Even as the need for casting line
item vetoes in the mind of Gov. Bobby
Jindal seems to have greatly diminished, his treatment of Louisiana’s fiscal
year 2015 budget shows he continues with no less enthusiasm to use
them when needed that hints maybe a hypothesized
inability to influence policy concerning the Legislature seems exaggerated.
The edition of the state’s
spending plan drew only eight
line item vetoes from Jindal. This contrasts with the 258
from the first one that came his way in 2008, when he had laid out
guidelines to govern the funding of nongovernment organizations which many line
items didn’t follow. Very quickly legislators got with the program and in
recent years most of his vetoes of this kind have come over policy
disagreements about what government should fund and where.
One was to close off an attempted
carving out of funds for a University of Louisiana at Lafayette organization
that didn’t make the final cut, another to axe a favoring of one area New
Orleans NGO at the expense of others, and still another was to prevent an
apparent sweetheart deal concerning a nursing home that could keep its
reimbursement rates higher than otherwise that had germinated in the House
Appropriations Committee. But the two most consequential dealt with emergency
room reimbursement rates and a continuing feud propagated by a legislator.
Earlier this year, the Department
of Health and Hospitals put out a notice of intent
for a rule about Medicaid reimbursements for non-emergency services performed
by hospital emergency services. In essence, the idea was to reimburse at a much
lower rate for a triage procedure, many of which would not be expected to require
further emergency services, whereas currently these would be conducted by
emergency personnel and billed at a much higher figure. The idea was to have
hospitals perform this where for genuine emergency cases reimbursement now
would be $50 more, but with many fewer payments going for emergency services
overall not having to be performed the state hoped to save $4.5 million.
Naturally, hospitals objected to
the point that the original
rule was withdrawn, saying this was really a rate cut by other means and it
would be problematic, citing
one example that even symptoms that appeared minor could lead to major
difficulties where full testing needed to be done. DHH has continued to work on
this while in the interim the budget was
adjusted up by the amount that would have been cut had the rule been
promulgated.
Interests representing hospitals
and emergency medicine did have a point of the necessity of a broader
perspective on the issue, which DHH has now adopted by bringing in the state’s
contracted Medicaid insurance administrators in sorting out a rule. One that
would provide incentives for them to engage in triage prior to and/or
additionally with the providers could create greater efficiency and savings.
But the larger populist political
culture of Louisiana also is to blame and will require different means to
reeducate the indigent public that use Medicaid and providers. Through decades
of having state-owned, state-run charity hospitals, having been trained in the
legitimacy of anybody walking up at any time to get treated for anything
through emergency medicine will take time and behavioral incentives to wean
patients and providers out of this mentality. Concerns about liability that
encourage defensive medicine practicing in these cases can be reduced by the one
major reform left undone regarding malpractice claims in the state, that of
capping legal fees, to ease transition into new rules.
While Jindal left the restoration
money in, he did excise a paragraph that would have disallowed any changes in
reimbursements for the coming year for emergency services. This properly arms
DHH with tools to provide these behavioral incentives.
However, no amount of prodding
seems to work in the case of state Rep. Joe Harrison,
who once again tried to undo a Jindal policy decision that seems to be saving
money with no reduction in service quality. To make a long
story short, Jindal had wanted to have the same unit administer both Adult
Protection Services, in DHH, and Elderly Protection Services, in his office, the
tasks performed by which are largely the same requiring largely the same skill
set, with only the populations served differing, to save through reduction of
duplicated effort.
In 2012, legislation to do so
narrowly failed, so Jindal allies basically stuffed the change into the budget
by funding DHH to perform EPS functions, which would contract with his office
to do so. That has to happen every year without a law like that, so every year
Harrison tries to undo it. His amendment to keep out the money and employees got
in again, so Jindal crossed it out like brushing away a pesky gnat.
Interestingly, whereas in 2008 Jindal’s
actions saved the state tens of millions of dollars not being spent, none of
these save anything in terms of outgoing money. Rather, they concentrate on putting
dollars in the right places and maximizing the state’s discretion in their
uses. That and that so few got cast (fitting the trend of declination over his
terms) would indicate that he and the Legislature seem pretty much on the same
page in budgeting at least. This runs counter to the impression a number of
observers have articulated that a waning interest in state governance on his
part as his time in office wound down due to interest in other matters would
impair his ability to provide policy leadership.
It might be more accurate to
characterize his place in state government presently as his ardor has cooled for
major policy initiatives or changes (with one
notable exception), but within the policy landscape as is he has the
Legislature pretty well trained to budget as he prefers. That reminds, 18
months from his planned departure, not to write off his impact on state
politics prematurely.
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