Category: Medicaid News and Analysis

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Monday Morning Medicaid Must Reads: May 27, 2019

Helping you consider differing viewpoints. Before it’s illegal.
other MMRS – http://bit.ly/2T7CP7K
In this issue…

Article 1:      A First Look at North Carolina’s Section 1115 Medicaid Waiver’s Healthy Opportunities Pilots, KFF, May 15, 2019

Clay’s summary:     $600M to address SDoH for about 25,000 to 30,000 members. May seem steep, but its our first real attempt to measure this concept we’ve all been yapping about for 5 years.
Key Excerpts from the Article:
Medicaid funds typically cannot be used to pay for non-medical interventions that target the social determinants of health. However, in October 2018, CMS approved North Carolina’s Section 1115 waiver which provides financing for a new pilot program, called “Healthy Opportunities Pilots,” to cover evidence-based non-medical services that address specific social needs linked to health/health outcomes. The pilots will address housing instability, transportation insecurity, food insecurity, and interpersonal violence and toxic stress for a limited number of high-need enrollees.
Read full article in packet or at links provided

Article 2:      Block Granting Medicaid is Still a Terrible Idea, Suzanne Wikle, CLASP, May 15, 2019

Clay’s summary:     Op-ed writer may not realize that what she thinks is a bug is the key feature (reducing spending). Good one to have bookmarked if you are anti-block grants, though.
Key Excerpts from the Article:
While the promise of increased flexibility can sound enticing, the reality is that so-called flexibility pits funding choices against one another and ultimately leads to cuts. Medicaid already has the flexibility it needs to respond to economic downturns or public health crises, and capping funding for the program makes these responses more difficult. Block grants have not worked in the Temporary Assistance for Needy Families (TANF) program. What we know from 20 years of experience with TANF is that funding has not increased with inflation or in response to poverty and need. Moreover, states have used TANF funds to support alternative programs and have significantly decreased the aid going directly to families. Despite assurances they would fund key supports like affordable child care, policymakers haven’t been able to deliver on their promises.
Read full article in packet or at links provided

Article 3:      Medicaid could save $2.6 billion if 1% of smokers quit, Stanton Glanz, JAMA, April 17, 2019

 
Clay’s summary:      Ain’t nobody gonna tell Medicaid bennies they have to stop smoking. So we all just keep paying…
Key Excerpts from the Article:
 “Medicaid recipients smoke at higher rates than the general population … suggesting that investments to reduce smoking in this population could be associated with a reduction in Medicaid costs in the short run,” Stanton Glantz, PhD, of the Center for Tobacco Control, Research and Education at University of California, San Francisco, wrote. He noted that in fiscal year 2017, Medicaid costs totaled $577 billion. Glantz evaluated Medicaid expenditures and the economic response between changes in smoking prevalence and health care costs. All data were from 2017 and came from all 50 states and Washington, D.C.
 
Read full article in packet or at links provided
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Monday Morning Medicaid Must Reads: May 20, 2019

Helping you consider differing viewpoints. Before it’s illegal.
other MMRS – http://bit.ly/2T7CP7K
In this issue…

Article 1:     Medicaid Demonstrations: Approvals of Major Changes Need Increased Transparency, GAO, 5/17/2019

Clay’s summary:    Now that Medicaid waiver requests are asking for something besides “more,” we may see an interest in actually doing the 1115 “demonstration” reviews.
Key Excerpts from the Article:
 About a third of Medicaid spending is for demonstrations, which allow states to test new approaches to delivering services. States and the federal government are supposed to be transparent about the demonstrations that are proposed and give the public a chance to weigh in. Is that happening?
The short answer is sometimes. Transparency has improved, but there are still significant gaps. For example, the federal government doesn’t always require states to share the projected effects of proposals, even when they could significantly affect beneficiary eligibility.
Read full article in packet or at links provided

Article 2:     The inconvenient truths of Louisiana’s Medicaid expansion, The Advertiser, Chris Jacobs, May 17, 2019

Clay’s summary:     All that “free” federal money? Federal funding still comes from taxpayers like you and me. And expansion may just be killing people on waiting lists.
Key Excerpts from the Article:
Second, the truly vulnerable continue to get overlooked due to Medicaid expansion. Secretary Gee claimed that her “top priority is to ensure every dollar spent [on Medicaid] goes towards providing health care to people who need it most.” But Louisiana still has tens of thousands of individuals with disabilities on waiting lists for home and community-based services—who are not getting the care they need, because Louisiana has focused on expanding Medicaid to the able-bodied.
Since Louisiana expanded Medicaid in July 2016, at least 5,534 Louisiana residents with disabilities have died—yes, died—while on waiting lists for Medicaid to care for their personal needs. Louisiana should have placed the needs of these vulnerable patients ahead of expanding coverage to able-bodied adults—tens of thousands of whom already had private health insurance and dropped that insurance to enroll in Medicaid expansion.
Read full article in packet or at links provided

Article 3:     Why Medicaid carriers are wary of joining the ACA marketplace, BenefitsPro, Scott Woolridge, May 13, 2019

Clay’s summary:     Making money on the exchanges is hard. Just stick with the safe bet of Medicaid capitation revenues, and invest in carving out hard stuff.
Key Excerpts from the Article:
 The analysis by the Robert Wood Johnson Foundation (RWJ) notes that in areas where Medicaid insurers compete with other carriers in the ACA individual market, premiums for that market tend to be lower overall. Of the 31 states that had Medicaid buy-in programs for at least some state residents, 18 states reported premiums that were priced lower than the national average.
“This suggests that convincing more Medicaid insurers to sell marketplace plans could lower marketplace premiums,” the report said. “Participating in marketplaces can benefit consumers as well as insurers: several large Medicaid insurers are turning a profit on marketplace plans. Yet many other Medicaid insurers have chosen not to sell marketplace plans.”
Read full article in packet or at links provided
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Monday Morning Medicaid Must Reads: March 11, 2019

Helping you consider differing viewpoints. Before it’s illegal.
 other MMRS – http://bit.ly/2T7CP7K
In this issue…
Article 1:     Medicaid backlog delaying care for Ohio’s needy, and payments for health providers
 
Clay’s summary:     Its’s bad but its getting better?
Key Excerpts from the Article:   
More than 88,000 applications from poor Ohioans are awaiting processing by caseworkers to determine if they are eligible for Medicaid. Nearly two-thirds of the applications have been pending 45 days or longer.
 
The backlog actually has improved since one point last year, when nearly 110,000 requests were awaiting review, but lengthy delays continue to cause uncertainty and delayed care for needy families — and financial difficulties for many health-care providers.
 
Advocates for the poor say many Medicaid applicants have no or limited access to health care while they wait, which can cause life-threatening problems.
 
Read full article in packet or at links provided
Article 2:     
State sued over Medicaid application backlog
 
Clay’s summary:     Advocates lawyer up and push for a yes or no on the growing pile of apps.
Key Excerpts from the Article:   
 The state of Alaska is facing s a lawsuit for failing to process Medicaid applications in the time frame required by federal law.
Medicaid applications are supposed to be processed within 45 days, or within 90 days if it involves determining a disability.
 
As of February, at least 15,000 Alaskan have submitted an application that has not been processed. At least 10,000 of those applications were submitted in 2018.
 
“We’ve been following the problem for some years and hoping that it would get redressed, and it seemed to be getting worse and worse no matter what issues are raised to the state,” attorney James Davis said.
 
Davis, an attorney with the Northern Justice Project civil rights law firm, filed the suit on behalf of one client with intent for it to be certified as a class-action case. Davis’ client applied for Medicaid in November, but still has not had her application processed.
 
Read full article in packet or at links provided
Article 3:      Sen. Kennedy asks feds to investigate Louisiana Medicaid program
 
Clay’s summary:      State lawmaker turns in his state to the federals for Medicaid shenanigans.
Key Excerpts from the Article: 
 
Sen. John Kennedy has asked the federal Centers for Medicare and Medicaid Services to investigate Louisiana’s Medicaid program after he publicly blistered the state’s health agency and its leader earlier this week.
 
Kennedy, R-La., wrote a letter to federal Medicaid Administrator Seema Verma asking the agency to “investigate whether or not the Louisiana Department of Health has violated federal Medicaid regulations.”
 
His action was prompted after the state said as many as 37,000 Louisiana Medicaid recipients may be ineligible for the coverage because their income exceeds the limit for coverage.
Read full article in packet or at links provided
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Monday Morning Medicaid Must Reads: Feb 18, 2019

Helping you consider differing viewpoints. Before it’s illegal.
In this issue…
Article 1:     Maryland Mulls Medicaid Reimbursement for Telemental Health Services
 
Clay’s summary:     I have said for years there’s lots of good reasons to move MH/BH into telehealth.
Key Excerpts from the Article:
“Tele-behavioral health can help improve the efficiency and effectiveness of our provider workforce and remove unnecessary obstacles to provide treatment for MassHealth members who have difficulty leaving their home environment, who live in rural areas, and or have other unique needs,” Dan Tsai, MassHealth’s Assistant Secretary, said in a press release. “In addition, behavioral health providers are also incentivized to promote and utilize telehealth services and are reimbursed at the same rates as in-person visits.”
 
Read full article in packet or at links provided
Article 2:     Texas announces record $236M Medicaid fraud settlement
 
Clay’s summary:     State settles for pennies on the dollar (compared to original damages sought); re-named tech behemoth ready to put legacy brand behind it so it can win some new MITA bucks.
Key Excerpts from the Article:
Texas hired Xerox in 2004 to evaluate applications for Medicaid-funded dental procedures. The company was supposed to have dental professionals carefully review each application to make sure the tooth repairs were medically necessary, the standard for Medicaid to cover them.
 
According to the lawsuit, however, the company did little more than rubberstamp the paperwork. Under pressure to keep pace with the exploding number of applications from dentists and orthodontists, Xerox hired untrained workers who often barely glanced at the medical records, molds and x-rays, spending only minutes on each application in some cases, court records show. Those who didn’t keep pace were reprimanded. The company employed a single dentist to review and sign off on several hundred preapproval applications per day.
 
Read full article in packet or at links provided
Article 3:     Passport sues Kentucky over Medicaid cuts – Louisville Business First
 
Clay’s summary:     In which Passport says mean things.
Key Excerpts from the Article:
 
Passport alleges that the cuts to its payments and the increase to its competitors’ payments “are the result of either an improper motive to harm or eliminate Passport; a motive to assist one or more of Passport’s competitors in expansion of market share at the expense of Passport; or gross and deliberate indifference to the harm inflicted on Passport, its 315,000-plus members, its employees and the communities it serves generally.”
Read full article in packet or at links provided
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Monday Morning Medicaid Must Reads: Feb 11, 2019

Helping you consider differing viewpoints. Before it’s illegal.
In this issue…

Article 1:     State wrestles with sizable backlog of Medicaid applications

 
Clay’s summary:     Expansion nearly doubled the AK Medicaid rolls. Doubled. 
Key Excerpts from the Article:
As of Jan. 29, Alaska had a backlog of 15,639 cases of new applicants or renewals on the books. About two-thirds of those, or 10,200 cases, were filed in 2018. The average wait time to be approved is currently 55 days, according to Clinton Bennett, the media relations manager for the Alaska Department of Health and Social Services… That’s the average, but not everyone is waiting that long, he wrote in an email…“Cases that are tagged as emergent, involve a pregnant woman or adding a newborn to any case are being processed on average within 2 days,” he wrote.
Alaska has a fairly large Medicaid population with about 210,276 people enrolled in the Medicaid and CHIP programs as of October 2018, according to the Centers for Medicare and Medicaid Services.
That’s about 24 percent of the state’s total population, and up from 123,335 people enrolled at the end of July 2015, just before the Medicaid expansion took effect in the state.
Though it’s still a sizable backlog, it’s significantly down from the total in May 2018, when the Alaska Ombudsman’s Office published a report highlighting the difficulties in the Division of Public Assistance. At the time, the ombudsman noted a backlog of more than 20,000 cases, itself down from 30,000 in July 2017.
 
Read full article in packet or at links provided

Article 2:     Medicare, Medicaid Enrollment Growing Faster Than Private Coverage

 
Clay’s summary:     New analysis says Care/Caid spending growth is nothing to be concerned about. What do they think we are, idiots? Of course they do. Shut up and pay your taxes. Don’t have opinions about how they are spent.
Key Excerpts from the Article:
 Over the course of 11 years, annual spending growth averaged 5.2% for Medicare and 6% for Medicaid. This eclipsed the 4.4% spending growth among private insurers.
However, spending per enrollee from 2006 to 2017 was markedly lower for public programs compared to their private counterparts. Medicare spending per enrollee amounted to 2.4% per year, Medicaid registered at even lower 1.6%, while private insurance posted 4.4% annually.
Medicaid and Medicare also achieved positive annual enrollment growth rates over the same period of time, 4.3% and 2.8% respectively, while private insurers finished with a flat enrollment growth rate.
The study’s findings conclude that while CMS projects Medicaid and Medicare spending per enrollee to grow sizably over the next decade, both programs have “successfully moderated growth.”
The Urban Institute states that the results indicate that neither program require “major restructuring” to reduce national health spending and that the more concerning spending figures lie in the private insurance market.
The study’s authors support “modest policy proposals,” such as limiting state use of provider taxes in Medicaid or modifications to Medicare cost-sharing.
 
Read full article in packet or at links provided

Article 3:     Medicaid cost concerns are valid

 
Clay’s summary:     An op-ed considers a litany of examples when the state was left to deal with federal funding changes that made programs cost a lot more than originally promised- AND they connect the dots to Medicaid expansion and the “free federal money.” How dare they use logic and past experience???!!? Evil Republicans!
Key Excerpts from the Article:
 Even if the state’s portion of Medicaid expansion costs doesn’t rise, the $150 million price tag is still significant. That $150 million is more than twice the amount required to provide a proposed $1,200 pay raise for every teacher this year. It’s more money than what would be saved if roughly 12,400 inmates were released from state prisons, according to one estimate. It’s more than four times the amount required to eliminate a backlog of local government reimbursements for emergency responses.
Every dollar spent on Medicaid expansion is a dollar that doesn’t go to other needs like schools, roads or public safety. And voter rejection of a 2016 sales tax increase shows limited public appetite for the kind of broad-based tax increases required to avoid such tradeoffs.
The real debate is not simply whether one supports Medicaid expansion, but whether one believes Medicaid expansion should be a higher priority than school funding increases or other causes. And, beyond fiscal considerations, debate should also focus on this question: Does Medicaid expansion improve health outcomes? Much research has found little real improvement.
 
Read full article in packet or at links provided
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Menges Group 5 Slides Series for December 2018 & January 2019

The Menges Group puts out these great analyses and insights each month. And is kind enough to let us repost them for the MM audience. Check out themengesgroup.com to learn more about the work they do. 

Attached are the December 2018 and January 2019 editions of our 5 Slide Series.  The December edition presents our tabulations on an “average family’s” federal, state and local taxes for CY2018 and how their tax contributions are spent.   The January edition tracks the national Medicaid enrollment projection from January 2014 through September 2017, showing enrollment growth dynamics between the expansion and non-expansion population, and across states that adopted Medicaid expansion versus those electing not to do so.

Taxes for an Average Family — December 2018 Medicaid Enrollment Progression 2014-2017 — January 2019

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Monday Morning Medicaid Must Reads: Jan 21st, 2019

Helping you consider differing viewpoints. Before it’s illegal.
In this issue…

Article 1:    Feds OK Medicaid Work Requirements in Arizona, Health Leaders Media

Clay’s summary:    This is only the 8th one approved. Must be a fluke.

Key Excerpts from the Article:

Arizona has permission from the federal government to begin imposing work requirements next year on certain Medicaid beneficiaries in the state, but most Native Americans will be exempt, the Centers for Medicare & Medicaid Services announced Friday. Arizona’s waiver is the eighth of its kind, signaling that the Trump administration intends to continue pushing forward with Medicaid work requirements despite pending legal challenges in other states. This is the first waiver to exempt members of federally recognized tribes, resolving a major sticking point with Arizona’s application. State officials had asked CMS to exempt all Native Americans from the new requirement, but Trump administration lawyers said doing so would constitute illegal preferential treatment on the basis of race. The tribes contended, however, that the administration’s position contradicted longstanding legal principles and Supreme Court precedent, as Politico reported.
“There were a lot of complex legal issues here,” CMS Administrator Seema Verma told Politico’s Rachana Pradhan. “I think that we were able to find a middle ground.”…

Read full article in packet or at links provided

Article 2:    Strategies for an Affordable Medicaid Buy-In Option in Colorado, Manatt

Clay’s summary:    We will sell Medicaid on the exchange, and offer subsidized premiums (so nobody really pays for it, except taxpayers). And oh yeah – we’ll pay providers at Medicare rates. What could possibly go wrong?

Full study
Key Excerpts from the Article:

In Colorado, where average Affordable Care Act (ACA) benchmark premiums have increased 71% since 2014, advocates and stakeholders initiated an analysis to evaluate the feasibility and potential impact of a Medicaid buy-in offered outside the individual ACA market, with access to Advanced Premium Tax Credit funding under an ACA Section 1332 State Innovation Waiver. The product would be offered statewide, leverage the current Medicaid infrastructure, provide the same benefits and range of cost sharing as coverage on the state Marketplace (Connect for Health Colorado), and reimburse providers at Medicare rates. The analysis evaluates expected premiums for the buy-in product, the impact of its introduction on existing individual market premiums and the potential for state savings under this program design. The effort was led by a coalition of Colorado health policy advocates, represented by the Colorado Center on Law and Policy, the Colorado Consumer Health Initiative, and the Bell Policy Center. Manatt Health provided the policy and technical support, and Wakely Consulting Group, LLC, conducted the analytical modeling of the proposed program design and scenario alternatives….
 
Read full article in packet or at links provided

Article 3:    Ohio mental health agency closes, blames changes in Medicaid claims, Columbus Dispatch

Clay’s summary:   I’ve seen this movie before.

Key Excerpts from the Article:

Tener said her problems began in July, when the Ohio Department of Medicaid, which had been reimbursing providers for mental-health services provided to Medicaid clients, transferred that responsibility to managed-care insurance plans. Tener said she’s owed $40,000 from the plans, which have been criticized for failing to pay claims in a timely manner or rejecting them for unclear reasons..The Ohio Department of Medicaid has been reviewing the plans continuously and the providers since July 1, said Thomas Betti, the department’s press secretary.
“We understand the significant learning curve with the new system; however, data suggests that month over month, significant improvement is being made in the area of claims payment,” Betti said. “Issues have been minimal and quickly resolved.”Betti said the state sought to assist providers through the transition by disbursing about $146 million, via the managed-care plans, in advance payments from July through October. Those payments are similar to loans; providers are required to repay the money, and the state has instructed managed-care plans to delay repayment schedules, which had been set to begin in November….

Read full article in packet or at links provided

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Monday Morning Medicaid Must Reads: Jan 14th, 2019

Helping you consider differing viewpoints. Before it’s illegal.
In this issue…

Article 1:    Why 700,000 Ohioans were removed from Medicaid coverage, Columbus Dispatch, Jan 12

Clay’s summary:    Could be: a) improving economy, b) glitch in enrollment system, c) evil Republicans working with Putin to hack Ohio’s democracy. You decide.
Key Excerpts from the Article:   
More than 700,000 Ohioans were removed from the state’s Medicaid program in just the first 10 months of 2018. Franklin County had the most disenrollments, with nearly 90,000 losing the health-care coverage from January through October, the most recent data available show.
But no one quite knows why such a huge shift took place in the state-federal program for low-income Ohioans.
Read full article in packet or at links provided

Article 2:    Trump admin’s Medicaid block grant waiver idea invites legal and political firestorm, Axios, Jan 14

Clay’s summary:    They’re baaack (read in Poltergeist voice).
Key Excerpts from the Article:   
The Trump administration is considering giving states the ability to receive Medicaid block grants, Politico reported on Friday, a move that has experts unsure of its legality and the political world bracing for its volatility.
Read full article in packet or at links provided

Article 3:    Public Option And Medicaid Buy-Ins Emerge From 2020 Democratic Presidential Hopefuls, Forbes, Jan 13

Clay’s summary:    Dems see writing on wall re unravelling ACA, start to work on workarounds at state level.
Key Excerpts from the Article:   
Several Democratic governors – including one likely to run for President – are working on legislation to expand coverage to the poor in their states with legislation that would allow residents to “buy into” government subsidized Medicaid or other state coverage.
In all, “at least 10 states” are looking at Medicaid “buy ins,” Stateline reported last week. These proposals are akin to earlier proposals by some Democratic Senators mentioned as Presidential candidates to expand Medicare to Americans as young as 50 years old.
Such public options are seen by some as an alternative to more progressive single-payer “Medicare for All” proposals that would have the government control health insurance and require more taxpayer dollars. Most public option proposals emerging would continue the role of private insurers in helping administer the health benefit expansions.
Read full article in packet or at links provided
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Monday Morning Medicaid Must Reads: Jan 7th, 2019

Helping you consider differing viewpoints. Before it’s illegal.
In this issue…

Article 1:   Healthy and Working: Benefits of Work Requirements for Medicaid Recipients, Buckeye Institute, December 2018

Clay’s summary:   Beware the red pill.
Key Excerpts from the Article:
Extending Medicaid benefits to individuals who are able to work may reduce their lifetime earnings over the  long-term and adversely affect their consumption patterns in the short-term. Although households may benefit in  the short-term from Medicaid coverage through little- or no-cost health care, the ACA’s Medicaid expansion does  not promote individual long-term earnings growth or wealth accumulation. Workers have less incentive to invest in  their human capital than if they were required to work in order to receive benefits.
 
To address this concern, states that have participated in the ACA’s Medicaid expansion are now considering—or  have already begun to impose—work requirements for some new Medicaid enrollees. Work and “community  engagement” requirements, such as education and job training, tend to keep benefits recipients participating in the  work force, helping them to gain valuable work experience and generate higher earnings and income over the  long-term.
Using publicly available economic data, this report reveals the potential impact of imposing work requirements on  healthy, single individuals with no children. We study how eligibility work requirements may affect the lifetime  earnings of some Medicaid enrollees and find that Medicaid work requirements could:
 
* • Increase lifetime earnings by $212,694 for women and $323,539 for men—even assuming that the  individual remains on Medicaid for their entire working life; and
* • Raise the hours worked per week by 22 hours for women (from 12 hours to 34 hours per week), and by  25 hours for men (from 13 hours to 38 hours per week), bringing Medicaid recipients well above the typical 20  hours per week requirement.
 
We also find that the financial prospects look even brighter for individuals who transition off of Medicaid; they  may earn close to $1 million more over the course of their working years.
 
Requiring labor force participation for benefits eligibility creates an incentive for individuals to increase human  capital investment through the labor market. We show that there is a significant potential economic benefit for  those able-bodied adults who would change their work effort in response to a work requirement for Medicaid  eligibility.
Read full article in packet or at links provided

Article 2:   State Trends and Analysis, Pew Trusts, November 2018

Clay’s summary:   Turns out you do have to choose between healthcare and education. Until we find where the unicorns are hiding the magic wands, that is.
Key Excerpts from the Article:
Medicaid’s claim on each revenue dollar affects the share of state resources available for other priorities, such as education, transportation, and public safety. Because Medicaid is an entitlement program, states must provide certain federally required benefits for any eligible enrollee, even during times of sluggish revenue growth. So policymakers have less control over growth in states’ Medicaid costs than they do with many other programs.
Read full article in packet or at links provided

Article 3:   Estimated Impacts of the Proposed Public Charge Rule on Immigrants and Medicaid, KFF, October 2018

Clay’s summary:   The potential safety net costs for newly arriving Americans may be getting more attention if the rule is passed.
Key Excerpts from the Article:
On October 10, 2018, the Trump administration released a proposed rule to change “public charge” policies that govern how the use of public benefits may affect individuals’ ability to obtain legal permanent resident (LPR) status. The proposed rule would expand the programs that the federal government would consider in public charge determinations to include previously excluded health, nutrition, and housing programs, including Medicaid. It also identifies characteristics DHS could consider as negative factors that would increase the likelihood of someone becoming a public charge, including having income below 125% of the federal poverty level (FPL) ($25,975 for a family of three as of 2018). This analysis provides new estimates of the rule’s potential impacts. Using 2014 Survey of Income and Program Participation data, it examines the (1) share of noncitizens who originally entered the U.S. without LPR status who have characteristics that DHS could potentially weigh negatively in a public charge determination and (2) number of individuals who would disenroll from Medicaid under different scenarios:
Nearly all (94%) noncitizens who originally entered the U.S. without LPR status have at least one characteristic that DHS could potentially weigh negatively in a public charge determination. Over four in ten (42%) have characteristics that DHS could consider a heavily weighted negative factor and over one-third (34%) have income below the new 125% FPL threshold.
Read full article in packet or at links provided
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2018 Year in Review: You Can’t Put a Bow On It (Or Maybe You Can)

And now its that time of year we do the annual Mostly Medicaid (really Clay’s) Year in Review. For past reviews, visit here and here. If this is your first Year in Review with us, fair warning: it’s the one time I get all sappy. Provides a nice contrast to the cynicism and sarcasm you probably read the RoundUp for.[1]

 

You will need tissues.

 

Winter is a time for thinking.

A certain type of thinking, really. Reflection, introspection. All the eckshuns.

Spring is for hope and eagerness. Summer is for playing (and if you are a teenager in love it is a time of rhapsody and skirting curfews). Fall is for slowing down a bit, and breathing in the fresher, cooler air. Watching the oranges and reds and yellows on the trees.

But winter is a time for thinking.

And so I think, sitting in front of my fireplace. Warming my toes, my thoughts and-  I hope – my heart. For just as winter brings cold outside, it also brings cold to many hearts.

Hot soup can help. Or a game of cards with an old friend.

 

***

 

Sometimes we do things not knowing exactly why, but trusting they are important and will be valuable at some point in the future.

About 20 years ago, I started saving every single card people gave me and put them in a box. After a year or so, I outgrew that box. And now I am about to outgrow a large plastic tub.

Being a strict minimalist, cards are the one thing I let myself pack-rat.

I can remember the exact conversation that started this habit. A friend of mine and I both loved the same band (the Weakerthans). In their song Left and Leaving[2], are the lyrics:

 

Duct-tape and soldered wires
New words for old desires
And every birthday card I threw away

I wait in 4/4 time
Count yellow highway lines
That you’re relying on to lead you home

 

When discussing this song, my friend was struck by this particular line about throwing away birthday cards. They said something to this effect: “You know, every time someone sends you a card, they were thinking of you. Thinking of you enough to spend $2.99[3], write something about you specifically from their heart, and place it in the mail or hand it to you. We really shouldn’t throw those cards away.”

And from that moment on I didn’t.

I get rid of most things. I hate clutter. I don’t hold onto anything else for sentimental reasons. But – I have a box of birthday cards, get well cards, letters, graduation notes, thank you notes,[4] and myriad other similar items that has grown over the past 2 decades.

My thought is that one day when I am 80, I will sit and read these cards and be reminded of a time that I was loved and surrounded by those that I loved. That memories will flood in and drown out the sadness I see so often in the nursing homes I visit. That the effort to read someone’s poor handwriting inside a Snoopy-themed missive will pay off in smiles and remembered inside jokes.

Hold that thought. This will be the bow we put on the boxes that are sometimes painful to open.

 

 

But first, let’s talk about what happened in 2018 in Medicaid

 

Its been a wild, wild Medicaid ride hasn’t it dear reader? I looked back at the topics in our Monthly Medicaid News Roundtables, and made a short list of major happenings in our world this year:

 

Work requirements; Good vs Evil; Darth Vader; Orange Man Bad

It’s all a bit overblown, don’t you think? Reasonable people can disagree without casting each other as Nazi’s. At least they used to be able to. I yearn for a return of reasonable people discussing Medicaid. Hint – it does need fixing. Start there.

Another hint- a rebalancing of the state/federal “partnership” is long overdue.

 

Expansion on the ballot

This one took me by surprise. I wasn’t surprised that in state after state people voted for it (put any entitlement on the ballot and of course people will vote for it). I was surprised that it can even work this way. And I’m still not sure it can because it all has to go through the budget process. Stay tuned…

 

Social determinants

All 3 of these things are true:

  1. I believe food, clothing and shelter do impact healthcare outcomes
  2. I can’t sit through another academic presentation on this
  3. Its time to share info on specific, practical, starting point strategies. Go!

 

Managed care in the Tarheel State

North Carolina was added to the “managed care” column this year. Seems like 85% of the 2018 Medicaid conversations I had were around this. Now if we can get through the protests (I know we don’t have them yet, but I will bet you anything we will).

 

 

 

And now back to the things you think about sitting next to a fireplace (a wood fireplace, the only real kind)

 

Yes, it gets cold even in Birmingham, Alabama. Not as cold as some of the places you lunatic Yankees live (I’m looking at you my good friends in Michigan, Ohio, Maine- I mean, why not just live at the North Pole? That’s the one with penguins, right? Or is it the south pole? Or both?).

And I love fire.

I was the kid who other kids could not play with because I taught them how to play with fire. My first “date” was when I was seven and I went to see E.T. in theatres with a little girl my age. When her parents dropped her off, the first thing I did (to try and impress her?) was walk over to the nearest tree and show her how to strike a match and throw it at the tree.

I like fire. And fireplaces.

Many of you who have spoken to me the past few years know I have been slowly remodeling a 1974 elevated ranch. Well, I finally got around to fixing the fireplace. Which really was a chimney repair/ash dump investigation/damper replacement/flue cleaning/new cap install project. Just a small project. Only took me 2 months.

But now its done. And we sit by the fire whenever we can (I have come to think that first-thing-in-the-morning fires are the best. How nice it is to start your day with a fire and its heat and its light and the smoke wisping up into the flue as you drink a cup of coffee. Or see you children stumble out into the living room in their pajamas).

And these are the things I think about when I sit next to my newly working fireplace and stare into the flames.

I do not think about Medicaid.

I think about people.

 

My mom brought me a stack of old cards and I finally cried about Daddy dying for the first time almost a year after he died

 

As many of you know, Daddy died a year ago today (12/28/2018). My grieving has been different than most of my family members. For whatever reason, I did not really cry a lot when it happened. Or at the funeral. Or pretty much the entire year of 2018. I did cry here and there, but only a little.

I wasn’t holding it back (at least I don’t think I was). But it was noticeable to others, including my daughter who asked me – “Are you not sad? Now that Papa is gone?” I didn’t have a good answer. And I still don’t.

I am sad. But also not. Daddy left me with a clear view of death.

And its not that I don’t think about. I think about him most days. But in a good way. Memories of his little strange habits, or of conversations we had. Or ones I wish we would have had.

I try to spend my rememberings on things from when he was most alive. I do try to block out the gruesome final months of his life as he succumbed to brain cancer.

That was hard.

So hard that all I could do was work. Sitting in the room next to his, working away. Furiously trying to deny that he was 10 feet from me, his body and mind mangled more each day by this evil opponent.

I have many, many, many regrets in my life. But the one that has stuck with me most this past year is that instead of spending most of my time next to his bedside holding his hand in those last few weeks, I instead spent most of my time typing and analyzing and staring at a computer just a room away.

I’m sorry about that, Daddy.

 

 

I have learned in recent years, sometimes all our urges to find a silver lining, to make a happy ending, to put a bow on it (just look at all the idioms we have for this)- sometimes we can’t overcome the brutality of certain events. Sure, we can say “they’ll always live in our hearts” (never has made sense to me), or “make the most of life since its so short, and it will be ok as long as you live a full life” (always seemed like it missed the main point).

Sometimes we have to face the reality of loss. We have to accept for what it is. We can’t deny it. We can’t escape forever into our hobbies or pursuits or careers. Loss (primarily death) refuses to actually be transformed into something less than an awful, horrible, total thing.

We can’t put a bow on it.

 

 

I can still remember calling a friend and colleague who shares this Medicaid world of ours last February. I was at the Medicaid Innovations conference in Florida, and had stepped out to make a call to Dr. G.

The purpose of my call was to ask his opinion on a partner I was considering bringing on. Dr. G is someone whose opinion I trust (and his judgment even more). He started out as a client years and years ago.

And he is the reason I have a beard.

Dr. G was a key client stakeholder for a giant technology implementation contract my company at the time had (if I remember correctly, about $80M over a few years). In my first meeting with Dr. G, at the end of the meeting he had a new agenda item. It went something like this:

“You seem like a very impressive young man. And it seems like you have everything in order for the preparation for this project.”

He paused.

“But you look so young. I for one would appreciate a little more gray hair on a project of this size and complexity.”

I have always had a baby face.

I thought for a moment.

“Give me a month, Dr. G.”

 

I spent the next month growing a beard to try and look older (it used to work for my friends in high school when they tried to buy cigarettes, so why not for this?)

At our next meeting, I pointed to the beard.

“Do you feel better now, Dr. G?” I asked.

“Yes.”

It was the start of a wonderful working relationship, and I have gotten to know one of the most committed, honorable men in this space. All because I threw away my razor.

 

 

Back to the call from sunny Florida this past February.

After giving me his insights into the question that occasioned the call, he also asked how I was doing.

And I told him it was hard to have not cried about Daddy yet now (at that time) that it had been more than a month.

And he told me of the story about how it took him a long time to cry about the loss of his parents. He shared a sacred part of his life with me that day.

And he let me know it was ok to not cry yet. But that it would come.

And to hope that God would bless me for it to come in a private moment. For when it comes, there will be no holding back the tears. It will overwhelm you and consume you and take control of not just tear ducts, but also breathing and your muscles and all your emotions and your mind. It will be an experience of recognizing the totality of the loss.

And then it will somehow be better.

 

 

My mom has been cleaning out things since Daddy died. I think people do this for various reasons. Some people do it to get rid of clutter. Some people do it to busy themselves and avoid thinking about the one who has died.

Some people do it as a way to remember the people who have died.

I think that’s what Momma has been doing with all her cleaning.

And in cleaning out things, she found a stack of letters and cards of mine. She brought them over one day in early November and left them on my kitchen counter.

At first all I noticed was the letter from my elementary school congratulating me on coming in 2nd place in the city-wide spelling bee. And I remembered how much I did not like the experience of 2nd place. And I remember vividly the face of the little girl who beat me (I do not remember the word I lost on).

And I told my children the story of this. And they laughed. And that was that.[5]

The next day, I saw the stack of cards on the counter again. If your house is like mine, there is a constant battle between you and one spot on your counter to keep it free from mail or books or keys or change or Home Depot receipts. The stack of cards was in that spot, staring back at me.

That’s when I noticed the other things under the spelling bee letter.

I opened the first one and began to sob. It was a highschool graduation card to me from Daddy’s very best friend. Emmet Ladner. Emmet and Daddy became fast friends on the Mississippi Gulf Coast due to their shared love of fishing. Emmet had died 10 years or more ago and I watched Daddy miss him.

And then I opened more cards. Many of them from Daddy. Or from aunts long dead. Or friends forgotten.

And I simply could not stop crying. But it was of joy. I was remembering the good things, all the many people God had placed in our lives and the times they thought enough of me to spend a few bucks and write down a few thoughts about me that they felt in their hearts.

It was not – as Dr. G had wished for me – a private moment.

My wife was there to hug me. My kids were there to see my cry. And I’m glad they did.

 

 

 

3 Kinds of People

I think this year I realized recently that there are mostly 3 kinds of people:

  1. Those you don’t want to be around. You choose to avoid these.
  2. Those you do want to be around, but can’t. They may be far away, they may dead, they may have an illness that prevents contact. They may be missionaries in a country where they have to be almost like secret spies for Jesus or else get killed, and that’s the reason you probably won’t ever get to see them again. There may be an un-crossable emotional rift between the two of you, spreading across and between your hearts like a chasm. With only darkness and echoes where what once was joy and laughter. And a bond you never doubted until one day it simply wasn’t there.

There are many reasons that created situation #2- the people you want to be around but cannot.

And that leaves us with the 3rd kind:

  1. People you do want to be around and still can.

 

I now think about the people in #2 a lot. And you should, too. You shouldn’t avoid it (if you do).

Its good to think about the people in #2. It is important to miss them. Important to grieve. To mourn. To ache. To cry.

 

But I need to start paying more attention to the people in group #3. (And so do you).

 

And this is where we put the bow on all this.

 

 

 

Card by card

I’m still saving this big ole’ box for when I am old and gray. I’m working on the old part. And the gray pokes through. But hopefully I still have decades longer to fill this box up and look at it when I am old.

But – I did sneak a peak at a few of them when Momma brought them over. A little stack. A small bundle of memories that jarred in me tears of joy.

And I would like to share just a few of those cards – or rather share a bit about who sent them- with you before we land this plane.

  • Emmet and Nell-  They are both dead and gone, but some of my earliest memories are of them.
  • Jo Elaine –Jo is my aunt and she’s a peach. On my Nanny’s side (who has been gone a long time). Jo is one of many aunts who always thinks of me on birthdays even though I rarely see her.
  • Bobby and Betty –Mr. B was also one of Daddy’s very best friends. I remember riding my bike next to he and Daddy as they ran at 4am each morning in Gulfport, MS. Mr. B was a Marine, rough around the edges but with a gooey center that loved people. He was a good man. He is also now gone.
  • Carrol and Nancy –Carrol was a true friend to Daddy in his toughest times, hiring him to work in his hardware store during one of Daddy’s hardest bouts of depression (it lasted 3 years that time). Nancy died in a car crash in the rain on an interstate exit ramp. But she was a dear friend to my mom before she left. Momma still misses her and I think of her every time I pass that exit ramp.
  • John and Louise – a sweet, sweet couple who managed a large farm operation in Kiln, MS (where I watched Brett Favre play highschool ball). They stopped smoking when 7 year old me told them I couldn’t be around it. They are both gone now but in no way forgotten.
  • Ganky and Pappy- Pappy was a retired railroad man and he sure did love Ganky. She was the first person I ever heard of with Lou Gehrig’s disease. Pappy once snuck into Daddy’s garden in the middle of the night to dig up and replace small tomato plants with very large ones to convince Daddy of the astounding overnight effectiveness of Miracle Grow. They have both been gone a long time.
  • Aunt Annette – one of my mom’s aunts who still sent me cards even though she had been estranged for decades. My mom misses her a lot.

And so many more even just in this little stack. From my siblings, from Momma and Daddy. Somewhere in the big box is a letter from my friend Cecille who died (along with her little brother) when she was hit by a train in her late teens. Way too many to write about.

What do I take away from all these cards? People come and go and everyone dies. But in the in-between parts, the times you spend with them, the times they still send you cards (and even after that when you read the cards years later)- something amazing happens. Somehow, despite all the insurmountable despair of loss we all must face, somehow we have the capacity to love one another.

Let’s do more of that in 2019.

 

One last detour

I almost didn’t write this part up. This thing has gotten way, way longer than I intended. And I hope for the 2019 Year in Review I can find a topic besides death and loss. 3 years in a row is surely enough.

But this part is fun.

When I was kid, we went to every Auburn game. Home and away.

This was before that jackass Alabama fan poisoned the big oaks on Toomer’s corner.

Back when you could still park all over campus on gameday, in crazy places. And camp out for 3 days before the game with 100,000 of your closest friends.

Like an idiot, I hated much of those times as a kid. Or at least I thought I did.

Now, I do things like return to Auburn and walk around with my kids. Just like Daddy did with me.

Not knowing why, we often return to the places our fathers took us.

What was really crazy, was that Daddy would just walk on the field after a game and walk into the locker rooms just to talk with players. And after that we would walk over to the players dorms and hang out with them. So as a 12 year old I’m chilling with the dude that just kicked the winning goal against LSU. Or the guy that missed the pass that could have beat Arkansas in the last 3 seconds. Those 2 guys have very different moods, by the way.

But the point is that Daddy had a way of getting into places (and people’s hearts) simply by acting like he was supposed to be there. Let them tell you no if they feel they must. But until then, sneak into the stadium.

And that’s what we did a few weeks ago. Passing through Auburn on our way back home from a trip with the kiddos.

There was one gate open at Jordan-Hare stadium that day (pronounced Jur-dan for those of you who don’t know). I snuck in first and waved to the kids to follow.

There was a worker there. He looked at me.

I froze.

“I gotta lock the gate, so please make it quick.”

I had the feeling he sees this a lot. And he was so kind and probably is to every Auburn fool wandering back in. Whoever he is, he was my hero that day. And I hope I get chances to be so kind to others in need of sneaking into stadiums, too.

We go back to the places our fathers took us.

 

Wrapping Up (Finally!)

So I know what I need to do now. How 2019 needs to go.

My box is overflowing.

I need to send more birthday cards so others can put them in a big box and pull them out one day and go through each one and defiantly shake their fist in the face of death and loss and separation and tell the Evil One he has not won because there was joy. There was love. There still is. But – most importantly- there still will be.

And it can be forever for those of us who choose it. Beyond time, forever joy. With our loved ones and with Christ. For all of you readers who are non-believers (so many of you are, and I hope you know by now I love you regardless of any differences of opinions or beliefs), suffer me one more time in 2018 to share the simple gospel:

You (and me and everyone ever born) are a sinner. You need a savior. His name is Jesus.

 

Merry Christmas and Happy New Year my dear readers! You are loved by me, each and every one of you. If you like you can print this out and put it in your box and count it as a card from me to you. Me thinking about you and writing it down.

Please don’t stop writing in (clay@mostlymedicaid.com) and calling (919-727-9231). You have no idea how much it means to me when you write in and tell me your thoughts about what I write.

War Eagle!

Onward and Upward!

Trystero: The Father Sent the Son to Save the World (English)

 

 

 

[1] I have found my old love of footnotes again. It’s like a little side conversation beyond me and you. Titles that were also considered:

A Box of Letters

Looking At Life With Clear Eyes and A Full Heart

Memories as a Gift to Get Us Through Our Journey

Returning to the Places Our Fathers Took Us

 

[2] For those of you who have enjoyed my musical recommendations in the Roundup over the years, this song, album and band are in my opinion one of the most important things to happen to music in my lifetime. For people who have never heard The Weakerthans, I tell them their art is the closest thing to perfection in the combined genres of music and poetry that I have ever encountered. It may not be your style – but I drove from Baltimore to Toronto once just to see them play and its still one of the best life decisions I have made.

[3] For a fun look at the greeting card industry (including average prices, which have gone way up since the mid-1990s), see https://www.thesprucecrafts.com/greeting-card-industry-facts-and-figures-2905385

 

[4] Oxford forever! Grammarians, unite and #Resist! https://en.oxforddictionaries.com/explore/what-is-the-oxford-comma/

[5] 6 sentences in that segment started with “and.”