NM HSD Tribal Consutlation "Centennial Care" presentation 07/30/12

There is the link to the Presentation that HSD gave to tribal leaders at the last Tribal consultation at Dancing Eagle Casino.  The document is also on HSD's main Site www.hsd.state.nm.us



http://www.hsd.state.nm.us/Medicaid%20Modernization/index.html

ABQ Journal Article "Medicaid a Broken System That Can’t Withstand More Pressure"

A different look at Medicaid.

http://www.abqjournal.com/main/2012/08/05/opinion/medicaid-a-broken-system-that-cant-withstand-more-pressure.html


Medicaid a Broken System That Can’t Withstand More Pressure
By Joe Montes / N.M. State Director, Americans for Prosperity on Sun, Aug 5, 2012
 
Carol Vliet was 53 years old when she discovered her cancer had returned and spread to her brain, liver, kidneys and throat. With her life on the line, she turned to her primary care physician, who had monitored her health for the past two years.
But shortly after consulting with her doctor, she was devastated to learn that his practice was no longer accepting Medicaid patients. She would have to go elsewhere for treatment.
Unfortunately, Carol’s predicament isn’t unique among those covered by Medicaid. Over the years, Medicaid patients have suffered from dropped coverage, denied care and poorer health outcomes – sometimes placing patients in worse situations than those encountered by the completely uninsured.
Ultimately, Medicaid is a broken program.
When politicians speak of Medicaid, it’s often in glowing terms. Sen. Jeff Bingaman recently said in a statement that Medicaid stands to “improve the quality of life for many New Mexicans” and, when part of Medicaid was reauthorized, New Mexico Rep. Martin Heinrich called it “the change the American public wants and the change our children deserve.”
But if these politicians had to live with Medicaid, they’d certainly get a reality-check. Being covered under Medicaid isn’t a picnic.
One of the primary difficulties with Medicaid coverage is that fewer health care providers are accepting Medicaid patients. The New England Journal of Medicine published a study last year that showed that two-thirds of children on Medicaid are denied appointments to deal with serious medical conditions (compared with 11 percent of privately insured children).
Now nearly three in 10 physicians across the nation will not accept Medicaid patients.
Doctors aren’t refusing to take Medicaid patients out of cruelty. Many have admitted to feeling guilty over refusing these patients and have put off denying care for as long as possible. But, ultimately, accepting Medicaid has been costing health care providers just too much.
Currently, Medicaid reimburses doctors only 55 percent compared with private insurers. Moreover, those payments are often below the actual costs of providing the health care (meaning physicians lose money on every Medicaid patient).
This simply is not sustainable for any length of time.
Even for those patients who can find doctors that accept Medicaid insurance, studies have shown that they often receive worse care than those with private insurance and even, sometimes, those who are uninsured. A study published by the University of Virginia found that the mortality rate among surgical patients on Medicaid is 97 percent higher than those with private insurance and 13 percent higher than those uninsured.
If this is life with Medicaid currently, we have to ask ourselves – what will life be like if New Mexico implements the Medicaid expansion called for in President Obama’s health care reform? How many more doctors will decide to close their doors to all Medicaid patients when more than 200,000 new enrollees are added to the program in our state? How many more Carol Vliets will it take before our politicians see that Medicaid can’t withstand the strain of additional enrollees served by a diminishing pool of medical professionals?
Additionally, as more and more Americans join Medicaid, the costs for states and the federal government skyrocket.
And while some call this expansion the “deal of a decade,” because the federal government would pay the full cost for the first three years, either way, the average taxpayer is paying for it. Keep in mind, the same source of money on the federal level is the same source of money on the state level: the taxpayer.
New Mexico’s portion after the initial three years of Medicaid expansion could exceed $200 million.
Expanding a broken, overstretched program is not the right policy for New Mexico. Instead of breaking budgets and subjecting more New Mexicans to a broken health care system, Gov. Susana Martinez should pressure Washington for real, patient-centered reform.
This just simply isn’t “the change our children deserve.”
Americans for Prosperity is national conservative political advocacy group that promotes economic freedom.

NHELP "50 Reasons Medicaid Expansion is Good for Your State"

Here is a very informative document regarding the Medicaid Expansion

NHELP
National Health Law Program

50 Reasons Medicaid Expansion is Good for Your State
Prepared by Jane Perkins
August 2, 2012
http://www.healthlaw.org/images/stories/2012_08_02_50_reasons.pdf

Medicaid Expansion and States
: 1. The Medicaid Expansion is an exceptionally generous deal for the states. States will receive 100% federal funding for the expansion population for the first three years, to be gradually reduced to 90% thereafter. Between 2014 and 2022, a fully implemented Medicaid Expansion will cover 17 million lower-income people while increasing direct state Medicaid spending by only 2.8% more than if health reform had not been enacted.
1 These figures do not reflect savings that will be produced elsewhere as the ACA is implemented (see below). When these savings are factored in, states are expected to save an estimated $101 billion from 2014-2019.2
2. The Medicaid Expansion will generate savings for some states’ Medicaid programs. Between 2014 and 2019, a few states will save money by making the Expansion: HI, ME, MA, and VT. Other states will experience an increase of less than 1% in their state Medicaid spending, including AZ, DE, DC, NY, ND, SD, WI and WY.3
3. The Medicaid Expansion will help free up state and local spending that now goes to uncompensated care. State and local governments help offset the cost of care that is provided to uninsured patients who cannot afford to pay—paying an estimated 30% of the cost of uncompensated care. The ACA will roughly halve state spending on uncompensated care, generating savings of $26-$52 billion.4
4. The Medicaid Expansion will reduce state spending on mental health services for lower-income, uninsured patients. This includes spending on state mental hospitals, hospital emergency rooms and community health clinics. This spending has been growing over time, with state and local governments covering 42% of the cost of state mental health expenditures by 2009.5 Full Medicaid Expansion is estimated to save between $11 and $22 billion in funds states will otherwise spend on mental health programs from 2014-2019.6
5. The Medicaid Expansion will enable states to continue using health care provider assessments as part of their state matching funds. Although federal Medicaid funding to states is open-ended (i.e. a state entitlement), it is limited by a states’ ability to raise its matching share. Some states have taken advantage of federal provisions that place assessments on hospitals and other health care providers that are then used to match (and draw down additional) federal dollars.7 Without the Medicaid Expansion, hospitals and other providers may be unwilling or www.healthlaw.org 2 unable to pay these assessments, resulting in the loss of federal funds and a negative impact on state and local governments. 　
unable to pay these assessments, resulting in the loss of federal funds and a negative impact on state and local governments.

6. The Medicaid Expansion will avoid costs associated with transitions and churning. As individuals change jobs or fall in and out of work, income and eligibility for health insurance coverage fluctuate. Medicaid Expansion will provide stability in coverage; for example, individuals whose income moves them above 100% of the poverty line can remain in Medicaid and thus with the same providers.8 Stability in coverage means lower administrative costs. Stability in coverage improves continuity of care and the health care provider’s ability to provide good care.9 The ACA includes numerous options for state Medicaid programs to improve continuity of care; expansion will allow the affected populations to take advantage when a state elects these options.10
7. The Medicaid Expansion will keep residents’ federal taxes flowing into the State. Almost every state resident pays federal taxes, and federal dollars will fund the Medicaid Expansion. Taxpayers residing in states that do not implement the Expansion will be paying out dollars to states that do expand, states like CA, CT, CO, DC, MN, MO, NJ, WA, which have already obtained approval for Medicaid Expansions.11
8. The Medicaid Expansion could help avoid work force flight. States could lose valuable members of the work force, as some low-income working adults will move to states that are making Medicaid coverage available.

9. The Medicaid Expansion will attract managed care to the state. Medicaid managed care companies are experiencing some of the fastest growth among U.S. managed care firms. They are aggressively seeking to move into states that implement the Medicaid Expansion, as states have been actively seeking to move more of their Medicaid populations into managed care.12 States that do not implement the Medicaid Expansion will lose this population group as part of their business and bargaining strategy.
10. The Medicaid Expansion will have a deep and broad impact on the state economy. New federal Medicaid dollars will travel through the state economy, improving employment, labor income, and capital income. New federal dollars will turn over multiple times in the state economy (for example, from physician to employee to grocer).
13
11. The Medicaid Expansion will generate revenue. State and local revenues will increase when state residents pay income, sales, and other taxes generated by the federal funding for the Medicaid Expansion, which in some states will offset much, perhaps all, of the additional costs.14 These increased state income taxes are a major factor in the Arkansas Department of Human Services’ estimate that the Expansion will save the state $372 million in the first several years.15 Medicaid Expansion and Health Care Providers:
12. The Medicaid Expansion will help hospitals caring for a disproportionate share of low-income and uninsured people. Many community and public hospitals have been receiving enhanced federal funding, called Medicare and Medicaid disproportionate share hospital (DSH) funding, to compensate them for some of
www.healthlaw.org 3 　
the costs associated with treating large numbers of the uninsured. On the assumption that the number of uninsured people will fall dramatically beginning in 2014 when the individual mandate and Medicaid Expansion take effect, the ACA decreases DSH payments.16 In states that do not expand Medicaid, the need for uncompensated care may remain relatively stable, while the amount of DSH funds that can be used to subsidize some of that care will fall substantially. This may result in severe financial hardship for hospitals, meaning that they will increase costs to paying patients or provide less uncompensated care.
13. The Medicaid Expansion will reduce use of costly hospital departments. Uninsured people often cannot find a regular source of care and depend on hospital emergency departments for emergency and non-emergency care. Emergency room care is expensive. By contrast, once people get Medicaid, they use the hospital emergency department at the same rate as people who have private insurance for both emergency and non-urgent care. As with the privately insured, most of the Medicaid visits to the emergency room are for urgent or serious issues.
17 Fewer people in ERs means less waiting time for people with real emergencies, which includes everyone regardless of income.
14. The Medicaid Expansion could help safety net and low-profit margin hospitals keep their emergency departments open. From 1990 to 2009, the number of hospital emergency departments in non-rural areas declined by 27%.
18 Medicaid funding for uninsured patient care could help emergency departments open.
15. The Medicaid Expansion will be a source of revenue for hospitals, regardless of what the Independent Payment Advisory Board decides. The ACA establishes the Independent Payment Advisory Board, which must propose measures to reduce Medicare spending in years when spending growth will outpace target growth rates. The proposals cannot ration care, raise revenue by increasing beneficiary cost-sharing or reducing services, and until 2019 cannot reduce some provider (e.g. hospital) payment rates.
19 In years when the targets are not met, the IPAB’s proposals to reduce Medicaid spending could mean that hospitals will face even deeper cuts in states that do not implement the Medicaid Expansion.
16. The Medicaid Expansion will benefit community health centers. Federally funded health centers are the main source of primary care for medically underserved populations. The Expansion will enable these centers to expand capacity to serve the uninsured as well as those newly covered by Medicaid. Fully implemented by the states, the Medicaid Expansion will allow health centers to reach approximately 19.8 million new patients. Without the Expansion, health centers’ new patient care capacity will be reduced by nearly 27%, a 5.3 million drop in new patients.
20 Medicaid Expansion and the Residents of the State:
17. The Medicaid Expansion will significantly reduce the number of uninsured adult residents, particularly in southern states, where, on average, a 50% reduction will occur.
21
18. The Medicaid Expansion will help stop the deterioration in health access that nonelderly adults have been experiencing over the last decade. Their likelihood www.healthlaw.org 4 of having a usual source of care and having an office visit have all declined while the likelihood of having an emergency room visit has increased. Nonelderly adults were 66% more likely to report having unmet medical needs in 2010 compared to 2000. Uninsured adults experienced the most dramatic declines. By comparison, children experienced increased coverage through Medicaid and CHIP over the decade and by the end of the decade were more likely to have a usual source of care and office visits.22 　
of having a usual source of care and having an office visit have all declined while the likelihood of having an emergency room visit has increased. Nonelderly adults were 66% more likely to report having unmet medical needs in 2010 compared to 2000. Uninsured adults experienced the most dramatic declines. By comparison, children experienced increased coverage through Medicaid and CHIP over the decade and by the end of the decade were more likely to have a usual source of care and office visits.22

19. The Medicaid Expansion will reduce adult death rates. In states that have already expanded Medicaid, mortality rates have been reduced significantly. Death rates were the greatest among adults between the ages of 35 and 64 years, people of color, and residents of low-income counties. Adults also experienced significant reductions in delays getting health care due to cost. Comparable states that did not expand Medicaid did not have similar results.23 A report in Tennessee concludes that expanding Medicaid coverage to 225,000 people would save 9 lives in the state every week for the next 10 years.24
20. The Medicaid Expansion will improve the financial security of the state’s residents. Tracking of Oregon’s Medicaid expansion to uninsured adults found the coverage reduces by 40% the probability that people report having to borrow money or skip payments on other bills because of Medicaid expenses. It decreases by 25% the probability that they will have unpaid medical bills sent to a collection agency.25
21. The Medicaid Expansion could reduce the growing role of health debt as a cause of personal bankruptcy. The financial security brought about by the Medicaid Expansion can lead to reductions in bankruptcies. Medical debt factors into fully 62% of all bankruptcies-up from contributing to 46% of bankruptcies in 2001.26
22. The Medicaid Expansion will allow access to health services for the state’s residents working in low pay jobs. Medicaid Expansion will provide access to health care for these workers. If these individuals remain uninsured, the costs of their illnesses and injuries will continue to be shifted onto privately insured state residents. As Congress noted when it enacted the ACA, this "cost shift" is now raising family health insurance premiums, on average, by over $1,000 per year.27
23. The Medicaid Expansion will help ensure a healthier workforce for employers of low-wage workers, including states that are employing large numbers of low wage state employees. Improved health decreases absenteeism, which in turn increases productivity.28
24. The Medicaid Expansion will provide coverage for working persons who lose their jobs through no fault of their own and cannot afford to continue with their employer-based insurance coverage because the COBRA premiums are unaffordable.29
25. The Medicaid Expansion is critical for women. Compared with other countries (e.g. Germany, Australia, France, Canada, UK), more women in the U.S. report that they cannot get care because of cost. Fully 77% of uninsured women aged 19-64 experienced cost-related access problems.30 In 2010, 55 percent of the 19 million currently uninsured women in the U.S. had incomes low enough to qualify for coverage under the Medicaid Expansion.31 The Expansion will produce a significant reduction in the number of uninsured women aged 16-64 in each of www.healthlaw.org 5 　
the 50 states.32 Expansion will offer a strong benefit package to women because it will include at least all of the benefits offered in the exchanges, including maternity and preventive services and family planning benefits.33 26. The Medicaid Expansion will avoid discrimination against people with mental health disabilities. When it enacted the Expansion, Congress included a provision that requires newly eligible individuals to receive mental health and substance use services at parity with other benefits.34
27. The Medicaid Expansion will help individuals with mental illness. Approximately one in six currently uninsured adults with income below 133% of poverty has a severe mental illness. Many others have less serious mental health conditions.35
28. The Medicaid Expansion will help homeless individuals. Half of the newly eligible individuals have incomes at 50% or less of the poverty line. Many of these very-low income people are homeless, and approximately ¼ of them have a serious mental illness.36 Medicaid Expansion will mean more comprehensive care for these individuals, allowing them to obtain chronic care management and preventive services. Medicaid will allow the state to leverage numerous service options, such as health homes, to provide these new beneficiaries with care management services linked to supportive housing.37
29. The Medicaid Expansion will help the LGBT community. Unemployment and poverty are higher for LGBT individuals than for the general U.S. population (an estimated 14% of LGBT individuals earn less than $10,000 per year, compared to 6% of the general population).38 As a result, a significant proportion of LGBT adults will be likely benefit from the Medicaid Expansion.
30. The Medicaid Expansion will link adults with chronic and disabling conditions to health care, including individuals who do not qualify for Medicare because of that program’s two-year disability waiting period.
39
31. Medicaid Expansion will allow access to health services for low-income Veterans, covering about 650,000 of the 1.3 million currently uninsured Vets. Texas, Florida and California have the most uninsured veterans, with the highest number in Texas.40
32. The Medicaid Expansion, while targeted to adults, will actually help children. In the typical state, parents lose eligibility for Medicaid when their incomes reach just 63% of the federal poverty line (approximately $12,000 for a family of three in 2012). Medicaid Expansion will increase coverage for parents; thus, their health status is expected to improve. When parents and caretakers are insured, their children are more likely to be insured and to make more effective use of their coverage. Coverage of parents also improves continuity of children’s coverage and reduces the likelihood of breaks in coverage.41 Children coming onto Medicaid will be eligible for the program’s tailored child health benefit package, Early and Periodic Screening, Diagnosis and Treatment.42
33. The Medicaid Expansion will ensure that low-income parents are not punished when they move more fully into the workforce. By contrast, in states that do not expand, low-income parents may avoid increasing their work time because they need to maintain Medicaid coverage for their children.

34. The Medicaid Expansion will increase access to and use of health care by people of color. If implemented as written, the ACA is expected to cover 32 million www.healthlaw.org 6 Americans. Half of the 32 million will come into the health care system through Medicaid, and three out of four of those individuals are people of color.43 　
Americans. Half of the 32 million will come into the health care system through Medicaid, and three out of four of those individuals are people of color.43

35. The Medicaid Expansion will reduce healthcare costs by reducing health disparities. Between 2003 and 2006, more than $200 billion could have been saved in direct medical care expenditures if racial and ethnic health disparities did not exist. Since the lack of insurance is a contributing factor causing health care disparities, expanding Medicaid to provide insurance can save money.

36. The Medicaid Expansion will help slow the spread of HIV/AIDS by allowing individuals to obtain testing and initiate treatment sooner, which can help prevent the transmission of HIV. Currently, nearly 30% of people with HIV are uninsured, and up to 59% are not in regular care.44 Existing programs for low-income people with HIV/AIDS, while effective, have been increasingly strained as their budgets decrease while demand grows. For example, nine states currently have waiting lists for joining an AIDS Drug Assistance Program (ADAPs). Most low-income people living with HIV have to wait until the onset of a life-threatening opportunistic infection to qualify for Medicaid on the basis of disability. Expanding Medicaid to individuals living with HIV, but who have not yet progressed to AIDS, will not only keep those individuals healthier longer, but will help reduce the number of new infections in the future.
37. The Medicaid Expansion will ensure that 11.5 million people—the poorest of the poor—are
not left out in the cold. Under the ACA, individuals with incomes below 100% of the federal poverty line will not be able to obtain premium tax support for insurance products available through the exchange.
45 These individuals are likely to remain uninsured if states do not expand Medicaid.46
38. The Medicaid Expansion will provide tailored coverage for lower-income people, including coverage that is particularly relevant to adults and couple, such as family planning services and supplies, and to individuals with chronic conditions, such as prescriptions and home health care.47
39. The Medicaid Expansion will ensure that enrollees help pay for their health care while maintaining affordability, by allowing nominal copayments for individuals with incomes below the poverty line while capping cost-sharing at five percent of monthly income.48
40. The Medicaid Expansion means jobs. The Expansion would bring over 7500 jobs to Tennessee in 2014 alone;49 in Maryland, 9,122 jobs in FY 2014 alone (and nearly 27,000 jobs in FY 2020).50 Following the increase in the federal Medicaid matching rate in the American Recovery and Reinvestment Act, one estimate from Illinois found the Medicaid program supported as many as 385,742 jobs and generated wages as high as $15.8 billion during FY 2009 alone.51 Medicaid Expansion and Efficiency and Fairness:
41. The Medicaid Expansion is an efficient way to cover this group of low-income individuals. The Expansion merely requires addition of a new coverage group to Medicaid’s existing market-based benchmark coverage options. It does not require a new insurance program to be designed and a new bureaucracy to be
www.healthlaw.org 7 created. Addition of this population group will increase the bargaining power of the state with health plans and providers. 　
created. Addition of this population group will increase the bargaining power of the state with health plans and providers.

42. The Medicaid Expansion will extend a highly successful health insurance program that every state has aggressively implemented over the years. Every state has extended eligibility and/or services beyond the minimum coverage requirements of the federal law. At this point, more than 60% of current Medicaid funding covers optional population groups and services that no state is required to cover. In some states, the uptake of optional spending has been particularly dramatic, for example: 76.5% of expenditures in North Dakota are attributable to optional spending; 74.7%, in Ohio; 74% in Wisconsin; 69.4% in Iowa.52
43. Medicaid is efficient. The per enrollee cost growth in Medicaid (6.1%) is lower than the per enrollee cost growth in comparable coverage under Medicare (6.9%), private health insurance (10.6%), and monthly premiums for employer-sponsored coverage (12.6%).53
44. The Medicaid Expansion and ACA will produce cost savings to states even as individuals who are currently eligible but not enrolled in Medicaid come forward to enroll. Some states are concerned that the federal government will not really be paying the entire bill in the first three years because individuals who are already eligible for Medicaid will take advantage of the coverage "welcome mat" and "come out of the woodwork" to enroll. The states will receive their regular federal matching funding for these already-eligible individuals. The estimates of state costs (see #1 above) already include the costs associated with these potential new enrollees who are currently eligible. Equally important, the welcome mat effect will occur whether or not the state implements the Expansion. Beginning in 2014, the opportunity for uninsured people to purchase health insurance with federal subsidies will drive adults to insurance exchanges to obtain the health insurance, and upon arrival, their eligibility for Medicaid will automatically be determined—whether or not the state has expanded Medicaid.

45. The Medicaid Expansion represents fiscal responsibility and shared responsibility between state and federal government. It will be more efficient for all of the federal taxpayers who live in the state if individuals between 100-133% of the poverty line are covered through Medicaid rather than the exchange. The Congressional Budget Office has determined that the per capita cost of covering this population in the exchange will be $5,926 in 2019, as compared with $1,826 through Medicaid Expansion.54 Using these numbers, a state leaving the 100- 133% group to exchange coverage instead of a Medicaid Expansion would effectively be arguing that the Federal government should pay $5,926 per person, to save the state from paying $182.60 – the state’s 10% share of the $1,826 Medicaid cost. That leaves the government paying $5,926 instead of $1,643.40 – the Federal government’s 90% share of the Medicaid cost.
46. The Medicaid Expansion will mean that states’ spending of state and federal dollars for state program upgrades will not have been wasted. Beginning in April 2011, states could receive significantly enhanced federal matching funds (90% instead of the usual 50% administrative matching rate) to upgrade their eligibility systems and make them ready for the 2014 expansions. The majority of states have approved (19 states) or submitted plans (10 states) to overhaul or build
www.healthlaw.org 8 1 January Angeles, Center on Budget and Policy Priorities, How Health Reform’s Medicaid Expansion will Impact State Budgets (July 12, 2012) (discussing CBO estimates). 2 The Lewin Group, a frequent consultant to state Medicaid programs, estimates savings of $101 billion. See The Lewin Group, Patient Protection and Affordable Care Act (PPACA): Long Term Costs for Governments, Employers, Families and Providers (June 8, 2010) (Working Paper #11); see also Matthew their systems.55 If a recipient state refusing now to implement the Expansion, it will have made an inefficient use of taxpayer funds.
47. The Medicaid Expansion merely echoes what a number of states had already
obtained Medicaid funding to do. States have already obtained approval from the federal government to expand their Medicaid programs to uninsured adults—at the current, rather than Expansion, federal matching rates. By 2008, 18 states had already received federal permission to extend this coverage, including Arizona, Idaho, Indiana, Maine, Michigan, Tennessee and Utah.56
48. Successes in the states illustrate the value of the Medicaid Expansion. The success of health reform in Massachusetts demonstrates that making health care coverage available for most everyone, as would be accomplished by full implementation of the ACA—i.e. with the Medicaid Expansion—is the key to successful reform. The Commonwealth Care program provides health care insurance without premiums to all adults up to 150% of the poverty level. Combined with other aspects of health reform in Massachusetts, this has resulted in 439,000 more Massachusetts residents having health care coverage compared to before reform, with 98.1 % of residents now having coverage, the highest rate in the country.57 Medicaid Expansion and the Law:
49. State law may require the State to implement the Medicaid Expansion. For example, an Arizona law requires the Director of the State Medicaid program to ensure that sufficient funds are available to provide Medicaid benefits to "all persons" whose incomes are at or below the federal poverty, to be supplemented "as necessary, by any other available sources including … federal monies."
58 An Alaska law says that "[a]ll residents of the state for whom the Social Security Act requires Medicaid coverage are eligible to receive medical assistance" under Title XIX of the Social Security Act.59
50. It is the law. While the Supreme Court found that a state could not be "coerced" into implementing the Expansion, its full remedy was to "limit[] the financial pressure the Secretary may apply to induce States to accept the terms of the Medicaid Expansion."60 Thus, the Expansion population is still listed in the Medicaid Act as a group that the state "must" cover.61

Continued comments Centennial Care and consultation

Continuing on my comments on the Tribal Consultation on July 30th at Dancing Eagle Casino:

Having searched the HSD website again today I still have not beena ble to find the new version on the 1115 Waiver "Centennial Care" or the presentation that HSD presented to Tribal Leaders last Monday.  Of course Sec. Squir and Julie Wienberg did say that the waiver would not be avaliable to view by the public until after they submitted it to CMS in mid August.

Going off the limited inforamation that we do have from the slide presenation I will start with slide 2 :
Opperational/ Implemenation Time Line

According to the slide HSD submitted the Waiver on April 25, 2012 to CMS and will submit updated by mid August 2012?  This is where I have and issue with HSD.  For those of you that do not know there was a couple of news articles regarding the Waiver submission to CMS and the fact that both NM and Kansas wrote to CMS asking them to volunteeraly resend their waivers because they will have a hugh affect on Tribes and that they needed to have more tribal consultation.  I am looking for my copy on this letter if any one has it please forward to me or post it.  We first heard this from non-native health advocates and then confirmed it from a member of US HHS Sec Sebelius STAG.

Since these articles and statments were made public HSD has stated on several instances that "NO CMS DID NOT REJECT the WAIVER" and then "WE are voluntarily pulling back the waiver to get more PUBLIC input" and " WE DID NOT resend the waiver".  I would not question HSD as much if they were just honest about the situation.  The following letter is a respone to Govenor Madalena from Jemez Pueblo regarding the Waiver

My thoughts on State Tribal Consultation at Dancing Eagle hosted by Laguna Pueblo

Frist of all I would like to Thank Governor Luarkie for hosting the consultation, and the Governors/ Representative for attending and speaking clearly on behalf of Pueblos and Tribes.  I also would like to thank all of the other attendees for showing that we, Native American Indians, are not just going to smile and whatever the State chooses to give us.

the following is the comment paper written on behalf of the New Mexico Indian Council on Aging's Health Committee by Dr. Ron Lujan:

State Tribal Consultation and Collaboration

Dancing Eagle Casino

Pueblo of Laguna

July 30, 2012

The Health Committee of the New Mexico Indian Council on Aging (NMICoA) has followed NM Human Services Department (HSD)’s Centennial Care waiver proposal to the Centers for Medicare and Medicaid (CMS) since it’s unveiling earlier this year.  The Health Committee has these following concerns and issues with HSD’s attempts to have its 1115 waiver accepted by CMS.

·         HSD has not been transparent in properly informing and involving Tribes and Pueblos to input grassroots solutions and networking to inform HSD about possible problems incurred with developing strategic health planning from a unilateral perspective. The government to government process is still not evident in meetings attended by members.  Discordant information was presented at the NM Primary Care Association meeting and UNM Cancer Center meeting sponsored by the Navajo Nation.

·         HSD does not understand the sovereign status of Tribes and Pueblos of NM and the Federal responsibility

o   HSD needs to review Federal-Tribal policy and understand Tribes and Pueblos should be funded directly for their members who are enrolled in Medicaid

o   This allows a 100% Federal Medical Assistance Percentage (FMAP) funding for natives to obtain medical services at Indian Health Services (IHS), 638 facilities but more importantly, network providers who provide services not available at IHS/638 facilities.

o   Carve out of Medicaid funding to Tribes/Pueblos should be considered such that local facilities and service providers can benefit patients with case management, care coordination, transportation, personal care, respite care in a more intergraded fashion.

o   The health committee believes that the opt-out category should still be intact and the choice to enroll in Managed Care should remain with the individual Medicaid enrollee.

o   In the past, with the institution of the Salud program, Native Americans were mandatorily enrolled in Managed care.  This experience resulted in a loss of revenue to IHS and 638 facilities and confused the Native population. Currently approximately 80 % of Native Americans enrolled in Salud still opt-out of managed care in the face of enrollment efforts by the state and MCO’s

·         Managed care organizations need to involve Tribes/Pueblos early in the proposal process to allow Native programs and providers the opportunity to be included in strategic planning

·         The Health Committee also stands by its support of Tribal leadership and does not accept the State mandate for enrolling Natives into managed care.

·         Tribes and Pueblos should be allowed to develop their own system of care management which includes all on and off reservation providers which provide primary and secondary services. The State should allow Tribal/Pueblo programs and providers to be in these case managed systems with HSD collaboration to provide technical assistance such as getting billing, coding and reimbursement services, integrative systems need to be developed to track clinical, behavioral health and long term care services needs and documentation of non-duplication by service providers, and patients are not inappropriately utilizing Medicaid services.

In conclusion the Health Committee still believes the opt-out category should remain intact and if patients choose to enroll in managed care, it should be a personal choice.  The State needs to understand Tribal Protocol from the Tribal/Pueblo perspective and honor these protocols when meeting on reservation lands.  The Health Committee also believes that All Indian Pueblo Council (AIPC) resolution allows them to represent Pueblo elders and disabled members on matters of elder healthcare.

Respectfully,

Dr. Ron Lujan

For the NMICoA Health Committee

Now, having attended this and other consultations regarding this topic (Centennial Care) by the NM HSD, I have the following Statements, comments, questions:

How can these sessions be considered meaning full when Tribes have no advanced viewing of the material?  After searching HSD Web Site I have not found a current copy of the waiver or a copy of the Slide presentation that was given on on June 30, 2012.  How are Tribes who did not attend suppose to make informed decisions on Centennial Care without viewing these two Documents?

The waiver information that is posted on the HSD web site is the one that was submitted (and later resented) to CMS in February 2012.  The slide presentation that was given to Tribal leaders had a lot of new material  that is not part of the February version of the Waiver. 

I share Governor Madalena's sentiment regarding the state referencing data, that does not include Tribal data, that shows we have the worse health disparities and outcomes. 

All Tribes are still opposed to the Mandatory inclusion into Managed Care, the opt out category being taken away, charging co pays for any Medicaid Service regardless of where medicine is obtained, and getting rid of the prior quarter coverage.  The State believes that Enrolling Native American Indians in Managed care will elevate their health, but even though we have asked many times for the Data supporting the claims, NM HSD has not provided this information.  That is a claim being use across the country to advocate for managed care but there is no evidence that being enrolled in and MCO improves the individuals health, it does decrease state spending and increases MCO profits.

Even though the State HSD has come up with several new ideas to help entice Tribes into accepting Centennial Care, they still have not done their homework,  many of the incentives like, mini block grants, and paying a PM/PM for services provided by IHS and 638 facilities, would require Federal approval, IHS direct services Tribes would not be able to take advantage of them. 

These are just  a few of the concerns I have that we all should be taking into count.

I will be posting more comments and questions regarding Centennial Care as I analyze the current documents.

ABQ Journal OP-ED "Rep. Pearce Opposes Affordable Care Act"

Rep. Pearce opposes affordable care act

By Journal Staffon Fri, Jul 27, 2012

Why Repeal a Law That Benefits Us?

I DON’T LIVE in U.S. Rep. Steve Pearce’s district, but his op-ed column on the Affordable Care Act (Obamacare) gave me reason to pay attention to his campaign.

It surprised me the many things he had to say about the act, which is the sole reason I currently have insurance. I am covered under my mother’s insurance and am very grateful for it.
My own issues aside, I did a little investigating into Pearce’s rationale to repeal the Affordable Care Act. In Pearce’s opinion, the act is “causing layoffs, suppressing job creation, forcing employers to consider dropping coverage for employees and doing economic damage to communities and job creators across New Mexico,” but I need help to understand how.
The text of the Affordable Care Act does not require any business with fewer than 50 employees to purchase insurance at all. I have shopped at, serviced and even worked for small businesses in and around the Albuquerque area, and even the most well-off of these seem to have fewer than 20 employees. I am unclear why an act that requires nothing of them and provides financial incentives to provide insurance is causing them to reduce their workforce.
I can only conclude that other factors are to blame, and I am a little offended by Pearce’s insistence that this law that helps me so much is hurting people, statements for which he provides so little real evidence from the law itself.
REN PRICE
Albuquerque

The Old Gravy Train Finally Going Away
SOMEONE COULD evaluate Rep. Steve Pearce’s op-ed column of July 20 on the Affordable Care Act in one sentence that contains the words “Christmas turkey,” but I won’t go there.
The opponents of a bill tell you a lot about it. The ones who are so adamantly opposed to the health care act are those who benefit from the status quo. The benefactors are pharmaceuticals, insurance and portions of the health care industry.
Billions are at stake, and they are not giving up without a fight. The opposition to the ACA has not come up with any facts against it or proposed any logical alternative plan. Instead they have resorted to voluminous misinformation through conservative columnists and organizations such as the Rio Grande Foundation.
The Affordable Care Act and the Massachusetts health care program are based on a Heritage Foundation Plan that called for everyone to be covered by insurance. The Massachusetts system is going about as planned, is well liked and costs are near projections.
Pearce and the vast majority of conservatives profess hatred for the individual mandate. They have always preached individual responsibility. What is so different about this? For the plan to work, everyone has to be in it. …
The old system was the most expensive in the world, the dominant reason for bankruptcies, allowed 30,000 plus per year to die and was ranked 37th by the World Health Organization. …
I agree with Pearce on one thing: I also would like for Congress to look at the facts and act accordingly.
I guess it would be too much to ask conservatives to do the same thing.
LEON LOGAN
Tucumcari

Best Solution Is Easy: Single Payer
I AM A LOCAL businessman with more than 80 employees, and I pay 100 percent health insurance coverage for my employees and half for their families. Many have been with me for decades, and I believe they are the best.
In our system we use health benefits as the opportunity to recruit and retain the best staff we can find, but insurance should not be a benefit available to only the lucky few.
One of my key employees recently had an accident at home that will leave him out of work for a year and probably permanently disabled. This is a tragedy, but without insurance it would be a catastrophe. At most other businesses like mine in Albuquerque, he would be without help and without hope.
My problem is that some of my competitors — no doubt the gang beseeching Rep. Steve Pearce to protect them from the evils of providing health care to their employees — have a cost advantage over hundreds of employers who like myself value their employees enough to incur these costs.
And health insurance premium costs, whether paid for by employers or individuals, are significantly higher than the phony tax the congressman refers to — he knows there is no such tax on families in the law.
What is needed is single-payer national health insurance paid for by all citizens and available to all citizens. The Affordable Care Act builds on our existing system — as it stands, health care coverage for employees comes from their employers or they go without. This means those of us with insurance pay real “hidden taxes” in our premiums for those who don’t have coverage but use our health system when they have emergencies.
If Pearce is reconsidering this model and has concluded he does not support employer-based insurance, will he support single-payer instead? He might even get my vote if he does.
RICK THALER
Albuquerque

Status Quo Simply Isn’t Good Enough
I’M GLAD REP. Steve Pierce concludes his opinion by stating, “Congress has the responsibility to listen to the facts …” Well, here are a few.
In the two broadest and most accepted measures of the efficacy of any given health system, longevity and infant mortality, the United States ranks 50th and 34th, respectively. This is behind all of those “socialized medicine” countries such as England and Canada, and virtually all of Europe. This is in addition to the fact that in the U.S., the per capita spending on health care delivery is 40 percent higher than in the next highest country.
Anyone who has the capability to think for her/himself could only conclude that our historic system is at best broken, and at worst a significant fraud perpetrated on the consuming public.
Pierce and his political colleagues would have done better to offer specific fixes to the prior system which was obviously out of control, or at least to have gone along with the elements — most of them — of the Affordable Care Act that they originally developed and proposed over the last 20 or so years.
DAVID PAUL BLACHER
Albuquerque

Tell a Big Lie, And Keep Repeating It
IN REP. STEVE Pearce’s op-ed column on July 20 he claims that the average U.S. family or household will pay $4,700 a year in new taxes. This type of claim is often made by Republicans as part of their script for bashing the Affordable Care Act.
This claim is absurd and fails a simple sanity check. According to the Census Bureau, as of 2010 there were 116.7 million households in the United States. At $4,700 per household, the total new tax revenue would be $548 billion per year. That would eliminate half of the OMB’s estimated $1.1 trillion deficit for 2012.
This seems to be one of those political myths that Republicans hope if repeated often enough and loudly enough, people will believe without checking. If they actually believe this often-repeated claim, it suggests an unwillingness or inability to do the type of serious budget analysis, as opposed to ideological posturing, needed to solve our budget problems. If they don’t believe it and know it is not true, then we have a different, even more serious, problem.
Later I saw Journal business reporter Win Quigley’s article on how Pearce got his $4,700.
Pearce says that since the health care mandate penalty is a tax, then all health insurance premiums are taxes and this is the average number for New Mexicans. Calling a health insurance premium (as opposed to just the mandate penalty) a tax doesn’t make it one. …
To imply that these are new taxes is highly deceptive, but I guess that has become the norm for some campaigns. … Maybe political fraud or political malpractice should be criminalized. But I guess Congress wouldn’t pass it. Keep up the good work.
OLIN BRAY
Albuquerque

Serving Overlords Blindly Since 2002
U.S. REP. Steve Pearce should be in the pretzel-making business. It’s hard to find a pretzel as twisted as the statements he made in his specious Journal op-ed article.
Let’s start with the health fees he labels a “tax.” No one who has insurance will be charged an additional dollar. His “taxes” are actually a “penalty” for anyone who can afford health insurance but refuses to buy it.
Why? Because the costs of their care when they’re sick will need to be borne by the rest of us. …
Pearce also fails to mention the Affordable Care Act allows children under 26 to remain on family policies, or that 32 million more Americans will now finally “have” health care — care the nation’s insurance companies have been denying them for years.
Some 25,000 uninsured Americans die each year. That number should dissolve to nothing. …
Bad for the 99 percent of us? I don’t think so, Mr. Pearce.
What’s bad for us are politicians like you who espouse the dishonest claims of a party that’s beholden to the 1 percent.
DAVID PAULSEN
Santa Fe

Washington Post Article "Why Republican state leaders are resisting Medicaid expansion"

Why Republican state leaders are resisting Medicaid expansion

By N.C. Aizenman, Published: July 13 | Updated: Sunday, July 15, 5:41 PMThe Washington Post

The expansion of Medicaid called for in President Obama’s health-care law would seem an irresistible deal for states: Starting in 2014, in exchange for spending a percent or two more of their own funds, states will get nearly a trillion additional federal dollars during the next 10 years to extend health insurance to 17 million of their neediest residents.
So why are so many Republican state leaders balking?

Increasingly they speak of two experiences that, they charge, raise questions about whether the federal government can be counted on to hold up its end of the bargain: Congress’s decision not to fund a mandated increase in Medicaid pay rates for doctors beyond two years and Obama’s recent willingness to consider cutting the federal contribution to Medicaid.

The latter idea came up during Obama’s unsuccessful negotiations with House Speaker John A. Boehner (R-Ohio) toward a “grand bargain” to slash the deficit.

Obama suggested scrapping the system of varying rates at which the federal government reimburses states for insuring people through Medicaid — which is jointly financed with state and federal funds. Instead, Obama proposed using a single “blended rate” for each state that would have effectively reduced the total federal contribution to Medicaid by tens of billions of dollars in a 10-year period.
After an outcry from liberal groups, Obama scaled back the idea, including a version in his proposed 2013 budget that would reduce federal spending on Medicaid by less than 1 percent.

Still, Republicans now point to the episode as proof that, down the line, even Democrats could be open to making the terms of the health-care law’s Medicaid expansion less generous to states.
Under the law, if states adopt the new eligibility rules for Medicaid — opening the program to people with incomes of up to 133 percent of the federal poverty level — the federal government will initially pay almost the full cost of insuring those who are newly qualified.

“Today Washington may pay. But what’s going to happen when reality sets in and they realize they can’t continue to run up the nation’s credit card?” asked Joe Negron (R), a Florida state senator and chairman of the state’s budget subcommittee responsible for Medicaid. “I think ultimately there’s a very high likelihood that an additional burden will be placed on states.”

Edwin Park, an analyst with the liberal-leaning Center on Budget and Policy Priorities, noted that the 2013 budget adopted by the GOP-led U.S. House would not only repeal the Medicaid expansion but also reduce the current federal contribution to states by 22 percent in the next 10 years.
“They are the ones pushing the biggest cuts to Medicaid,” Park said. “They have been supporting huge cost shifts to states.”

Another point of contention is a provision in the health-care law intended to raise the historically low Medicaid compensation for primary-care doctors. Many doctors say they simply cannot afford to accept Medicaid patients, and beneficiaries must often travel long distances or endure substantial waits to get care.

The law mandates that, starting in January, state Medicaid programs must pay primary-care doctors the rate offered by Medicare — a generally far-higher rate. The federal government will pick up all the extra cost. But the mandated pay boost — and the $11 billion in additional federal funding for it — expires at the end of 2014.

At that point, congressional and state leaders will probably face pressure to keep the higher rates in place. Can Congress be relied on to renew the increase?
“I think most pragmatic state budget officers would say, ‘We cannot bank on that.’ And I think they are right,” said Matt Salo, director of the National Association of Medicaid Directors.
Here again, he and other state officials point to a previous experience that gives them pause.
In 1997, Congress adopted a new formula for setting the rates at which Medicare pays doctors. The formula was intended to prevent federal spending on doctors from growing faster than the economy as a whole. But the new arrangement soon became unworkable because mandated pay cuts were unrealistically steep.

To repeal it, Congress would need to come up with billions in savings to offset the resulting increase to federal spending. Instead, over the years Congress has adopted a Band-Aid approach, periodically postponing the cuts called for by the formula by a year or two — often after a round of eleventh-hour haggling that keeps doctors on edge.

Now some state officials worry the pay boost for Medicaid doctors will fall victim to the same dynamic. And they argue that because, in contrast to Medicare, Medicaid is partly funded by states, future Congresses could seek to pass the buck — essentially telling states that if they want to keep the higher pay rates in place they will need to start picking up the tab.

Salo said states would be hard-pressed to refuse.

“Certainly it would be a legal option,” he said. “But is that going to be a feasible decision to make at the state level, given the political leverage of hospitals and physicians? Once you giveth, it’s very hard to taketh away.”

Matthew Buettgens of the Urban Institute said that if state leaders are going to speculate about such downside scenarios, they should also consider the windfall in potential additional savings that states are far more likely to reap.

These include the likelihood that with so many of their uninsured residents gaining Medicaid coverage, states will be able to cut back on the millions they pay hospitals and doctors for providing uncompensated care.

Similarly, states that offer Medicaid to people with incomes above 133 percent of the poverty level could choose to eliminate that coverage and direct those individuals to buy private plans with federal subsidies that the health-care law will also provide, beginning in 2014.

In a study last year, Buettgens and his co-authors estimated the effect if both scenarios are taken into account. “Overall, when you factor in the savings, states would spend less under [the Medicaid expansion] than without it,” he said.

Buettgens cautioned that the effect would depend on how aggressively states choose to go after the savings and would not be evenly distributed across states. Florida, for instance, could see additional expenses ranging from $95 million to $2.4 billion from 2014 to 2019 — a few percentage points above what its outlay would have been without the expansion. For Texas, the result varies from savings of $554 million to extra spending of up to $2.4 billion. Total state spending would be reduced by between $23 billion and $49 billion.