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10.3.07

Result shows pro-GOP, anti-incumbent trend continues

The next marker in the quest to figure out where the 2007 elections are headed came with the special election in House District 94. The term-limited unreliably conservative but entertaining (we will miss his banter in committee and on the House floor) state Rep. Peppi Bruneau will hand over the reins of the district just as the regular session starts, doing so he said to give the winner more seniority in the chamber, while critics said he was trying to better position to succeed him his son Jeb Bruneau .

I’ve noted that, with the coming of term limits for legislators and the increasingly apparent internal contradictions and invalidity of the liberal/populist ethos in Louisiana as the state gets kicked dragging and screaming into by events beyond its control, that Republicans and/or non-incumbents will make major gains in political contests this year. This contest proves interesting in this regard, for it is a reliably conservative district but with Bruneau the younger a kind of quasi-incumbent and having three other GOP challengers along with a pair of Democrats putting up a fight to prevent his ascension.

If Bruneau won outright, it would tend to support the Republican part of the hypothesis but not the incumbent one (whose only real strong support to date comes from the dismantling that newcomer state Sen. Ted Cassidy brought to potential-chamber-jumper state Rep. William Daniel IV in both Republicans’ quest in December for the Senate District 16 open seat). If another Republican won outright, that would provide strong evidence for both. Two Republicans, or even one, in a general election runoff would keep us guessing, but that Bruneau was denied an outright win would tend to bolster the anti-incumbent hypothesis.

And the answer? Certainly no sign that it won’t be a favorable Republican year, as Bruneau with 32 percent and another Republican, Nick Lorusso (endorsed by the Alliance for Good Government) with 25 percent, made the runoff. And, the fact that Lorusso pushed Bruneau into a runoff, not trailing him by much, may mean that anti-incumbent sentiment may swell in support of Lorusso.

One interesting dynamic was the two Democrats picked up 39 percent of the vote, with one not far behind Lorusso. Much of this vote could go to Lorusso out of spite of Bruneau. Running just one of them might well have gotten that one into the runoff, although it’s not likely anti-incumbent sentiment would cancel out partisanship and ideology leading Bruneau to win. No doubt this will displease my good friends at a rabidly pro-Democrat blog that occasionally links to this space who must feel like they have their fingers in the creaking Democrat majority dike in the state (I must correct them about one thing in that, as they refer to me as a “Republican operative,” that other than a GOP party registration I proudly acquired just after graduating high school I have no affiliation with the party).

It’s just one special election in one small part of the state, but it’s more evidence pointing to a favorable Republican trend this election cycle, and, given that Bruneau was forced into a runoff so his chances of winning are at best even money, that the anti-incumbent feeling is itself alive and well.

8.3.07

Selective, self-serving information distorts health care debate

Reform, while desirable in the case of indigent health care in Louisiana, will threaten certain entrenched interests. Thus it is understandable why Michael Butler, LSU Health Sciences Center chief medical officer, might try to present a skewed picture of the quality of indigent care in the state.

Changing the system from a money-given-to-the-institution to a money-follows-the-person regime would pose problems for the charity hospital system run by the Louisiana State University system. Money would flow away from that organization into for-profit and nonprofit providers, in part because patients will choose these other options because of the services available and/or quality of care, and LSU and other state politicians do not want to see that happen because it would mean fewer jobs and less power.

Butler did his best to deny this reality by arguing at a press conference that “[c]ontrary to popular belief, the public hospitals ... are a valued asset for patient care. When people say we are not delivering high quality care, they are not being honest. Most are just too lazy to dig in deeper and pay attention.” Further, he said “There is evidence that charity does better than private.” In fact, as federal statistics show, it is Butler who is not being honest and needs to dig a little deeper and pay attention.

Note that Butler tries to establish two different arguments here, that the charity system is “high quality” and in some ways it is better than the private sector. The first is somewhat misleading: it all depends on how you define “high quality” but, more importantly, what if one could have “highest quality” instead that could come only from outside government hospitals? That connects to the second argument, that if we define the charity system as doing as well as the non-government sector, then perhaps that means there is the “high” or “highest quality” and no significant advantage there could be obtained by shifting more care to private institutions.

But when reviewing federal statistics in four areas, using just as an example the flagship institution in the system, the Medical Center of Louisiana New Orleans (“Big Charity”), it comes up short. These statistics deal with quality in the areas of heart attacks, heart failure, pneumonia care, and surgical care improvement/infection prevention. While Big Charity slightly outperforms New Orleans-area non-government hospitals on the first category, it does worse, sometimes much worse, on the other three. The news gets worse for other system hospitals. The other major facility, LSU Health Science Center Shreveport, does a little better relative to its area institutions, but the smaller ones seldom do as well, and sometimes much more badly, on average than their surrounding non-government institutions.

Conclusions drawn in the draft report by the Public Affairs Research Council also cast doubt on the quality of charity hospital indigent care. To quote it, “Overcrowded emergency room and outpatient clinics have caused diagnosis and treatment to be delayed for countless uninsured patients …. Louisiana charity hospitals since the mid-1990s show significant decreases in services delivered while budgets continue to rise.” Butler apparently disputed none of this at the press conference.

Butler trotted out some indicators showing in some areas the system does decently, perhaps even better than the non-government sector. However it is selective and he certainly ignores the substantial evidence that charity hospital performance lags that sector. In doing so, Butler does a disservice to the debate over this issue and appears more as a champion of vested interests than in improving indigent health care in Louisiana.

6.3.07

Report confirms need for LA indigent health care overhaul

I was pleased to see the Louisiana State University Daily Reveille had the brainstorm of serving a public records request on its own administration to pry free a copy of the preliminary report by the Public Affairs Research Council that sent LSU system officials into a tizzy. The report is critical of the money-given-to-the-institution system of indigent health care in Louisiana, while promoting the money-follows-the-person reform resisted by Gov. Kathleen Blanco and the state’s vested health care interests.

However, I am disappointed that I received so little credit in the report, as over the past five months in this space much of what was in this report has already appeared (perhaps in the final draft they will cite my postings). PAR in this report drew almost all of the conclusions that I did: shift to money-follows-the-person to improve quality and efficiency of care, centralize medical education in just a few charity hospitals and dispose of the rest to help achieve these savings, and do not build a grandiose new “Big Charity” hospital in New Orleans as it should be there primarily for medical education, not as a charity provider.

The report makes one excellent point of which I was unaware. Despite medical education of some form occurring in most of the charity system’s units, the report indicates that often these hospitals are behind the times in treatments in many differing areas. Perhaps this is why their outcomes tend to be no better, and are often worse, than nearby non-government institutions. It indicates how a restructuring of medical education could be used to generate more federal dollars for the state in this area.

Disingenuous Montgomery uninterested in lowering taxes

When you get a politician of advanced years and long service such as state Rep. Billy Montgomery, chances are he’s forgotten more about politics than many ever knew. But in his case, some recent statements and actions by him suggest he’s also forgotten more about himself and how to best serve his constituents than they ever would care to know.

Montgomery has prefiled HB 36 which is designed to undo income tax increases courtesy of the so-called “Stelly Plan.” In 2002, the House passed (interestingly enough, the same-named) HB 36 which constitutionally increased these income tax rates, subject to a vote of the people as with any constitutional amendment which led to its narrow adoption.

Montgomery now calls this is mistake. “I believe most people were misled or didn't know exactly what the Stelly Plan did,” he recently said at a public forum. Apparently, “most people” included Montgomery himself, for he was part of the two-thirds legislative majority that voted in favor of HB 36 in 2002. It received exactly the 70 votes needed to pass it along to the Senate. If not misled or he didn’t know exactly the plan’s implications, then by definition he knew what it was about exactly and thereby aided and abetted in misleading people.

Assuming he himself was “misled” or “didn’t know exactly,” being that at the time Montgomery had been a member of the House for 15 years, despite all of that experience, by his own testimony Montgomery appeared to be confused and/or ignorant about the true nature of a bill he was voting on – yet he voted for it anyway rather than opting for a safer vote against. As it was, Montgomery’s vote was the one crucial vote that allowed the measure to continue into law.

In essence, Montgomery is trying to undo what he now calls a mistake, something that by himself alone he could have stopped five years ago had he been a wiser politician. Whether repealing what he foisted on the public years ago now is sufficient penance is one matter. But, the fact is, with this bill Montgomery really isn’t actually asking for an unambiguous tax cut, another matter entirely.

This is because for its provisions to go into effect, his prefiled HB 38 also would have to be passed. Part of that bill would lock in the lower income tax rates. But there’s more to it: another part of the bill would remove the prohibition on the state’s ability to place a sales and use tax on food for home consumption and consumer purchases of natural gas, electricity, water, and prescription drugs.

In other words, Montgomery’s intent is not to cut taxes, it is literally to repeal the Stelly Plan. Because in exchange for lowering income tax rates that by his crucial vote he helped to raise in the first place, he is inviting the Legislature to raise sales taxes. Significantly, these kinds of taxes disproportionately fall upon lower-income families.

The explanation for this behavior is simple: Montgomery, in violation of the spirit of legislative term limits, is running for state Senate District 37 later this year. He has no real interest in cutting taxes because, as his legislative career shows, the Democrat-turned-Republican has been a tax-and-spend liberal and would rather empower government by taking resources from the people than to empower people themselves. He just wants to fool voters in probably the most conservative district in the state into thinking he’s one of them.

If Montgomery were a quality elected official, he would not have made a mistake after 15 years of seasoning he now claims he’s trying to correct. If Montgomery were a true conservative, when the state is sitting on $3.2 billion in surplus funds he would be trying to cut taxes without any chance of raising them in another way, instead of giving with one hand and taking with another – appropriate to his tax-and-spend legislative career.

Either he’s disingenuous, a dunderhead easily misled or confused about his job, or wrong on the issues for District 37. Maybe it’s time for those voters to give Montgomery a retirement he richly deserves. And the guy that should lead him to it is Jay Murrell, but that's a subject for a future posting.

5.3.07

State's increased cost figures for reform plan dubious

Perhaps the best argument used by opponents of indigent health care reform in Louisiana is that it would cost more money than with the present system. Of course, the argument conveniently ignores that the present cost level helps to produce the worst health outcomes in the nation, and that because reform would make for a more efficient system, that in time better care for less money per patient would result. But it is logical that in the short run, with two systems operating beside each other as the old money-given-to-the-institution system fades away the new money-follows-the-person system will grow, that costs would be higher.

But the revelation of some numbers dealing with indigent care pokes holes in this large increased-cost assertion, even in the short-run – something which the federal government, eager to see the change, has said all along while it’s been the state and the state only that has claimed costs would be quite a bit higher.

Statistics show that money spent on the charity hospital system, some units of which also feature some advanced medical training hard to replicate outside of the public sector, totals $912 million. In addition, $1.1 billion is spent on reimbursements to private institutions dealing with the indigent and those on Medicaid. In other words, over $2 billion is spent mostly on the indigent, with some of it going to medical education and Medicaid reimbursements to institutions. Another $361 million goes to reimbursement of private physicians for Medicaid patients.

In other words, the state spends about $2.4 billion on the indigent and poor (most people on Medicaid would be uninsured without it, essentially making them part of the indigent care system) with some of that used for medical education. It says the indigent portion of that is $935 million, but reform plans it says would cost over twice that.

Reviewing these numbers, the state’s figure doesn’t make sense. Is it arguing that the reform is so expensive that it essentially would double the state’s costs in this area? Then why are other states, some whose relative wealths are similar to Louisiana’s, moving in that direction and no other state maintains a charity system if it’s supposed to work so well? More importantly, does this imply that Louisiana is underfunding care for the poor and indigent by 30 percent presently?

The federal government has conjectured that the real initial extra cost of the system may be as little as $100 million a year. Given that it is hard to believe that a charity system is half the cost of a reformed system where the indigent would be given vouchers to purchase their own health care (then why isn’t every other state doing it?) and that the bulk of $2 billion a year already covers the indigent (which sounds like the state’s estimate, which it never has publicly released the method by which it was calculated, simply is taking most of what is spent on reimbursements to private institutions and saying that is the extra billion), that the federal government’s increased cost projection seems much closer to the truth than the state’s.

4.3.07

Make LA state-owned hospitals primarily for teaching

Appropriate to the continuing debate over restructuring of indigent health care in Louisiana with a goal of improving its less efficient, reduced quality-of-outcome nature is whether a best performer in the current charity system can have its characteristics replicated over a larger such system.

Currently, Louisiana in the only state whose indigent health care system relies almost exclusively on a money-goes-to-the-institution rather than a money-follows-the-person system. This has created a situation where the indigent must make pilgrimages to a handful of large institutions for even routine care. The federal government is urging the state to get with the program by revamping the system to allow the indigent to select their own health care options and to make that portable.

Established interests in the state resist ending the institutional bias. They include not just political elites such as Gov. Kathleen Blanco and nursing home operator and state Sen. Joe McPherson, but the Louisiana State University system which has control over the charity hospital system. The federal government mostly has no leverage over trying to influence this change because it has not committed to throwing in extra money as an incentive to pay for transition costs.