Medicaid Reform

Research & Thoughts

With the multi-billion-dollar, four-month enroll-a-thon for Florida’s Statewide Medicaid Managed Care program now complete, totals show WellCare Health Plans still on top.  The Tampa company’s Staywell plan now has more than 600,000 Florida Medicaid members. That’s 23 percent of the state’s roughly 3.3 million residents with Medicaid coverage, according to calculations by Citigroup Global Markets’ analyst Carl McDonald.

via WellCare, Centene Medicaid Winners | Health News Florida.

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 |

Crist said, “Expanding Medicaid would create 63k jobs.”

A study released by the White House said federal dollars that Florida would have gotten to expand Medicaid would create 63,800 jobs between 2014 and 2017.

Most of the health care experts we interviewed agreed that injecting billions of federal dollars into Florida for Medicaid would spark some job growth, but it’s difficult to pinpoint a number, particularly as there are other changes in the health care landscape. Other studies have found numbers as high as 120,000 and as low as 10,000.

We rate this claim Half True.

via By not expanding Medicaid, Florida is missing out on 63,800 jobs, Charlie Crist says | PolitiFact Florida.

Mental illness is a big driver of Medicaid costs because it is twice as prevalent among beneficiaries of the public insurance program for the poor as it is among the general population. Studies show that enrollees with mental illness, who also have chronic physical conditions, account for a large share of Medicaid spending.Yet many Medicaid programs, including Florida’s, have traditionally contracted with separate companies to provide coverage for mental health services, making coordination more difficult. “We don’t want to have a situation where your brain is in one HMO, your teeth are in a second HMO and your eyes are in a third HMO,” said Florida Medicaid Director Justin Senior. “Your whole head should be in the same organization and that is why we have done this reorganization.”About 140,000 low-income Floridians are expected to be eligible and Magellan predicts about 20,000 will participate voluntarily in the first year.  Medicaid recipients who meet the plan’s criteria will automatically be assigned to it by the state, though they have the option to switch to a different managed care plan within 90 days of enrollment.Coverage begins July 1 in Miami-Dade and Broward counties, then will roll out to other regions by September.

via Florida Shifts Medicaid Mental Health Strategy – Kaiser Health News.

The new funding formula was a little-known part of Florida’s 2011 Medicaid reform law, a Republican-driven overhaul of the state and federal insurance program for the poor.

The provision was intended to make the distribution of an estimated $1 billion a year in federal Medicaid matching funds more equitable. But its unintended consequences are now becoming clear, as the funding mechanism known as “tiering” is scheduled to take effect.

Hardest hit are hospitals that serve large numbers of uninsured and Medicaid patients, and counties such as Miami-Dade that put their own residents’ tax dollars toward Medicaid. Those local dollars are matched by federal funds.

via TALLAHASSEE: Jackson Memorial Hospital expected to lose $140 million under new Medicaid law – Miami-Dade –

Bloomberg News talks about how the Affordable Care Act impacts Medicaid Hospital Grants.  Without adoption of the Affordable Care Act Hospitals in states such as Florida will not have access to federal grants to pay for those who can not pay.  States like Florida are at major risk of small rural hospitals closing. However few citizens are aware of the mighty impact this well have on large urban hospitals.  In the future services will be limited for those without insurance coverage.

Take a look at the cite below.

Obamacare Cutbacks Shut Hospitals Where Medicaid Went Unexpanded

via Obamacare Cutbacks Shut Hospitals Where Medicaid Went Unexpanded – Bloomberg.


Book review: ‘Reinventing American Health Care’ by Ezekiel Emanuel

By Amanda Bennett, Published: March 14

Amanda Bennett is the author of “The Cost of Hope,” about her late husband’s journey through the health-care maze.

Early in his new book, “Reinventing American Health Care,” Ezekiel Emanuel pictures the late senator Arlen Specter (Pa.) holding up an incomprehensible chart of the U.S. health-care system — in 1993. What Emanuel calls the “interconnected weirdness” of our health-care system has only gotten weirder since.

Yet what he does is enormously helpful: He sorts it all out and gives us a clear and straightforward accounting of a system that is anything but. Emanuel starts at the beginning (1790, to be exact) and progresses logically to the present, through the development, political wrangling and legal journey of the Affordable Care Act (ACA). Then he hurtles into cheerily optimistic projections about the future — perhaps more than a tad more optimistic than his own accounting of the past would warrant.

His review of how our health-care system got this way is a depressing reminder of forces that have little to do with health care and nothing to do with health. How did hospitals become so dominant? How did the Depression lead to the spread of health insurance? How did World War II price controls help lock health insurance to employment? And what do tax breaks have to do with it?

Quick: What’s the biggest single tax break in the United States? Tax-free health benefits, nearly four times as large ($250 billion) as the mortgage interest deduction ($70 billion). With employers able to offer health insurance to employees free of tax, the benefits became an increasingly important part of pay over the years. Getting rid of that deduction, Emanuel makes clear, is one fix that he regrets was left out of the new health-care law.

Despite this and other critiques of the legislation, it’s clear that he’s a wildly enthusiastic fan. Consider his view that “beginning in 2020 or so, the ACA will increasingly be seen as a world historical achievement, even more important for the United States than Social Security and Medicare has been. And Barack Obama will be viewed more like Harry Truman — judged with increasing respect over time.” Wow. His logic is that by 2020, the law and its effects will arrest health-care inflation to simply match the rise in gross domestic product, instead of the recent rate of two percentage points above the annual increase that has rocketed costs to nearly 18 percent of GDP today. That would indeed be a major accomplishment.

Emanuel is no dispassionate outsider. A professor of medical ethics and health policy at the University of Pennsylvania, he was a special adviser to the White House on health-care reform and worked directly on the Affordable Care Act. He also peppers his story with accounts of expletive-laden exchanges with his brother Rahm, current mayor of Chicago and former Obama White House chief of staff.

In 2009 and 2010, Ezekiel Emanuel was labeled “Dr. Death” after Michele Bachmann and Sarah Palin, among others, twisted his medical ethics work to conclude that he favored withholding health care from the disabled and advocated “death panels.” That’s sheer nonsense.

Whether you agree with his conclusions or not, they’re well argued, and he has marshaled an impressive amount of information. Some of the simplest facts bear repeating. For example, how vulnerable every one of us was before passage of the health-care law: More than half of us got health insurance through our jobs. But three-quarters of the uninsured were in households with at least one paycheck, and nearly one in 10 uninsured households brought in more than $94,000 a year. It wasn’t just money that kept some people from having health-care coverage, it was also access. For some, their jobs didn’t provide insurance. And yet others were rejected, ironically, because they were too sick.

Emanuel also reminds us that there is much more to the Affordable Care Act than the troubled insurance exchanges. There are targets to induce hospitals to lower infection rates, incentives to adopt electronic medical records, rules for better pricing transparency (a current nightmare!) and more complete data on hospital safety and outcomes, and better access to free preventative services such as immunizations and mental health screenings.

Where Emanuel goes off the rails is in extrapolating from these provisions of the law a vastly different future. He posits the end not only of health-care inflation but also of medical insurance as we know it. He sees employers ceding their roles as providers of access to health care, technology replacing costly hospital stays and specialists, hospitals closing in large numbers, and the remaining ones becoming safer and more efficient.

That’s wishful thinking. His own very persuasive review of history shows how exterior forces — and grabs for dollars — have thwarted and distorted sensible plans.

Look at the advertising in the D.C. Metro opposing cuts to hospital funding to see how rocky the path to hospital closings will be. Check out the sad fate of a Maryland nonprofit start-up, the faltering Evergreen Health Co-op, for a view of how hard it will be to create alternatives to traditional care. Anyone who has ever been part of a technology changeover anywhere can imagine what it will take to link the whole messy U.S. health-care system electronically. And consider the travails of 23andMe, a genetics company whose medical service was shut down by the Food and Drug Administration, for an example of how difficult it will be for newcomers to break into spaces that others own.

The nightmarish launch of the health-care exchanges alone should be enough to convince anyone that just because something is in a law doesn’t mean it will happen. At least not exactly the way it was planned. Or as Bob Kocher, another Obama health-care adviser, was recently quoted as saying, “It is actually harder to do some of these things in reality than we thought when we put it down on paper.”


Amanda Bennett is the author of “The Cost of Hope,” about her late husband’s journey through the health-care maze.

REINVENTING AMERICAN HEALTH CARE How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System By Ezekiel J. Emanuel PublicAffairs. 380 pp. $26.99

States Accelerate Shift Of Nursing Home Residents Into Medicaid Managed Care – Kaiser Health News.

By Jack Rosenkranz

Kaiser Health News reports that ” States had traditionally been reluctant to place frail and elderly people into managed care. But that caution is fading as officials become comfortable with managed care and more anxious to curb Medicaid spending.”

The State of Florida has mandated a limit to its Medicaid spending.  They are hoping that a managed care approach will support elders to stay at home or seek less expensive care rather that nursing home.

Kaiser Health News calls this an ‘Unprecedented’ Shift

The State of Florida approach is a massive change.

The report continues:

“The mandatory transition of large numbers of consumers who use long-term care … is unprecedented,” says Laura Summer, an analyst with the Georgetown University’s Health Policy Institute.

The shift has consumer advocates and nursing home operators worried, especially since Medicaid pays the bills for nearly two thirds of nursing home residents nationwide. 

“It throws a monkey wrench in the equation to get care issues resolved quickly,” says Brian Lee, executive director of Families for Better Care, a patient advocacy group in Tallahassee.

Nursing homes are concerned about losing residents, money and autonomy. “We are not anti-managed care,” says Mike Cheek, a vice president with the American Health Care Association. But he worries the plans will delay payments and that states won’t have the capability to properly oversee them.

Review the report by clicking on the link above

As I contunue to study the Medicaid Reform,  I think there is a loss of understanding that  Provider Service Networks  are provider owned rather than an insurance company. The report states: Earlier studies by the same group did not discover “the relatively large savings” found in the new report, which was published in a health policy journal, Health Research and Educational Trust. The UF team noted  that it appears to take several years before such changes start to show. Earlier studies had less data they could use for analysis. The new study also provides good news for those who run Provider Service Networks (PSNs) – non-profit organizations that are owned by doctor groups or other health-care providers, rather than an insurer. via Medicaid ‘Reform’ Pays Off: Study | Health News Florida.

AP  Reports.

Results from a study of Florida’s Medicaid Reform Pilot Project show that provider service networks, which the state intends to implement this year throughout the state, control costs better than traditional Medicaid.

PSNs, like HMOs, or health maintenance organizations, are managed care companies that coordinate patient care. HMOs deliver care through contracts with provider organizations such as hospitals, while PSNs are directly organized by providers.

The idea of both is to guide, and ideally streamline, patients’ care without sending them to expensive specialists unnecessarily, explained Paul Duncan, one of the study authors and a University of Florida professor in the College of Public Health and HealthProfessions and the director of the Florida Center for Medicaid and the Uninsured.

via New study: Florida’s networks control health costs better than Medicaid – Health – The News Herald.

April 8, 2013

Be Fruitful and Simplify!



Conquering the Crisis of Complexity

By Alan Siegel and Irene Etzkorn

Illustrated. 237 pages. Twelve. $26.99.


The Future of Government

By Cass R. Sunstein

Illustrated. 260 pages. Simon & Schuster. $26.


Less is more. The bare essentials. Back to basics. User-friendly. No fine print. Clutter-free. Transparent. Clean. Easy.

Back in the mid-19th century Henry David Thoreau exhorted us to “simplify, simplify,” and his appeal to distill things down to “the necessary and the real” has only gained more resonance, as our Internet-driven, A.D.D. culture has grown ever more complex and frenetic.

The re-embrace of simplicity is not exactly new. In the 1990s some neo-hippies and fed-up yuppies took up the idea of Voluntary Simplicity, Downshifting or Simple Living. In 2000 the commercial possibilities of this trend were ratified with Time Inc.’s introduction of the magazine “Real Simple,” and in 2005 Staples started promoting itself with an “Easy Button.”

Two tech behemoths are completely identified with their minimalist design styles: Apple, with its coolly modernist iPods, iPads and MacBooks; and Google, with its distinctive, pared-down home page, which has become synonymous with its brand. Now come two new books that are part manifestoes, part templates for achieving simplicity in business and government. Both display a lot of common sense, arguing for the elimination of bureaucracy and redundancy and insisting that consumers (of health care, insurance, credit and products large and small) deserve more transparency. But both also sidestep some of the difficulties involved in reducing or containing complexity in today’s lawyered-up and interconnected society.

Simple,” by two business consultants, Alan Siegel and Irene Etzkorn, is a straightforward brief on simplicity, providing the reader with interesting examples of companies that have successfully embraced it as a business strategy while only occasionally slipping into overly simplistic advice. (“Simplification requires a thorough and pervasive commitment by an organization to empathize, distill and clarify.”)

Simpler,” by Cass R. Sunstein — who as the administrator of the White House Office of Information and Regulatory Affairs from 2009 to 2012 helped “oversee the issuance of nearly 2,000 rules from federal agencies” — is a more detailed, more nuanced look at how rules and regulations can be made simpler, and how the social environment in which we make decisions can be “nudged” in ways that help us to make more rational, sensible choices. Many of the more original and illuminating ideas in this book, however, were previously mapped out by Mr. Sunstein and Richard H. Thaler in their fascinating 2008 best seller “Nudge: Improving Decisions About Health, Wealth and Happiness,” or build upon the groundbreaking ideas laid out by Daniel Kahneman in his compelling 2011 book “Thinking, Fast and Slow.”

Both “Simple” and “Simpler” stress the importance of understandable language. Mr. Sunstein writes that he pushed for “the use of plain language, reductions in red tape, readable summaries of complex rules, and the elimination of costly, unjustified requirements.”

Both books also emphasize that more information does not necessarily mean more clarity, that disclosure, as Mr. Sunstein puts it, “must be not merely technically accurate but also simple, meaningful, and helpful.”

Mr. Siegel and Ms. Etzkorn cite a study showing that half of the gadgets returned to stores (and the cost of returned products in America, they estimate, is some $100 billion a year) are “in good working order, but customers can’t figure out how to operate them.” The authors also mention a study showing that “80 percent of child safety seats are improperly installed or misused and the instructions for installing them are the root of the problem.”

Needless to say, identifying such problems hardly equals finding a plausible solution. Ms. Etzkorn and Mr. Siegel point out that “banks, credit card companies, insurers and other types of businesses find ways to make money from the fine print nobody can read or understand,” and that “lawyers have inundated us with mind-numbing disclaimers, disclosures, terms, instructions, amendments and amendments to amendments” to “avoid lawsuits or other potential problems.”

We are reminded of the challenges of simplifying the federal government by the fact that the United States tax code, according to Mr. Siegel and Ms. Etzkorn, has “nearly tripled in volume during the last decade” to 3.8 million words. And CNN recently reported that the Veterans Affairs Department has almost 630,000 benefit claims that have been pending for more than 125 days, because of an outdated paper-based process and the complexities of returning veterans’ cases.

Government simplification, Mr. Siegel and Ms. Etzkorn argue, requires many of the same things needed to simplify businesses: “strong leadership, clarity of purpose” and a culture “that prizes openness, empathy, and innovation.” In New York City, they write, “Mayor Michael Bloomberg has demonstrated that it’s possible to radically simplify the way one of the largest cities in the world communicates with its residents.” Back in 2003 pages and pages of listings in the city directory were replaced with one phone number, 311, to cover a wide range of complaints and questions (in the authors’ words, “everything from leaking fire hydrants to gaping potholes”).

In “Simpler” Mr. Sunstein puts a lot of emphasis on the utility of “nudges”: approaches, based on how human beings act and think, that “influence decisions while preserving freedom of choice”: for example arranging items in a grocery store so that healthy foods are conspicuous, letting voters know on the day of an election exactly how to get to the polls or working with the private sector to discourage texting while driving.

Some of the nudges Mr. Sunstein mentions here are really default rules, which, he says, can have a huge effect on outcomes (in part because of inertia, in part because people see an implicit endorsement in a default choice). Take for instance a default rule that automatically enrolls people in a health care plan (unless they opt out), or a default rule that automatically protects users’ privacy online (unless they say otherwise). Such nudges, he says, “respect free markets and private liberty,” allowing people to make their own choices while at the same time emphasizing “that people may err and that, in some cases, most of us can use a little help.”

One of the central principles animating Mr. Sunstein’s tenure at the Office of Information and Regulatory Affairs — known as OIRA (pronounced oh-EYE-ruh) — was an empirical testing of regulations, he writes; another involved cost-benefit analysis and the maximizing of net benefits. He says that during the Obama administration’s first three years the net benefits of regulations reviewed by his office and issued by executive agencies exceeded $91 billion.

While at the Office of Information and Regulatory Affairs Mr. Sunstein reviewed rules related to President Obama’s health care act and Dodd-Frank financial reform legislation. He backed higher fuel efficiency standards for motor vehicles and new toxic emissions rules for power plants, and he helped oversee a deal that would make appliances more energy efficient.

Along the way he also came under considerable criticism from environmentalists, consumer advocates and progressives who argued that under his stewardship the regulatory office had been too deferential to business interests and insufficiently tough in its regulatory role. Among the most frequently cited complaints was its role in a decision to postpone a plan to cut ozone emissions. In “Simpler” Mr. Sunstein describes that decision as “controversial but unquestionably correct” and writes that “we refused to issue a large number of rules favored by progressive groups, generally on the theory that they could not be justified, especially in an economically difficult time.”

Such debates over decisions made by Mr. Sunstein underscore just how difficult it can be to find consensus-winning solutions to complex problems. In other words, simplification is often not so simple at all.

For another view of Medicaid reform in Florida read below:

Medicaid Cure patients rate better than patients trapped in old Medicaid in nearly two-thirds of national health categories. And Medicaid Cure patients report higher satisfaction rates in 83 percent of satisfaction measures compared to patients in both old Medicaid and commercial HMOs.

The Medicaid Cure makes patients healthier and happier through choice, competition, accountability and personal responsibility. It is saving patients’ lives. But is it saving budgets?

Florida taxpayers have saved an estimated $118 million annually since the five-county pilot began. When the federal government green-lights the Cure for statewide expansion, taxpayers here are expected to save almost $1 billion every year. And if the Medicaid Cure was replicated in every state, not only would Medicaid patients across the country be healthier and happier, American taxpayers would save more than $1 trillion over the next decade.

via Florida’s pro-taxpayer cure for Medicaid.

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.

Nearly 9 million poor and sick Americans are “dually eligible” for both Medicare, the federal health care program for seniors and disabled individuals, and Medicaid, the joint federal health system for low-income people.  They use a lot of health services and their care is often fragmented.

Melanie Bella’s new job is to help fix that.

via When Care Is Split Between Medicare And Medicaid: KHN Interview With Melanie Bella – Kaiser Health News.

JUNE 23, 2010 4:00 AM
A Conversation with Arthur C. Brooks, Part 1
The new culture war is not about guns, gays, and abortion — it is about free enterprise, which in turn is about human flourishing and human freedom.
By Interview
AEI’s Arthur C. Brooks always manages to see the world from a fresh prospective, one that is buoyed by first principles. A manifestation of this is his latest book, The Battle: How the Fight between Free Enterprise and Big Government Will Shape America’s Future. Brooks, the president of the American Enterprise Institute, talks about The Battle — and the future — with National Review Online’s Kathryn Jean Lopez in this two-part interview.
KATHRYN JEAN LOPEZ: Culture war? Didn’t we evolve beyond such talk somewhere around a Pat Buchanan speech at a Republican convention?

ARTHUR C. BROOKS: For many, that 1992 convention speech defined the term “culture war.” But what I’m talking about is a new culture struggle — one fought not over guns, gays, and abortion but over the core characteristic of America: free enterprise. In my book I don’t just demonstrate that free enterprise is the most efficient way of organizing an economy (which it is). I also show that it’s an expression of American values, and, thus, that a fight for free enterprise is very much a fight for our culture.
LOPEZ: Has President Obama made Americans less happy? Is it even fair or reasonable or constructive to ask such a question?

BROOKS: Happiness is important to discuss. The opponents of free enterprise always claim they will make America a happier nation, and we always lamely respond with arguments about economic efficiency. Yet in truth, the better prescription for happiness is on our side, not theirs.

Redistributionists always make the argument that relative income is a huge driver of unhappiness — that poorer people are unhappier than richer people simply because they have less money through no fault of their own — and thus we can get a happier, fairer society by equalizing incomes. This is based on a colossal misreading of data and a whole lot of ideology. The truth is that relative income is not directly related to happiness. Nonpartisan social-survey data clearly show that the big driver of happiness is earned success: a person’s belief that he has created value in his life or the life of others. Of course, in a capitalist system, earned success is often rewarded financially, so people who have earned a lot of success tend to have more money than others. But it’s the success, not the money, that does the trick. (We show this by comparing the happiness of people who have the same level of income but have different perceived success levels.)

The system that enables the most people to earn the most success is free enterprise, by matching up people’s skills, interests, and abilities. In contrast, redistribution simply spreads money around. Even worse, it attenuates the ability to earn success by perverting economic incentives. Free enterprise is essentially a formula not just for wealth creation, but for life satisfaction.
LOPEZ: Are free enterprise and big government natural enemies?

BROOKS: There are some things that government does well. When the U.S. government was fighting Nazi Germany and Imperial Japan, it was the champion of freedom in the world. It took a big government to win World War II. But it takes a smart one to realize it is only the entrepreneurialism of individuals that can deliver thriving economies and human flourishing. Government has a role, of course, such as enforcing the rule of law. But when it takes resources out of the hands of innovators and risk-takers, when it regulates small businesses out of existence, when it favors crony corporations instead of entrepreneurs, when it taxes corporations so much they move abroad — then, yes, big government becomes the enemy of free enterprise.

LOPEZ: We’re always told that free enterprise is merciless. Isn’t it the source of misery for everyone but the guys at the very top? (And of course they are guys, because everyone knows women are oppressed in the American economy.)

BROOKS: Absolutely not. The data show that a poor man who earns his success and believes he has a chance to get ahead through his own efforts — that man is happier than a “guy at the very top” who does not feel he has earned his success (or that anyone really can). And it’s as true for women as it is for men. Free enterprise does not bow to gender, class, race, or ethnicity. It rewards hard work, dedication, initiative, talent, and street smarts. It’s truly a force for liberation, not oppression.
LOPEZ: Is big government always an enemy of conservatism? And of a lot of what makes America America?

BROOKS: Well, as I said earlier, not when the government is defending American interests and liberties. But when the government takes over large parts of the economy that could be better run by the private sector, when it brings the top down simply to level outcomes, and when it picks the winners and the losers and makes markets fail, it is a problem not just for conservatives but for Americans in general. Government’s role is an important (but restricted) one: protecting the environment in which honest people can earn their success.
LOPEZ: You talk about the “soul” of America” being “at stake.” Is there even a consensus about what exactly that soul is? Do we even all want her to have a soul? And can I call her “her”?

BROOKS: By “soul” I mean the essence of what it means to be American. And yes, there is a fairly broad consensus, a shared understanding of what makes us American. In the mainstream — among at least 70 percent of Americans, according to nonpartisan data sources — there is a strong belief in liberty, equality of opportunity, and entrepreneurship. In other words, the free-enterprise system is understood as being more than an economic alternative — it is understand as being the center of our culture.
LOPEZ: What is the “30 percent coalition”?

BROOKS: The last question hinted at the answer to this one. The “30 percent coalition” is a term I coined for the minority in this country who do not like or support our free-enterprise culture, and who seek to change it for the rest of us. The 30 percent are led by the usual suspects — opinion-leaders in academia, the media, the entertainment industry, and so on. All the data available tell us these are among the most radical players in the battle against our culture of free enterprise. But adding them all up doesn’t get us to 30 percent. The ranks of the coalition are swelled by others, especially young people, who have not (yet) experienced the depressing realities of a redistributive economy. A January 2010 Gallup poll found that a majority of Americans between the ages of 18 and 34 actually hold a positive view of socialism. Which probably makes sense, since the only socialists they’ve seen are their professors at college.

LOPEZ: What’s the “Obama Narrative,” and what’s so wrong with it?

BROOKS: The Obama Narrative is the administration’s basic account of how we got into the financial crisis of 2008 and how President Obama said he would get us out of it. It blames Wall Street and weak regulation for getting us in — and promises big government and strong regulation to get us out. It’s not accurate. Ill-advised government policy was responsible for a large part of this mess (particularly the federal mandates for Fannie Mae and Freddie Mac to ramp up their lending even to people who had sub-par credit). Bigger government will not clean it up. The enterprise, initiative, and ingenuity of the American people will — if we allow these forces to work.
LOPEZ: Are you a defender of economic inequality? Isn’t it the cause of misery?

BROOKS: Unequal outcomes don’t make us miserable. Americans like success stories — they feel they can succeed, too. Misery comes from thinking you have no chance to improve your lot in life, no chance to get ahead through hard work and drive. If you approve of people getting big rewards for big efforts, that’s not defending economic inequality — that’s defending fairness. A fair system is not one that levels outcomes — it is one that rewards hard work, merit, and excellence (while penalizing free riding and laziness). Fairness is a concept that we in the free-enterprise movement have to take back.

Incidentally, none of this is to suggest that we can’t ever be in favor of minimum basic services for people, which might be necessary to allow citizens to exploit opportunity. Even Hayek noted that this is can be a legitimate competency for government. But protecting people from starvation is very different from what the welfare state increasingly focuses on today: redistribution for the sake of equality (“fairness and balance” in our tax code), social engineering (everybody deserves a mortgage, no matter how lousy his credit), and policies intended to take the downside risk out of our decisions (bailouts).
LOPEZ: You write that “People are surprisingly satisfied with their jobs in America.” How can that be so? Everyone seems to tell us otherwise.

BROOKS: I know, it’s surprising, but it’s true. A great deal of data show that Americans are overwhelmingly satisfied with their jobs, and this doesn’t depend on education or even income levels. And Americans in general are much more satisfied with their jobs than Europeans. According to the International Social Survey Programme, we are 52 percent likelier than the Germans, 42 percent likelier than the British, and about 190 percent likelier than the Spanish to say we have complete job satisfaction.

LOPEZ: Is it fair to say that conservative economic policy is as bleeding-heart as the Left portrays itself as being? That it actually could tackle poverty if truly implemented? Or is that way too simplistic and idealistic?

BROOKS: If by “conservative economic policy” you mean free enterprise, then yes. It’s absolutely about the heart. Free enterprise promotes human flourishing and individual achievement, earned success and personal well-being. These are the arguments I make in the book — and the reason some have even characterized it as a self-help book. It doesn’t tell you how to get rich or win a promotion or get elected to office or win friends and influence people. But it tells you how you can pursue happiness — and why free enterprise is the best system to make that happen. Entrepreneurs really are the New Age radicals, tapping into the transformative power that comes from striving, achieving your potential, and creating value in your own life and the lives of your loved ones. The fact that it also produces the most explosive economic outcomes, for individuals and societies alike, is secondary (although nice).
LOPEZ: How important is free trade in this new culture war?

BROOKS: It is important. Free trade has been responsible for the greatest increases in prosperity for the poor all around the globe. Since 1950, the volume of merchandise traded worldwide has increased by a factor of 27. This has led to rising living standards for the people of China, India, Brazil, and many other places in the developing world — and for Americans too. And there’s another benefit. Free trade among nations also fosters cross-cultural understanding and the growth of democracy and civil society worldwide. Unfortunately, we currently have an administration that is not clearly committed to free trade because, many argue, of its political debt to labor unions.
LOPEZ: You use the phrase “world stewardship.” How do conservatives reclaim the language of talking about these things? We’re so often buying into others’ frameworks. You’re not.

BROOKS: To me “world stewardship” means being cognizant of the fact that we are blessed in America with great abundance, having the wisdom to understand why, and then sharing the means to that abundance. I strongly believe that what will keep America strong is (1) a deep confidence that our success as a nation is earned, (2) a national willingness to share the means to prosperity — the free-enterprise system — with others around the world, and (3) an ironclad resistance to policies that will mortgage away our system from our children and grandchildren. This is world stewardship. In the book I talk a little about actual policy prescriptions that do these things, and I refer readers to works by scholars who really get it, like my colleagues Mauro De Lorenzo and Glenn Hubbard.
LOPEZ: So how do we stop America’s current slide toward Europeanization? That’s a big question, I realize.

BROOKS: One way is simply to point out the ethical differences between the Greek and the American street today. In the past month, Greek citizens have rioted and gone on strike against the government. Why? Despite the worst economic conditions in years, labor unions and state employees are demanding that others pay for their early retirements, lifetime benefits, and lavish state pensions. In America, by contrast, our tea partiers demonstrate not to get more from others, but rather against government expansion, bloated government debt, bailouts, and a government overhaul of the health-care industry. In other words, the tea partiers are protesting against exactly what the Greeks are demanding. It is a near-perfect example of American exceptionalism.
LOPEZ: Why do social conservatives need to care about the fate of free enterprise?

BROOKS: Our founders wanted Americans to be the freest people in the world, and Alexis de Tocqueville believed they had succeeded. Liberty is more than a theory, though — it is a value to be practiced. And the way we practice liberty in our workaday lives — the way we express our values as we support our families — is through free enterprise. It is fundamentally a cultural issue in itself, and bound up in what each of us sees as a moral, equilibrated life.

– Kathryn Jean Lopez is editor-at-large of National Review Online.


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 –

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 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.”

From PR Newsletter:

JACKSONVILLE, Fla., Jan. 5, 2012 /PRNewswire via COMTEX/ — Blue Cross Blue Shield of Florida (BCBSF) and the AmeriHealth Mercy Family of Companies (AMFC) today announced an agreement to enter into a joint venture to bring best-in-class Medicaid managed care and services to Florida beginning in mid-2012.

The joint venture, called Florida True Health, Inc., will be an equal partnership between BCBSF and AMFC. Both companies will share in the startup costs, financial risk and risk-based capital, among other business practices. Florida True Health will be responsible for Medicaid member enrollment, claims processing, provider network development, utilization management, quality management, customer service, community outreach, marketing, finance, actuarial and public affairs.

“This joint venture with AmeriHealth Mercy enables us to enter the Florida market with competitive capabilities from day one,” said Steve Booma, executive vice president of strategy and diversified business. “AmeriHealth’s exceptional operations and strong history in serving Medicaid members, combined with BCBSF’s 67-year history serving the health care needs of all Floridians, creates a unique organization dedicated to serve the state’s Medicaid population.”

Michael A. Rashid, President and Chief Executive Officer of the AmeriHealth Mercy Family of Companies said, “It is a privilege to bring our proven care management expertise to Florida. Our medical management and outreach programs have improved the health of our members for nearly 30 years. We look forward to working with the providers, community partners, the state and our BCBSF partner to make a positive difference in the lives of Floridians in need.”

Florida True Health will be headquartered in Florida, although the specific location of its offices has yet to be determined. Florida True Health will enter Medicaid as soon as state approvals are obtained.

About Blue Cross and Blue Shield of Florida

Blue Cross and Blue Shield of Florida (BCBSF) is a leader in Florida’s health industry. Since 1944, the company has been dedicated to meeting the diverse needs of all those it serves by offering an array of choices. BCBSF is a not-for-profit, policyholder-owned, tax-paying mutual company. Headquartered in Jacksonville, FL, BCBSF is an independent licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. For more information concerning BCBSF, please see its website at .

About AmeriHealth Mercy

The AmeriHealth Mercy Family of Companies is one of the nation’s leaders in health care solutions for the underserved. AmeriHealth operates in 11 states and serves more than 4 million Medicaid, Medicare and SCHIP members through its Medicaid managed care products, pharmaceutical benefit management services, behavioral health services, and other administrative services. Headquartered in Philadelphia, AmeriHealth Mercy is a mission-driven company with more than 25 years of experience serving low-income and chronically ill populations. AmeriHealth Mercy’s divisions include:

Keystone Mercy Health Plan, a Medicaid managed care health plan servicing over 321,000 members in five southeastern Pennsylvania counties;

AmeriHealth Mercy Health Plan, a Medicaid managed care health plan servicing 108,000 members in 15 Pennsylvania counties;

Select Health, a Medicaid managed care health plan serving 214,000 members throughout the State of South Carolina;

MDwise Hoosier Alliance, a Medicaid managed care health plan serving 133,000 members throughout the State of Indiana;

PerformCare/CBHNP Behavioral Health Services, servicing almost 1.1 million members in Pennsylvania, New Jersey, Indiana, and South Carolina;

Perform Rx, a pharmacy benefits manager servicing over 1.8 million members.

The AmeriHealth Mercy Family of Companies also provides other administrative services in New Jersey and Kentucky.

SOURCE Blue Cross Blue Shield of Florida

Copyright (C) 2012 PR Newswire. All rights reserved

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.

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.

“At the state level, Gov. Rick Scott is trying to persuade the Obama administration to give Florida a waiver from federal requirements in return for Medicaid funds. The main issue is how to control the unmanageable costs — Medicaid now takes the lion’s share of the state budget — without shortchanging patients. The irony is that Republicans in Tallahassee condemn the federal healthcare overhaul for “rationing care” but they’ve devised a system that perforce rations care for Medicaid patients by putting them into managed-care systems.”

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.

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