Line item vetoes show continued Jindal policy relevance

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Naturally, hospitals objected to the point that the original rule was withdrawn, saying this was really a rate cut by other means and it would be problematic, citing one example that even symptoms that appeared minor could lead to major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.