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Court ruling could wreck LA spending efficiency plans

Its relevance often lost to a wider audience given the complexity of the function involving it, Louisiana’s provision of health care services is an important area of reform because of the potentially huge savings that can result while service levels promise to remain undiminished or actually to improve. A legal test brings this into sharper focus in the shadow of budget cuts.

By law, through the federal Medicaid program (if a state chooses to accept money for that program), a state must provide health care for the indigent. For less-healthier individuals that have some kind of developmental disability (meaning mental and/or physical handicap) while the levels of income and wealth are somewhat higher that would permit service delivery, the concept is the same in that if they or their families qualify, the state must provide these services within a reasonable time frame of qualification.

Two outcomes are possible at qualification. One is going on a waiting list for a “waiver” to the regular program, and the waivers themselves designate different kinds of tasks to be performed in provision for different amounts of hours per week. The waiver providing services most intensely is the New Opportunities Waiver which can be 24 hours a day of services provided. The other is for the client to be placed in a facility run by or whose place in was paid for by the state which, if residential, would provide for 24 hours a day of care.

In fact, the waiver program exists only because of a pair of lawsuits, one at the federal level and one in Louisiana courts that were settled a decade ago. The plaintiffs had argued that the state’s policy of an all-or-nothing approach, institutionalization or no provision, violated clients’ civil rights. The settlement was the creation of the waiver programs to allow clients to live at home or in group homes in the community to receive services in those settings. (The settlement actually expired at the end of last year.)

However, the intake process was not well-considered and, in the time since implementation, two major problems have emerged that have ended up spending precious dollars very inefficiently. First, insufficient consideration was given to matching resources to needs. In other words, some clients got much more in the way of services than they really needed, and others got less. Second, waiting lists created by lack of funding would have individuals are far greater demonstrated need on them than many receiving services.

The first in particular spawned a related difficulty. In the waiving of the typical Medicaid spending parameters, which favored institutionalization, federal regulation permits this only when the home- or community-based provision is less costly than institutionalization. With the imbalance of services to actual needs in many cases, this artificially drove up costs to where Louisiana began to be in violation of the regulations, meaning it could be stripped of funding unless corrected.

In the past couple of years, the state has begun that process through the application of a Resource Allocation Model that theoretically should better match actual need to hours of service provided. While there have been questions over the fairness of the application of it, in that waiver program participants first went through the assessment process and only now has the state said it would get around to applying it to institutionalized clients (fought by the nursing home industry because it would lose a number of clients and therefore funding), if done fairly this realigning could save the state hundreds of millions of dollars annually in the future and/or expand services to those who truly need them.

That process is being challenged in court by the family of a 38-year-old man both physically and mentally developmentally disabled whose hours were reduced from 24 to three to seven daily. This is outside the normal appeals process conducted through the administering agency itself, the Department of Health and Hospitals, which for most individuals produced a maximum of 42 hours a week of benefits that in some cases reduced their hours by more than half. However, in some ways it has the same effect as department policy which is to continue services at the higher level until a resolution is reached.

The suit seems to rest on two bases, that the assessment was done improperly (the state contracts them out) and that the cut would necessitate a move from home- to institutionalized-based care which its argues solely is triggered by a need to reduce spending which would violate the civil rights of the man. The first issue largely is administrative but the second teeters on the fulcrum of a profound impact to state policy and spending.

Presently, clients do not have a right to be at home to receive services by the state. At present, if the state can demonstrate that the costs involved in home provision to service his needs adequately, how ever many hours up to 24 that would involve, would exceed those of his living in an institution to provide the same level of service, then he would be compelled to live in an institution or accept fewer hours outside.

Thus, the case rests on two things, whether the model itself accurately gauges need but, more broadly, it may wander to the question of whether there is such a qualitative difference in home vs. institutional provision that home provision can be the only alternative. If the court were to agree with the latter, this could dramatically increase costs of provision, not only defeating savings attempts but also perhaps increasing costs even further. That’s the broader picture; more narrowly it would stretch state resources further and give it the opportunity to continue denial of waiver services for those still on waiting lists.

Hopefully, by court decision or consent decree, the outcome will balance accurately the needs of the client with the overall obligation of the state. Health care using taxpayer resources, much less one in a preferred setting, is not a right and any standard that interjects the opposite ideology into the process risks a huge fiscal hit on a citizenry willing to pay to help the less fortunate, but which should not have to subsidize a mode of living that is not absolutely medically necessary.


Stunts, attacks only tools left for desperate Melancon

At first glance, with big issues of the day including economic revival, a push by the White House to radically overhaul health care insurance provision, and dealing with ruinous spending endorsed by the Democrat majority, that a fundraising letter by his opponent is the issue Democrat Rep. Charlie Melancon spends his time and energy on might surprise folks. But that would misunderstand his Senate campaign strategy in his quest to knock off Republican incumbent Sen. David Vitter.

Recently, Vitter sent out a fundraising letter that, by its described appearance, would be the mirror-image of the Great Seal of the United States. A Melancon campaign operative requested a Senate ethics investigation of its use, even though Senate ethics rules technically just reiterate the relevant statute which reads that knowing display of the seal “or any facsimile thereof” would be a violation. By the letter of the law, since Vitter’s is not an exact copy, there is no violation. If there were, Melancon’s campaign would have asked for Vitter’s prosecution.

Combine this with the fact that when Pres. Barack Obama did something similar during his campaign to which Melancon did not raise objections that this situation is described accurately by Vitter as “frivolous.” So why is Melancon wasting the Senate’s time on a campaign stunt?

Because it is an integral part of a campaign strategy that will have to do something special to resuscitate Melancon’s terminal hopes of winning. He is down massively in the polls because the only major issues on which the finds himself in agreement with the Louisiana public are those with which he agrees with Vitter. On those important positions where he disagrees with Vitter, the public solidly is on Vitter’s side. There is no way to defeat an incumbent given these dynamics.

Unless he can attack Vitter’s character. Thus, the entire strategy of the Melancon campaign has been to obscure issues and his points of agreement with the deeply-unpopular Obama by trying to make Vitter seem unethical and thereby Melancon the only candidate deserving of a vote. This has stemmed from Vitter’s admission some three years ago that he committed a “serious sin” presumably connected to a prostitution service.

With assistance from willing allies among Democrats and other interested parties, for months a broad offensive has taken shape where anything imaginable that could make Vitter look unethical has been thrown against the proverbial campaign wall, hoping that any of it will stick or that enough accumulates to cause a decidedly negative turn of public opinion towards Vitter.

But nothing like that works not only because none of it is convincing but also because Vitter has run a very issue-oriented campaign that has given the voting public what it wants with so many pressing matters in play while Melancon has stuck almost exclusively to personal attacks on Vitter. The only new thing about it all is that the charges levied by Melancon’s campaign are straining credulity further than ever.

Yet don’t expect them to stop coming. Desperate men do desperate things, and that Melancon’s campaign continues in this direction shows its sense of desperation only is escalating.


Citizens deserve analysis, not posturing, in budget talks

Because of the asymmetry of information that exists between Louisiana’s executive branch and its legislative in the matter of budgeting – the former knows far better the intricacies of program operation – when legislative committees get together some members end up using the occasion more for trying to score political points than any substantive discussion of the material. It’s particularly lamentable when an officer of the committee pursues this strategy, but that’s what we got in the Senate Finance Committee’s recent meeting over several categorical areas within Republican Gov. Bobby Jindal’s budget.

Perhaps more than any other department in state government this year, streamlining is shaping the Department of Social Services with the transfer of several functions out of it. However, it also is facing some resource cuts as well, which raised the hackles of committee Vice Chairwoman Democrat state Sen. Lydia Jackson. Told that, among others things, summer programs for “at-risk” youth and tax preparation help for low income individuals is being cut, she declared there was forming a “a gap in services,” implying the necessity of government spending in these areas.

But just what are these “services?” For one, last year the state spent $1.2 million on telling low income people how to fill out tax returns. This comes as a result of encouraging them to take the two earned income tax credits, the federal and state. Essentially, this redistributes money from taxpayers to individuals who make little money and do not pay taxes. And the state devoted this money to telling them how to apply for it.


In Blanco/Rove dispute, verified facts rest on his side

Because she so thoroughly botched the state’s response to Hurricane Katrina in 2005 – and maybe because even with nothing to do for the past couple of years she has made apparently insufficient progress on her promised tell-all book – Democrat former Gov. Kathleen Blanco has to use strong language in her quest to rehabilitate herself in the eyes of the public. Regardless of whatever words she uses, however, they do not alter the historical record that differs decidedly from her description of it.

Blanco lashed out as a result of prepublication releases of former Republican White House Special Counsel Karl Rove’s memoirs of his time working for former Pres. George W. Bush. Rove wrote that the ineptitude of and infighting between Blanco and New Orleans Mayor Ray Nagin hampered responses and the most effective strategy would have been for the federal government to have found a way to take over managing the situation.

She retorted that Rove “lied and played games, putting lives at risk for the sake of politics,” and claimed that even before the storm hit she spelled out in a letter what kinds of assistance would be needed, and confirmed the request in a timely fashion, claiming she has documents to prove all of this. Unfortunately for her, the verifiable, historical record suggests that between the two of them Rove is not the liar.

First, the federal government never received a written, detailed request for a response that comported to federal law. The only explanation that could then reconcile both views was the old got-lost-in-the-mail ploy. Which begs the question: why didn’t Blanco, in the search for the crucial immediacy of the request, choose the postal service over a FAX or e-mail message? Conditions weren’t so bad on Sep. 2, 2005 (three days after landfall) or earlier that somewhere in the Capitol complex in Baton Rouge there wasn’t a working computer or FAX machine. And if the letter was ready before the storm hit, why not send it then? That she would not take such obvious routes immediately casts doubt on her veracity.

Significantly, in the days right after the disaster unfolded, Blanco acknowledged she had done a poor job at the official request that was received. She did make a vague and confused request she later complained about that she didn’t know how it properly should have been done – despite the fact that only a year early there had been a whole drill about a very similar scenario and a few months after that real-life Hurricane Ivan that provided a real-world drill opportunity. Then, no mention was made of any, more formal and detailed request that had been sent by mail.

Second, this is fueled even more by her subsequent behavior. She immediately began to worry about, as messages demonstrated, the political impact of her handling of the situation and within days was developing a strategy to deflect criticism from her. When Congressional investigations rolled around some three months later, Blanco then refused initially to provide some information, then, when it was given incompletely, it was peppered with odd redactions. None of it contained direct, primary documents authentic to the time period that would support assertions she made about her acting decisively and the federal government stonewalling.

In her comments about Rove, Blanco claimed documents secured from the governor's office verified her assertion. Was she referring to the original, unexpurgated documents that she never turned over to Congress? If so, why were they sent to Congress in incomplete fashion and expurgated? And does she include in this description the purported letter sent in a timely fashion with a detailed assistance request of which there was no contemporary corroboration of its existence?

Third, some days later Blanco testified in front of Congress in ways that charitably could be called confused, at worst mendacious, including stating she never had refused federal assistance when in fact, as Rove wrote it should have insisted on doing so despite her, the federal government did offer to take over the entire situation and send in troops immediately early on but did not at her dithering refusal.

Since then, Blanco has crusaded for historical revisionism of her role in the initial days of the disaster. She has offered up plenty of denials and alternative interpretations of events. But she never has produced publicly irrefutable and authentic evidence that exonerates her fumbling of the situation that contradicts the lengthy record that supports Rove’s statements. Thus, her vitriolic rhetoric of political bromides about Rove masks the deep anxiety that she must feel about it all, perhaps unwilling to admit to herself that her poor judgment and execution not only cost her political life, but maybe the lives of others.


In dueling polls Melancon's, his chances found wanting

Only a couple of weeks ago, one poll showed Sen. David Vitter continuing to open up what already appeared to be an insurmountable lead even further on. Rep. Charlie Melancon’s bid to wrest the seat away from him. The last week, Democrat Melancon had one released showing that he was “only” 10 points down. What explains how the Republican can be up 24 points in the other?

First, understand that while Melancon’s poll was performed by somebody he picked and paid, a firm that specializes in working with Democrats, Vitter has no connection with the firm that has been tracking his (and many other candidates’ races), Scott Rasmussen. Generally speaking, independent pollsters such as Rasmussen produce results of greater validity because hired guns, even as they won’t admit this for obvious reasons, will pick question wordings and sampling strategies that tend to provide a small bonus for their clients. Their workers also tend to unconsciously alter emphasis, tempo, and even words in delivering questions, often subconsciously. As obviously they can’t introduce deliberately an unmistakable bias into their results (at least in the numbers they give their clients, which may be different from the ones reported) because then inaccuracies would show and they would lose business, but wordings and sampling frames can be subtly shaped to present typically a bit more optimism into the scenario.

Second and much more significantly, it appears that (because while Rasmussen’s are done on his own time and he reports extensively and publicly on them Melancon’s pollster’s information is proprietary so you can go only by media reports of it), as opposed to Rasmussen’s using likely voters, Melancon’s used all registered voters. Historically, this overestimates voters for Democrats and that looks particularly risky to do this election year as Republican-leaning voters seem far more enthusiastic than Democrat supporters to turn out in November. (Another bit of evidence and/or consequence of the presumed use of all voters by Melancon’s firm is it only got 86 percent of respondents to state preference while Rasmussen got 90 percent – unlikely voters are much more likely to call themselves undecided.)

Third, Rasmussen has built quite a reputation for accuracy over the years. The latest round of elections found his organization in the top spot for the top job. This is true even as Rasmussen often employs automated methods, as opposed to Melancon’s pollster who did not appear to do so. While there are a number of variables, all other variables outside of the live vs. recorded debate held constant, that might produce variance between the two methods (here is a good layman’s discussion), the fact is there seems to be no inherent bias in the direction of any party’s candidates using either method. Specifically in this case, that means use of interactive voice response polling would not inflate Vitter’s numbers, nor depress Melancon’s, and vice versa (if the interviewers are well-trained, experienced, and not themselves biased) for live-voice calling for inflating Melancon’s and depressing Vitter’s.

In any event, to some degree at this point the discussion still is moot – so what if Vitter is just a half rather than whole landslide ahead, he’s still going to win comfortably even with Melancon’s numbers. And while if it were a year such as 2006 with strong Democrat tides it could be argued Melancon could overcome a 10-point gap in the next eight months, when in fact conditions are the opposite as they are this year it would take extraordinary optimism and audacity to think that could happen.

Thus, weighing the evidence, the reality is much more likely to be closer to the Rasmussen numbers than Melancon’s.