Dueling editorials on Medicaid privatization

Adam Linker reads the tea leaves:

We have seen this exact plan play out in a number of states. In Kentucky, there is chaos. The state auditor there began a probe when he heard reports that small medical providers needed new lines of credit to stay open. In the first several months of implementation, the auditor discovered, managed-care companies received $708 million from the state and paid out just $420 million in claims.

When you have a multiple-tier system with a private entity disbursing public funds to other private entities, that pie is going to get sliced to death before it gets to the hands-on care provider. Again, it ain't rocket science. And it's not like NC doesn't already have a disaster of its own to reference:

North Carolina has traveled this path before. When the state identified problems in the public mental health system, politicians dismantled that network and privatized services. That process proved disastrous. If we repeat that mistake across Medicaid, it will hurt patients and wreck our brand as a national leader in health care.

I would be remiss if I didn't allow former Bush Ranger and Silver-Medalist in the GOP fundraising Olympics a word or two:

We began this reform process by putting out a call for ideas and suggestions and we received more than 160 responses. The responses shared many common concerns, including a disjointed IT system and too much administrative duplication. But there was also agreement that our Medicaid system did not look at a person as a whole, separating physical health and mental health and even substance abuse into different silos of care that didn't collaborate to improve patient outcomes. In our current system it is often difficult for Medicaid recipients to know where to go to get the services they need.

In other words, you really didn't know what was wrong with the system (nothing) before you decided to revamp it, you just knew there was a shitload of money involved that could be fiddled with. And that last sentence may be more revealing than Aldona meant it to be. Patients may be somewhat confused currently about where to go to get care, but at least they have some control over the decision-making process:

A long line of cases by the United States Supreme Court have held that when a state delegates a decision making function to a private entity, even though the state may still make the rules, the due process rights of the individual miraculously disappear. In the 1970’s and 1980’s New York had a tiered system for providing institutional care for the disabled elderly: Skilled nursing services provided in Skilled Nursing Facilities, custodial services provided in Health Related Facilities, and congregate care provided in Adult Homes. When the local Medicaid agency decided to move someone between the three types of facilities, the individual did not get notice or a right to appeal. Legal services programs challenged in federal court this lack of due process. The state acquiesced and agreed to give full due process rights including fair hearings with aid continuing pending a final determination before transferring a resident between levels of care. It then immediately turned around and delegated the decision making process to the Utilization Review Committees of the nursing homes and again denied due process and appeal rights this time based on the theory there was no longer any state action in the decision making process.

In Blum v. Yaretsky, 457 U.S. 991 (U.S. 1982), the U.S. Supreme Court reversed the 2d Circuit Court of Appeals and found that when private nursing homes conducted utilization review under New York state rules to determine the level of care that Medicaid patients needed, there was no state action and no due process rights required.

Later cases followed the precedent set by the Yaretsky Court. In Am. Mfrs. Mut. Ins. Co. v. Sullivan, 526 U.S. 40. (1999), the U.S. Supreme Court upheld Pennsylvania’s workers' compensation regime where an employer or insurer may withhold payment for disputed medical treatment pending an independent review because the insurers are not "state actors" and therefore due process does not attach. The Court also remanded Shalala v. Grijalva, 526 U.S. 1096 (1999), in light of Am. Mfrs. Mut. Ins. Co. v. Sullivan. In Grijalva 152 F.3d 1115, 1117 (9th Cir. Ariz. 1998) the 9th Circuit had previously affirmed due process rights for Medicare beneficiaries enrolled in health maintenance organizations ("HMOs").

In New York when Medicaid home care decision-making was turned over to Certified Home Health Agencies (CHHA’s) similar results occurred. In Catanzano v. Dowling, 60 F.3d 113 (2d Cir 1995), aff'd in part, vacated in part, 103 F.3d 223 (2d Cir 1996), the 2d Circuit Court of Appeals held that when a private CHHA and the treating physician agree, then there are no appeal rights for the consumer from a determination to grant, terminate or reduce care. The only saving grace is Catanzano was the fact that there is a fair hearing right if the treating physician disagrees with the CHHA.

The only time you miss having to talk to a government bureaucrat is when you really need to talk to a government bureaucrat, and you find out you no longer have that option.

There's a fine line between privatization as an effort to economize, and privatization to cover up a desire to shirk responsibilities. Considering the way Republicans have treated various subsets of our population with callous disregard and/or outright contempt, my money is on the shirking responsibility thing.

Comments

I have buyer's remorse for

I have buyer's remorse for voting for McCrory. I am so tired of hearing that EVERYTHING is BROKEN. Yes...there is always room for improvement in every department and program ...but everything is not broken. I take that back...since Aldona's arrival...moral at DHHS is broken. What in the world did we do before McCrory came riding in on his white horse with his benefactors in tow? I regret casting my vote for this pompous man and his equally pompous appointees.