And now its that time.

We review another 12 months of the Medicaid industry together. And I also attempt to share what has been going on in my life for the past year.

If you have missed the last 3 of these, here is a link. (Hint- each icon in the section breaks represents one of the years in reviews. Not sure if that’s how you pluralize that. Sort of like how toothbrushes works).

So glad you are here this year, all my reader friends.

Let’s review all the work / industry stuff first.

Work Requirements 2019 Edition

Let’s do this in memes.

Yes- you read that right. We are going to review Medicaid 2019 in memes.

Work requirements carried over as an issue from 2018 and the update for most of 2019 was “lawsuits are pending.” I think for me it mostly got tiring hearing lefties monolithically argue against work requirements using one of the 3 following canards:

1. Most Medicaid bennies are already working, so this is pointless -This argument was supported by a few “studies” (limited surveys) trotted out by the usual ideological suspect publications in 2019- but we don’t really know that this claim is true unless its actually reported, do we? At its heart, the opposition is really resistance to anything that slows down the death march towards universal healthcare paid for by taxpayers. No matter what Kaiser, et al tells you – there are still plenty of people who are not Nazis that oppose universal healthcare funded by taxpayers for a lot of different reasons.
2. Tracking compliance will cost a lot– sure. But since when do we care about the costs of doing anything in Medicaid? Especially technology investments? And how much is saved for every member removed who should not be on Medicaid if earning your health insurance for the able-bodied is a legitimate requirement for coverage?
3. Orange man bad– This is just something in the air, I guess.

So here’s my answer to all this nonsense in the form of a meme:

See the thing is – the thing no DoubleSpeaking expansion advocate (work requirements and expansion are inextricably linked) will let you notice – is that healthy, able-bodied Medicaid members who got added under expansion bring lots more (90-100%) federali money than the traditional aged, blind and disabled (you only get regular ole’ federali cash for those folks, usually between 50%-75%). Its not the altruistic pretty picture expansion zombies would have you believe. Its cash, cash, cash. Screw the disabled so that healthy adults can get a Medicaid card. Screw that, I say.

And of course, there are a few intellectual contortionists who came up with junk analysis to say expansion doesn’t hurt traditional Medicaid members. Don’t believe them. If you are a state budgeteer and you can get 100% federal money for one population, or have to come up with millions more in state funds to increase services for another population- what are you going to do? And please, please, please don’t trot out the “free federal money” argument to pretend you can have sufficient money for both ABD and expansion, too. If I hear that nonsense one more time I just might throw up in my mouth.

I have decided that waiting lists are the absolutely most clear condemnation of Medicaid expansion possible. Get the tens of thousands of truly vulnerable off the waiting lists in states across the nation – then I will listen to you boo-hoo about work requirements. Until then – I have to work for my own healthcare coverage, and I think anyone who can work should have to, too.

Show me the money

2019 was the year Medicaid spending didn’t go up. All these innovations around value-based payment have finally started to pay off. Just kidding! (or psych! as we used to say in middle school in 1989).

We saw another round of budget crises in nearly every state this year. And it was the same script in 2019 as it was in 2018 as it was in 2017… In order to keep services the same, and not have the sky fall and kill all the children (of course), every statehouse heard the plea for more, more, more. Some states- like Alaska- actually tried to tighten the belt. Guess what happened there? You guessed it, a judge ruled that Governors actually don’t have any power and allowed the provider lawsuits needed to “restore cuts.”

So here’s the conclusion I have come to. Price is the issue. Not cost. Price as set by providers. As differentiated by what it costs to make a product (or provide a service) versus what the merchant charges for it (price).[1] If we don’t address healthcare price- which absolutely has been on a cocaine-fueled, skyrocketing joyride for nearly all of recent history- no amount of policy smoke and mirrors (“innovation”) will ever put a dent in it.

And the scariest thing to me about price is that I don’t think there is a single example of anything (i.e. student loans, housing) that is subsidized by the government ever NOT having nightmarish price trends. Its almost as if the merchants say – “Hey look, the government has to buy it, and we get to set the price, so why not set it higher and higher and higher?”

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One more meme just for giggles

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And now for the personal / life stuff. Thanks for letting me wrant (I just made that word up- its when you rant in written form) about the Medicaid industry stuff.

NOTE [1] Don’t believe providers who tell you they are losing money on Medicaid. Once we have actually data on costs, or until we have at least more price transparency, the black box of provider “costs” is simply a tool to allow the merchants to charge uninformed buyers whatever they want. And make the buyers feel guilty for pay “so little.”

Overarching analogy (the glue)

Let’s set up the overarching analogy first. The thing that will make this globby read stick together.

____________ is what you play and when you play it.  

You can fill in the blanks, but any musicians out there with a lick of theory will know that Music goes in that blank nicely.

I heard it from Earl, my very first guitar instructor when I was 19 years old.

“Really, Clay – music is just what you play and when you play it. The notes are the what, and when you play them is as important as what you play.”

I think this applies to just about all of the human experience. Let’s run with it.

Reviewing the non-work part of life

This year’s disclaimer: For some reason – I think its because I write these things in December, which is a reflective time, and reflection is almost always somber, or at least not chipper- my Year In Reviews (we are up to 4 or 5 now, I think) tend towards bittersweet. I am not sure why you people keep reading them, but you do (based on all the wonderful notes I get each year), so I will keep writing them. And honestly I probably would write them whether or not anyone read them.

But thank you for reading. Please write in (clay@mostlymedicaid.com) with any reactions you have.

This year is bittersweet, too. But not as much of a tear-jerker as last year.

And it includes football, and old people, and hymns, and dogs and graveyards. What’s not to love about that?

Pros of 2019

• No one died this year. Well no one that I know. I am sure many readers lost some people dear to them.
• No pet died this year, although we did lose one. Funny thing about border collies. They are bred to herd and they herd by nipping. And they don’t distinguish between 6-year olds and sheep. Up until December 27^th, the verdict was still out if Shepherd remained a Farris, but we ended up driving him to a farm an hour and a half from home and setting him off on his next chapter. He was a great dog, but the time was just not right. Its what you play and when you play it.
• I leveled up on my love for my wife. At first I wanted to say that it is natural that this happens when the one you love has a progressive auto-immune disorder. But if I am honest, I have simply been able to see more of her beauty that was always there. Although my eyeglasses prescription gets worse each year, some things not seen with the eyes are better seen with age.
• I played 48 nursing home gigs. The first Monday and Friday of every month. More on that later.

Cons of 2019

Taxes are still a thing. If only I could select what they went to (like a sushi menu), I would gladly pay more. As it is now, I resent them and look for all legal ways to minimize them. I guess if the only real con I can think of for a whole year is that I have to pay taxes in the very best country that ever existed on the face of this planet, 2019 really wasn’t bad at all. 

Life in the old folks home

One of the very best decisions I made in recent years was to go into nursing homes and sing old hymns to the residents. Correction- with the residents.

My first few gigs were in 2017. I loved them so much I scheduled standing gigs in 2018 and this year I played 48 gigs. The value of those moments with elderly believers worshipping God is incalculable. I have cried so many tears of joy singing with them. At least once a month my voice cracks up as I sing Great Is Thy Faithfullness. Or Victory in Jesus. Precious Lord is the real crowd pleaser, and for me it is tied with Because He Lives and Precious Memories. Who am I kidding? I love all of these songs, nearly equally well.

Go into a nursing home the first Monday of every month and you make friends. They start to look for you. And you for them.

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Mr. Brown (not his real name) taught me a whole new verse to Amazing Grace. One that is not in my 1975 Baptist Hymnal.[2] But first let me tell you about how I met Mr. Brown.

I and the older 2 kids (they LOVE seeing children. And I finally learned when I bring the kids to just put them in front of the mic. The residents do not care what I sound like at that point) had just finished playing. There were maybe 20 residents there (which is a huge gig for us). We were packing up the gear, and Mr. Brown asked if he could have the mic.

At first I hesitated. This hadn’t happened before.

What was he going to say?

He didn’t say anything, but instead starting singing.

Let me back up a minute and describe Mr. Brown so you have a picture of him. Not that his appearance matters, but just you can visualize him. And maybe so I can, too. Years later when I read this again, like I obsessively re-read things I wrote years and years later.

Mr. Brown is in his early 80s. He is about 5 10 (I’m just guessing- Ive only every seen him sitting down). About 300 pounds. Wears sweatshirts and jeans and a ball cap. His smile – though missing a few teeth- is on my top 10 smiles of all the ones I’ve seen in my life. Mr. Brown is also black- but from a time where calling him “African-American” would be as weird to him as it is to me.

After I got to know Mr. Brown over the course of a few months, he was sitting out on the front porch while we were loading in. Loading in from out of my 1996 Blazer (I have a thing for old run down cars and keeping them running. There’s an analogy for me in there somewhere. Maybe underneath the catalytic converter). That Blazer was a gift to me from my father in law when we were just starting our family. And at that point it was 10 years old. But it was huge blessing.

I can not see myself getting rid of it. Ever.

But Mr. Brown remarked that it was a nice car. And I agreed, but also thought to myself that most people would not think so. I can almost guarantee you that the majority of people reading this consider a Lexus a nice car. Or a brand new Pilot. Or maybe – maybe- a new Camry. But not a 22 year old blazer with 150,000 miles on it.

But I kept my thoughts to myself. And I’m glad I did, because it gave Mr. Brown space to continue.

“I never had no car. That’s a nice car.”

In that moment I knew my appreciation of the blessing of this old car was insufficient. That I had any car at all was such a blessing. Mr. Brown had lived 80 years and never had a car.

Back to that secret verse of Amazing Grace you may not know about.

Once I hand him the mic, Mr. Brown started singing two words over and over, to the melody of Amazing Grace:

Praise God

Praise God

Praise God

Praise God

I had never heard this done.

It was so powerful. And the other residents all sang along. He was their leader and I knew in that moment he played an important role in that community of aging, dying believers. Day in and day out he was there. Encouraging them with his toothy smile and loving words. I was just there for an hour every 30 days.

From that moment on I looked to include Mr. Brown however I could.

But I didn’t get many more chances. He was there maybe 3 more times. I asked the activities director if he was ok for a few months. She would always say he was just tired.

Now I haven’t seen him in nearly a year, and I fear he is gone (dead). I think the activities director wanted to spare me the sadness because she could see how fond I was of him.

But that’s the gig in these gigs – you are playing (and bonding with) to an audience not long for this world. I often wonder how people who work in nursing homes are not crying every day. Maybe they are.

There are so many people I want to tell you about from these gigs. But let me share just a few more.

There is a lady in the memory care unit of one of the places we go. If you have never been to a memory care unit, the important thing to understand if that these residents are an elopement risk. Many of them wear anklets that are paired to alarms near doors so staff know they may be attempting a break out. There is a wide range of memory issues seen in these units, but in general the very mildest cases are what you would consider “severe” from a lay person’s perspective.

What I noticed early on with this population is you need a different set list. You need older songs. Instead of hymns from say 1940-1960, you need ones from the late 1800s (those songs are what their parents taught them as young children). They know hymns from both time periods, but the older ones resonate with them much more deeply (think Blessed Assurance vs His Name is Wonderful). But the really beautiful thing is that these residents may not know their children’s name (of course that is sad, but wait for the concluding clause)- but they remember all the words to How Great Thou Art. And they light up when they sing it with gusto.

I am very impressed with this particular facility. Not all of them are as compassionate as you would hope. Or maybe the word is not compassionate, but rather thoughtful. This facility does things like buy a jukebox with pop songs from the 1950s in it. And they put cribs in one of the common areas, complete with baby dolls in them. You may think that’s strange. I did at first, too. But then I saw how soothing it is to some residents. And I was thankful that the staff are working to meet the residents where they are in their journey.

I have heard nursing homes referred to as “Heaven’s Waiting Room.” I think there’s a lot of truth to that. When I first tell people (people not in nursing homes) the songs I sing, they are somewhat shocked. Because all the old hymns pretty much talk about death. And about looking forward to it as the only way to reunite with our Savior. That last part is key.

But what I noticed is that the residents don’t mind. Not only do they not mind- they are encouraged by it. Sometimes not just encouraged, but emboldened.

And so am I.

Which is one of the reasons I love “When We All Get to Heaven” so much. I tell them it’s a marching song. And they love that.

But back to this lady in the memory unit.

Most times she is completely silent and sits there and cries while listening to us sing. Sometimes she mouths a few words of the song. Lately she has actually spoken a few sentences and smiled.

Normally her daughter (I assume its her daughter) is there when we play. I think she comes to visit on her lunch break. And I am so grateful that someone has a child that still comes to visit. Almost none of the residents have that. But that daughter comes to see her mother regularly – Praise God.

When the daughter is there, she stands behind her mother (who is sitting on a couch) and leans in to place her cheek on her mother’s cheek. And they just share the time together like that. For an hour. Sometime the mom cries. The daughter only ever smiles. She has never said anything to me.

That woman did something right when she raised that daughter.

At that same facility is another lady who without fail asks my oldest son if he has a girlfriend. Like at least 20 times. From the time we are setting up the mic to when we break down. This is how Caleb remembers this place.

“Is this the one where the lady asks me if I have a girlfriend?”

“Yes, son.”

At first I think it may have bothered him a bit, but now he understands. And he is nothing but sweet and answers her question every time.

“Do you have a girlfriend? How old are you?

“No, mam. I am 9.”

“You sure are handsome. You’re gonna have lots of girlfriends.”

“Thank you, mam.”

Repeat that about 20 times.

She asks Nora if she has a boyfriend. The exchange plays out similarly, but when Nora tells her no, the lady adds: “Well, you are smart, then.”

NOTE [2] I have the Broadman Hymnal as well somewhere in this old house. Its red and smells like wood, carpeted pews and maybe holy water. But of course there’s no holy water in a Baptist Church so maybe my smell-brain is confusing memories…

A few quick others.

One lady, wearing a bright read sweater and hair all done up (it humbles me to tears that they think my songs are worthy of dressing up for) called out once-

“I have a testimony!”

Having learned to not hesitate after the Mr. Brown incident, I told her by all means to go ahead. And she gave a few minutes of her testimony[3] and it is one of the treasures I carry with me in my heart.

My last example is the lady who always thanks me for reading Scripture during the set. I think we assume there are people going in and ministering to these people all the time, but that may not be the case. She seems like she has been starved of hearing Scripture spoken each month. And so grateful for me simply reading from the Psalms.

I don’t know that playing these songs ever would have occurred to me when I was younger. But I learned them all before I turned 12.

It’s what you play and when you play it. Now is the right time to play these songs for these people. The nursing homes may be Heaven’s Waiting Room, but those folks need music, too. And if I can be a part of singing them into heaven, then I am blessed beyond measure.

[3] For those of you who didn’t grow up in a protestant church, this is when people share either their personal salvation story or something God has done for them in their lives.

Life in the Graveyard

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If you are not familiar with the national wreath laying program for our veterans laid to rest in national cemeteries, it’s a wonderful event where families and friends of our lost heroes gather to lay a wreath on their graves. It happens every year in early December. You can find out more at https://www.wreathsacrossamerica.org/. I highly recommend you participate at least once.

We went this year (and have each year so far since Daddy died and was buried at the national cemetery in Alabama). We are always amazed at how many new headstones there are each time we visit.

What struck me most this year was that the living have basically made the graveyard (cemetery, I guess, since not attached to a church- but there is a chapel, I think) a part of their life. By that I mean they place everyday items that mean something to them (and I assume to the deceased) at the tombstone. We were accustomed to the coins left on headstones (learn what that is all about here). But there are also very specific rules about what can be used as decoration, and I think we saw lots of violations that day. My guess is the groundskeepers look the other way around Christmas to help the grieving make it through another December without their daddy, or momma. Or daughter, or son. Or best friend.

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Looking at what the grieving choose to leave is eye-opening. In a good way. It shows you that not only does life go on after the burial, but it includes the one buried. Some objects are very specific to that family (like a sea shell or a snow globe). Some are sports teams- we found 2 Alabama Crimson Tide items, and are in the process of making sure we get some Auburn ones in there soon.

To me this shows that there is life in the graveyard. It shows me that the people buried there played the right things and played them at the right time. They left an impression- a good one. They are missed but in no way forgotten.

You should participate in a wreath laying sometime. Here’s that link again – https://www.wreathsacrossamerica.org.

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Life in an Empty Stadium

We took the kids and Momma to see the Christmas lights at Callaway Gardens this year. This is another thing I recommend you do at least once- its actually on various lists of top 10 lights events in the world.

On the way back home from Callaway, we stopped in Auburn (see last year’s Year in Review for a similar pilgrimage). We checked out the new Arena first (the basketball facility). And it was cool.

In it I found this quote on the wall:

That quote says it pretty well, I think.

As we were leaving the Arena, my oldest asked to go over to the football stadium. As we also did in last year’s escapade, we snuck in.

Once inside, it all took care of itself.

We were in the right place at the right time. What you play, when you play it.

We made our way, like salmon back to where we were spawned, to the field. Anyone who was ever a teenager knows its cool to get into places when you’re not supposed to. None of that high school mischief compares to standing on that grass at Jordan-Hare Stadium. And stand on the grass we did.

And we took pictures. And remembered the amazing game where we beat nasty Alabama just a few short weeks before. It was an astonishing game and if you watched it and didn’t like it, then you don’t like football and I can’t help you.

We got into an open construction entrance near section 44. We made our way down about 25 steps or to that little gray gate in the corner of the endzone. It wasn’t locked. We were supposed to be there.

The kids and I took pictures. Walked over spots we knew those Auburn Tigers had run over with amazing skill just recently. To beat Alabama. (Praise God)

And quietly Nonna walked 100 yards to the other side of the stadium to the other endzone.

Where she and my dad had sat together in the same seats for decades. Where their season tickets had been. (We lost my dad 2 years ago).

And she just sat and looked out over an empty stadium. Staring across a lifetime. Back from when she lived there as a young wife with my Dad in the early 1970s. When he went to school, coming off a stint in the Navy to pay for his degree. Back when she and he attended games in this same stadium but in the student section, instead. I am sure much crossed her mind as she sat there and stared on this beautiful December day in 2019 some 40 odd years later than all that long, lost time. But this time she was alone, without her Bill. And he without his Preppie.  

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Jordan Hare stadium has seats for about 86,000 people. If its sold out at halftime the will let in another 20,000 or so to stand in the ramps that lead to the upper deck. You then have a gathering of people – all there because they love Auburn and know it is the very best a college or town either of those things can be- that is bigger than most cities in the world.[4]

But that day there were only 7 of us in that stadium. And as momma sat on the cold, metal stadium seats, to her there were only 2. I cannot fathom the feelings of both emptiness and fullness of heart she must have been feeling.

Yet there was life in the stadium that day.

As kids we had season tickets about 2,000 feet in the air in the upper deck. My kiddos saw these upper seats towering above us and were amazed. ‘Can we go up there, Daddy?”

Trying to say yes more these days, I said “As long as we can find a working elevator.”

And we did. Pretty quickly. We were meant to be here this day.

God was opening stadium gates and turning on elevators.

Once we got to the upper deck, I walked the kids about 70 steps or so to the very top.

“We are as high as the birds,” Nora said in awe as a group of pigeons flew level with us about 4 sections over.

After a few minutes up there, we descended back down to the bottom of the upper deck to head home.

We got back to Momma (Nonna) and Stacy (Momma). “Its time to head on,” I said. They had been talking about who knows what while I and the kids journeyed to the upper deck and back down.

And a few minutes later, two police officers walked up to us from behind that little tunnel area where you walk into the stadium from the corridor where the concessions and bathrooms are.

I smiled at the officers and turned back around to look at the stadium again, committed to acting like we were supposed to be there.

“The stadium is closed.” The officers words came from behind me, and I turned around and smiled.

“Yes, sir. It’s time to head on kids.”

“Are you guys from around here?”

“No, sir. Well, my mom’s husband – my dad- went here. And so did my sister.”

“There’s just some construction going on in the stadium today, but no one is supposed to be here.”

“Thank you, officer. We will head out now. Please remind me where the elevator is.”

We made our way down the elevator and back down to the ground floor. The officers were walking about 100 feet behind us to make sure we left.

And we did.

On the way out my oldest daughter asked me if I had ever been arrested.

“No, Nora.”

“Well have you had a lot of interactions with the police? You seem to know what you were doing speaking with them.”

“Those are stories for another time, honey.”

Life is what you play, when you play it.

Thank you officers, for letting us play that day.

NOTE [4] To give a little more perspective – those 2 numbers together around about 100,000 people, round figures. Shakespeare’s London had about 200,000 people in it. So imagine about half of all Londoners going to see Hamlet, screaming their lungs out, grown men crying tears, women jumping for joy- for about 3 hours straight. And that’s an Auburn football game. Except you can understand all the words, because it ain’t the Queen’s English.

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Challenge to readers

I want to leave you with encouragement.

I want to remind you one last time- Life is what you play, when you play it.

I want to wish you this:

When you enter old age, may you have visitors every day. May the graveyards of your kinfolk be filled with mushy trinkets and singing. May your empty stadiums overflow with Precious Memories. And may whatever demons you tilt at turn out to just be windmills after all.

Here’s your assignment- Find something to do consistently (and monthly) that brings joy to strangers and do it 12 times next year. It will change you. Vets are a great target market for this. So are the elderly.

2020 is your year.

Go play something awesome. Play it loud. Make your voice crack. Break a sweat.

Report back December 31^st, 2020.

The thief comes only to steal and kill and destroy; I have come that they may have life, and have it to the full. John 10:10 (NIV)

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