When the Supreme Court releases its decision today or later this week on the Affordable Care Act (Obamacare), there will be analyses galore on the law, the politics, and on policy as well. We’ll likely join in.

But, in the midst of all that as far as healthcare is concerned , there will be one essential to remember. Overturning any part of the Act will mean that fewer people are covered, more will be unhealthy, and more will suffer. And some will die.

One of the two or three most important things we’ve learned about healthcare in the past three decades is that no single factor has as much effect on whether and when people get necessary medical care than does whether or not they have health insurance.

Coverage matters.

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Should state and local governments borrow from the Federal Reserve?

Yes.

Why? They’ll pay lower interest rates, thereby saving money without reducing services. The only losers will be the banks and other lenders, who are doing just fine, thank you.

Should the Federal Reserve Lend to state and local governments?

Yes.

Why?

See above.

And because state and local cutbacks are a drag on the economy and, such as it is, on an economic recovery.

Where did this idea come from?

Credit goes to Mike Konczal of the Roosevelt Institute and Richard Clayton of Change to Win. Konczal writes it up in Should the Federal Reserve Go into the Muni Market?

What else could it do? Here’s a suggestion Richard Clayton, the Research Director of Change To Win, emailed me after my interview with Joe Gagnon, that I haven’t seen as part of the discussion:

One question that Gannon doesn’t deal with directly: under Section 14 b 1 the Fed has the authority to purchase any obligation of a state or local government of 6 months maturity or less. This provision seems clearly to permit a mass refinancing of state and local government debt at the current 6 month interest rate (very close to 0), which would save state and local gov’ts approximately $75 billion a year (going by the flow of funds #s for state and local interest payments). Moreover, since state and local govts do the bulk of infrastructure investing, the fed could create a program to fully fund such investment through purchases of newly issued 6 month bonds, for projects that meet criteria the Fed sets out (such as being approved by a small committee of civil engineers appointed by the regional fed branches for that purpose). Finally, under section 24 of the Act, the fed can buy from national banks loans to finance residential construction, which in effect would give the fed the ability to spur new multi-family construction (sorely needed, as evinced by rising rents) by enabling lending banks to effectively sell the loans off their books.

Should we be pushing the Federal Reserve to purchase from the muni market, buying short-term state or local government debt? Asking around, a big practical issue is how much to buy from each state, but the Federal Reserve could come up with a solution. If the estimate is correct, that $75 billion would make a major difference to weak state and local budgets, which is a major form of austerity and a major check to recovery during this Great Recession.

See also Steve Roth at Angry Bear.

I think the six month limitation is manageable, especially for short-term notes. It would require extra work and nuisance for longer term debts and some risk for local governments that such longer term debts might ultimately get locked in a higher rates. But in the meantime, rates would be remarkably low. Hell, if the banks are getting what amounts to interest-free loans from the Fed, why not state and local governments?

This makes a lot of sense.

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Buried deep within the structures of public finance is the cash for capital projects that has not yet been spent because projects take time. This cash sits in accounts that earn interest. And the interest paid is determined by auctions. But many of these auctions are rigged.

Matt Taibbi, of Rolling Stone, covers a trial – which led to convictions – of Wall Streeters who cheated so blatantly that they talked on phones they knew to be recorded.

Someday, it will go down in history as the first trial of the modern American mafia. Of course, you won’t hear the recent financial corruption case, United States of America v. Carollo, Goldberg and Grimm, called anything like that. If you heard about it at all, you’re probably either in the municipal bond business or married to an antitrust lawyer. Even then, all you probably heard was that a threesome of bit players on Wall Street got convicted of obscure antitrust violations in one of the most inscrutable, jargon-packed legal snoozefests since the government’s massive case against Microsoft in the Nineties – not exactly the thrilling courtroom drama offered by the famed trials of old-school mobsters like Al Capone or Anthony “Tony Ducks” Corallo.

But this just-completed trial in downtown New York against three faceless financial executives really was historic. Over 10 years in the making, the case allowed federal prosecutors to make public for the first time the astonishing inner workings of the reigning American crime syndicate, which now operates not out of Little Italy and Las Vegas, but out of Wall Street.

The defendants in the case – Dominick Carollo, Steven Goldberg and Peter Grimm – worked for GE Capital, the finance arm of General Electric. Along with virtually every major bank and finance company on Wall Street – not just GE, but J.P. Morgan Chase, Bank of America, UBS, Lehman Brothers, Bear Stearns, Wachovia and more – these three Wall Street wiseguys spent the past decade taking part in a breathtakingly broad scheme to skim billions of dollars from the coffers of cities and small towns across America. The banks achieved this gigantic rip-off by secretly colluding to rig the public bids on municipal bonds, a business worth $3.7 trillion. By conspiring to lower the interest rates that towns earn on these investments, the banks systematically stole from schools, hospitals, libraries and nursing homes – from “virtually every state, district and territory in the United States,” according to one settlement. And they did it so cleverly that the victims never even knew they were being ­cheated. No thumbs were broken, and nobody ended up in a landfill in New Jersey, but money disappeared, lots and lots of it, and its manner of disappearance had a familiar name: organized crime.

Both telling and sad that it’s Rolling Stone with this story. You’ve got to wonder how many government financial officials are regular readers of Rolling Stone. Go read the full story.

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As we discussed earlier, New York (and many other states) is moving its Medicaid policy toward managed long-term care. Here’s an excerpt of what we wrote earlier:

First, the State finally decided to bring the rest of the Medicaid population into some form of capitated, case-managed care. When the State originally imposed mandatory managed care in the mid-1990′s, it exempted, the elderly, those needing long-term care, those with behavioral/mental health issues, and those with other disabilties, i.e., everyone who was sick, i.e., those who used the vast majority of services and accounted for the vast majority of expenses.

But this year (2011, ed.), as part of the State budget process, New York decided it’s time for everyone to get into the case managed/managed care pool. They’re using lots of new names, lots of new program definitions and there are a lot of open issues, some of them pretty big, about how the transition is going to work, but clearly there’s a new direction. And the change of direction is a big one.

What difference might these Medicaid policy changes make for counties operating nursing homes? These Medicaid changes will likely also affect all other nursing homes as well, but public nursing homes will be more threatened. Moreover, the Medicaid changes will also likely affect counties operating home care agencies. But home care is not nearly as expensive for counties as nursing homes. So we will first focus on counties operating nursing homes.

The operational changes in Medicaid will appear most quickly and be most obvious. For example:

  • The primary payment relationship between Medicaid and public nursing homes will be indirect rather than direct. The Medicaid program will not directly reimburse nursing homes for care. Rather, it will pay managed care and managed long-term care plans – insurers and care coordinators – and they will pay nursing homes for care to their enrollees.
  • The plans will enroll Medicaid beneficiaries, including current nursing home residents.
  • The plans may choose to not include all nursing homes in their service areas in their provider networks.
  • The plans will have the ability to negotiate prices with nursing homes in order to become part of their networks.

Care integration is a central theme and a necessity for Medicaid’s new policies to succeed. To enable care integration to succeed, will also require integrated information and integrated information strategies and systems. Though these will take time, they will be essential for all participants. If you don’t already have or are not already moving aggressively in the direction of information systems that can share data with other systems, you’re already late. This area will likely be the most important capital investments you can or will make, more so than buildings.

The system changes resulting from these policy and operational changes are likely to include the following:

  • A dispassionate analysis and systematic calculation of “public need” will no longer determine the size and scope of the nursing home or other long-term care systems. The social welfare concept of “need” will no longer be central. Rather a seemingly related but actually very different concept, the economic concept of “demand” will dominate.
  • Competition between nursing homes will intensify and price competition will become part of the system. This is not to say that plans will uniformly seek the lowest price services regardless of the quality and reputation of services offered by their provider networks. Certainly some may, but plans that disregard provider network reputation will likely not be able to enroll as many members. But it is to say that plans will eventually, consider “value,” the tradeoff between price and quality/reputation.
  • Public nursing homes will lose the price competition and because the price differences will be so great, they will lose the value competition. Primarily because of their compensation policies, and the slowness of their governance and management structures (e.g., Civil Service, extra approvals required for purchasing), public nursing homes cost much more than their private counterparts of the same quality. If they price based on their cost, they lose to their private counterparts. The likely exception will be in cases in which the public nursing home holds a totally dominant share of a local market. And even that advantage might be time limited.
  • Moreover, in pure price competition, public nursing homes will be at information and time disadvantages. Each nursing home participating in a plan’s network will have to contract with that plan. A private nursing home will be able to negotiate a contract relatively quickly and quietly. At least for a time, it may be able to keep its price agreement private. That is, its competitors won’t necessarily know what price it has negotiated. In contrast, public nursing home contracts, will due to their very nature, be public documents. Moreover, because of the legal requirements binding local governments, their approval and execution will public and relatively time-consuming.
  • Due to their higher cost foundations, the only means for public nursing homes to maintain or increase their share of total nursing home patients will be to lower their prices to match those of private facilities of comparable quality. This, of course, would require larger local government subsidies. (Imagine the politics around that – counties would be effectively subsidizing not only patients, but managed care plans. Try explaining that to local taxpayers.)

There is also considerable uncertainty regarding what the changes in Medicaid policy will likely mean for total demand for nursing home services – the total size of the market. On an even larger scale, expansion of managed long-term care is likely to have an effect on total statewide demand for nursing home capacity. Demand is already declining and, in New York, and other states changing their Medicaid policies to emphasize managed long term care, “demand” at most will be in flux for at least a decade and more likely will, in the aggregate, decline. Even the thundering herds of baby boomers won’t begin to need significant long-term care services for at least another decade.

  • Some forces will drive down nursing home use such as the plans financial incentives to dampen the use of high cost institutional services like nursing homes and hospitals.
  • Other forces might have the effect of increasing nursing home use. For example, plans are likely to resist 24-hour home care, especially for extended periods. Look for this to be a contentious issue, especially in New York City. However, it’s not likely to have much, if any effect, in areas that have underdeveloped home and community based capacity today.

How these forces will balance out are uncertain and none of these changes will achieve and settle into a new equilibrium quickly. To use round numbers, it will probably take at least five years, perhaps 10 after enrollment in managed long-term care begins for any geographic area to see a new stability.

First suggestions? Think a lot about system forces. Be nimble. If you’re going to bet the ranch on a single strategy, be prepared to lose all of your investment. That’s not much help is it?

If you’ve spent more than a few moments on this site, you already know I think that continuing to operate county nursing homes in New York is at best, high risk, and more likely a fool’s errand. However, for those that do intend to stay in the business, be aware that this business is going to change fundamentally. And the changes will very likely further disadvantage county nursing homes.

Rather than investing in new buildings, a county wishing to make new capital investments in improving long-term care in their communities would be well advised to consider information systems for coordinating, not only clinical care, but other aspects of the long-term care system (e.g., home delivered meals) that they already operate or finance.

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June 15, 2012. This post has been edited for clarity.

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As they do from time-to-time, all over New York, county officials are screaming about “unfunded mandates.” Candidates for the State Legislature are touting reforming “unfunded mandates” as an essential part of their platform.

Even aside from the funded unmandates (read that carefully) of county nursing homes that so many still wish to maintain and some wish to rebuild, the issue just ain’t what it seems. Most who talk about it simply don’t know what they’re talking about. And some who do may want to reconsider the long term implications. And as you read this, think about the relationship to reforming the State Budget.

Beware, this post is a really long one. Scan it and come back to it if that’s what it takes; it’s that important. It’s also essentially a first draft with all that that means.

“Unfunded mandates.” Let’s think this out …

There are two types of mandates. Let’s call them operational and programmatic.

Operational mandates govern how counties operate. They include such state statutory requirements as including employees in the State’s Employee Retirement System, adherence to Civil Service processes and criteria, purchasing rules, accounting standards, investment restrictions, and so on. Though some of the requirements are unduly restrictive, there’s history and rationale behind most, if not all of it.

  • Should we allow local governments to operate their own pension funds? Let’s call that what it is: a really bad idea. Experience in other states which allow it is bad and getting worse. Besides, it’s not like local governments don’t have some discretion on how many people they hire and how much they pay. Would local officials rather than their pension obligations be unfunded like the dirty little secret of retiree health benefits? In the latter case, there is no mandate. Indeed, one county does not offer retiree health benefits. But everyone else has a looming unfunded obligation entirely of their own making, i.e., a financial disaster in the making precisely because there is no mandate.
  • Should we allow local governments to invest in complex financial instruments, like derivatives that have gotten financial organizations and municipal governments elsewhere into such big trouble? Another really bad idea.
  • How about dumping Civil Service requirements for local government? I’m sure local pols would love that. Not that I didn’t have some related frustrations as a local government manager and not that Civil Service doesn’t need some significant revamping, but eliminating the basic mandate? Neither likely nor advisable.
  • What about removing purchasing standards and requirements. Here too, some streamlining and more flexibility are in order, but fundamentally changing the process? Nah.

We could go on, but operational mandates are not where the big money is. That’s in program mandates.

Program mandates grow out of New York’s history and they exist because, unlike most other states, key functions are operated by county governments rather than the state itself. If you go back a century or more, many governmental functions in New York were performed by local governments. Take social welfare functions. With the advent of the New Deal, during the Great Depression of the 1930s, Federal funds became available to support such functions. Rather than build an entirely new infrastructure, New York chose to channel that Federal aid, along with State funds to the local governments already performing those functions. But with the new Federal and State money, came some standardization – in the form of rules – mandates. Until the 1950s and 60s, when these functions were consolidated at the county level, many cities and towns were still involved in welfare administration. This was in contrast to what many, if not most states, did which was to centralize administration in state government.

New York’s structure emerged long before modern communications technology did. It developed in an era that even preceded copying machines, much less personal computers. But while those technologies are now pervasive, even if inadequately so, the pre-information age organizational structures still prevail. As a result of this history, the essential operational responsibility is still local – at the county level, but for the key programs, the bulk of the funding comes from the Federal and State governments. There are exceptions, but it’s still predominantly non-county money.

We’ll get to Medicaid, which is the big Kahuna financially, but let’s start with something else, child protective services, which is a really good example, and then go on to Medicaid and some other programs.

  • Child Protective Services. Let’s get right to the heart of the matter. Should New York abandon requirements for reporting and investigations of child abuse and neglect? Doing so would certainly relieve counties of the burdens of a significant mandate. If your answer is yes, I’m surprised you’re reading anything on this site. My answer is, of course not. Protection of children is an essential social/governmental function. Next question, should New York abandon standardized requirements regarding how and how quickly reports of abuse and neglect are investigated and when intervention is warranted, acted upon? Again, of course not. So the function will be performed.

    Despite the mandates that the services be performed, counties have considerable discretion in organizing and staffing how the function is performed. The next question is whether the State and Federal governments should pay counties 100 percent of the costs that counties incur? Of course not. If they have discretion, especially on staffing and payment levels, they need to have some “skin in the game,” enough to make them price sensitive.

    What might be an alternative? To have the State itself take over administration. Hmmmm.

  • Medicaid. In raw dollars, this is the big one. Statewide, county governments contribute about $8 billion to the cost of Medicaid. Here too there is history, but over time, counties have had less and less discretion and less and less direct operational involvement. Moreover, New York, as it should, is clearly moving toward the assumption of all administrative responsibilities for the program. So what about the residual financial obligation that counties do have? However “unfair” it may be that counties have a financial obligation that is vastly disproportional to their discretion, there is no way in which the State can simply fold an $8 billion item into its budget without a new source of revenue. Were New York to raise its current taxes or impose new ones without guaranteeing an equal reduction in locally imposed taxes, by simple arithmetic, this would yield a net increase in total taxes paid by its citizens.

    Fortunately, there’s already a model of how to transition the Medicaid financial obligation from the counties to the State. In 2005, New York started the process of transferring the financial burden of Medicaid to itself by capping the growth in each county’s obligation, ultimately to three percent of the base year of 2005. As a result, local obligations did not experience compound growth and most of the growth in Medicaid costs was and is being absorbed by the State itself. When it instituted the cap on growth, New York offered counties a one-time choice.

    At the time the cap was created, counties had the option of taking Medicaid off their books entirely. The base year county obligation was compared to local sales tax revenue during the same period and calculated as a percentage of that tax revenue. In return for permanently diverting that percentage of sales tax revenue from the county to the state, the county Medicaid obligation would vanish. It would no longer even appear on their books. Only one, maybe two counties chose the option because sales tax revenues had been growing faster than Medicaid under the cap, but that only lasted until the Great Recession when sales tax revenues collapsed.

    The cap on growth in county’s Medicaid share was tightened further in the SFY 2012-13 budget. From the Governor’s press release: “In 2013-14, local government Medicaid growth will be reduced to two percent, and then reduced by an additional one percent annually over the subsequent two years so that in 2015-16, counties and New York City will no longer have to contribute toward the growth of Medicaid expenses.”

    To eliminate this entirely, re-open the offer made in 2005. No, don’t do that. Don’t make it an offer. Just do it, gradually maybe but do it. Determine what the residual Medicaid obligation represents as a percentage of local sales tax revenues and transfer both the local Medicaid liability and the percentage share of sales tax revenues from local governments to the State. Perhaps this should be done incrementally and completed at the same time as local Medicaid staff are transferred to State employment, but do it. This might also be combined with reform of the current process of requiring State approval of local sales tax rates changes, even temporary ones. Create a permanent upper limit that’s the same for every county, while incorporating the transfer of the Medicaid liability.

  • Cash Assistance. Here too, with programs like TANF and Safety Net (New York’s general assistance program for clients that do not qualify for Federal aid), the Federal and State expenditures considerably outweigh the counties’. Here also, we find an increasingly standardized, increasingly computerized program that could be well operated directly by New York State, as is the case with most states. Why, for heaven’s sake does Hamilton County, with a population of less than 5,000 need to have its own, separate Department of Social Services?
  • Probation. Unlike the programs above, the State contributes less than half of total costs. There are still program requirements that leave counties with less than full discretion. For example, local probation directors, must be in specific State Civil Service titles are the positions are competitive rather than exempt. So local officials have even less discretion in appointing local probation directors. However, probation is operated in parallel to the State’s parole program. They are used at different times in the criminal justice process, but they are not fundamentally different. Any good reason not to integrate them at the State level?
  • Nursing Homes and Home Care Agencies. Regardless of what happens to county government, get counties out of the business. Period.
  • Mental Health and Substance Abuse Services. This one’s a bit trickier than nursing homes and home care, but one that could be figured out nevertheless. Let me tell you a little story to illustrate why. OASAS, New York’s substance abuse program, “operates” some programs through county agencies, but in a manner which I always found bizarre in its extra complexity and expense. OASAS selects private organizations to provide services of a particular type. They notify the counties in which those services are to be provided and, in effect, order the counties to contract with those agencies. Then they pay the counties 100 percent of the program expense. So counties are merely a conduit. Of course, when acting as the conduit, the counties must incur extra administrative expenses, for which they are not paid. And it takes time, effort, and annoyance. Many, if not most of those contracts even require local legislative approval. Now pray tell me, why? If OASAS is going to bear the full program costs and if they’ve already chosen the providers, why don’t they just go ahead and contract directly? All this Rube Goldberg mechanism does is add administrative overhead to the system as a whole. And it adds no value at all to the process or service.
  • Jail, Local Courts, Sheriffs, District Attorneys, Indigent Legal Services, and Other Criminal Justice Functions. Without seeming to be too flippant about it, many of these functions can also be integrated with State or the functions of other local governments. Why, for example, should there be overlapping jurisdictions for Sheriffs and local police? Why should every county have their own model of indigent legal services (some have several)? Why not have regional jails, funded by the State? And on and on …

Now you might ask about public health, a function that’s increasingly important, but under-acknowledged and underfunded. However, it’s not a legally mandated service. Counties are not required by State Law to operate public health departments. When they don’t the State Health Department performs the key functions.

You can see where this is going, can’t you? We can go down the entire list of county functions, but you’ve been patient or tenacious enough to get this far. So let’s wrap it up.

Very quickly, we find that the real solution to “unfunded mandates” is eliminating county governments which is essentially what Massachusetts did in the late 1990s. It abolished all but a handful of county governments and, with some exceptions, it assumed direct responsibility itself.

Eliminating county governments would remove a huge, expensive layer of overhead from New York’s governmental functions. This alone probably costs us in excess of $2 billion. Of equal importance, because they are so intertwined, organizationally and financially, we cannot fully grapple with New York State government’s budget and operations without also dealing with and solving county governments.

The only reason for an alternative path, would be to regionalize what are city and town functions now. Of course, that would make county governments look quite different from what they look like now. The same results might also be accomplished by merging cities and towns.

What the “unfunded mandates” debate should really be about is whether we should maintain a pre-information age organizational structure for governmental services that are elsewhere administered directly by state governments. We don’t need three layers of government (or four if you consider villages as part of towns). We need two. State and local. Rather than continuing in an industrial – or even agricultural – age organizational mode, it is time for New York to seriously consider redistributing county responsibilities.

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NYC Hospital Merger

by John W Rodat on June 7, 2012

Here’s today’s big New York City hospital/health care story: NYU and Continuum take the first formal step toward merger.

Interesting that even the NYT and presumably they still use their old names, Beth Israel and St. Lukes/Roosevelt.

And where is that proverb from? “When elephants fight, the grass loses”? Or something like that.

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Last week, we noted that the Federal government wants some of its IGT money back. I’m not, not, not going to try to explain how this program works or why and how counties put up $.50 on one day and the next day their nursing homes get back $1.00. But during the recession, counties only had to put up $.42 or $.38 or some number lower than $.50 to get a dollar the next day. Turns out that some of those calculations were optimistic. So now the Feds want the difference back and it adds up to real money.

At the time of our last post, we provided some figures for those counties that would be hurt the most. Going back to State fiscal year 2006-07, these figures were based on a multi-year, multi-issue net calculation. For State fiscal years 2009-10 and 2010-11, this included in that net calculation an enhanced Federal Medical Assistance Percentage (FMAP), which is the basis for Federal Medicaid reimbursement. As it turns out, this enhancement may not yet have received final CMS approval (yes, indeed we keep talking about the uncertainty of IGT’s future).

So the total recoveries sought by the Federal government by the end of this month would be $46 million. Even if that’s not the final result, it would place a greater immediate cash burden on the affected counties.

Big immediate hits in absolute dollars?

  • Albany, $4.8 million
  • Broome, $2.1 million
  • Erie, $8.1 million
  • Monroe, $2.8 million
  • Nassau, $1.6 million
  • Niagara, $1.3 million
  • New York City, $5.7 million
  • Onondaga, $1.2 million
  • Orange, $1.0 million
  • Sullivan, $1.6 million
  • Westchester, $2.1 million

The relative effects on some of the smaller counties not listed here may be greater, but I haven’t yet had the time to figure that out. However, I should note two counties with smaller numbers. Contrary to what everyone else is doing, three counties are in the process of or seeking to build new nursing homes. In addition to Albany, they are Schenectady and Columbia Counties.

In addition to Albany’s required repayment of $4.8 million, Schenectady’s would be $672 thousand and Columbia County’s would be $249 thousand.

The central IGT issue is a dispute over whether the date of service or the date of claim should be used for the FMAP calculation. Historically, it didn’t make any difference because FMAP was stable. But FMAP was temporarily increased in the ARRA, the Federal stimulus during the Great Recession as a means of speeding funds to state governments. Had that not been applied to IGT at the worst of the recession, then county governments in New York that operate nursing homes would have had considerably less revenue to offset their nursing home losses.

So several points are worth adding to this discussion:

  • While it’s true that CMS has changed the interpretation of the rules at the end (not the middle) of the game, had they made their intentions clear earlier, then counties would have had much less money when they needed it most.
  • At least in Albany County, a number of local officials, most notably the County Executive, Dan McCoy, then the Chair of the County Legislature and the current Chair of the County Legislature, Shawn Morse, then the Chair of the Committee on Audit and Finance, were desperately trying to appear to have balanced the budget while avoiding layoffs. They took advantage of the higher IGT numbers then, in one case by simply faking it. So today, they may complain that CMS is changing the rules of the game, but they clearly benefited at the time. Live by the sword; die by the sword.
  • All of this is a reminder of how tenuous the IGT’s future is. It’s not likely to survive any significant Federal budget cutting, much less the long term.
  • If CMS reverses its decision, then some counties will lose and most will lose prospectively. So just asking CMS to reverse its position is a mixed bag financially and politically. Don’t expect all counties to like the idea. But asking for a waiver to take the new FMAP, but protect the losers costs the Federal government even more.
  • The State’s hands are not entirely clean on this, but asking them to pick up the difference would be risking their role as intermediary negotiating with the Feds for IGT. The State has been willing to help with IGT precisely because it doesn’t cost them any cash. Change that formula and you not only take away their interest, you make it costly for them to be helpful to counties. Good luck with that.
  • Because of the way IGT is structured, county nursing homes get the revenue, but county departments of social services pay both the local and the State share of Medicaid costs. This expenditure is part of the county’s Medicaid payment to the State. Generally, that’s just an accounting convention, but financially it’s a wash to the county overall. However, there are exceptions when local facilities are operated as public benefit corporations (PBCs). In such cases today, the PBC that operates the nursing home gets to keep the revenue, but their related Counties still have to pay back the money owed to CMS. Those counties only have a cost with no benefit. This is one of the hazards of moving county nursing homes to public benefit corporations.

Full disclosure: I was personally involved in Albany County’s decision making on budget and IGT issues during the periods in dispute. We had no way of knowing at the time that CMS would change its interpretation and we were explicitly offered options by the State to change our claiming dates (within a fiscal year) and we chose to do so. Under the circumstances, I have no regrets at all about the decisions we made.

Also in the spirit of full disclosure: At the time that I was involved in Albany County budget and IGT decisions, those same Albany County officials, now the County Executive and the Chair of the County Legislature, were accusing me and County budget staff of artificially decreasing revenue estimates (read that as “lying”) to heighten the sense of crisis, lay it on the Albany County Nursing Home, and reinforce the argument that the Nursing Home be closed. I’ll admit to now being amused that those very same officials must now deal with the consequences of our increasing County revenues during the worst of the recession. Like I said, I have no regrets at all about the decisions we made.

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Despite intense objections, the Essex County, NY Board of Supervisors has voted 12-6 to sell its nursing home, Horace Nye. The 100 bed facility loses about $2 million per year. The sale price is $4.05 million.

Essex County is also seeking an increase in its sales tax rate (from 3.75 to 4.0 percent). Mere coincidence?

Essex is selling to Centers for Specialty Care Group, which is also the leading contender to buy Orange County’s nursing home, Valley View Center. The Orange County Legislature has not made a final decision, but the Executive has threatened that further delays will lead to closing admissions and filing a closure notice and plan with the State Health Department.

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Taking care of bicyclists is better for economic development? At least in cities

Far and away, the biggest reason business owners resist the addition of bike infrastructure is that they’re afraid it will limit parking. Once they realize they can get 12 bike parking spaces for each car spot, sometimes they begin to change their tune. Even better, they begin to discover that cyclists can be their best customers. “We tend to shop closer to home and shop more often,” said April Economides, a consultant who helped the city of Long Beach, California build bicycle-friendly business districts. Rather than jumping in the minivan and heading to the suburbs to go to the big shopping malls, cyclists patronize the businesses in our neighborhoods.

Easier to stop and spend a buck too.

Makes sense.

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The Health Care Cost Institute has released a new report, but which is still another reminder of why we cannot afford the US healthcare system. Last week, we pointed to a study that showed increasing dissatisfaction and increasing prices.

The 2010 HCCI Health Care Cost and Utilization Report is the first report of its kind to track changes in expenditures and utilization of health care services by those younger than 65 covered by employer sponsored, private health insurance (ESI). This report assesses the levels and changes in prices and utilization (including changes in the mix of services) focusing on 2009 and 2010.
This report is also the first of what will be an ongoing series of reports from HCCI. Future reports will provide updated numbers as they become available and focus on additional aspects of health care costs and utilization.
Key Findings from this Report

  • Per capita health spending among people under 65 is growing moderately, up 3.3 percent from the previous year but still nearly three times the rate of general inflation.
  • Higher spending was mostly due to price increases, rather than changes in the use of health care services: Prices for hospital admissions, outpatient care and prescription drugs all grew at a much faster rate than general inflation in 2010.
  • Health care spending grew fastest among those who are 18 and younger.

Here’s an excerpt of a summary from Dr. Aaron E. Carroll, an associate professor and vice chair of health policy and outcomes research in the department of pediatrics at the Indiana University School of Medicine:

The average under-65 American covered by employer based insurance spent $4,255 on health care in 2010 (from all sources, including premiums and out-of-pocket payments). Older Americans spent much more than younger Americans, as those between 55 and 64 years spent an average of $8,327. But even those under 18 years of age – kids, who are supposed to be cheap and healthy – spent an average of more than $2,000 each in 2010. That’s staggering.

What accounts for this? Well, it turns out that care in America is extremely expensive. The average inpatient admission to the hospital cost $14,662 in 2010. If you were admitted to the hospital for a surgery, the average cost was $27,100. The average newborn delivery – if things went well – cost $7,371. Instruments like cost sharing and high deductible health plans that are designed to empower consumers lose much of their appeal when confronted with numbers like these. If you have a baby, or need to go to the hospital just once in a year, you’ve likely already spent as much as allowed out-of-pocket, meaning that any cost-sharing incentives to reduce spending are gone.

Moreover, it appears that prices, not utilization are the cause of increases in spending.

Between 2007 and 2010, overall utilization trends were stable or went down. Inpatient admissions went down more than 3% from 2009 to 2010. You can’t blame increased spending on longer admissions as the length of stay didn’t go up that year. Outpatient visits, including those to emergency room visits and outpatient surgery centers, also declined by more than 3% from 2009-2010. Even outpatient radiology services went down 2.7% from 2009-2010. The use of prescription drugs went up slightly overall (0.9%), but this was mostly in generic prescriptions (up 2.5%), not brand name drugs (down 3.9%).

Prices are going up, while utilization is going down. This can’t even be accounted for by the intensity of care.

As we’ve said before and will say again and again …

If you want to understand what is happening in healthcare and if you want to anticipate what will be happening, then the single most important measurements to track are overall healthcare spending, the carrying capacity of the economy that’s paying for it (whether family, regional, employer, governmental, or macro-economic), and their relationships to one another. With healthcare cost growth rates exceeding economic growth rates, the larger the gap between growth rates in healthcare spending and economic capacity, the closer the day of reckoning.

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