When Red States Attack: Medicaid in Iowa

This is a brilliantly executed feature on how hard it is to actually get services from Medicaid in Iowa even if everyone agrees you are owed those services.

A Des Moines Register investigation into those 200 cases found an appeal process that presents a thicket of administrative and legal roadblocks to patients and their families, who must clear hurdle after hurdle to secure care.
Specifically, the Register investigation found:
• Due process violations: In at least four cases, administrative law judges concluded or the Medicaid recipient alleges in ongoing district court appeals that the companies failed to properly notify recipients about health care reductions and their appeal rights.
• Denials of in-home care: Medicaid expenses for in-home care that had been routinely approved when the state ran the program are now being rejected by managed-care providers as unnecessary and outside the scope of what the program authorizes. Families say they are left struggling to care for their loved ones, who are losing their independence and autonomy.
• Endless appeals: Even when Medicaid patients win their cases in administrative hearings, the managed-care companies routinely "re-evaluate" their health needs, again denying their care in as little as 60 days. That forces patients to embark on yet another round of appeals.

What's more, as I reported in November, the situation in Iowa is going to get worse.

I'm struck by the way that disability systems are built, funded, and run on the assumption that people mostly won't get full access to the services they are due.

Red States and Disability

My latest in The Nation:

Mostly buried beneath early November’s onslaught of news, stories from Oklahoma, Iowa, and Maine reveal the ways that state governments, through both apparent incompetence and maliciousness, are failing disabled residents and their families. In the first two examples, disability programs are being cut as a result of self-imposed budget crises. In the third, the governor is using disability as a shield to ignore the will of the voters, while at the same time not serving disabled Mainers.

Oklahoma is the worst of the three. At the beginning of November, agencies received letters stating that the “ADvantage Waiver,” a program funding home-based care for disabled individuals and seniors, would lose funding as of December 1. About 21,000 Oklahomans will lose the care that enables them to live independently. About 10,000, according to the Department of Human Services, will be forced to move into nursing homes—except that the state doesn’t have enough beds in nursing homes. So disabled Oklahomans are caught waiting to find out what will happen: Will they be trapped in their homes without services? Will they be forced into nursing homes or Hospitals? Will they be abandoned?

The problem, of course, is money. The conservative state has stripped awayits tax base in a wave of Tea Party glee. Now it’s broke and, rather than raise taxes (a budget just failed to pass in special session), it is closing nursing homes and slashing Medicaid.

What Happens When You Cut Medicaid? - Texas

New from AP today on the time Texas cut 350 million from Medicaid:

Some Texas children with special needs like Addison have lost critical services since the state implemented $350 million in Medicaid cuts to speech, occupational and physical therapy in December. In Texas, reimbursement offered to providers fell up to 50 percent for certain therapy procedures, said Rachel Hammon, president of Texas Association of Homecare and Hospice. Clinics closed and therapists quit.

The Texas cuts are separate from Republican proposals now before Congress, which academics say could cut federal Medicaid spending as part of a law to replace the Affordable Care Act. But the fallout could eventually be similar if some form of what’s been approved in the U.S. House, and is under consideration in the Senate, becomes law, said Elizabeth Burak, the senior program director of Georgetown University’s McCourt School of Public Policy’s Center for Children and Families

The Texas Legislature voted in 2015 to cut the state’s Medicaid reimbursement for pediatric acute therapy services, which effectively capped how much providers can be paid. Proponents of the cuts argued that Texas’ previous reimbursement rates were too high, sometimes even encouraging fraud.

In related news, my piece on the history of Republican attacks on Medicaid was picked up by the Dallas Morning News. My inbox has been lived.

Block Grants: A History

I have a piece today at The Washington Post about the history of Republicans trying to gut Medicaid, why they failed, and why they might win this time. 

As detailed in a 2013 report by the National Council on Disability (a nonpartisan, federally funded advisory council) on Medicaid block grants and their effect on Americans with disabilities, the first attempt to turn Medicaid into a block grant came in 1981, in Reagan’s first year in office. It made it into a big omnibus budget bill, but was stripped out in a congressional committee. House Speaker Newt Gingrich (R-Ga.) actually got block grants passed in 1995 as part of his “Medigrant” proposal, but President Bill Clinton vetoed it (with strong backing from health policy experts), and it was dropped from the subsequent compromise bill. President George W. Bush and the Republican congresses of 2003 and 2005 could have passed block grants at any time, but sustained resistance from advocacy groups, Democratic leaders such as Rep. Henry A. Waxman (Calif.) and Edward M. Kennedy (Mass.) and the legislative distractions of forming Medicare’s prescription drug benefit kept the bill from advancing.

 Moreover, at the time, many Republicans wanted to find bipartisan solutions whenever possible. Henry Claypool, who has been working on Medicaid policy in and out of government since the 1990s, told me that the Deficit Reduction Act of 2005 did include some Republican changes to eligibility, but also expanded support for home- and community-based services in ways that have helped many disabled Americans.

Today, everything has changed. House Speaker Paul D. Ryan (R-Wis.) has been proposing block grants since 2010, but he had no chance to get them enacted under President Barack Obama. Now, he and McConnell have co-opted the legislation intended to fulfill GOP promises to “repeal Obamacare” (which would be bad enough) as a way to sneak through decades-long assaults on the basic American promise of Medicaid.

This time, the phrasing is “per capita caps.”