hospitals will miss out on $22.6 billion in federal reimbursements, the report projected. During that 10-year time span, a combined $423.6 billion in federal monies will not flow to the two dozen states that declined the expansion.

via Florida to suffer most for not expanding Medicaid, studies show |

Gov. Rick Scott having refused millions of dollars of federal grants for setting up an insurance exchange now appears ready to move forward.  However the Governor and other Republican leaders still are not in favor of expanding the Medicaid roll by another million citizens.  The state may well decide to opt out stay under the funding cap of the old system.  This approach would save the state over a billion dollars by 2018.

via Florida reluctantly starts to implement Obama’s health care law – Orlando Sentinel.

A physician’s perspectiveAs a family physician, I have struggled to help my patients get necessary health services, but with Thursday’s Supreme Court ruling upholding the health-care-reform law, my patients and millions of Americans have improved access to health care.The Affordable Care Act ACA provides insurance security for everyone; no longer will health-care access be determined by how much you earn, where you live or what you look like.Under the ACA, insurance companies are required to use more of your premium on insurance benefits instead of salaries and administrative costs. Insurers must cover everyone, regardless of pre-existing conditions, and are no longer able to impose yearly or lifetime caps for needed services. Adult children can stay on parents’ insurance plans until they turn 26. Preventive care is available to all Americans without co-pay, allowing health-care providers to detect illnesses before significant harm is done. The ACA expands access to Medicaid for our nation’s poorest citizens and strengthens Medicare to protect seniors.With the Supreme Court’s ruling, now we can put patients ahead of politics, and Americans can realize all the benefits of the Patient Protection and Affordable Care Act PPACA.— David Evans, M.D., Seattle

via U.S. Supreme Court upholds Obamacare | Northwest Voices | The Seattle Times.

Perhaps ObamaCare will be remembered as the breaking point for top-down planning. There is not enough information available for the government to micromanage a system as complex as health care, which represents more than 15% of the economy. Austrian economist Friedrich Hayek wrote some 50 years ago about the “pretence of knowledge,” meaning the conceit that planners could know enough about complex markets to dictate how they operate. He warned against “the belief that we possess the knowledge and the power which enable us to shape the processes of society entirely to our liking, knowledge which in fact we do not possess.”

via Crovitz: Complexity Is Bad for Your Health –

A cut of 60.5 million a year will effect Florida Nursing Homes in a big way.  These cuts are effecting how the Nursing Homes are paid by Medicaid for those residents that have not paid there bills.  There is an  a way that the Nursing Home industry  can add  the bad debt to their cost of doing business, which will effect the rate medicaid will pay.  Under a new law this will be changed.

A new Avalere Health analysis detailing the negative impact on Skilled Nursing Facilities (SNFs) resulting from so called “bad debt” provisions passed in the Middle Class Tax Relief and Job Creation Act of 2012 finds facilities in Florida, Ohio, Illinois, Pennsylvania, North Carolina, Louisiana, Indiana, Tennessee, Georgia and New Jersey will absorb the largest Medicare funding cuts. Nationally, the provision will cut SNF payments by at least $3 billion over the FY 2012-21 budget window.

Alan G. Rosenbloom, President of the Alliance for Quality Nursing Home Care (AQNHC), pointed out that the phrase “bad debt” is a complete misnomer. The federal government itself, he said, prevents SNFs from collecting as much as 90 percent of SNF bad debt. “SNFs have no legal recourse to collect ‘bad debt’ from state Medicaid agencies — and is more accurately described as ‘uncollectible debt’ as mandated by federal law,” he stated. He noted the U.S. SNF sector, America’s second largest health facility employer, faces yet another $8-9 billion in cuts between FY 2012-21, resulting just from the looming sequestration threat

via New Avalere Health Analysis Details State Impact of “Bad Debt” SNF Medicare Funding Cuts – MarketWatch.

According to a Kaiser Family Foundation poll .pdf released last week, the Medicaid expansion provision in the Affordable Care Act has 70 percent approval from Americans.

The poll also found that most provisions in the law have considerable support from the public, except for the individual mandate, which bottoms out with a 32 percent approval rating.

via Poll: 70 percent like Medicaid expansion in health care reform law | Florida Independent.

The Financial State Of Florida’s Medicaid | – Florida Health News.

University of South Florida Public Radio Reporter,  David Gulliver has written one of the best analysis of the funding of Medicaid.  In great detail he describes the two billion dollar cuts to Medicaid that only saves the state of Florida 442 million. To understand the scale of the Medicaid Program and the programs impact to the state economy, Gulliver reports, that medicaid represents 21.2 billion of Florida total budget of 70 billion.  The cuts represent less than a 10 percent cut.

David Gulliver also drives home the point that in tough economic times the Medicaid enrollment grows.  From 2003 to 2008 Medicaid caseload  was flat. As the recession impacted Florida, over 1 million people joined the Medicaid rolls.

The article ends by looking at the future of Medicaid reform and the pilot program that privatized Medicaid in five Florida counties. It is still unknown if real savings are achieved by this approach. David Gulliver cites the two studies done at the University of Florida and Georgetown University.

Great Reporting.

Miller – McCune has a great article about the politics of the Supreme Court. As the Supreme Court considers the Affordable Care Act and Medicaid today, they must do so with great respect for their opinion to be honored. However the backlash will be great what ever decision they will make. It is my prediction that the Supreme Court will not render a decision until after the Presidential election this fall.

If the smear of partisan decision-making tars the unelected U.S. Supreme Court after these decisions, the fundamental legitimacy of the institution may become precarious.Why exactly is legitimacy so important?Legitimacy means that an institution has the right to make decisions, and, because those decisions are fairly, impartially, and procedurally properly made, citizens are under the obligation to accept those outcomes, even when they disagree with them. So, in this sense, legitimacy is for losers — those on the losing side of the issues the Supreme Court decides.

via Can the Supreme Court Survive a Health-Care Decision? – Miller-McCune.

The Miami Herald reports:

A controversial measure that would shift $300 million in disputed Medicaid bills to counties has been received by Gov. Rick Scott’s office, triggering the 15-day window for him to either sign or veto the legislation. If Scott does neither by the March 29 deadline, it becomes law automatically.

via Clock ticking for governor to sign controversial Medicaid legislation | Naked Politics.

Some of questions asked by the Federal Government to the State of Florida regarding the transition to managed care for those on Medicaid. In a recent article some of these questions have been revealed.  If you were the State of Florida how would you answer them.

“The State must ensure that plans maintain a network of providers in sufficient number, mix, and geographic distribution to meet the needs of Medicaid beneficiaries,” one part of the list said.

“What are the standards that will be used by the state to ensure access to Medicaid services and to which managed care plans will be held accountable? How have these standards been vetted? Describe the ongoing oversight and review that will be in place to ensure plans maintain a sufficient network.”

via Feds Question Florida on Medicaid |

Florida Medicaid shift could take longer than expected | The News-Press |

Well written article, about the shift to managed care for seniors on medicaid and how the state and federal governments still do not understand how it will all work.  The need for independent advice on choices and care seems manifest for seniors and their families as these changes in the medicaid program are put in place.

The Miami Herald editorial page reviewed the Florida legislature 2012 session with a judgmental tone.  The editorial staff at the Herald were concerned that the legislature failed Neglected Elders and meaningful reform of the Medicaid Program.


Gov. Rick Scott and lawmakers talked a good game, calling for major reforms to improve assisted living facilities in the state. In the end, however, only the Senate was willing to impose serious reforms to help vulnerable ALF residents. But with no willing partners in the House and little leadership from the governor — who swore that this issue was a priority — ALF reform went nowhere this session. Shameful.


Jackson Health System dodged a bullet from the governor’s original proposal, which sought to cut a quarter billion dollars in Medicaid funding. Instead, the Legislature’s formula trimmed Jackson’s Medicaid allotment by about $47 million, with the ability to recoup about $12 million of that amount and possibly more through expected federal revenue.But even so, the Legislature forced Florida hospitals to absorb a cut of more than 5 percent in Medicaid funding in a state that already covers far less than what it costs to care for sick, indigent patients.Most maddening: The Legislature rejected $440 million from the feds to improve Medicaid reimbursement rates to physicians, money designed to encourage more doctors to serve the poor and disabled. This is all politics, designed to show displeasure over the Obama administration’s Affordable Health Act, but it winds up hurting Florida’s neediest.

via Missed opportunities – Editorials –

Forbes is reporting Long Term Care Issues are not a top issue for presidential candidates. An exception is Newt Gingrich. Forbes reveals:

Gingrich, who has shown real interest in long-term care issues in the past, was typically provocative though sometimes contradictory and often not specific. The former speaker used the survey as a platform to renew his calls for repealing the 2010 Affordable Care Act, turning Medicare from a guaranteed federal benefit into a defined contribution program, and replacing the existing Medicaid system with a federal block grant.

Gingrich said consumers should be able to use tax-advantaged Health Savings Accounts and Flexible Savings Accounts to buy long-term care insurance. This is somewhat curious since Gingrich has also proposeda flat income tax system that would seem to effectively end HSAs and FSAs.

Still Gingrich also said he’d “promote new models of care” that focus on primary medical care and home care. He also embraced the use of new assistive devices, though he didn’t say how consumers would pay for them.

In addition, Gingrich said Medicare should cover training for family caregivers. This is a very interesting idea through it is not clear how such a mandate would be implemented once Gingrich shifts Medicare to a largely private insurance model.

via Long-Term Care Services: Forgotten By Most Presidential Candidates – Forbes.

Local and County governments are on the hook for more cost sharing for Medicaid patients. Currently at stake is over 300 million dollars in disputed Medicaid billings. These funds owed are over a three year period.

p>The state wants to get that money, as well as future Medicaid payments, by withholding revenue sharing dollars from counties. That in an unfair burden on local governments that will hurt taxpayers, the Tea Party says.

“This is going to require counties to cut services or raise taxes to pay for what the state is mandating for the counties,” said Henry Kelley of Ft. Walton Beach, the Tea Party Network’s legislative liaison.

via Tea Party defends counties in Medicaid billing dispute | Naked Politics.

As Courts interpret Medicare and Medicaid laws, they ponder the language that the public policy is described in the laws. In todays Wall Street Journal JOE PALAZZOLO, writes about the difficulty in understanding the plain meaning of the enabling laws.

James Madison warned in the Federalist Papers about laws "so voluminous that they cannot be read, or so incoherent that they cannot be understood."

If only he had lived to see the Medicare and Medicaid programs.

via Here's a Funny Idea: Medicare Laws That Are Easy to Read –

As goes Florida so does Kansas.

Medicaid in Kansas has grown by 7.4% annually over the last decade, and Mr. Brownback would reform it by contracting with managed-care organizations to oversee and coordinate care. His plan would also provide monetary incentives for insurers and providers to improve quality and use health-care dollars more economically.But heres the rub. To execute most of these Medicaid changes, Mr. Brownback needs Health and Human Services Secretary Kathleen Sebelius to issue a global waiver, which frees the state from most Washington strictures in return for a cap on federal funding. George W. Bush granted Rhode Island a global waiver that has had excellent results, but Ms. Sebelius is a former Kansas Governor and may not want to give her party rival the power to succeed.

via Review & Outlook: Whats Right With Kansas –

What’s it show? It’s the hospitals — the hospitals that are behind the unchecked growth in state Medicaid spending, even though their rates have been cut and they’ve cried “crisis” year after year.

Florida’s one of only 10 or 11 states that pays hospitals a per-diem rate rather than a per-service rate. The hospitals themselves must submit cost reports to the state Agency for Healthcare Administration, and each hospital’s per-deim rate is set according to a complex formula.”

What’s behind Florida’s Medicaid spending surge: It’s the hospitals | On Call with Stacey Singer.

[Gov.] Scott said the reimbursement “adjustment” would create a flat rate for hospital groups using average costs. “No program has grown as fast and as much as Medicaid, and we must find a way to control the cost. If we do nothing, this program will bankrupt our state,”

via Florida plans to slash Medicaid funds ahead of health reform | Government Health IT.

In the Gainsville Sun Attorney Anne Swerlick writes “The Florida Legislature has an opportunity to address these problems. The state pays billions of dollars to mostly private-for-profit HMOs to care for some of the most vulnerable Floridians. It is imperative that these health plans provide Medicaid patients, their physicians and the public a transparent process by which health care decisions are made. This is especially important now as more Medicaid patients will be required to enroll in HMOs and other managed care plans.”

via Anne Swerlick: Will the Legislature protect Florida’s most vulnerable? |

RCPALM Editorial Page points out ‘Here’s what is particularly insidious about the Legislature’s proposed cuts to Medicaid: At the same time Florida lawmakers are planning to reduce vital health care services for hundreds of thousands of state residents, both chambers have approved state budgets that continue to offer overly generous health insurance premiums for high-ranking state officials. The governor, lawmakers and other powerful elites would remain eligible for health insurance premiums at significantly reduced rates — $8.34 a month for single coverage; $30 a month for family coverage. (By contrast, rank-and-file state employees pay $50 a month for single coverage and $180 for family coverage.)”

via Editorial: Florida Legislature’s proposed cuts to Medicaid too draconian; stakeholders must find reasonable solution »

Fred Grimm in the Miami Herald writes “If the Senate version prevails over a less Draconian appropriation in the House, 34 percent of the mental health funding, and 25.5 percent of the money for substance abuse, would disappear. Some 140,000 patients would be tossed from their community treatment programs. A number of these non-profit programs would shut down. (Even without the Negron cuts, the Department of Children & Families has admitted that it hasn’t been able to provide services to 170,000 adults and 40,000 children with serious mental illnesses.)”

via Commentary: Florida, this is insanity – Sacramento Living – Sacramento Food and Wine, Home, Health | Sacramento Bee.

My research has always revealed that health care follows the money. So I was not surprised that the Insurance Company industry is profiting from the Health Law Mandate.  This is not a “bad profit” if coverage has high quality of care and high quality of life.

Bloomberg reports

The industry that was the loudest, most persistent critic of this law, the industry whose analysts and executives predicted it would suffer immensely because of the law, has thrived,” Gosselin said. “There is a shift to government work under way that is going to represent a fundamental change in their business model.

Panel Wrestles with Federal Rules for Health Funding
“The issue centers on a $1-billion-a-year program known as the Low Income Pool, which sends extra money to hospitals and other providers statewide that care for large numbers of poor and uninsured patients. The so-called “LIP” program was created as part of the pilot, which is controversial primarily because it requires most Medicaid beneficiaries in five counties to enroll in managed-care plans.

Federal officials agreed in December to extend the pilot through June 2014 but placed strings on how $50 million of the LIP money could be used. Those strings call for taking money that otherwise could go toward hospital services and requiring that it be spent on new or beefed-up programs to improve quality of care.”

CNN is reporting that  with Medicare reforms Doctors are going broke.  As a counter point, accountable care organizations start this month, Doctors may seek shelter in these practices. ACO may offer more compensation to those providers if they can keep patients  from needing expensive care.  This is part of great effort to rewrite our social contract of care. If all the doctors roll into ACOs and this approach fails then we will start to head in a single provider system.  We will need to keep an eye on this.

Health Care Reform has been attempted by seven presidents.  Obama’s administration with the Affordable Care Act, has put forth meaningful change. Even it’s detractors will state that it is legislation that is significant and can’t be ignored.  There is strong argument that this is a mixed public policy debate on how to spend limited resources and survive in the political arena.

Whoever provides medical care or pays the costs of illness stands to gain the good will of the sick and their families. The prospect of these good-will returns to investment in health care creates a powerful motive for governments to intervene in the economics of medicine. Political leaders since Bismarck . . . have used insurance against the costs of sickness as a means of turning benevolence to power. Similarly, employers often furnish medical care to recruit new workers and instill loyalty to the firm. Unions have used the same means to strengthen solidarity. To be the intermediary in the costs of sickness is a strategic role that confers social and political as well as strictly economic gains. Paul Starr, The Social Transformation of Medicine

The quote above is a bit stale in today’s marketplace of medicine. Health Care services will always follow the streams of payment from whatever sources are available.  With state governments unable to afford federal matching funds for entitlement programs the infrastructure of our community’s health care structure is truly at risk.

As the true cost of this health care infrastructure becomes more of a local government issue, limited funding may cause consolidation at the Hospital Level. Special Taxing Districts may increase to fund Hospitals.  As the debate becomes more local a closer look a medical outcomes and cost of care will be fought at our doorsteps. We need to be watchful of this issue.

In the Tampa Bay Times, Sue Brody the CEO of Bayfront Health System, has written an excellent editorial on health care reform. She states, “health care is experiencing a paradigm shift unrivaled in the last 25 years.”   According to Ms Brody providers have a tough mandate from the community and the government.  While noting that “providers are re-engineering processes to make way for increased access and improved quality at lower costs”, she warns of risks to the community’s quality of care due to drastic cuts from the state budget.  Large amounts of government money provide the funding for the poor who need specialized medical care.  This enables private insurance and their insureds to access medical specialist at their local hospital who were made available due to Medicaid funding. click here

Michael Porter a Harvard professor on strategy looked at Health Care financial waste and suggested that only a few centers of excellence exist and redundant facilities of care be closed.  There are more choices in the public debate, but we need to keep our eyes on this one.

On March 23, 2011, Governor Rick Scott established a commission to review whether government-run hospitals are in the best interest of taxpayers. He was motivated by a Florida Tax Watch report. This report show the rapid growth in hospital special taxing districts to pay for indigent care.

The Commissions draft report does highlight how concerned hospitals are over the medicaid reform approach the state is taking. The report did not suggest that public hospitals are not in Florida’s best interest.  Here is the pull quote from the report. It

The Legislature has also established timeframes for the Medicaid program to move to managed care for the vast majority of its recipients. This is to be completed for the individuals receiving Medicaid long term care services beginning July 1, 2012 and completed by October 1, 2013; and for Medical services by October 1, 2014—Implementation begins January 1, 2013.

In a managed care environment, health plans and hospitals will negotiate a rate. They are not tied to the Medicaid rate, but the Medicaid rate is normally used in the negotiations as a reference or starting point. Sometimes, it ends up being the negotiated rate. If the state moves to DRGs, questions will occur as to how this may affect the health plans/hospital negotiation and establishment of a rate, as well as how local contributions may be affected.

Health plans will be required to contract with “essential providers” that offer services that are not available from any other provider within a reasonable access standard. Statutory teaching hospitals, hospitals that are trauma centers, hospitals located at least 25 miles from any other hospital will be included in this group.
It will be essential that managed care companies selected by AHCA in the competitive procurement process for the new managed care programs receive a fair portion in the capitation payment for the cells that represent the hospital component for each individual. Providing a system where managed care companies and hospitals receive fair compensation is a major challenge that will need continued monitoring and development by the Agency and the Legislature. It has been a somewhat contentious battle between hospitals and managed care companies surrounding the rate issues. Hospital rate increases should not be implemented without coordination of the managed care rate for the new program to be a success.

Taking both reports together, it would seem likely that property taxes may increase to fund local indigent care in the public hospitals.  Keep an eye on this issue.

Politifact 2011 Lie of the Year.

When the journalist becomes the story, critics will state the myth of objectivity is exposed.  Politifact named the Lie of the Year Democrats claim of the end of Medicare. However, the program called Medicare will continue. For the Baby Boomers, however Medicare will be nothing like it is today. For a nuanced view, take a look at the NPR posting on the issue. Click Here

Watch carefully as the social contract for care changes to reflect the decision that our great society can not afford the health care we made available to our parents. Personal responsibility will be one of the main terms of the new social contract.  Phrases like “skin in the game” and “medical loss ratio’s”
will cause major shifts in political debate.  Social Media tools will also be exploited.  Fear and extreme examples will define the edges of the debate. 

Contrast with

Keep your eyes on the spin factor as the fallout of CMS approval of Florida’s Medicaid Waiver expands.  The Heritage Foundation post on Medicaid Reform shows how the politics of reform can be hyped.

Florida’s Medicaid Reform Pilot is pro-patient and pro-taxpayer, and the Obama Administration agrees. ….The Florida reforms work by giving patients a choice of the private health plan that works best for them. Enrollees can choose from plans with varied benefits and provider networks, and a monetary rewards system creates incentives for healthy, responsible behavior. By shifting away from failed policies of central planning toward a consumer-driven program, the program has been successful on a number of levels.

Compare and contrast to Floirda CHAIN. Florida CHAIN is a statewide consumer health advocacy organization.

“The message sent today by the Administration is clear: insurance companies will be held accountable and there’s no way around it. The decision by HHS sends a strong message that the important consumer protections in the ACA can’t be stripped away, regardless of maneuvers by insurers to boost profits or by state leaders to push a political agenda. “Individuals and families in Florida are expected to gain up to an additional $70 million in health insurance rebates, which is anticipated to be paid out by August 2012. We are thrilled to be able to report this huge victory for the hard-working people of Florida, who stand to gain money saved in their health care premiums and peace of mind that they’re health care dollars are being spent to keep them healthy.” click here for full report

Insight can be gained on the Obama Administration response itself.  As Forbes reports:

The Department of Health and Human Services has denied the State of Florida’s request that they be permitted a waiver to the medical loss ratio requirements of the Affordable Care Act.

Rather than live with the 80 to 85 percent requirements established by the health care reform law, Florida had asked for an adjustment that would allow insurers to meet the signficantly lower thresholds of 68 percent in 2011, 72 percent in 2012 and 76 percent in 2013. Click Here for full report

So as the groundwork of private insurance for medicaid patients is established in the state of Floirda, all parties are fighting for how much profit can be in the system to administer the program and adjust to the risk of utilization of services.  If private insurance can in fact step up and provide mandated services in a more efficient manner, they will be fighting a steady retraction of funding per patient as the Baby Booms start into the long term care system.  With limited financial reward for improvement, then it stops being true insurance and becomes “dollar trading”. Dollar Trading will result in significant limits in profitability and shareholder value.  The public policy debate will continue to twist the politics of Medicaid Reform.

For those clients seeking Medicaid at this time, the value of good advice can be very helpful.  Understanding the changing landscape of care and how families will be asked to contribute more financially is a radical shift from the Medicaid of the past.  With proper planning clients can have more choices and a better understanding how the system works. Once the impact to famlies is understood a more nuanced discussion can take place.  Until then, more shouting from both sides is needed to create well thought out solution to Long Term Care.

Pull full article from the Floirda CHAIN website:

Greg Mellowe, has an expansive post explaining the extension of Florida’s Medicaid Reform Experiment.  Although the posting is broader than just senior issues, to is one of the clearest statements of the current Medicaid Reform. A few of the points raised in the agreement between CMS and the State of Florida are below.

* Obtain federal approval for any type of expansion of Medicaid managed care beyond the five Pilot counties. Florida has such a request pending at this time.

* Spend at least 85% of taxpayer-funded Medicaid payments on direct patient care or direct care quality improvement activities.

* Set a well-defined minimum standard for plans to provide Medicaid benefits that meet the needs of at least 98.5% of enrollees. Plans may not reduce benefit levels below this minimum standard.

* Prevent disruptions in patient care, particularly those caused by plans in the past. Florida must take steps to prevent plans from pulling out of any geographic area. The State must also use a detailed procedure to ensure continuity of care for patients when they’re forced to change plans.

* Hold managed care plans more accountable to ensure access to and quality of care.

– must set, justify, and enforce standards for plans, including standards for provider network adequacy and access to care.
– must ensure that the patient-level “encounter data” that has been promised for more than five years is collected, analyzed, and used to monitor health care access and quality.
– must receive federal approval of any process used to select and negotiate with managed care plans as well as plan contract documents.

* Allow most recipients who do not have a choice of at least two managed care plans to enroll in the MediPass program (or regular fee-for-service Medicaid).

* Improve its choice counseling efforts, not reduce them. Florida must not only continue its choice counseling activities to help patients make informed choices, the State must also perform activities that were supposed to have been doing since 2006, including increasing health literacy and reducing minority health disparities through outreach. Choice counseling must also use a plan rating system.

* Apply the same rules for determining eligibility and requiring co-payments in any Medicaid managed care experiment that apply elsewhere in Medicaid. The State cannot use the flexibility of the Medicaid waiver to jack up co-pays, demand payment of premiums, or restrict who can qualify for Medicaid. In other words, the State cannot use the waiver to evade the basic protections of Medicaid.

The Wall Street Journal, today, states on its editorial page the definite and imperative need for Medicare reform in one sentence. “The brutal math is that Medicare spending has been growing about three percentage points faster every year than the overall economy for the last quarter-century and is now the main driver of the financial crisis.”  Legislative leadership is shifting to a stipend approach.  This may cap the Federal Government’s financial exposure.  With a stipend one often finds not enough payment to cover the choice you prefer. 

How will Health Care marketplace respond to this change of focus? How will consumer directed care be better served?

These questions and many others will reframe the debate about health care entitlements.  It is probably time to reframe the debate, the boomers are not their parents elders.  Choices and alternatives to traditional long term care approaches are desired by the boomers.  Life style and personal preferences are key to the boomers making these choices.  As the role of the patient changes into a health care consumer the market place and pricing for care will respond.  The Boomer who desires to create a supportive care environment that does not financial exhaust may find satisfaction with the flexibility that a market driven choice could provide.

Keep you eyes on the ball, the politics of Medicare is an interesting game.

Medicaid pays for 75% of total Nursing Home Care costs through the Institutional Care Program. The State of Florida pays only 35.17% of this expense, the balance is paid for by the Federal Government. The 35.17% share of cost, however, has become one of the most expensive items in the state budget.

Lawmakers in the state have demanded a cap of future growth in Medicaid budget despite decades of annual increases.  The State of Florida also seeks to control not only its Medicaid Nursing Home costs but its total share of cost for Medicaid Care in the Community.

In the past Florida received a small amount of funding under a program called Money Follows the Person.  The Federal Government was offering a federal grant of $35.7 million to enlarge choices other than nursing home for frail elders.  Despite work by several state agencies and disability support groups, Florida will not receive a federal grant of $35.7 million. 

“Not only would accepting the Money Follows the Person grant go against our policy of implementing federal health-care reform, but it would be redundant to the multiple efforts that Florida has already made to improve the delivery of long-term care,” said Rep. Denise Grimsley, R-Sebring, chairwoman of the state’s House Appropriations Committee. Source Orlando Sentinel

This is reminds me of the book Whats the Matter with Kansas. . The federal grant would have only cost the state $627,963. $35.7 million would have created a lot of jobs and services that would have been delivered to the citizens of Florida. This was done to consolidate all efforts into the medicaid reform waiver. 

A key aspect of the medicaid reform waiver is to incentivize insurance companies to manage the care of all florida nursing home residents and those seniors in the community on medicaid. Profits for the insurance companies will also result in a huge savings for the state. As the boomers reach out for nursing home care, other choices may be available, that do not fall under a government entitlement.  This will result in more personal responsibility within the extended family.

So Floridians will not have a slow exodus from Nursing Home Care. It will be a dramatic change resulting in nursing home care for those who need only the most acute care.

Jack M. Rosenkranz

The Rosenkranz Law Firm has sought to shift Vets from Medicaid to the VA health care system for almost 15 years.  In a rare press release on the topic Kaiser Health News reports:

“It is commonly accepted that many poor veterans and their families find themselves on Medicaid, even though, in many cases, they would qualify for more generous benefits from the Department of Veterans Affairs.

The VA’s Aid and Attendance program, for instance, helps wartime veterans receive the care they need to stay in their homes or assist with long-term care expenses. But many who are entitled to this benefit end up on Medicaid — which has significant implications for the veteran’s family members.

In 2003, the state of Washington began a pilot program to identify veterans who were falling through the cracks. In the years since, the program has served thousands of people who qualified for this assistance. At the same time, it has helped relieve some of the fiscal pressure placed on the state’s Medicaid program by shifting these costs to the federal VA. Viewed as a win-win, the program has become a model for other states.

KHN asked two state officials invovled in the program’s operations to explain the basics of the Veterans Benefit Enhancement Project — how it came to be and why it is making a difference for both the state’s veterans and its budget. Commentaries follow from Bill Allman, who developed and now manages the Washington State Health Care Authority’s program, and from Alex Deluao of the Washington State Department of Veterans Affairs.

How PARIS Is Helping Veterans In Need

Bill Allman writes: “About 10 years ago, I first heard about a federal databank called PARIS — the Public Assistance Reporting Information System. … Astonishingly, a broader use of such a databank had gone unrealized until I started asking questions, particularly about the military and veteran program information available to the states. With my background in medical assistance for the state of Washington, I was well aware of the fact that many poor veterans and their families were winding up on the rolls of Medicaid, never realizing that they might also be eligible for richer federal benefits.”

For more information click here

From an extensive report by Families USA:

“Medicaid makes it possible for Floridians to get the care they need. People with Medicaid have better access to health care than do the uninsured. A recent study that used a randomized, controlled design—the gold standard in medical research—found that, compared to the uninsured, people with Medicaid had better access to outpatient and hospital care and prescription drugs. They were also more likely to have a regular source of care.  For people with serious health care needs, having access to care and having a regular source of care can improve health and lower rates of costly, and sometimes deadly, complications, or it can keep a disease from progressing.”

For the full report.

This headline ran over a Wall Street Journal article about rationing of health care in Canada.  It offers a sad outlook if the US Health Care System follows the Canadian “Too Old for Hip Surgery” model.  Preventive care will be the focus of the future.  Quality of Life depends on having a supportive and conscientious environment within which to age.  Recognizing the risks in the American system, scholars and policymakers have begun to differentiate between the fundamental causes of healthcare disparities – access, education, poverty – and patient level disparities.  Scholars Peter Franks, MD and Kevin Fiscella, MD use the term “downstream reforms” in an effort to describe the disparities that occur at the patient level.  In the January 2008 edition of The Journal of Internal General Medicine, they highlight downstream reforms that are important to improving the health care for the chronically ill. 
These Doctors argue that disparities can be addressed by examining both the provider-patient interaction and the manner in which clinical decisions are made.  Much of their discussion centers on what individual doctors and patients can do to change their own biases and actions.  The Baby Boomers are moving to individualize health care where personal preferences, desires and comfort are often just as important as clinical factors.
Until widespread reforms are made that affect physician and clinical decision-making, elders and their families will need to implement their own downstream reforms through self-education and advocacy to improve care and prevent disparities.  The Rosenrkanz law firm may be able to help build a supportive care environment that does not financially exhaust the family.

Friday, June 03, 2005
Highlights From The First Rosenkranz Report
Welcome to! I hope you have all had a wonderful memorial day weekend.

When the Jeb Bush released his plans to alter Medicaid in the up and coming year, I took action. I consumed a tremendous amount of time researching the governor’s plans, alternatives, the key players involved, and all articles that had been released on the subject in the year before the governors first official release. We have seen a tremendous amount of political activity in Tallahassee since that first release in January. I have followed these events with cautious optimism. I have released a series of reports over the last six months entitled, “The Rosenkranz Report.” I am posting some highlights from the first Rosenkranz Report, and will publish them in their entirety on this web site in the months to come. Thanks!


In his continued effort to support the elderly of the great state of Florida, Jack Rosenkranz of Rosenkranz Law firm has come across information that is of unparalleled importance to you. In early January of 2005, Governor Jeb Bush (R-Florida) released a proposal for overhauling Medicaid. He is calling for many changes to the system that will greatly affect everyone who has a stake in the future of Medicaid.

The wheels are already turning. A joint committee on Medicaid reform composed of some thirty Senators and Medicaid experts toured Florida taking public suggestions for changing the system. It has become evident that something needs to change: at the current rate of growth, Medicaid spending will consume more than 60% of all spending by the State of Florida. Lawmakers are not going to allow this to happen. There are other important programs that also require money: education, safety, highways and roads, just to name a few. Medicaid currently costs more per year than any of these programs.

So what is going to change? Governor Jeb Bush has proposed dramatic alteration to the system. To summarize: if the governors original plan passed today, people on Medicaid would be assigned a counselor to help them pick the type of health care they want. Recipients would then be given money to help them purchase private insurance. Some sort of co-pay structure would likely be involved. This proposal assumes that the majority of Medicaid recipients will participate and have the ability to make good choices about their medical care. Jack Rosenkranz believes, after years of experience working with the elderly, that many people will be intimidated by the system and not use it at all. He is also concerned about elderly people with dementia and other cognitive impairments. How would these people be protected to ensure that they are not overlooked by the system?

Rules of eligibility to obtain Medicaid benefits are being challenged and reworked to drastically altering the look back times to obtain benefits. Some proposed changes would remove two of the three tests for determining eligibility and rely totally on household income. The new system would also factor in a portion of assets for determining eligibility. Basically, the higher a persons combined income/asset level is, the less likely they will be to qualify. Removing the Medicaid annuity is also being proposed, which will reduce benefits for some people.

Yet another proposal suggests creating a Medicaid HMO; a model that many of you are familiar with from experiences with Medicare HMO’s. This would undoubtedly bring about the same cumbersome aspects of accessing medical care and obtaining prescription coverage Medicare recipients experience. Recipients will have to travel from doctor to doctor to get specific types of care and deal with the limits associated with insurers making medical decisions. This is just one option that has been looked at.

The most disturbing aspect of the governors proposal involves giving recipients the chance to obtain coverage rather than entitlement to coverage. Basically, having entitlement gives a person a legal right to the money allotted by Medicaid. If you have the opportunity to obtain coverage and the funding is not there, you would be out of luck. You could not sue to get the money because you would not be entitled to it. Entitlement also ensures that medical facilities get paid. Without entitlement, businesses would have no legal recourse and many would become insolvent in a short time.

Jack Rosenkranz is following these proposals with cautious optimism. None of these things has happened yet. Legislators are still in the planning process. So what does this mean to you? Medicaid is going to be overhauled in the next year to eighteen months. Florida lawmakers are going to take action to change Medicaid. What will change and to what degree remains to be seen.

posted by Jack Rosenkranz @ 6:48 AM

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