The Smart Money: The Alexander Report

Posted Tuesday, May 20, 2014 in Analysis

The Smart Money: The Alexander Report

by Gina Hamilton

The time has come to review the report we will be paying almost a million dollars for, and see if any of it is worth the paper it's printed on, or the bandwidth it's hosted on.

Gary Alexander and the Alexander Group won a no-bid contract to produce a report which was a thinly disguised campaign document for Candidate LePage. The report is likely to backfire, because people are incensed about the cost of the report, at $975,000, which seems like a too-healthy chunk of change for Mainers who think their taxes are already too high, plus, as been pointed out in numerous publications, including this one, there was nothing new in the report in the first place. It simply provided cover for the LePage agenda of driving the poor deeper into misery than they already are.

The 228-page report is very light on process, but there are some nuggets of ideas that make sense in a couple of areas. 

First, let's look at what won't work, and is a huge part of the report.

Maine expanded MaineCare, to parents of children on "Cub Care" who are at 150 percent of poverty, and to others earning between poverty and 133 percent of poverty, of its own free will during the Baldacci administration.  LePage  proposed scaling it back, but it was a difficult sell, politically, especially in a state where the average income is low and insurance costs are relatively high.  MaineCare is a popular program. LePage decided to try for a federal waiver anyway, even though the government had already told him that one was unlikely to be forthcoming. To no one's surprise, the federal Department of Health and Human Services denied Maine a waiver to remove 21,000 Mainers from MaineCare.

The Affordable Care Act — as part of a section of the law called “maintenance of effort” — largely prohibited states from scaling back existing Medicaid services in advance of the law’s major expansion of Medicaid in 2014. While the Supreme Court in June of 2012 largely upheld the health-care law as constitutional, the court ruled it unconstitutional for the federal government to penalize states for not participating in the Medicaid expansion. In Maine's case, however, Medicaid had already been expanded, and therefore, fell into the maintenance-of-effort rule.

The LePage administration argued that it was entitled to make MaineCare cuts through a routine plan amendment. Then-Attorney General William Schneider had argued that the maintenance-of-effort provision was “part and parcel of the Medicaid expansion that was struck down.” However, in the letter to to Health and Human Services Commissioner Mary Mayhew, federal officials wrote that the Supreme Court’s June ruling “did not strike down any part of the Affordable Care Act.” In short, because Maine had already expanded its program in prior administrations, it was disallowed from making changes to the program now that would remove large numbers of people from the rolls. LePage asked for an expedited review; the expedited review was denied, but the review duly took place, in December of 2012, too late to affect the election cycle, during which LePage lost his majority in the Legislature, so it was all a moot point anyway. In addition, Schneider was replaced by Janet Mills, and there was no legal will to do anything else.

Federal officials did give the LePage administration permission to reduce coverage under the Medicare Savings Program, which helps seniors and people with disabilities pay prescription drug and other Medicare costs, as well as eliminate coverage for parents making between 133 and 150 percent of the poverty level. But he never had the majority to do it in the Legislature.

One of the cornerstones of Gary Alexander's report, however, ignores all this history. He suggests that Maine go for a "global waiver", such as Rhode Island got in 2009. But Rhode Island was not in the same situation as Maine at all, and the federal government has already made it crystal clear that no waiver ... global or not ... will be forthcoming.

Even without the waiver, which Maine won't get, there are ways to solve some of the financial problems that Medicaid presents, mostly based on establishing protocols that keep people from using the most expensive health care option if it's not necessary, and it hardly ever does. But that can be done now, and would have broad bipartisan support.

For instance, hospitals should maintain clinics for "urgent" but not "emergency" care, staffed lightly overnight with a nurse practitioner and a medical assistant. A smart urgent care clinic would also have a dentist during most hours. Patients who turn up at the emergency room should politely and firmly be directed down the hall to this clinic. Many things fall into this category — ear infections, chest infections, asthma attacks, sore throats, toothache, minor bumps and bruises, sprains and strains. 

Patients on MaineCare should be required to sign up with a primary health care provider and should see the doctor within 30 days for an annual checkup once per year. Maintenance medications can be provided at that time with 12 month refills. The doctor checks the patient's chart and gives whatever vaccines and schedules whatever tests are due at the annual visit. The primary care provider can also be seen during weekday hours for urgent care situations. Doctors should be required to accept MaineCare patients.

Medications should be generic first, and the simplest and least expensive choices unless those prove not to work. 

The goal should be wellness, so education, exercise classes, dietary consults, and smoking cessation programs should be free and open to all, regardless of age.

These modifications alone would save the program many millions of dollars.

Working with low-income people to obtain long-term care coverage, at rock-bottom rates, both for themselves as they age and for their children with disabilities, should be a priority. Care for people with developmental disabilities and the frail elderly costs $330 million per year, currently. Some of those funds will be recouped from the patients' estates, but in many cases, there is no estate to tap. People with disabilities represent 18 percent of the population and 43 percent of expenditures, or $330 million for institutional care, plus $196 million on outpatient mental health care. The other large driver of costs, hospitals, for both inpatient and outpatient care, totals $618 million currently.

Alexander also assumes that most people receiving Temporary Aid to Needy Families are capable of working. A sizable percentage of people on TANF are disabled, either physically or developmentally, or are caring for someone who is.  When one parent is incapacitated, and the other is caring for the incapacitated one, both members are considered "incapacitated" since neither can work outside the home. Alexander would like to end that, meaning it would cost more for nursing care for the parent who is incapacitated, as well as care for the children.

Of those who are able to work, Alexander recommends aligning ASPIRE, a program that helps people get ready to hold a job by various means — training, education, job coaching, as well as help with transportation, appropriate work clothing, etc. — with federal standards. This would require someone who is attending school full time to hold a job for at least 20 hours per week, without consideration to issues of childcare.

Alexander would get Maine involved in a program that requires work for Supplemental Nutrition Assistance. Doing this, he says, would get people off SNAP because they would have an income that would exceed federal limits; however, that is not necessarily true, and if he had done a survey of Maine businesses, he would have noticed that people are working full time and are still eligible for assistance. 

Alexander would scale back state support for town General Assistance. Most people on GA at the town level are ineligible for support at the state level, especially single adult men and the homeless. Indeed, he would like to eliminate this funding altogether, which would have the effect of increasing crime.

Two items that do merit some consideration are paying childcare providers directly, rather than giving parents access to funds in their EBT cards. This makes sense. Providers get the funding immediately, and parents do not have the opportunity to use it for some other pressing need.  The other item from this report that seems rational is investing in subsidized job creation for people who have been out of the workforce for a long period of time, and simplifying the paperwork and process.

With a little thought and some creativity, and a less hostile attitude toward the poor, a real, meaningful analysis of Maine's welfare system and ways to improve delivery of services, and a means out of the welfare cycle could have been achieved.

It's too bad the Alexander report isn't it.


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