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Opponents to LA indigent care reform show hands

Battle lines have become clearer as a result of testimony in front of the Louisiana Senate’s Health and Welfare Committee regarding the future of indigent health care, starkly illuminating the direction of this policy the decision about which could provide better health care at reduced costs if vested interests don’t get in the way.

A group of private health care providers and insurers argued for a modified money-follows-the-person system to replace the current money-goes-to-the-institution indigent care model that, unique among the states, Louisiana follows. Its plan calls for steering 61,000 uninsured adults into managed-care "medical homes." The group said the premiums would average $194 a month for an annual cost of $156 million, which would come from the "disproportionate share" of Medicaid dollars that now pays for most of the care in the Louisiana State University-run charity system.

But members of the committee were unimpressed, and their comments are instructive in terms of how opponents will try to attack this reform if instituted statewide – policies that more states are adopting to improve outcomes often at reduced costs for the indigent. State Sen. Cheryl Gray remarked the idea didn’t seem to have an endorsement from LSU nor the state’s Department of Health and Hospitals.

As far as the latter, its Secretary Alan Levine made approving noises about the plan but stopped short of endorsing it. This reluctance should prove temporary on theoretical and practical grounds. Levine probably is looking to roll out a plan similar to that he helped institute in Florida which would skip the “medical home” concept and go straight to the vouchers, but he is not yet ready to do so and tactically probably would wait until the next fiscal year after the legislative session has ended (the state needs no legislative action on this, just approval of a waiver request to the federal government).

Also, Levine needs to finish a recommendation on the size of the new “Big Charity” hospital in New Orleans. Simply, a plan along these lines would mandate a decrease in the size of the palatial facility envisioned by the Kathleen Blanco Administration, and would make sense only if Levine and his boss Gov. Bobby Jindal backed a smaller-sized hospital. And, of course LSU never would endorse such a plan because it would be taking money from that agency, so Gray shouldn’t hold her breath on this one.

The fact that temporary facilities currently serve the New Orleans-area indigent is why the plan envisioned just starting in that area; politically speaking, it wouldn’t threaten existing LSU resources in other areas of the state. State Sen. Sherri Smith Cheek thought that wasn’t good enough and said she couldn’t justify that to her constituents, that it was unfair. But if Levine rolls out a similar plan to go statewide, watch for Cheek to change dramatically her tune, to sound like state Sen. Joe McPherson.

McPherson, who operates a series of nursing homes, called the cost figures “unrealistic” and said health care premiums for his employees are at least 250 percent higher. Understand that this conflict is quite personal to McPherson: if the state succeeds in steering money away from institutions on this front, his nursing homes, the collective of which in Louisiana are probably the most inefficient users of taxpayers dollars in the entire nation according to the Louisiana Legislative Auditor and which typically derive the vast majority of their revenues from government payments, might be next.

Of course, being in an industry so heavily regulated and subsidized by government, McPherson is a poor judge of what actual costs are. Using a pioneer state in this kind of plan extending not just to the indigent but the uninsured, Massachusetts, a state with higher costs but healthier people, had for a standard set of benefits a target premium for a 37 year-old single male at $250 a month, but the marketplace currently actually prices it at $184. That is consistent with the coalition’s estimate, not McPherson’s. (And Massachusetts is seeing lower costs and improved outcomes.)

Expect these kinds of arguments to resurface if and when Levine forwards an indigent care plan, integrated with a smaller Big Charity, along the lines of the Massachusetts model restricted to the indigent. This is because senators like these and their allies have as their primary goal not more efficient delivery of health care to the indigent, but that big government be as involved as possible in its delivery to protect powers, privilege, and patronage of the existing LSU hospital system. They are believers that big government makes better decisions than do individuals, and that state employees’ jobs and agency resources must be protected.

Hopefully, that is not the attitude of the Jindal Administration and it will prove as such over the next several months.


Jindal impresses on outlay reform, but challenges remain

Gov. Bobby Jindal’s declaration that the capital projects he wants the state to pursue are only those approved in prior years and constitute nothing new casts optimism and uncertainty into the reform process.

Under the current process, far more items are stuffed into the capital outlay budget each year than constitutionally the state can spend money on. The items that pass muster really emanate from the governor’s office when the State Bond Commission is brought spending proposals and then approves, a body lined with gubernatorial allies. As a result, roughly three-quarters of authorized spending annually lies on the table where, maybe, in future years it might actually get funded.

Jindal has said for this year’s round, he’s going to take previous years’ choices and not introduce anything new. He can say legitimately that he is not ignoring any new broad needs because the state spent over a half billion dollars last month in a special session on such needs.

Impressively, Jindal also issued an executive order with new guidelines to determine spending priorities. A more formal ranking system would be imposed, and anything local would have to have some commitment from local governments. Jindal also backs reform bills that would stop the state from making future commitments that do not have a scheduled appropriation attached to them.

This sets the state up well for reform of the process, but questions remain. For one, until the process reform becomes law, nothing stops the Legislature from doing the same thing again, loading up this years capital outlay bill with three times the authorized amount – except for a committed governor, willing to use a line item veto on items that he thinks will bust that budget and, most importantly, telling legislators he will do that.

Also, the interim procedures established in the executive remain hostage to politics. The Jindal Administration still will have to choose if all goes well, just one out of three dollars instead of one out of four, and make sure these are the best choices. And the Legislature will have to be sufficiently under control not to pass instruments overriding the executive order.

Most importantly, Jindal’s crew must choose wisely. It’s assumed the order’s standards will be used, and Jindal must resist political ploys to bend them. Finally, even if the reform bill gets through and moots much of this interim strategy in the future, nothing about this addresses the nagging problem of earmarks that appear in the general appropriations bill, where only stern threatened use of a line item veto can rid it of projects that almost uniformally are of very low priority and really do not help the state as a whole.

Especially the executive order ratifies Jindal’s pledge of reform of state spending priorities. Now he needs to follow through by getting the reform bill into law and holding fast threatening, even using, his veto power, despite the political challenges no doubt coming his way.


Paranoia, selective arguments mark SB 561 opponents

All the fire and brimstone surrounding SB 561 on the docket of the Louisiana Legislature tells more about the paranoia and insecurities of those trying to create a controversy than the bill’s language actually suggests.

Sen. Ben Nevers introduced this bill to increase academic freedom in Louisiana schools. It asserts that it is to create an environment within public elementary and secondary schools that “encourages students to explore scientific questions, learn about scientific evidence, to help students develop critical thinking skills, and respond appropriately and respectfully to differences of opinion about controversial issues.” Also, it is to prohibit the state or its officials from interfering with this.

But the innocuous language has gotten some people very upset. People associated with organizations that claim they are interested in education have spoken publicly and sent out e-mail messages calling the bill essentially a “backdoor” for the teaching of creationism in schools. Interestingly, they base this interpretation (one which, in its reading, is exceptionally broad in taking selected passages) not on the actual language of the bill, but on the bill’s digest.

A bill’s digest is written by a legislative staffer and has no legal importance. The actual wording, if these alarmists would care to read it instead of dispensing with it because it doesn’t fit their agenda, contains the following section what that the law is to do: “protects the teaching of scientific information, and this section shall not be construed to promote any religious doctrine, promote discrimination for or against a particular set of religious beliefs, or promote discrimination for or against religion or non-religion.”

It couldn’t be less ambiguous that the bill does not in any way endorse that creationism or any other religious or non-religious (like the imperfect theory of evolution) idea be advocated uncritically in the classroom. It simply buttresses the academic freedom of instructors to explore the merits and demerits of any particular scientific theory.

The reaction of those who argue against academic freedom in this instance is telling, however. One wonders whether they see the theory of evolution itself as a religion, given they are so scared of any critical examination of it.

Any educator at any level should support this bill for the protection it gives the concept of academic freedom – the pursuit of which seems to make some who call themselves educators very nervous.


LA Democrat superdelegates will go with most electable

There’s much confusion about the role Louisiana’s Democrat Party Leaders and Elected Officials (PLEO) delegates (“superdelegates”) will play in the party’s nomination of either Sens. Barack Obama or Hillary Clinton for the presidency. Having taught how the Democrats’ system works for almost two decades, let me be of assistance.

Initially, it must be understood that the complicated system of the Democrats – no unit rule decisions by state or territory or Democrats Overseas (that is, no winner-take-all), the presence of the PLEOs, and the diversity mandates (for example, half of delegates must be female) – came as a result of the disastrous 1972 nomination of former Sen. George McGovern. Simply, the existing system permitted popular passions of the party’s most liberal members to be translated into an unelectable candidate. Thus, the reform efforts beginning with the party’s 1974 meeting and tweaked several times since was to give those with a substantial stake in party affairs – officers and elected Democrats – significant weight in the nomination process while balancing that with grassroots representation of all meaningful parts of the party. It was believed the superdelegates would use good political sense in their choices to vote for the candidate most capable of winning in the fall.

In short order, they almost became critical deciders of nominations. Both in 1980 and 1984 the eventual nominee barely squeaked out enough “pledged” delegates to have an absolute majority (note: technically, no delegate is officially “pledged” among Democrats – delegates apportioned as a result of primaries essentially are chosen by the candidate’s campaigns themselves, and of course pledged caucus delegates already have promised, and are expected to be loyal to that candidate, but any delegate can vote for any nominee although defection is very rare). Both Obama and Clinton will fall far short in 2008, making the superdelegates, who represent almost a fifth of the total nomination votes, in fact the critical deciders.

So, in analyzing what superdelegates intend to do as a matter of course it is mistaken and facile to assume generally they’ll follow some standard such as how a state’s vote turned out. Some who have been early backers of a candidate out of loyalty will continue that support regardless of anything else, and those who rate the candidate’s chances and equal for November victory might use a popular vote standard. (Note also that not all superdelegates are yet picked – each state gets anywhere from one to several picked by the party’s leadership, usually at the state chairman’s discretion; Louisiana’s singleton will be chosen May 3).

But the large majority of these officials will use a very parsimonious decision rule in making their choice (hopefully from the national party’s perspective by a self-imposed Jul. 1 date): who has the best chance of beating presumptive Republican nominee Sen. John McCain? That’s regardless of any other consideration, especially since both candidates can claim a mandate from the party: likely after all nomination contests cease in early June, Obama will have a non-PLEO delegate lead in the neighborhood of a hundred, but Clinton actually will have received more popular votes and will have outperformed Obama in the predicted closely contested “swing” states.

While it’s tempting to try to reduce the complexity of the situation to buzz phrases, such as believing Obama has the nomination wrapped up because blacks would abandon the party in the fall, it also misunderstands the situation. Using this as an example, if superdelegates swing the nomination to Clinton, it will be because many of them believe Clinton has a better chance of winning even if some blacks (actually, it won’t be many) might sit out the presidential election because Obama doesn’t get the party’s nod.

It’s still anybody’s contest, which is why so many Louisiana superdelegates have yet to give public endorsements. They’ve got their fingers in the air, seeing which way the wind blows, and they’ll decide when they feel certain enough one candidate has a better shot than the other.