Medicaid Cut Puts Schools in a Jam, Children With Disabilities and Others Disadvantaged at Risk

June 6, 2017

Our Secretary of Education seems still confused (charitable word) about our equal opportunity in education laws.

She was asked again in a Congressional hearing whether her department would deny federal funds to private schools with students who have vouchers her budget would pay for if they discriminated. And she said again she thinks that’s a choice for states to make.

But the Individuals With Disabilities Education Act is one of three major federal laws prohibiting discrimination in federally-funded education programs. And it’s by far and away the most specific.

Schools must assess children with disabilities and develop plans for each that will meet their unique needs, enable them to learn as much as they possible can of what’s expected of their classmates and in the “least restrictive environment,” i.e., by including them in regular classrooms and other such settings, except in special child-specific circumstances, rather than routinely segregating them.

States get federal grants to help defray their school districts’ costs. But that’s not the only source of funds they use. They tap Medicaid to reimburse them for the costs of screening and providing appropriate health services to their low-income disabled students.

They may also use Medicaid funds for the early and periodic screening, diagnostic and treatment services that the law entitles all enrolled children to. Their parents may not even know their children can get them until the school informs them and perhaps helps them apply.

Needless to say, I hope, the House Republicans and Trump administration plans to convert Medicaid to a block grant or set a per beneficiary reimbursement limit have school officials very worried.

A recent member survey conducted by the American Association of School Administrators tells us why, both in summary form and numerous personal responses.

Once the federal government shifts costs to states by whichever means, they foresee a losing competition with other institutions that rely on Medicaid funds, e.g., hospitals, doctors, other providers like the Federally Qualified Health Centers I wrote about.

States will have the flexibility to choose who’s eligible for their programs, what services they can receive and, as we now learn, time limits perhaps, work requirements, premiums they’ll have to pay or get kicked out of the program.

States may, AASA says, decide that school districts can’t get any Medicaid funds at all. But schools will still have to comply with the IDEA requirements. Where will that money come from?

A top line answer is that schools would lay off health professional staff and others with expertise in educating children with disabilities. Alternatively — or perhaps in addition to — schools would cut back on services for all students in so far as they legally can.

AASA and some members quoted cite mental health services in particular. About one in five children show symptoms indicating needs each year.

Neglect them and children suffer not only anxiety, depression and other effects due to trauma or toxic stress. Their academic performance suffers, setting them on the path to drop out when they’re teens.

Their abilities to control their emotional impulses, plan and manage their activities productively and relate well to others suffer too.

These so-called social and emotional competencies obviously give those that have them advantages in both their personal lives while young and long thereafter — and advantages that make getting and keeping a job every so much more likely.

Seems like a lot I know to pack into a post on only one — and hardly the most consequential — impact of what Trump’s roughly estimated $1.3 trillion cut to Medicaid funding would do — or even the House Republicans’ $839 billion.

But the well-being and futures of school-age children ought to matter to all of us. And as I said, it’s not only children with disabilities those cuts would put at risk, but all their peers.

Most at risk are the other educationally disadvantaged students for whom Title VI of the Elementary and Secondary Education Act—now called the Every Child Succeeds Act—aims to make the equal educational opportunity guarantee in the Civil Rights Act a reality.

Trump’s budget would increase ESSA by $1 billion, but channel the extra only to districts that promote parental choice.

It would also siphon off money from high-poverty schools by shifting each student’s share to any publicly-funded school s/he transfers to. And we know that’s not going to be another high-poverty school.


House Majority Denies Low-Income Seniors and People With Disabilies Choice of Living in Their Homes

May 12, 2017

Some followers may have noticed a long silence. I’ve just rejoined the networked world after another fall — this one, unlike the first, a complication of a complication of a condition only recently diagnosed.

As you might imagine, I’ve been dwelling on health care even more than I would have otherwise. So I was ready to launch a diatribe against major, widely-reported harms inflicted by the House repeal-replacement bill.

I’ll instead focus on another that a columnist for TalkPoverty.org ferreted out. It’s directly relevant to people in my condition, i.e., elderly and/or disabled, at least temporarily, but only those with incomes low enough for eligibility in their state’s Medicaid program.

The Affordable Care Act did more than aim to expand Medicaid eligibility nationwide. It also offered state incentives to expand Medicaid in-home services to the overlapping groups I cited above.

Among the most successful, says the TalkPoverty columnist is the Community First Choice program. It increases states’ usual federal match on their spending by 6% for services that will maximize recipients’ ability to continue living safely and as self-sufficiently as possible in their own homes.

They can receive not only help with so-called activities of daily living, e.g., bathing, eating, and health-related tasks like taking medications on schedule, but also training so they can master these tasks. They can also get equipment to assist them and training on how to use it.

Agencies may further support living at home by providing hands-on help with tasks like meal preparation, light housework and transportation.

Here’s a true win-win. We all, I suppose want to stay in our homes, assuming they’re safe and in relatively good repair.

We surely prefer living in our community to an institution where there’s no one we know and good care is far from assured. Perhaps also not one we know who cares enough and lives close enough to visit regularly.

Government agencies surely prefer this too. An in-depth AARP study found that Medicaid paid roughly three times as much for institutional care as for home-based services. The data are far from current, but there’s no reason to think the basic cost saving has significantly changed.

Another study — this one of a pilot project — found that Medicaid costs dropped by about $11,900 a year for every older adult transitioned from a nursing home back into his/her community.

The House bill would eliminate the CFC program in 2020, cutting an estimated $12 billion in federal Medicaid funding in the first six years.

It’s a minuscule fraction of the nearly the nearly $840 billion the bill would cut from Medicaid. But it would somewhat more than pay for the late-added funds states could use for high-risk insurance pools, if they opted to let insurance companies deny coverage because of pre-existing conditions.

You may have already read about this provision because it’s how the Republican leadership quelled colleagues’ well-grounded anxieties about eliminating the ACA’s guarantee against such discrimination.

People who’ve suffered injuries like mine would be vulnerable, of course. But we’re told that insurance companies have classified a wide range of conditions as pre-existing, including acne, transexuality, pregnancy and recovery from domestic violence or rape with help from therapy.

For this and other reasons, the high-risk pools probably won’t offer insurance that’s either sufficiently broad or affordable. We need only look to pools states established.

They surely won’t without a lot more money than the Medicaid shift, even if states also tap other, more broadly defined funding streams. Two conservative economists estimated the annual cost at $15-$20 billion — this back in 2010. The left-leaning Center for American Progress estimates at least $31 billion.

I’m inclined to think that some House Republicans who voted for the bill knew this, though, as we know for sure, House Speaker Ryan chose to rush it through, rather than wait for an official score from the Congressional Budget Office.

We can also, I think, be pretty sure that House Republicans know they passed a bad bill, from both the promised repeal and replace-with-something=better perspectives. They believe passing nothing would be worse, what with their valuing their re-election prospects more than their constituents’ well-being.

Happily, the Senate will start from scratch and clearly intends to take as much time as the drafters (all Republicans) feel they need.

So the story’s far from over. But broad-based research and advocacy organizations—and the rest of us interested parties—need be less focused on this one hot issue, when there are already many others.


Looming Threats to Health Centers and Their Low-Income Patients

April 10, 2017

I recently met someone who follows my blog — one of the benefits I treasure. She’d come to the District for a meeting of the National Association of Community Health Centers. I learned a lot about this important piece of our federally-subsidized healthcare system.

I could see right off ways that they and the low-income people they serve are threatened now. But Terri told me about another that’s more than a threat.

Federally Qualified Health Centers

Terri serves as the strategist and advocate for a Southern California network of Federally Qualified Heath Centers — outpatient clinics that have met a set of requirements and receive grants from a Health and Human Services Department agency.

The FQHCs must, among other things. provide specific healthcare services — primary, preventive and emergency, plus education so that patients with diabetes and chronic kidney disease can monitor and control their conditions.

They must serve an otherwise under-served area or under-served people elsewhere. And they must use income and family size as the basis for their fees. So people with no income can get care, even if not enrolled or eligible for Medicaid.

A number of clinics provide additional services, e.g., dental care, mental health and/or substance abuse treatment. The clinic where Terri is based does all this and more.

It has social workers, for example, who link patients to sources of help, according to their individual needs, including navigating them through online enrollment in Medicaid.

The clinic goes beyond its diabetes management requirement by giving its diabetic patients cellphones that read their blood sugar levels and relay them to the clinic.

Terri, her colleagues and counterparts across the country are worried about how they will continue to operate — and what will happen to the low-income they serve if they can’t.

Her network receives some donations. But like all FQHCs, it depends largely on the HHS grants and partial cost reimbursements for patients enrolled in Medicaid.

Raid on Medicaid Still a Threat

California jumped at the chance to expand its Medicaid program when the Affordable Care Act became effective. The clinic Terri works in experienced a large influx of newly-eligible people with untreated conditions, e.g., diabetes, high blood pressure, oral diseases, mental health problems.

Congressional Republicans haven’t block-granted Medicaid or the similarly cost-shifting per capita alternative.

But the Affordable Care Act assured states that the federal government would reimburse 90% of care costs for their newly-eligible enrollees from 2020 on forward — the last phase in the incentive pay scheme.

What with Trump now trying to cut a deal with far right-wing members of the House, one might reasonably expect the product to end this level of funding like the failed repeal-replace bill. All expansion states, including California would face some tough choices then.

Federal Grants in Two-Part Jeopardy

The legislation that authorizes the federal government to award the FQHC grants will expire at the end of September. Without the grants, the health centers will collectively lose about 70% of their federal funding.

So a must-do for Congress is a straightforward extension, like the one included in the same law that kept the Children’s Health Insurance Program alive. Given the lack of hearings, other preoccupations and usual long summer break, simply kicking the expiration deadline forward is the only way to avert a for-sure funding loss.

But that would only give HHS authority to spend as much money as Congress chooses — and the President agrees to. Trump’s budget plan would cut the HHS budget by 17.9% — $15.1 billion less than it’s getting now. We don’t know the details, but we shouldn’t, I think, rule out anything.

Even if Congress won’t go along with such radical spending cuts (a likely response), the Budget Control Act’s cap on spending for non-defense programs will kick in again, after the latest two-year halt.

What this means it that Congress will have to cut spending on these programs by $2.9 billion. So the size and/or number of the FQHC grants are at risk — unless Congress decides to again defer or altogether eliminate the caps.

Immigrant Roundups and Healthcare Needs

The clinic where Terri is based is in a community where many immigrants live, including some unknown number without the documents authorizing them to live and work in this country.

Even immigrants here legally generally can’t qualify for Medicaid for the first five years, though they can receive Medicaid-financed emergency services.

California, as well as some other states provides a few others, regardless of immigration status. But as the Los Angeles Times reports, the community health care centers “treat all comers.”

We all know how federal immigration enforcement authorities have aggressively ramped up raids aimed at deportation. They’re active in the clinic’s community, where local authorities have partnered with them.

The agents have started patrolling side roads, including one leading to the clinic. Staff have witnessed a large drop off in immigrants seeking care.

One day an agent showed up in the building, with a warrant for something (not somebody). He opened the door to the waiting room. Patients fled, dragging children by the hands. What’s going to happen to them and their kids now that fear will keep them away?

These aren’t the only threats to the health of low-income people. The unremitting efforts to defund Planned Parenthood clinics put them at high-risk too, notwithstanding the anti-choice Congress members’ and supporters claim that clinics like Terri’s can fill the gap.

May have more to say about this than I already have.


Republicans’ Healthcare Word Choices Can’t Alter Facts

March 27, 2017

Maybe it’s because my formal education trained me to be sensitive — even hypersensitive — to words. Whatever the reason, I’m impressed and riled up when I read how House Republican leaders and some top officials in Trump administration are styling the features of their Obamacare repeal-replace bill.

Both responses because their word choices artfully appeal to widely-shared values, while obscuring basic truths that anyone who reads even a summary of their plan can see.

And just because neither the Republican House leadership nor Trump could herd enough of their cats to pass their final bill, doesn’t mean we’ve seen the end of this. Some notable examples then.

Access to Coverage. A favorite word. House Speaker Paul Ryan says it’s the Republicans’ “job to have a system where people can get access to affordable coverage.”

A Republican House staffer, speaking anonymously and thus perhaps less focused on the selling the work-in progress, said, “We would like to get to a point where we have what we call universal access, where everybody is able to access coverage to some degree or another.”

Now, access isn’t the same thing as ability to buy. For example, I have access to a full-length mink coat. The coat’s in a store I can get to. I can walk right up to it. And it’s great coverage, especially when in cold weather.

So a poor person can review a health insurance policy, with ample coverage, a minimal deductible and small co-pays. Doesn’t mean s/he can pay for it.

Now that we’ve got credible estimates of the many millions of Americans who’d no longer have health insurance, Ryan harps again on access, coupled with another favorite word — and not only in the healthcare context.

Choice. For families, Ryan says, access means, among other things, “more choices.” Well, who doesn’t like having choices? Do we like being told we must do or have some specific thing — or can’t?

But the bill, as I’ve just said, doesn’t mean more choices for lower-income families, except the choice of going without health insurance — or buying one of those low-cost, high deductible plans.

Ryan touts the larger maximum people can contribute to a health savings account, avoiding the corollaries, i.e., that only people with high-deductible plans can have them and that those who live paycheck to paycheck don’t have money to stash away.

Only 6% of families with incomes less than $30,000 a year contribute anything to an HSA now. More than half the families that contribute have incomes of at least $100,000 — a tax saver for them, rather than a needed savings account.

Freedom. When Ryan was asked how many Americans would lose coverage if the Republican’s bill became law, he said he couldn’t answer. “People are going to do what they want with their lives because we believe in individual freedom.”

And indeed we do, but only up to a point. We don’t believe everyone should be able to do whatever they want, especially when what they would cause harm to others, directly or otherwise.

In the immediate case, people would be freer to go without health insurance, since the bill would eliminate the annually-growing penalty for that.

But they’d drive up premiums because most would have reasons to believe they’d remain healthy — at least for awhile. But if they then had a medical emergency, a hospital would have to eat the costs of treating them.

An immigrant from Finland cites several other instances of the Republicans’ using “freedom” as a selling point and, as her op-ed’s headline says, explains why it’s “fake,” in contrast to the freedom she had before.

Care. The Director of the Office of Management and Budget asserts that the Republicans’ goal isn’t health insurance coverage nor a plan people can afford.

It’s care they can afford. He cites his family’s high deductible when he was in the House of Representatives, earning considerably more than would qualify them for a tax credit to subsidize it, let alone one for a family eligible for the highest.

We earlier heard something, though more extreme from the Secretary of Health and Human Services — a former orthopedic surgeon and then Republican House member who proposed his own version of repeal-replace.

While in the House, he said that he “knew oh so well how the intervention of the state and federal government into the practice of medicine destroys the ability to take care of people.”

Seems fair to gather what he means from the reported views of a radically right-wing professional organization he belonged to — minimal, if any health insurance regulations or medical quality standards, e.g., that physicians be licensed to practice, no vaccination requirements and no Medicare at all.

Well, save me from care so free of intervention. But these views hardly reflect what the majority of doctors believe — even those represented by the traditionally conservative American Medical Association, which has decided that the repeal-replace is far worse than the “imperfect” law we have.

Rebuttal Story. The Washington Post recently published a column by a doctor at primary care clinic that expressly rebuts the interference with care claim — and, by example, the other negatives that the Republicans’ word choices imply.

The doctor tells the story of one of his patients. Mr. R. first came to him when he got health insurance, having had none before because he couldn’t afford it.

The Affordable Care Act changed that, enabling him to purchase a plan that cost him less than $50 a month, thanks to the subsidies low-income people receive. But that’s not all.

Mr. R can neither read nor write. So he could hardly use the online system to choose and actually apply for a plan. He had the help of a navigator — a trained, unbiased helper — whose role the ACA established.

So he’d gotten help with logging on and entering some basic information. The the system then determined he had somewhat too much income qualify for Medicaid. So it kicked him over to the health insurance exchange.

The navigator explained terms like “premium” and “out-of-pocket maximum” and helped him fill out the forms. In short, as the physician says, “the federal policies … worked synergistically.”

Mr. R had — and still has — access to coverage, freedom, choice and care from a caring doctor. What “some politicians … seem not understand,“ the doctor says, “is that without the ACA, I wouldn’t have a relationship with patients like Mr. R at all.”

They actually do, I think, just as they understand the weasely way they’re using terms like “access,” “choice” and the rest. But what’s the alternative? To acknowledge that their bill would cause nearly as many people to have no health insurance than before the ACA?