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John
Lindstrom, Gongwer News Service, December 9, 2011
So much commentary on government focuses on headline issues, the
ones easily chewed and spun into bumper stickers and soundbites.
Let us consider something else, something that those who know
the newspaper industry know might be stuck in the agate columns.
If one massed about 220,000 people in Michigan into one spot, it
would be a pretty sizeable fondue of flesh. It would, in fact,
qualify as the second largest city in the state.
If one spent the 2010 Michigan per capita income of $35,597 on
each person in this entire group of 220,000, about $7.8 billion
would be spent. A tidy sum indeed.
That being the case, the $7 billion the state and federal
governments actually spend on this group of 220,000 seems a
relative bargain. Then again, maybe it’s not a bargain. Maybe we
can spend the money better and more cheaply. Maybe we can do
that and make sure none of the 220,000 people is harmed. Maybe.
This is not a theoretical group of 220,000 people. There are
actually about 220,000 people in Michigan who are eligible for
both Medicaid and Medicare. And it is them, and the amount of
money being spent on them, that is at the heart of one of the
more complex, potentially important and largely unknown stories
ongoing in state government. As was said, to find it you have to
read the agate columns.
This group also represents two of the essential elements
government must wrestle with constantly: money and personal
well-being. It must wrestle with the two issues, yet somehow not
quite win on either count.
It is also one of the big hidden issues of government. Hidden
not so much because government or anyone else is trying to hide
it. It’s hidden because it’s complicated, because it is
difficult to reduce to a bumper-sticker. One would have to be
willing to stretch adhesive paper across the entire bumper to
fit Justice For Dually Eligible Medicaid/Medicare Recipients or
Hell No, I Won’t Pay For Dually Eligible Medicaid/Medicare
Recipients!. It’s hidden because it is weighted down with jargon
and no dictionary yet exists to make sense of what people are
saying.
And it’s hidden, probably, because it deals with people whom we
are uncomfortable acknowledging. This issue deals with the old
and the poor, and the disabled and poor, and the mentally ill
and poor. It deals with, in fact, people we could all one day
become.
This also is the kind of issue government ends up dealing with a
lot. It is not the kind of issue that outraged groups create
social media sites for and hold rallies with tri-corn hats and
bullhorns, insisting they alone know the true meaning of the
constitution. It is not the kind of issue reporters tend to
spend a lot of time following. This reporter knows, since he has
been about the only reporter following the story.
But it also shows how despite cries from so many critics from
both sides that fixing government ought to be easy, it is often
anything but easy.
As backdrop, recall that Medicare, which pays for the medical
care of the elderly and many disabled persons, is entirely
federally funded.
Medicaid, which pays for medical care for the poor, is a joint
federal/state program with both paying for care.
For years now, states have clamored for the federal government
to do something about dually eligible recipients. Those tend to
be older, poorer people who often are in nursing homes. Tend to
be older and poorer. Many are not so old, but they suffer from
multiple disabilities. Many struggle to be heard because they
struggle to even speak. They are in wheelchairs. They fight off
mental illnesses.
They are the people any one of us could one day become. We all
will be older, we could well be poorer, we could find ourselves
disabled and ignored.
They are the people whom even the most strident anti-government
opponent agrees need help to live. Admittedly, the most strident
anti-government advocate might say that help should come from
families or churches. To others this is one reason why
government exists, to care for those who truly need care.
States, including Michigan, have pushed for the federal
government to pick up the costs of those individuals as a way of
easing their own budget struggles.
That, the federal government has not done.
But the federal Centers for Medicare and Medicaid Services did
call for the states to propose ways of consolidating and
coordinating those services. Doing so would make them more
efficient, possibly even save some money. Hard to argue against
that.
Could consolidation and coordination also help ensure that
recipients get as good or maybe better services at less money?
Always that is the Holy Grail of any government restructuring:
doing more with less.
Michigan applied for and received federal funds to help set up a
coordinated system for dually eligible recipients. And at a
hearing this week on the issue, Rep. Matt Lori (R-Constantine)
said finding a way to coordinate the services in hopes of saving
money — $7 billion is on the table, after all — definitely
interests him.
It was in its proposal to the federal government, however, that
alarm bells, warning sirens, watchdog yowls, blowing whistles
and frightened screeching set the care industry — and by that we
mean community mental health agencies, agencies for the aging,
organizations that care for the developmentally disabled and
others — on the warpath against the proposal.
That proposal called for “a single contractual relationship
between the payers (Medicare and Medicaid) and the entity
responsible for service delivery and quality.” Separately,
managed care organizations on the local levels would be
contracted to actually provide the care, but it would come
through this one proposed entity.
And that proposed scared the living breathing guts out of every
person involved in the issue. Local directors warned their
agencies would be shut down, that patients would have to get
care through a centralized agency. Patients and their families
were terrified. A level of fear and anger that surpassed even
that seen over the proposal to tax pensions was evident among
this population.
Candidly, the state was stunned at the reaction, and has had to
bend anyway it can find to bend to assure those individuals it
wasn’t trying to ram anything through, that it’s first
consideration was always patient care, and that all affected
persons would be part of the discussions on setting the program
up. The state added more public hearings, so affected
individuals could talk about the issue. It live-streams meetings
of different workgroups on the different facets of the issue so
people across the state can see how the discussions are
proceeding.
None of this seems to have assuaged the critics, who before Mr.
Lori this week urged the state go slower in developing its
proposal (which it now intends to take to the federal government
in spring), and to be sure the work they do is included in
whatever proposal is made.
In its own way this issue triggers so many catch-phrases we have
heard on a federal level applied now to the state. Is this an
example of “one size fits all” governing? Will patients be able
to “keep their own doctor (or therapist, or case worker)?” Isn’t
this an overreach by a centralized government against local
control?
One cynically could also say these agencies are simply trying to
keep their piece of the pie, no matter what the state does.
What is indisputable though is the genuine worry by recipients
and their families that their care will be dramatically and
drastically affected by whatever changes are made. The changes
the state makes wouldn’t amount to a set of inconveniences.
Those changes could trigger a massive change of life for some of
these recipients.
It is also indisputable that the state workers drafting these
changes understand that. Get this wrong, hurt too many people,
and they can count on political blowback hitting them harder
than a hurricane.
All that makes this the really tough work of governing, the kind
of work that goes on all the time though usually over less
personally pressing issues. It is also the hard work that goes
on outside of public view, mostly because the public is
preoccupied elsewhere.
The public is preoccupied even though everyone in the public
could be affected by the decisions made on this issue. So much
of the agate stuff is exactly that, important but unnoticed.
This issue may never reach major headline size. It’s a sucker
bet to say most of the public will have any idea about this in a
year or more.
But it’s important. One should pay attention. It should at least
be bumped out of the agate columns and stuck in among the
crosswords.
John Lindstrom is publisher of Gongwer News Service. For nearly
50 years in Michigan, Gongwer News Service has provided
independent, comprehensive, accurate and timely coverage of
issues in and around Michigan’s government and political
systems. For subscription information, including a free trial,
visit Gongwer online.
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