Tag: ObamaCare

Tech guy on House Committee Hearing on Healthcare.gov: “it’s like watching my 1-year-old argue with my cat”

Posted by – October 31, 2013

Two Deeper Issues to Consider

So, I’m a little behind the curve on this one, as it happened in the late morning of October 24th and has been blogged and tumbl’d and tweeted about a bajillion times and now is a week old and largely forgotten… but that’s all right, since my blogging is all about providing long-view context and a unique perspective, not about news.

If you missed it last Thursday (10/24/2013) the House Energy and Commerce Committee held a hearing on the healthcare.gov glitches so

This political cartoon by The Hill‘s Chris Weyant sums up GOP complaints about healthcare.gov and Obamacare so well!

they could grandstand, bloviate on issues they don’t understand and mug for the cameras.  Congressman Frank Pallone (D – New Jersey’s 6th Congressional district) did some counter-trolling to the GOP trolling over the web site and privacy, saying “No, I will not yield to this monkey court or whatever this thing is,” which quickly went viral and was clipped on every news site and inspired a flood of tweets with the hashtag #monkeycourt.  Trolling against your opponents’ trolling…it’s pretty much the most we can expect from our Congress right now.  That’s the surface of the story, though I admit I found committee chairman Joe Barton’s hasty response “this is not a monkey court”—in a tone not entirely convinced himself—to be hiiiilarious (judge for yourself) but…

what’s the deeper context most news media isn’t giving you?

1) The content of this House Energy and Commerce Committee hearing consisted of questions not grounded in facts about web sites and internet tech, followed by answers just as unmoored from web reality.  This spectacle of a hearing/monkeycourt was every bit as indicative of Congress’ tech ignorance as then-Senator Ted Stevens’ infamous the internet is “a series of tubes remark, and it ought to be seen in that light.

Web entrepreneur Clay Johnson—@cjoh—provided some real substance on the oft-ignored web dev issues at the heart of the healthcare.gov problems when he was interviewed by Democracy Now! the day following the hearing.  Johnson pointed out that a core problem is Congress’ cluelessness around the subject matter at issue:

…so, you have these bizarre exchanges where, you know, a member of Congress is asking the vice president of CGI Federal about code inside of the website that isn’t even being displayed and isn’t even relevant to the user, and CG—and the VP of CGI Federal not even recognizing that it’s not displayed and not even relevant to the user. It was this really baffling set of exchanges. It’s like watching my one-year-old argue with my cat.

He also revealed that “Congress lobotomized itself” on technological issues when—under the direction of Speaker Gingrich—it canceled the Office of Technology Assessment (OTA), zeroing it out in the FY 1996 budget, so it had to close September 29th, 1995; significantly, this “defunding” was part of the dramatic budget cuts that triggered the battle over spending and government shutdown of 1995-96.  Because of the OTA’s absence, Johnson explains, Congress doesn’t have the kind of consistent advice it needs to understand the myriad of technology needs and requirements that crop up in the legislation that’s voted on each session.  Clearly, our members of Congress are left to rely on the advice of their staffers, which obviously can be uneven and/or skewed.  Read or listen to the rambling “series of tubes” remarks, spoken by the late Ted Stevens—then-Senate president pro-tem—and it’s apparent he was clumsily repeating parts of the party line on net neutrality, but interpreting it through his own very unique imagery, “…again, the Internet is not something that you just dump something on. It’s not a big truck. It’s a series of tubes. And if you don’t understand, those tubes can be filled….” etc., and lots of the substance is getting “lost in translation.” See and/or hear the comments Clay Johnson gave to Democracy Now! in full below:

 

2) the power, sweeping purview and deep-seated corruption of these House committees deserves coverage.  The House Energy and Commerce Committee oversees the health care industry along with Medicaid and Medicare and the implementation of the ACA, the energy sector—oil, coal, natural gas, etc., plus renewables—and other, enormously important, broad swaths of our socio-economic existence, including trade policy and the numerous ways that federal law regulates markets.  Run by the GOP Majority via committee chairman Joe Barton (representing mostly rural parts of Texas with more cows than voters) this committee has been accumulating power since 1795.  In 1885, Woodrow Wilson wrote about the out-of-control power and corruption of these long-standing House committees:

[the House of Representatives]…divided up, as it were, into forty-seven seignories, in each of which a Standing Committee is the court-baron and its chairman lord-proprietor. These petty barons, some of them not a little powerful, but none of them within reach [of] the full powers of rule, may at will exercise an almost despotic sway within their own shires, and may sometimes threaten to convulse even the realm itself.

—Woodrow Wilson, Congressional Government, p. 76

Congressional Government (1885), Woodrow Wilson’s John Hopkins University doctoral dissertation, became popular in the study of U.S. government and politics and has been published in many different editions.  Wilson’s scholarship aimed to Having long-since lapsed into the public domain, Congressional Government is available in full online: wikisource hosts its 15th (1900) edition

Obviously many aspects of Wilson’s presidency were problematic to say the least, but that doesn’t zero-out the insights from Wilson’s writings and scholarly works.  On his study of the federal government and its flaws, he aimed to be descriptive not prescriptive: “I am pointing out facts—diagnosing, not prescribing remedies.” His diagnosis of the House committee system was that its “barons” are out of control, exercising enormous power nationally without any national or in-House accountability, without checks and balances at all aside from the dude’s constituents’ power to reelect, and without competitive pressure as the chair is given on the basis of seniority not merit. This empowers said dukes and duchesses to act in the shadows, wield power in so corrupt a fashion it’d even make Lucifer blush, all because of the absence of mechanisms to impose repercussions.

The structural defects Wilson described in 1885 continue today, only more so, as the committees’ respective scopes of operations has continually expanded, including more and more of the economy (and more industries to shake down for campaign contributions). Joe Barton himself is the epitome of the corrupt committee chairman, just turn over the log and ewwww….

The questions need to be asked, loudly and repeatedly: should the committee system stay as-is in the 21st century? Should their fiefdoms include like half the economy? and if they are to have such a vast, national scope, can we—the people—vote for the chairs nationally on a quadrennial basis like the presidents?  or at least subject the chairs to a competitive vote of the Congressmen like the way that the Speaker of the House is elected?  Unlike the role of Speaker of the House, however, the committees are not in the U.S. Constitution, just look in Article One.  That makes reforming the committees more like the ongoing debate over filibuster reform, it’s about modernizing arcane rules and traditions that are increasingly prone to abuse.

We desperately need to address the flaws in the underpinning governing structure of our system.  Unfortunately the two parties don’t typically invite discussion of root and branch reforms that may remove some of the ill-gotten gains from the top of the heap they trade off controlling.

I’ll conclude on another quote from Wilson: “We know that the machines of both parties are subsidised by the same persons, and therefore it is useless to turn in either direction.” -from p. 27 of Wilson’s The New Freedom (1912) full text available online.

 

Nick

Insightful Blogging in the Wake of the Gov’t Shutdown

Posted by – October 22, 2013

October 2013 Roundup: Acts of Bloggery in the Shutdown’s Wake

My picks for the blogosphere’s most valuable insights into the shutdown insanity:

Moral lens:

The 8 immoral ways the government shutdown is hurting the needy On Faith – the shutdown inflicted pain on people already struggling and making due on government aid amidst the post-2008 “economic realignment,” cutting or threatening to cut already weakened social programs, though this has been badly underreported. 

The Day After | Talking Philosophy – The Philosophers’ Magazine Blog –  applies the measures of philosophy to the shutdown crisis, who has the moral responsibility and perceived “moral blame?” It’s a strenuous task to be sure, but valuable.

Unexpected impacts:

Government shutdown hits comics | The Comics Beat – the government shutdown’s impacts seemed to leak into every nook and cranny of American life.  Even comic books were impacted, new books delayed, stuck at the docks waiting to be cleared through customs.

Student projects interrupted by US shutdown | Nature – because of the shutdown, Siddharth Hegde’s extremophile PhD experiment at NASA Ames, after carefully nurturing and growing his extremophiles, might have died off for want of feeding since the Lab was locked up and 98% of NASA personnel were ruled non-essential and furloughed. It’s not known whether the extremophile experiment survived the extremophiles in Congress (I put the question to Hegde) but if the cell samples died he won’t be able to re-do the experiment, as his visa is only for three months.

Cartoon:

“Shutdown” by POLITICO’s Matt Wuerker

“Shutdown” by POLITICO’s Matt Wuerker

Political assessments:

In Washington and in Lansing, tea party zealots are costing us a fortune as they waste our hard-earned tax dollars | Eclectablog – “This is what happens when you elect people who hate the government to run the government.”  Eclectablog’s Chris Savage chronicles the heavy economic price paid for the shutdown shenanigans that were advertised as helping ease the deficit but did the opposite.

Lessons Learned? | Official Artur Davis – in this interesting assessment by (deeply strange black ex-Democratic Congressman—7th district—from Alabama) Artur Davis, who—after losing the black vote in Alabama—has re-made himself as an advisor to Republicans on winning the black vote, he says “The haziness of wishful thinking, overshadowed by a deeper failure to appreciate that shutdown itself validates the obstructionist label, the impression of being too inflexible to govern, that so threatens the party nationally and is even starting to creep into red states like Georgia and Louisiana.”   and “…conservatism has been painfully slow to distance itself from the radicalism that has surged in the party…”

Historical perspective:

The Philosopher’s Stone: A REPLY TO ANTHONY TSONTAKIS – philosophy professor Robert Paul Wolff reflects on the right-wing’s fierce opposition to the Affordable Care Act… are there core philosophical differences?  Wolff doubts there are deep ideological underpinnings to the opposition, noting that “the central features of the ACA entered public discourse in America as a set of conservative Republican proposals put forward by the right-wing Heritage Foundation…”

History Unfolding: How Much of a Victory? – after the shutdown ended, historian David Kaiser tried to put the House Tea Party guys in historical context, difficult given the unprecedented events involved.   “I have tentatively decided, after much thought, that perhaps the best historical analogy for the Tea Party are the Radical Republicans of the post-civil war era.   I must apologize for the analogy insofar as I admire the goals of those Republicans, namely, the full enfranchisement of freed slaves, while I feel the Tea Party is trying to undo all the good that the US government has accomplished over the last century.”

And this is just a slice of the ongoing discussion.  Will keep ya’ll posted.

Nick

How ACA “ObamaCare” Exchanges Work: A Nick Animation

Posted by – March 30, 2013

I made the above animated vignette to explain how the health insurance exchanges being established under the Affordable Care Act (ACA), online marketplaces for “shopping” for health insurance, roughly, will work. People will begin signing up for health insurance plans on the exchanges October 1st, and those plans will go into effect Jan 1st, 2014. And any credible fact check will tell you, as this one from the Associated Press does, that the tax credits that fuel the exchanges, that subsidy that will make the now-$20,000-a-year bronze plan cost $5,000 for a family of four in one IRS estimate, will be delivered directly to your insurer. You won’t catch a glance of your tax subsidy.

The insurance companies are raising prices through the roof, not only because they’re required to cover much more in terms of minimum health care services, but because they know the government will pay and pay and pay. Thus, sticker shock will put anything but the new-legal-minimum bronze plans out of reach for the vast majority of participants. Pouring cash by the dump truck onto insurance companies is emblematic of our “only in America” health care non-system, and a primary cause of its deterioration.

The dump truck-full of unimaginable, astronomical sums of money won’t come from the sky like in my cartoon, it will come from the IRS. The IRS will be in charge of doling out the tax subsidies, and extracting the fines from those who don’t comply with the individual mandate to buy health insurance. I gave a thorough overview of the individual mandate and subsidized insurance exchanges recently: What Is ObamaCare? 2013-2014: Overview Part 1.

Nick

What Is ObamaCare? 2013-2014: Overview Part 2—Medicaid expansion

Posted by – March 16, 2013

An ObamaCare Overview 2013-2014 Part 2: Medicaid Expansion

This is the second part of a two-part blog post: click here for Part 1

In the 2013-2014 period, states must decide whether to opt-in or opt-out of the “Medicaid expansion.”

Though it pains me deeply that the Affordable Care Act doesn’t fix any of the problems within Medicaid, even the most egregious, lethal flaws, I do understand how important the Medicaid expansion is, especially in the Southern states. The Medicaid expansion expands the number of people covered by raising the income threshold for eligibility. That means that families who are severely impoverished, making like $12,000 a year, can now qualify for Medicaid in places they couldn’t previously. like Florida. I know that it is hard to believe, but many states, especially in the Deep South, put their Medicaid eligibility thresholds ridiculously low; in Alabama, for example, you can’t qualify for Medicaid unless you make under $251 a month (or thereabouts, it may have changed slightly since I left the state). That means that Alabama Medicaid excludes the working poor, the bulk of all impoverished Alabamians unless they’re children or too disabled to work at all, leaving an enormous swath of Alabamians uninsured and bankrupting the hospitals who provide a great deal of “indigent care.” In Alabama, several rural hospitals have had to close following Medicaid budget cuts that came down from Montgomery, because their patients are mostly not covered, and they’re very dependent on the Medicaid reimbursements they can get for caring for the few rural people who are covered. A recent study published in the New England Journal of Medicine showed that prior Medicaid expansions led to a fall in mortality rates; in other words, expanding Medicaid saves lives.

Unfortunately, the states who need the Medicaid expansion the most, i.e. Alabama, are the ones refusing the expansion.

Medicaid works through matching funds, or FMAP (Federal Medical Assistance Percentage) that go toward each state’s Medicaid program. The FMAP varies based on the income of the state… here’s a cartoon I made to explain Medicaid funding:

Medicaid expansion explainer
Click to enlarge.

As you can see, the Medicaid expansion increases the number of eligibles, and grants states enhanced FMAP to cover almost all of the costs. But the Administration and Congress have given states enhanced match before, with the “stimulus” bill, the Recovery Act of 2009 (more about this round of enhanced matching). The news media is (per usual) misleading the public. Everywhere I’m seeing print headlines, radio segments and TV talking heads saying, without nuance, that governors opting-in to the Medicaid expansion are “accepting ObamaCare.”

This reddit headline, highlighted on the Brian Lehrer Show recently, is unfortunately typical of the dominant narrative around the Medicaid expansion:
Governor Christie Accepts ObamaCare  - GOP's heads explode

Just because this Medicaid expansion is tucked into an amendment of the Affordable Care Act doesn’t mean you’re “accepting ObamaCare” by participating in it. I agree with Chris Christie on almost nothing, but it is important to be fair to everyone. Christie isn’t flip-flopping on ObamaCare, which I explained in Part 1 is all about subsidized private insurance exchanges, he is participating in Medicaid—a state-federal partnership signed into law alongside Medicare by President Lyndon Johnson in 1965—and he’s taking the enhanced match to pay for almost all the tab new eligibles will incur.

If we’d stop mislabeling governors as “flip-flopping,” maybe more red states would opt-in to the Medicaid expansion; the Southern states need this assistance the most desperately, but are the least likely to take the Administration up on its offer.

Florida Governor Rick Scott (R – Columbia Hospital Corporation) is, so far, the only Southern governor to show any openness to the expansion. Scott’s change of heart, which since he explicitly denounced the Medicaid expansion, was really a flip-flop, is discussed here on PBS. This is one of the least awful talking head segments I have found, though its failure to distinguish Medicaid and ObamaCare clearly enough may further contribute to the confusion:

Nick

Previously: What Is ObamaCare? 2013-2014: Overview Part 1 (Insurance Subsidies)

Next: The Changing Use of Medicaid Waivers, For Evil

What Is ObamaCare? 2013-2014: Overview Part 1 (Insurance Subsidies)

Posted by – March 10, 2013

An ObamaCare Overview 2013-2014: Part 1

Oh man, I am so frustrated that people misunderstand ObamaCare—the Affordable Care Act (ACA)—and continually frame it as something it’s not. They frame it as some sort of universal health care coverage, or as some vague new program that replaces Medicare and Medicaid, or at least fixes their most egregious problems (Medicaid’s age 21 cut-off, for example). None of the above are true. I’m writing a book, a memoir of my fight against Alabama Medicaid’s age 21 cut off and a book-length exploration of the plight of young vent-dependent people in general, and if you’re wondering how ObamaCare changes things vis a vis Medicaid, it doesn’t. The Affordable Care Act expands Medicaid eligibility, but doesn’t change the underlying rules and regulations, or fill its most egregious gaps. So there’s very little about ObamaCare in my book; it just isn’t all that relevant for those of us with severe disabilities who have to rely on Medicaid and Medicare.

What is ObamaCare?

The public needs to ask this over and over again, until the wrong assumptions dissipate. Congress never debated universal health care coverage. When Congress debated the Affordable Care Act, they were debating a proposal nearly identical to a bill titled the “Health Equity and Access Reform Today Act” (HEART Act) which was introduced by Senate Republicans in 1993 as the conservative alternative to Bill Clinton’s health care legislation (which focused on an employer mandate to provide health insurance). The crux of the conservative proposal was essentially, “we want universal health care too, but through private insurance, and we’ll do that through an individual mandate; every American will have health insurance coverage.” The individual mandate means that the government requires individual citizens to have insurance.

The mandate made its political début in a 1989 Heritage Foundation brief titled “Assuring Affordable Health Care for All Americans,” as a counterpoint to the single-payer system and the employer mandate, which were favored in Democratic circles. In the brief, Stuart Butler, the foundation’s health-care expert, argued, “Many states now require passengers in automobiles to wear seat-belts for their own protection. Many others require anybody driving a car to have liability insurance. But neither the federal government nor any state requires all households to protect themselves from the potentially catastrophic costs of a serious accident or illness. Under the Heritage plan, there would be such a requirement.” The mandate made its first legislative appearance in 1993, in the Health Equity and Access Reform Today Act—the Republicans’ alternative to President Clinton’s health-reform bill—which was sponsored by John Chafee, of Rhode Island, and co-sponsored by eighteen Republicans, including Bob Dole, who was then the Senate Minority Leader.

Source: Why Republicans Oppose the Individual Health-Care Mandate : The New Yorker

By 2009, the debate had turned upside down, with Democrats supporting the Heritage Foundation‘s individual mandate as the core of the proposed Affordable Care Act, and the Republicans unanimously against the individual mandate. Inexplicably, Democrats have moved to the right and embraced the rightist policies of the past—Barack Obama has positioned himself as a George H. W. Bush-type of moderate conservative president, a dramatic break from prior black presidential candidates like Shirley Chisholm and Jesse Jackson—and Republicans have turned against their own policies after supporting them for two decades. It’s bizarro world!

The costs of the Affordable Care Act. almost all of the costs, come from the individual mandate and the associated subsidies. The core of ObamaCare, the nut meat, is the system of subsidized health insurance exchanges. The main idea is that “health insurance is unaffordable and we’ll fix that by adding subsidies that make insurance affordable, and for the poor we will expand Medicaid eligibility, then most everyone will have coverage.” Affordable Care Act proponents called this “achieving universality” by tweaking multiple pieces of the system, like a piecemeal universal health care. This rang hollow even then; it didn’t even sound like the proponents believed their own rhetoric. I didn’t buy the claims that we’d “get to universality” any more than the incredible claims about health care providers voluntarily holding down prices as part of the ObamaCare grand bargain.

The debate in Congress over the Affordable Care Act primarily revolved around the individual mandate, the potential costs and red tape nightmares involved, and, inexplicably, abortion. Though the ACA includes a firewall between its subsidies and abortion, there aren’t any abortion-funding provisions in the bill, and the legislation is not intended to address abortion at all, still, the debate centered on abortion to an unexpected degree, in the House of Representatives especially. President Obama signed Executive Order 13535 to reinforce the Hyde Amendment’s prohibitions on federal funding for abortion as related to the ACA.

During the 2008 Democratic primary, Hillary Clinton was for the individual mandate and Barack Obama was against it. I agreed with that version of Obama. The idea of requiring citizens to buy a defective product (health insurance scams) from select corporations is terrifying. The U.S. Supreme Court was asked to rule on the question of whether the federal government can require buying insurance and fine citizens for not acting, for non-activity. The court gave the individual mandate a thumbs up, as long as the fine is implemented as a tax. I think that this sets a horrible precedent in terms of the fusion of corporation and state. The Obama Administration, and future administrations, will decide which health insurance plans meet Affordable Care Act standards and are allowed into the insurance exchanges, and as we already have seen, for example with ACA requirements being waived for the most powerful companies, how corrupt that process can be.

In 2013-2014 the main provisions of ObamaCare, the subsidized health insurance exchanges—some, like New York’s, will be state-run, but where governors have refused to set up exchanges, for example Alabama, there will be federal-run exchanges—will go into effect, along with the individual mandate. Right now, only two percent of health insurance plans meet the minimum coverage requirements to be sold on the exchanges. We’ll see how things change as the requirements kick in and the exchanges come online (literally, the exchanges will be online marketplaces). Expect to see more than a few kerfuffles over the individual mandate penalty fines, plus some serious sticker shock—the cheapest type of plan under the ACA is a “bronze plan,” and according to an IRS estimate, bronze family plans for 4 and 5 person families are assumed to cost $20,000 a year in 2016—though it seems the exchanges’ subsidies may pay for the bulk of the exorbitant costs. I don’t know that pouring subsidies in won’t just incentivize insurers to keep raising prices. Removing the downward pressure on prices consumers exert when they can’t afford premium hikes, the feds saying “no matter how bad you gouge, we’ll pay it” seems INSANE to me, like something that would only make sense to an industry lobbyist.

Political cartoon by Nick, "Obama's Faustian Bargain"

Political cartoon by Nick, “Obama’s Faustian Bargain”

Massive subsidies that only increase are not a positive, in my view. Neither are subsidies to the health insurance companies amid an abusive dynamic “please stop killing children with preexisting conditions! Here, take $500 billion, just stop hurting us!” a positive; they’re actually the worst possible approach to this problem. And anyone who thinks abusive practices like the cruelty against those of us with preexisting conditions will end, you’re naive; new abuses and new loopholes to get old abuses through will appear on day 1. Awful unintended consequences are already arriving. The entire model desperately needs replacement.

Too often, health insurance is a scam. You pay in enormous sums each month just so the insurance company can deny you care in your hour of need. It’s essentially a very sophisticated, legal way to mug you each month. And when you subsidize something, you get more of it…

What is ObamaCare? it’s predominately a requirement to buy health insurance from select corporations with fines for disobedience, plus enormous subsidies for those selected corporations.

Next, in Part 2: the Supreme Court ruled that the “Medicaid expansion” provisions of the ACA must be voluntary for states. This has meant decision time for all 50 state governors across the country, but opting-in to the Medicaid expansion ISN’T “accepting ObamaCare.”

Living in Zomerica

Posted by – January 16, 2013

How I’ve Changed Since Moving to New York City

or…

Living in Zomerica

I started out and made my name as an activist in Alabama, where the left is deeply influenced by Martin Luther King Jr. I always spoke in the language of Biblical and moral imperatives, sometimes overtly, very much in the tradition of the Southern left, and I even had the chance to speak at Martin Luther King’s church in Montgomery (click for article and photo of that experience). I’m currently working on a memoir that details this part of my life, how I grew up in foggy South Alabama and became a successful activist.  It opens on my speech in Dexter Avenue King Memorial Baptist Church.  So, from the beginning, I feel a gap between me and left politics nationally; I come from a vastly different place than most people involved in politics.

That gap is now a chasm. After I moved to New York City in August 2008, the economy went belly up, and I saw every aspect of the world change. New York City’s hospitals began to crumble in a serious way. Several important hospitals closed. The state rehab hospital I was stuck in until September 10th, 2009, will close in 2014 and the patients they don’t move to the new location in Harlem—probably around 2,000 people out in the cold (by my own math) because of less available space—will be screwed. Living in this facility, the fact that most of my fellow patients had no hope of ever getting out, that the system is never going to respond, that I got out due to LUCK, was very clear to me.

For a time in fall 2008, it seemed the bad actors that built an elaborate house of cards atop mortgage scams and derivatives fraud would face the consequences of their actions, and, after going through bankruptcy as their victims had to, would finally make way for a new generation of financial professionals who would re-build. Instead, the Democratic party-run Congress gave the bad actors trillions, so an awful system can continue to hurt the American people. Constituents went ballistic; naturally, calls and letters were 100-1 opposed to TARP. Initially it was voted down in the House, right-wingers from Texas had the most impassioned arguments against this shocking, bald-faced corporate welfare. Then Vice President Cheney swooped in, lobbyists and their millions came knocking, and TARP passed overwhelmingly. Former IMF chief economist Simon Johnson characterized this as a “quiet coup.” That corporate influence could override the will of the people, and so quickly, indicated to me that FDR’s nightmare, private entities becoming more powerful than the state, was here.

Unhappy events abroad have retaught us two simple truths about the liberty of a democratic people. The first truth is that the liberty of a democracy is not safe if the people tolerate the growth of private power to a point where it becomes stronger than their democratic State itself. That, in its essence, is fascism — ownership of government by an individual, by a group or by any other controlling private power.
The second truth is that the liberty of a democracy is not safe if its business system does not provide employment and produce and distribute goods in such a way as to sustain an acceptable standard of living. Both lessons hit home. Among us today a concentration of private power without equal in history is growing.

— President Franklin D. Roosevelt, Simple Truths message to Congress (April 29, 1938)

I had always thought of government having enormous potential to be an instrument for all Americans, we the people, doing things together that we can’t do as individuals; after all, civil rights legislation triggered a tectonic shift in Alabama. But there I was, in a state hospital on the island in the East River named after FDR, realizing that everything had changed.  The U.S. experiment trying to have a democracy and unrestrained influence of plutocrats over elections simultaneously was over; the transformation into corporate state, by which I mean government of the corporation, by the corporation, for the corporation, was complete. The corporate class has utterly monopolized the levers of power via campaign finance; government will not be an engine of good for the foreseeable future. This was a very difficult conclusion for me to come to, I want government to be a change agent, but the conclusion became unavoidable.

The state is such a marionette, it props up banks that were already exsanguinated by malfeasance and mismanagement; instead of shuttering dead banks, the marionette pumps in billions and billions, creating zombie banks. These zombie banks are a new and disturbing sight in America, insolvent and decayed, but remaining open thanks to government largesse.  They take deposits, but no longer function as banks in the traditional sense; they don’t do loans or extend lines of credit to small businesses, but they may eat other banks and turn them into zombie banks. TARP wasn’t temporary as promised. It’s still reanimating zombie banks, and since the continued aid isn’t reviving the banks, I wonder if the purpose isn’t simply funneling wealth upwards to the puppet masters, the banks’ primary role to be conduits.

We also have zombie financial firms, zombie real estate, zombie schools, zombie hospitals. Too many of us have become zomericans.

A few months after that, I applied for affordable housing. I got a rejection letter back about 60 days later. It said that the Section 8 list had been closed since 2006, and “your application has been destroyed.” Great feeling.
In the Fiscal Cliff Bill, Goldman Sachs got subsidized housing for their building in Manhattan (triple tax exempt, no local, state or federal taxes, plus they get Liberty Bonds, only supposed to be for WTC reconstruction). Not kidding. Even in a time of supposed austerity.  This alone has really changed my thinking. For details, see Naked Capitalism | Eight Corporate Subsidies in the Fiscal Cliff Bill

If it weren’t for a series of serendipitous and bizarre events that made it possible to move in with Alejandra (my partner), who has affordable housing through a different, local, program, I’d still be in the facility. I’ve lived here since September 10th 2009, in Lower Manhattan. I am bizarrely lucky, and know it. And I’m very grateful.

We live very close to Zuccotti, so we observed the Occupy Wall Street movement closely. Alejandra and I are part of the Occupy “disability caucus,” trying to bring disability issues to the attention of the wider movement. Just holding meetings where people with disabilities can talk openly about their predicament following the collapse of the economy has been very valuable; our concerns never see the light of day in media and political circles. And contrary to media portrayals, the old economic configuration is gone and never coming back.

Occupy Wall Street is a reaction to the economic system dying, its apparent murder via mismanagement, malfeasance and predation shoving it off the cliff. There’s no complex list of demands. It’s a protest of the crimes of the bad actors of Wall Street, the resulting collapse of the economy and the attendant suffering, and our political system’s inability to even see the problem. The Occupiers tend to be students or recent grads who bought into the American dream, got into debt pursuing advanced degrees, then realized the economy had capsized and there were no jobs with a living wage, much less jobs in their fields they expected would provide them desperately needed upward mobility and loan repayment. A lot of dreams shattered on the iceberg of the 2008 economic collapse. The concerns expressed by Occupy Wall Street are completely legitimate.

The response to Occupy by the NYPD, the FBI, the rest of our agencies was awful. It removed any doubt I had that we have a corporate state, because the security establishment (NYPD, FBI, etc.) responded to protests against the obviously harmful practices of corporations like Goldman Sachs as a direct attack on the state itself. Though it was called Occupy Wall Street, the NYPD never let the protesters get near Wall Street around the NYSE building; they cordoned off the area around it and sent a very clear and violent message whenever Occupiers tried——in non-violent marches—to get past the barricade. Several times, I saw Occupiers, by the thousands—amazingly strong numbers, cross in front of our building to get closer to Wall Street. The most violent responses from the NYPD came in these moments, that’s when the tear gas and rubber bullets came out, that’s when you have officers breaking heads and mounted police blocking streets with highly coordinated Roman-style formations. I learned a lot from this. It seemed very important to protect the people in and around the NYSE from even seeing the protests. They also—in the final weeks of the occupations in Lower Manhattan—had a new satellite-dish-looking technology that disabled cell phones, cameras, and other digital devices, so the more violent incidents couldn’t be photographed or documented in any way.

Both the NYPD and FBI have acknowledged the non-violence of Occupy Wall Street. The movement has hewed to Martin Luther King’s teachings of non-violent civil disobedience almost flawlessly. But simultaneously the FBI labeled it a terrorist group. Heavily censored FBI memos (released in response to a FOIA request, but not until the media lull between Christmas and New Year’s to reduce exposure) revealed a lot about the government response to Occupy. The JTTF (Joint Terrorism Task Force) was deeply involved in monitoring the movement and writing memos about “the threat” to banks and other financial institutions; the memos’ tone treats the corporations like they’re the customers. Then there’s the infamous assassination memo, revealing the FBI knew an outside group in Texas planned to kill Occupy “leaders” with suppressed sniper rifles “if deemed necessary.” The memos provide a rare, disturbing look into the thinking of our security establishment, which, by the way, hasn’t lifted a finger to investigate ridiculously obvious malfeasance on Wall Street. For an excellent analysis of these memos, and links to the documents themselves, see: Naked Capitalism | Banks Deeply Involved in FBI-Coordinated Suppression of “Terrorist” Occupy Wall Street

A lot of things, especially the economy, have changed dramatically for the worse since autumn 2008. The system has decayed to a frightening degree. But it isn’t that I hate the rich. I don’t. And I don’t blame capitalism; capitalism at its best, when not corrupted beyond all recognition, encourages lower prices and better services through competition. Giant corporate welfare troughs like TARP and ObamaCare, requiring every American to buy health insurance from select companies, enshrining certain banks by name as “Too Big To Fail,” these things have nothing to do with capitalism. This is Mussolini-style corporatism. Corporatism is the problem. The segment of the corporate class that’s monopolized the Congress and executive branch with big money, the estimated .05% of Americans who max out at the legal limit for campaign contributions each year, these guys are the problem, not “the rich” writ large. As I document in a recent post, we’re now in the America of Congressman Bribo and the House of Bribasentatives. We’ve allowed a tiny, shadowy minority to monopolize the levers of power, which makes impossible the aim of our founding fathers, for, as Federalist No. 52 put it, a Congress “dependent upon the People alone.” (Source) Since we have allowed this, which isn’t a “conspiracy,” but rather total spinelessness and capitulation of our craven political class in the face of a corporate class that very openly pursues its self-interest with more and more sophisticated methods, we increasingly enter FDR’s nightmare, and the attendant “acceptable standard of living” problems that he mentioned.

My thinking has changed dramatically. Back in Alabama, surrounded by GOP wins in the 94% Soviet-range, I thought electing Democrats en masse would put us on a better path, or at least help a little via incremental reforms (I was always skeptical of the powerful). Now, I realize movements are everything. Now, the Left gets most of my resentment. They have capitulated and betrayed their own to such an extent, for so long, monstrosities like ObamaCare, which, at its core is $400 billion in subsidies to the dying private health insurance industry, are embraced as “liberal.” ObamaCare is not progressive; it takes us backward. It doesn’t address any of the Medicaid issues I have fought to bring to light over the years. Instead, it is almost solely about federal cash propping up zombie health insurance, as jobs increasingly no longer provide health insurance. We’ve entered an economy based on freelancing and short-term contracts, and I’m not saying that it is necessarily bad in-and-of-itself, but it’s the reality and instead of addressing the reality, ObamaCare addresses employer health insurance plans that are increasingly a relic of the 20th century economy. The economic configuration we grew up with is GONE. ObamaCare is like inventing a better 8-track player in 2012, there is a major disconnect from reality.

Ultimately there is no power to narcissistic, self-indulgent thinking. Authentic thinking originates with an encounter with the world.

— Abraham Joshua Heschel, in Ch. 5 of Who Is Man? (1965)

The disconnect between the liberal establishment and the realities for the rest of us has increasingly widened as the Left courts the same donors at the top of the corporate food chain, the .05%. That disconnect upsets me the most. It means they’re not encountering the world, not seeing the painful realities and unintended consequences of their policies. The hermetically-sealed bubble they live in is obvious when liberal pundits are baffled by protests. “Why are they protesting?” they ask, as debt, unemployment, and hunger reach unprecedented levels.

Death of the Liberal Class by Chris Hedges presents overwhelming evidence of the Left’s “death.” Obama is particularly appalling. I felt some guarded optimism at first, but what faith I had that Obama would help quickly evaporated; I don’t see anything that this administration has done as great. The few times Obama admits there are serious problems under his administration of happy optimistic shiny wonderfulness, like when he did the Q&A on immigration on Univision, he acts powerless to lead, or even affect change in any of the federal agencies that answer to him. Has corporate influence neutered him that thoroughly?

Here are my own observations: I’ve never heard Obama say the words “poor” or “poor people.” There’s no connection to Martin Luther King’s legacy or his poor people’s campaign. The newspeak-esque language that’s used is always “middle class families,” or “working families,” which is not only bloodless and doesn’t acknowledge the suffering out there, but also sends the message “don’t worry corporate lobbyists, we only want to help families that work, not those pitiful lazy wretches who can’t find work.” Never is the disintegration of the family that’s happened in-tandem with economic disintegration mentioned. Though the homeless heavily dotted the streets of Washington DC in 2003 when I was there, and it must be exponentially worse post-collapse, Obama can’t find the strength to say the word “poor,” much less mention the homeless people he must pass in the presidential limousine.

The fact that the left media meekly pleads with Obama: The Nation | White House Meeting with Low-Income Americans? —Obama has not met meaningfully, not once, with poor people or anti-poverty activists (but the author still can’t say the P-word!) and Salon | Will Obama cave on Social Security? shows how far we’ve fallen.

The bubble seems so impenetrable, it’s looking like the Orwellian caste system: there’s the Inner Party: the 0.5%, the segment that controls the elections, the president, Congress, and the corporate class, then the Outer Party: the craven media, political parties, left and right organizations, universities, etc., who are recognizable by their eagerness to serve and provide cover to those within the Inner Party so they maintain the pillowy cocoon of economic safety during the present instability. Then, there’s everyone else. I’m reluctant to call us proles, since there’s still a lot of wealth in our ranks, even an upper-middle-class, but we don’t have much voice and the Outer and Inner Party aren’t very aware of our concerns.

The collapse of The Left is so complete that Mussolini-style corporatism is now the “center,” and pursued doggedly by the Obama and his administration of corporate courtiers. I now blame The Left more than the GOP, much more than the Tea Party, who are responding to the economic collapse and bailout culture same as Occupy. I wish Occupy and the Tea Party could band together and fight the bailouts that are continuing.

We need to look at HOW it got so bad. The corporate culture is suspect #1. It bombards us constantly like the TVs in Orwell’s Nineteen-Eighty-Four you can never turn off. Turn that $#!T off. Too often, the messages coming through are “buy our newest product, and [subtext] buy this thing, it’s all you need to be happy! You don’t need community, church, a moral core, the Bible, etc etc etc.” The messages coming in via mass corporate culture are usually the exact opposite of the inherent value of human life, humans having inherent value and sanctity and dignity, instead, the only value lies in what you produce, your income, or how ruthless you are. Not to mention the pornification of everything; if I had a daughter, I would burn the TV. Several rabbis have pointed out, the dominant mass media culture is closer to the ancient Greek culture that glorified the body and beauty over everything else, than Jewish and Christian cultures that glorified spiritual and intellectual ability. The messages we’ve become acculturated with, have resulted in our loosening our grip on the moral imperatives we must hold fast to….

We’ve lost a lot. Movements which forced President Nixon to sign important legislation like the Clean Water Act, OSHA, etc., they’re gone now. The labor movement is mostly gone.
What do we need to do to fight back against corporate dominance, national decay, and the zombification of everything? First, we need a realistic assessment of where we are and how bad it’s gotten. Then, we have to, on the macro level, build new regional and national movements that articulate the concerns of the poor and disabled, in language that flows from the conscience and moral imperatives that can’t be denied. Only radical love can beat radical evil; I’m for radical love. Occupy Wall Street needs to come back into the streets, but much more is needed. We need the kind of movements that are so powerful, the corporate state has to respond, like Solidarity in 1980s Poland or Tahrir Square in Egypt. Movements are everything.

On the micro level, we must rebuild community. Americans have too often bought into the cult of the self, that if you just buy the new product, you don’t need others. We’ve been lulled into isolation, buying the idea that government will take care of those in need: the poor, the disabled, the elderly. Even when Medicare and Medicaid did provide for the material needs of people like me, which is less and less true today, there’s a need for social and spiritual connection. I myself really need community. We have to rebuild communities that provide those connections. Churches and synagogues need to be a part of this effort, and need to articulate the moral imperatives that give movements their power.

Here’s an example of the moral thinking movements need, from Catholic theologian Paul Tillich:

…When Augustine equates the Kingdom of God with the church and the Kingdom of Satan with the great world empires, he is partly right and partly wrong. He is right in asserting that in principle the church is the representative of the Kingdom of God; he is wrong in overlooking the fact…that the demonic powers can penetrate into the church itself, both in its doctrine and institutions. He is right to the extent in which he emphasizes the demonic element in every political structure of power

— Paul Tillich in Theology of Peace

…The technical development is irreversible and adjustment is necessary in every society, especially in a mass society. The person as a person can preserve himself only by a partial non-participation in the objectifying structures of technical society. But he can withdraw even partially only if he has a place to which to withdraw.

…It is the task of the Church, especially of its theology, to describe the place of withdrawal, mainly the “religious reservation.” It is the task of active groups within and on the boundary line of the Church to show the possibilities of attack, to participate in it wherever it is made and to be ready to lead it if necessary.

…Christian action must find a way to save the person in the industrial society.

— Paul Tillich, The Person in a Technical Society

We have to find the strength to build very new movements that articulate the reality the poor face. We can’t wait for a moribund Congress and Goldman Sachs-controlled presidency to do it. Without national renewal, we face national collapse.

Looking forward to your comments,

Nick

Recommended reading: The Working Poor: Invisible in America by David K. Shipler

The Death of the Liberal Class by Chris Hedges

Feed your brain a long-form meal, not a sound-bite

The Cost of Denial For People with Disabilities

Posted by – September 25, 2010

To respond to the comments made during WBAI radio’s roundtable discussion about my latest blog essay “Why It’s Time For Survival Politics For People with Disabilities…”

The last statement in the radio segment about my blog was Josie Byzek saying that (my paraphrasing) the Tea Party may win big in the midterm elections, but then there could be a backlash at the ballots in two years (in the 2012 elections).
I don’t think the problem of inadequate services for people with disabilities will just go away with a political pendulum swing in two years. The dramatic changes that have already happened and will keep happening will ensure that these monkeys stay on our backs; because we squandered the budget for so many years on tax cuts and wars, budgetary realities will force severe benefit cuts, even if you had a 100% Dem Congress. No Congress will be able to govern in the way we’d all like, because of these very severe budgetary and political realities. Yes, part of the political reality is the Tea Party; those Tea Party activists and candidates who embrace an extreme form of Randism are more comfortable with disabled people’s blood on their hands than any political group has been in my lifetime; they’re completely comfortable demonizing people on public benefits as “robbers,” “leeches” and “parasites” and (I would argue) they’re completely irreconcilable with Judeo-Christian morality. Tea Party candidates and their Rand philosophy will be shaping the debate and helping define what is achievable legislatively like never before, and people with disabilities need to know about this, educate themselves, because this is a force that will affect our lives. But overlaying that is the larger problem of “we outta money.”

In this Dave Granlund cartoon, poor jobless people with a HELP sign reach out to Uncle Sam, but he just pulls out his empty pockets and says "I was going to ask you the same."

We’ll be paying the price for decades for the decision to try and pay for two simultaneous wars with tax cuts and “just go shopping!” and paying for it in numerous ways, some very painful. We gotta pay the piper, and we’ve run up a huuuuuuge tab. If history tells us anything, it’s that the tab is always borne by the poor and disabled, the most vulnerable and least able to pour money into campaigns to fight back.

Josie Byzek herself touched on the budgetary realities when mentioning sales tax revenue that helps fund state Medicaid isn’t the same anymore, the bottom fell out. We’ve got *apocalyptic* job loss, the last of the manufacturing sector exiting en masse, etc. Those hardhat-type 9-5 jobs won’t be coming back and you’d have to visit China to see them. The information tech world will be the source of jobs, but it hasn’t adapted and kept up enough to provide that yet, and it may be another lifetime before that happens. This will be a really ugly transition.

This Concord Coalition graph shows how Medicare, Medicaid and Social Security, in addition to interest on our enormous debt, continue to bloat the budget by % of GDP. In order to sustain benefit spending, we would need to HUGELY grow the economy, but currently, it's shrinking. Terrible choices are coming soon.

I’m arguing that technology, the economy, and politics are drastically shifting, and Medicare and Medicaid will soon change BIG TIME, so disability community leaders need to get in front of this and negotiate hard for the services we want to preserve most, because a lot of them ARE going away, and we have to get out of denial and start coping and adapting NOW! Catastrophic institutionalization, re-segregation, will happen unless we acknowledge that economic and budgetary realities mean that a lot of services are inevitably going away and negotiate hard for keeping select services we can’t go without (i.e. HCBS, Home and Community Based Services) using a cost-effectiveness argument. Congress won’t give a damn about us, but will care about cost if we make the case.

and y’know how Obama’s health reform bill increases Medicaid eligibility? It gives subsidies to help pay for the increased enrollment, but that enhanced FMAP is temporary. Then what? Then FAIL!! I’ve written about this in detail here; the eligibility mandates will hit the poorest states the hardest and they are already slashing programs to the bone to the extent they’re leaving us in our own waste. Once the eligibility mandates fully take effect in 2014, will the poorest states have to drop most care for people with disabilities? They could have to dump the people most in need, in favor of reshaping their programs to bring them in line with the new requirements, i.e. providing major medical coverage to low-income (able-bodied) adults. This is one of the worst parts of health “reform,” so very disconnected from the needs on the ground and the harsh realities we face.

This is a map of the worst and best Medicaid agencies in the U.S., with the reddest being the worst, and the lightest being the best. What I'm telling you is, this map will soon get much, much redder across the country.

In light of the situation, we need to be having conversations like “yes, we know that Medicaid dentistry and ophthalmology and free eyeglasses and prosthetics and leg braces and numerous things we’re accustomed to are going away, but we have to protect HCBS or the nursing facilities will cost the states EVEN MORE.”

We can’t afford the COST OF DENIAL. We can’t stay in denial that benefits will be changing; we can’t stay complacent! I’m saying WAKE UP, the societal, technological, economic and political changes are so great that benefits will be changing dramatically, and we aren’t prepared and we aren’t identifying priority areas to protect because there is an unwillingness to sacrifice ANYTHING, so Congress will likely cut EVERYTHING. Failure to get in front of this thing, staying in denial, will mean Congress will just impose 20% or 30% austerity across the board on all departments without understanding the issues involved.

Nick

Feds Fiddling While State Medicaid Programs BURN

Posted by – May 21, 2010

Question: In light of Obama’s plan to expand Medicaid eligibility, is anyone in Congress noticing the MASSIVE state budget cuts to Medicaid across the country and ruminating about how that jives with this impending expansion? I fear that if states have to raise income eligibility and bring millions of uninsured onto the Medicaid rolls, that will mean even deeper cuts in “optional” home care programs to pay for the expansion, and even more people with disabilities’ dreams shattered.

I wish Congress would have put protecting the most disabled Americans ahead of uninsured able-bodied people, but they didn’t. For Congress, people like me are invisible.

The states slashing Medicaid the deepest (the Southern states) are the ones that will see the most new Medicaid eligibles thanks to “Health Care Reform.”

PERFECT
FISCAL
STORM

That means life for people with disabilities in the South is about to get even worse. Good thing I fled Alabama.

Medicaid, especially in the South, is increasingly in tatters. State Medicaid programs were slashed to the bone in the 90s thanks to “the Republican Revolution” and now there’s no fat left to trim, so they’re taking chainsaws to muscle and bone.

In the Wall Street Journal, it discusses a woman who’s had to sit in her own waste all day thanks to state budget cuts. I suppose the state hoped her bed sores and inevitable sepsis take her quickly, otherwise Medicaid will be on the hook for expensive hospital stays that would dwarf the cost of just leaving her f#$%ing home care uncut in the first place. I’ve seen this happen over and over again to people I fight for. It’s left me scarred to depths few of you could ever understand.

Here’s the Wall Street Journal piece, by Clare Ansberry.

FLORENCE, S.C—Tandem forces of shrinking state budgets and rising health-care costs have collided and struck a small brick ranch house in this rural town, home to Barbara Hickey.

Born with cerebral palsy, Ms. Hickey, now 67 years old, is confined to a motorized wheelchair. She lives alone and relies on certified nurse’s assistants to get her in and out of bed, bathed, clothed and fed.

In December, she received a letter from the South Carolina Department of Special Needs and Disabilities, saying her weekly 50 hours of personal-care help was being cut to 28 hours. That meant Ms. Hickey would get help for two hours in the morning and two hours at night. If she needed to use the bathroom in between, she would sit in a soiled diaper.

After several days of reduced care, the local office of the South Carolina Legal Services appealed the cuts on behalf of Ms. Hickey. Her hours have been restored pending the appeal.

Home health care—funded largely by Medicaid—generally costs less money than institutionalizing developmentally disabled people like Ms. Hickey. But the political reality is that it’s easier to cut back home services than to close a 24-hour facility, which can leave people with nowhere to go. Thus, some of the biggest cuts around the country are happening in the basic services that help the disabled cope at home.

South Carolina says it has little choice but to cut funding for Medicaid. It faced a $563 million deficit for the current fiscal year, and like other states must have a balanced budget. Medicaid, the joint federal-state health-insurance program for the poor and disabled, already consumes about 20% of its $5 billion budget and is one of its fastest growing costs.

The health-care program is on course to consume 40% of the budget of South Carolina in five years, and leaves little for anything else, says Gov. Mark Sanford. “It could force legislators to either cut further into bone in the areas of education, law enforcement and economic development, or raise taxes. Neither option is palatable.”

The state already is making painful cuts elsewhere. The state’s Department of Juvenile Justice has closed five group homes and cut 25 after-school programs. There are 1,000 fewer public-education teachers this school year than last.

Across the country, budget-strapped states are focusing on Medicaid. Created in 1965, it is now a $379 billion program, including state and federal funds. State spending grew an average 7.9% in fiscal 2009 as the economic crisis hit and more people signed up for Medicaid.

It was the highest growth rate since the last downturn six years ago. Spending is expected to keep growing at that pace for the next decade because of rising costs and growing enrollment.

But states don’t have much flexibility when it comes to what they can and can’t cut inside Medicaid. Although it is a state-managed system, the federal government pays a percentage of each state’s total costs and makes many of the Medicaid rules. Under federal Medicaid law, states must offer inpatient and outpatient hospital care, X-rays and lab services. They also have to cover nursing-home services and meet certain standards, such as staffing ratios.

There are further constraints this year. States can’t reduce Medicaid eligibility this year because of a condition attached to federal stimulus money, and under health-care reform, they can’t eliminate existing programs.

States also run up against other laws when they make deep cuts. Lawsuits have been filed in South Carolina, Florida, Connecticut, Virginia, Mississippi and New York, claiming Medicaid cuts make it impossible for those with disabilities to live at home and that it violates the Americans with Disabilities Act.
(I know the lawyers behind this class action. I say RIGHT ON!!!!)

Logically, states would cut the most expensive, least efficient services and keep the most cost-effective. But because of mandates and the need to save money quickly, that isn’t as easy as it sounds.

For example, home care—because relatives often provide some of the care—is generally cheaper than housing people with developmental disabilities in institutional facilities. In 1993, the average Medicaid cost for each person with disabilities was $48,500. At the end of 2008, the latest figures available, it cost an average $55,000. Adjusted for inflation, that actually represents a 23% decrease, largely as a result of more services being shifted away from costly institutions to the home, says Charlie Lakin, director of a University of Minnesota program that tracks services for the developmentally disabled.

But many in-home services, though critical to those receiving them, are optional. Furthermore, there aren’t many minimum standards set for in-home services, so it’s easier to cut them without violating funding requirements. There are fewer immediate consequences for the state when it cuts those services because families won’t generally abandon disabled relatives and leave states on the hook for housing.

Cutting home care could ultimately prove penny-wise and pound-foolish, however. It could push more people into institutions or large group homes because that is where services are guaranteed, even though institutional care is more expensive.

The department’s fiscal problems have been exacerbated by past spending decisions. A special state audit released in December 2008 showed that the department hadn’t provided many new services for which it had received funding and, as a result, it couldn’t recoup millions in federal matching Medicaid dollars. For example, the state spent less than $700,000 of $10 million allocated to serve autistic children, which resulted in the loss of $13.6 million in federal matching money. The state said it couldn’t ramp up the program fast enough because it couldn’t find qualified service providers. After the audit, the executive director of the department and four of the department’s seven commissioners resigned. The department has since implemented most of the recommendations made by the Legislative Audit Council.
(This same thing nearly happened with the NHTD –Nursing Home Transition & Diversion– waiver here in New York: the bureaucracy imposed on providers was SO ridiculous than very few participated, and the rules were so cumbersome for patients that, in the program’s first two years, only one patient downstate–me–transitioned home from a facility!)

Recent state cuts have targeted developmentally disabled people living at home. In December, families were told that some of their in-home support was being cut by as much as half.

Brian Phillips, a 37-year-old with cerebral palsy, was told that he was losing half of his personal-care hours. He can work a TV with a remote control but can’t dress or feed himself, or get in and out of his bed or wheelchair.

He lives alone with his father, James, 70. The elder Mr. Phillips, who has had open heart surgery and whose heart functions at only 26% of its capacity, cannot lift Brian on his own. He appealed the cuts and the hours were restored pending his appeal.

“These are cuts no one wants to make. They are very difficult for agencies to implement and they are very upsetting and very, very difficult for our families,” says Lois Park Mole, spokesperson for the state Department of Disabilities and Special Needs.

People will generally do what they must to keep their disabled family member at home regardless of the cuts. At some point, however, even the most dedicated may not be able to continue, especially as their own health deteriorates.

In Aiken County, Board of Disabilities Executive Director Ralph Courtney says waiting lists for services are growing. There are more than 5,000 on waiting lists for various services, from residential programs to in-home programs.

“We want to give families hope to keep their family unit together, but in reality there is very little we can put in place to assist them,” says Mr. Courtney.

In-home support is cheaper, he says, than the alternative: group homes and larger residential programs that need to be maintained and staffed 24 hours a day. “But you can’t put people out on the street,” he says. “You can cut in-home support.”

Even though Ms. Hickey lives alone and needs help with nearly every aspect of daily living, it cost less to have her live in a house with 50 hours of personal care help than in a nursing home. Institutional care in South Carolina costs about $100,000 per person a year, compared to $39,000 for home and community services, according to the University of Minnesota research.

Read the entire article here: Disabled Face Hard Choices as States Slash Medicaid

How does littering the entire country with families destroyed by Medicaid cuts, jive with HEALTH CARE REFORM?

Honestly, I have gotten so many hate messages over the years, I’m now convinced that the Americans will continue to react with cold indifference, or, worse, celebration–“good riddance! No one is gonna force me to pay for you useless leeches!”–as Medicaid policy continues to cull out people with disabilities like me, UNABATED.

And you wonder why I’m so angry that I’d consider reconstructing the U.S. entirely? It’s because my every day experience involves the above Kafkaesque Medicaid policies harming me or the people I care about!

Nick

Fix The Broken Foundation Before Building A Skyscraper On Top Of It

Posted by – August 22, 2009

My biggest beef with Health Care Reform right now is that we’re building a new tower on top of a broken foundation. Medicare and Medicaid are badly broken, and we’re building more programs on top of that. Bad idea.

Insurance company bureaucracy is even worse, but federal programs have to be significantly better in the future for there to be meaningful competition. Right now, the government health care system is still far too fail. Medicaid is deeply corrupt, admitting people to nursing homes because institution owners and their lobbyists line the pockets of state legislators; people are even stripped of home care just for turning 21, and forced into institutions. As far as Medicare goes, its fee schedule encourages procedures over responsible diagnosis and management, causing the death of primary care and creating a costly and disastrous situation for patients. An old man will have no problem finding a cardiologist to do an angioplasty, but may find it near-impossible to find a primary care specialist who can manage him with meds instead.  A crude example, but it speaks to how costs can explode when so few primary care docs are around and it’s mostly proceduralists who have survived the extinction. Most new doctors the past few decades have stayed away from family practice because Medicare’s the AMA‘s drastic undervaluing of the E&M (evaluation and management) reimbursement codes make it difficult to survive financially as primary care physicians. You get what you pay for, and Medicare (and the private insurance industry that follows Medicare’s lead) pays for procedures, procedures, procedures, NOT talking to patients and thinking about what’s best for us. According to Medicare, taking a detailed history from a patient is worth nothing more than something like the first 27 seconds of a proctoscopy; I rarely see doctors taking detailed histories anymore, outside of residents in university hospitals who are ordered to do so. Do plenty of docs have to do more and more procedures just to stay afloat and keep their doors open? YES!!

Aside from a fee schedule that has buried primary care and incentivized unnecessary procedures, Medicare has also become such an unwieldy bureaucracy that even the most basic functions are drowning in red tape.

Read this personal experience from primary care specialist Dr. Toni Brayer:

Dear President Obama,
I am in favor of Health Care Reform and I agree with you that universal coverage and eliminating the abuses that both patients and doctors have suffered at the whim of the for-profit insurance industry must be curtailed.

But I also want you to fix Medicare. Medicare is so bureaucratic that expanding it in its current form would be the death knell for primary care physicians and many community hospitals. The arcane methods of reimbursement, the ever expanding diagnosis codes, the excessive documentation rules and the poor payment to “cognitive, diagnosing, talking” physicians makes the idea of expansion untenable.

May I give you one small example, Mr. President? I moved my medical office in April. Six weeks before the move I notified Medicare of my pending change of address and filled out 22 pages of forms. Yes, Mr. Commander in Chief…22 pages for a change of address. It is now mid-August and I still do not have the “approval” for my address change.

I continue to care for my Medicare patients and they are a handful. Older folks have quite a number of medical issues, you see, and sometimes it takes 1/2 hour just to go over their medications and try to understand how their condition has changed. That is before I even begin to examine them and explain tests, treatment and coordinate their care. Despite the fact that I care for these patients, according the Medicare rules, I cannot submit a bill to Medicare because they have not approved my change of office address.

I have spent countless hours on the phone with Medicare and have sent additional documentation that they requested. I send the forms and information “overnight, registered” because a documented trail is needed to avoid having to start over at the beginning again and again. I was even required to send a signature from my “bank officer” and a utility bill from the office. Mr President, I don’t have a close relationship with a bank officer so this required a bank visit and took time away from caring for patients…but I certainly did comply.

I am still waiting to hear from Medicare. At my last call they said they had not received yet another document, but when I gave them the post office tracking number, they said it was received after all. They could not tell me when or if they will accept my address change.

I have bills stacking up since April and I just found out that they will not accept them if they are over 30 days old. I have cared for patients for 5 months and will not receive any reimbursement from Medicare. The rules state I cannot bill the patient or their supplemental Medicare insurance either.

Believe me, Mr. President, I commend you for taking on such a huge task. Please also know that Medicare reform is needed along with health care reform.

A loyal American,
Internal Medicine (aka: primary care) physician

Source: EverythingHealth: Fix Medicare

It seems like the government doesn’t want doctors participating in Medicare, and makes the reimbursements so low and the hassles so high (they can’t even manage a simple change of address without a half-year bureaucratic nightmare) that more and more providers just give up. Yes, this is yet another case of the government’s unfortunate cranial-rectal inversion.

Dr. IcedLatte lists more aspects of modern medicine that desperately need to change here.

The Tower of Babel

The Tower of Babel

I support a public option in the new health care reform package, but (unlike some conservatives) I realize we already have several widely-used public options, Medicare and Medicaid, that the government runs, and should fix as a core part of health reform. If a new government program just continues the failures of Medicare and Medicaid, that’s not reform. We have to include the CCA in the bill, include a wider adoption of the PROMETHEUS bundled payment system (PROMETHEUS stands for Provider payment Reforms, Outcomes, Margins, Evidence, Transparency, Hassle-reduction, Excellence, Understandability, Sustainability) so that the government’s skewed, guaranteed-to-fail fee for service billing system doesn’t bankrupt Medicare. Don’t build a tower of babel that’s just going to fall. Listen to all the experts, doctors and patient advocates, and FIX MEDICARE AND MEDICAID. I agree (mostly) with this article by David Ignatius, focus on health system reform, not just “health insurance.” We have to fix the foundation or the new skyscraper is going to collapse.

Nick

The Latest Leaked Info on Obama Administration’s Views About The Community Choice Act

Posted by – May 29, 2009

Director of HIV/AIDS Policy and a senior disability advisor on the Domestic Policy Council, Jeff Crowley, speaks at a Candidates Form at the George Mason Center for Health Policy Research and Ethics

Director of HIV/AIDS Policy and a senior disability advisor on the Domestic Policy Council, Jeff Crowley, speaks at a Candidates' Form at the George Mason Center for Health Policy Research and Ethics

Jeff Crowley from the president’s Domestic Policy Council met with the board of the NDRN (National Disability Rights Network, formerly NAPAS1) this week and a summary of how Crowley conveyed the administration’s views on the Community Choice Act was leaked to several listserves online. The disability community deserves to know what the thinking inside their government really is, so I am publicizing this text:

Jeff Crowley from President Obama’s Domestic Policy Council came to our NDRN Board meeting this week. I am certain many people on this list know him but this is the first time I’ve seen him. Here is a summary of what he said and how he said it.

He certainly confirmed that it is the administration’s intent to offer the initial health care proposal without including long term care.

He went on the express his regret at the outcome of the ADAPT action two weeks ago. He described himself as having “worked with ADAPT in the past” and certainly assumed no sense of apology or responsibility for the arrests or the dismissive comments of his colleague, just “live with it.”

In a very guarded and cautious way he expressed the desire to deal with long term care in the second session of this Congress. He described CCA as ‘one way to deal with it.’ But he also said there were other ways. As I said I never saw him before and maybe he’s always this taciturn. But his comments about CCA were lukewarm at best.

Several times he cautioned against ‘high expectations’ and was >generally very flat and careful in his delivery.

Others have more experience and insight in this but my impression was that if we are to succeed with CCA the thrust is going to come from Congress and that the administration is being very cautious.

For what it’s worth …

1. The National Association of Protection and Advocacy Systems (NAPAS). .I won the “2003 Advocacy Award” from NAPAS and traveled to Washington, DC to receive the award and deliver an acceptance speech.