Health care policy is a complex beast with seemingly intractable political positions, lots of data to support or refute almost anyone’s perspective, tons of financial impact analysis – just last week the Congressional Budget Office released yet another health reform cost impact study — and at the end of the day, lots of ragged emotions that cloud and obscure the conversation.
Here is an idea that should not be overlooked: People will get sick and have accidents regardless of who is making policy and whatever that policy-of-the-moment happens to include or exclude. And when that happens, they need someone nearby who is able to help them.
In Georgia, we need help. “You’ve hit on a significant issue for the state,” said state Department of Community Health deputy commissioner Blake Fulenwider. “There is no doubt about that.”
Fulenwider, two other state officials, an Obama administration official and a national children’s advocate sat together last week for a Georgia Children’s Advocacy Network discussion about what the recent U.S. Supreme Court federal health care law decision might mean for Georgia children. Might is a precarious word because of the November presidential election.
As the 90-minute session began to end, Fulenwider noted, “Today is an example that none of the things that we talk about have easy answers.” Debate will continue here for months about whether to expand Medicaid eligibility and how to create a health insurance exchange, if at all.
Here is a reality check: Today Georgia has a significant physician shortage and the state also anticipates a shortage of 38,000 nurses over the next decade. That is what a Georgia Health Sciences University report concluded last August when it was submitted to the University System Board of Regents. Urban medical facilities are overloaded and there are vast health care brownfields in rural areas.
An Association of American Medical Colleges report published in August 2011 said, “Without immediate statewide cooperation in expanding medical education and residency programs, the state may never again have an adequate supply of physicians. For too long Georgia has relied on out of state and international physicians to make up for the lack of Georgia trained doctors. Without changes in the state’s medical education system, Georgia will rank last in the United States in physicians per capita by 2020.”
No Silver Bullet for Medical Access
The University system report said the state is 1,450 graduate medical education positions below the national average and 315 below the average of southeast states. That forces students to leave Georgia for medical education which, in turn, decreases the possibility they will return to practice medicine back in Georgia. The state has 20.8 physicians per 100,000 persons; the national average is 35.7 physicians.
Governor Nathan Deal recognized the urgency of this shortage by creating 400 new physician residency slots in this year’s budget. Unfortunately, training hundreds of new physicians when you are short by many hundreds more means you are still short.
To further stress the already stressed system, about one-third of physicians and almost 40% of registered nurses statewide are eligible to retire now or within ten years. Many higher education programs are trying to address shortages but Georgia is clearly catching up, not getting ahead.
“Providing coverage does not mean providing access,” Fulenwider admitted. “We continue to be challenged with our budget environment and landscape that we’re in, in maintaining and being an attractive payer for our Medicaid providers. We’ve got to be sure that we’ve got boots on the ground to deliver service. I wish there was a silver bullet answer to that. There is not.”
Supreme Court Decision Impact
The U.S. Supreme Court decision threw a wrench into health care policy decisions. Whereas media was intently focused on what might happen with the individual mandate provision, the justices by a 5-4 vote blindsided nearly everyone by ruling states cannot be forced to expand Medicaid, and states cannot be penalized if they refuse to expand. The individual mandate was upheld as a legal tax. Health insurance exchanges were also upheld, although they will likely exist in many forms.
Here is part of the Georgia landscape. State decisions on Medicaid eligibility expansion and what to do about a health insurance exchange will not be announced until after voters decide whether Mitt Romney will replace Barack Obama. A state Medicaid redesign train that left the station early last year has been sent to a side rail but some elements will be implemented.
Georgia faces a November 16 deadline to tell the federal government how it plans to establish a health insurance exchange required by federal law unless a new Romney administration that would assume office in January issues exemptions and begins to dismantle the law.
“There will be an exchange in Georgia one way or another,” suggested JoAnn Corte Grossi, who works for the Obama administration as Mid-Atlantic States Director at the U.S. Department of Health and Human Services. That was her message to the Georgia CAN! panel last week.
Will the Obama administration be flexible with states that would prefer to receive Medicaid block grants? “We’ve obviously gotten lots of letters from lots of governors asking questions like that,” Grossi said. “Sorry to punt on this one but the honest answer is decisions are still being made.”
Some State-Based Decisions Already Made
Some state-based changes will happen regardless of November elections: Georgia foster care children – currently 26,409, according to the Department of Community Health — will move to care management organizations. Medical records will follow children regardless of where they live or how often their placement changes. This is similar to how the state manages health care for low-income Medicaid and PeachCare children. The change is anticipated in mid-2014 when the state executes new managed care contracts.
Georgia also decided Medicaid eligibility will continue to be done in conjunction with eligibility for food stamps, temporary assistance for needy families and child care subsidies. The state will launch a new consumer-focused web portal but that might take three years to develop.
Jonathan Duttweiler is Manager for Medicaid Eligibility at the Department of Human Services. He said 2,100 staff caseworkers currently average 571 Medicaid recipient clients. The average caseload would increase by 400 additional clients to almost 1,000 per caseworker if Medicaid expands starting in 2014. Duttweiler said the state has fewer caseworkers today than it had 15 years ago.
The state also requested and received a federal waiver from the health care law provision that insurers must spend 80 percent of each dollar earned on health care. The state position was that “smaller insurers wouldn’t be able to meet that 80 percent threshold,” said Jay Florence, legal counsel for the state office of insurance. The waiver required 70 percent spending levels last year, 75 percent this year and 80 percent starting next year.
The Georgia CAN! health care policy panel discussion was peppered with data. Indeed, at times it seemed almost no sentence was complete without a number included. One of those seated in the audience was Dr. Harry Heiman, director of health policy for the Satcher Health Leadership Institute at the Morehouse School of Medicine.
“I understand your lens,” Heiman told the panel. “My lens as a family physician is I am seeing children every day, adults every day that suffer health consequences for lack of access to quality care. Clearly, we need a balanced approach that understands your challenges and the challenges of the children and adults in our state.”
One challenge in almost every policy discussion is how to make the numbers mean something. So, let’s hope these numbers mean something. The annual cost to fully incarcerate someone in Georgia’s juvenile detention system is $98,000 per bed, more than five times greater than adult prison system per person costs. On the other hand, the state share is about $4,300 per pupil in the K-12 public school system. One is an investment in the future. The other is simply shocking.
“Where is that money going? Where is that $98,000?” That question – asked rhetorically – was among several posed this week when the newly reconstituted Special Council on Criminal Justice Reform held its first meeting to consider a vast rewrite of the state juvenile code. The Council retained all 13 members whose work helped to craft ideas for this year’s adult criminal justice system reforms, and it added eight new members, several with juvenile code expertise.
The Council is also expected to consider some unfinished business from the 2012 adult system reforms; in particular, more work on earned compliance credits, mandatory minimum safety valve sentencing ideas, and possible decriminalization of some traffic offenses. But make no mistake about it; the main course on this year’s menu will be juvenile justice reform.
“States across the country including Georgia are facing very high per child costs in the juvenile system,” Pew Center on the States public safety analyst Jason Newman told the Council. Part of the reason for higher per person expense is the juvenile system has costs that are not found in the adult system. For example, mandatory education and especially special education which is costly.
Newman also told the Council, “Most states are not getting very good outcomes.” That includes Georgia; 45 percent of juveniles who serve time in secure facilities commit another crime within three years. They return to the juvenile system, or after age 18 show up in the adult system.
This year the General Assembly nearly enacted a package of significant juvenile reforms. A bill that unanimously passed the House (HB 641) was sidelined because of questions about state expense and how local communities would afford services they would be asked to provide. The bill has existed in various forms for about five years, with lots of stakeholder contributions.
The Special Council faces a December 31 deadline to submit its recommendations to Governor Nathan Deal. A new bill is expected in the 2013 Legislature. The Council will again receive technical assistance from the Pew Center and this new venture is joined by the Annie E. Casey Foundation which has decades of juvenile code expertise.
There is a great deal more to this conversation than questions about incarceration or expansion of community-based alternatives, similar to the path being implemented in the adult system. For example, the juvenile code as envisioned in HB 641 would address juveniles who are unruly, but their actions would not be crimes as adults. Some Council members indicated they want to learn more about how to decide whether 17-year-old offenders should be treated as juveniles or adults.
The Georgia Department of Juvenile Justice will spend $300 million this fiscal year. That will pay for seven Youth Development Campus facilities where juveniles can be held as long as two years; this is the juvenile equivalent of the state adult prison system. DJJ operates 20 Regional Youth Detention Centers where juveniles are held while awaiting adjudication for an offense. The department is also responsible for some 14,000 youths in community-based settings.
When you look at all the services provided – and all the locations where service is provided – the state DJJ interacts with about 41,000 juvenile offenders per year and it maintains a daily headcount of almost 16,000 offenders in its secure detention or community-based programs.
As noted above, 45 percent of all committed youth will be charged with a new crime within three years and the number is 60 percent for those sentenced to confinement in a Youth Development Campus secure facility. “That rate has increased slightly over the last eight to nine years,” Pew’s Newman told the Special Council. “So despite significant costs the state is actually seeing recidivism rates that are on the rise.”
“With all due respect, those numbers are lower than I thought,” said Oconee County Sheriff Scott Berry, who is newly appointed to the Council. “It depends on what you are asking,” Newman said. “If you’re talking about re-arrested those numbers are higher. These are just the ones that are re-adjudicated,” meaning, they are back inside DJJ facilities or programs.
Changes Underway in the Adult Corrections System
This week’s Special Council meeting was notable for something else – a rare and illustrative discussion of changes already underway in the adult criminal justice system. Tracking system reforms is a complex challenge because implementation has no single executive team and it has no website that would help the public learn about what’s being done, when and where.
The Department of Corrections will open new residential substance abuse treatment centers this month in Turner, Appling and Pike counties. The Appling and Pike facilities are so-called dual diagnosis centers that also specialize in mental health services.
“We know mental health is a growing population, a growing segment of our probation and prison population,” said Jay Sanders, special assistant in the Corrections probation operations division. “Our goal is to keep offenders – those that we can, not everyone – out of prison and in the community.” Each center can provide mental health and substance abuse service to about 200 offenders.
A new probation day reporting center opened last week in Savannah and another will open within six months but the location has not been announced. “These hold 100-to-125 individuals,” Sanders said. “They report in every day, see their officer. They’re drug tested and go to counseling.”
Community impact program sites are now open in Atlanta, Augusta, Columbus, Macon, McDonough and Rome. These local offices connect mental health, education and labor resources with released offenders who are re-entering the community. Two or three more are anticipated. “We want to give you the opportunity to succeed so we don’t see you again on probation, in prison or on parole,” Sanders told the Special Council.
The Special Council did not announce a timetable for next meetings. It will divide into work groups. State Court of Appeals Judge Michael Boggs and Governor’s Office deputy executive counsel David Werner are co-chairs. ”Nothing is off the table,” Boggs told the panel. ”We want to make sure that we are inclusive.”
(Mike Klein is Editor at the Georgia Public Policy Foundation)
There is a tendency here in Georgia to consider that school choice is an open question. This is particularly true because of the high stakes – you might want to call it angst – on both sides of the charter schools commission constitutional amendment question that will be decided by voters in November. Another view suggests the national battlefield has already begun to move.
“This debate has been won to a large degree,” says University of Arkansas economist and education policy analyst Jay Greene. His school choice preference is at odds with traditionalists who would put four walls, a ceiling, a floor and locked doors around public school students.
“There are still dinosaurs walking the earth who say NO, choice is bad but politically that is becoming unacceptable,” says Greene. “Both political parties in their national platforms embrace parental choice, embrace the idea of competition. You hear this from (U.S. Education) Secretary (Arne) Duncan and from President (Barack) Obama. That war is over. Now the debate is over choice under what conditions and what regulations.”
Greene brought his pro-school choice message to a Georgia Public Policy Foundation audience last week in Gainesville. The education policy briefing honored the legacy of Milton Friedman, the earliest champion of school choice, who was born 100 years ago this month.
“Milton Friedman wasn’t just an articulate defender of the moral case for freedom. He was a rigorous economist,” said Greene. “The pursuit of freedom in education helps produce better outcomes just like the pursuit of freedom in our economy and in our personal lives.”
Using his trademark deep data and lots of power points, Greene relentlessly outlined why he believes the problem with public education today is not investment – he noted that per pupil spending has increased 131 percent nationally and 220 percent in Georgia during the past 40 years. “We’ve been hiring an army of teachers,” Greene said.
Nor does Greene believe there is a significant difference in students today and decades ago. “Kids aren’t dumber than they used to be or less capable than they used to be. They’re just about the same and if you think 1970 skills are fine for a 21st Century economy then we’re doing just fine other than the wastefulness of spending a lot more money to get the same outcome.”
There is ample evidence to suggest public schools have failed America. The nation has slipped way down virtually every chart that compares students from industrialized nations. The 2009 Programme for International Student Assessment of students worldwide ranked U.S. students 14th in reading, 17th in science and 25th in math. The Obama administration described that study as “an absolute wake-up call for America.”
States including Georgia have littered the landscape with tests that attempted to show student progress. No state test anywhere has as much credibility as NAEP – the National Assessment of Educational Progress exams that have measured reading, math and science performance since the early 1970s. NAEP scores over four decades show virtually no educational progress.
Nationally, 17-year-old students scored 285 on the 500-point NAEP reading test in 1971. They scored 286 in 2008, no improvement. Mathematics scores improved just two points from 304 to 306 during the same 37-year period. National science tests showed similar flat performance.
How did this happen? “Spending more money didn’t give us the outcomes that we wanted,” said Greene. “The truth is we don’t know what to do for everyone. We have ideas about what to do for different kinds of kids in different kinds of circumstances but there is no single solution to our instructional needs.”
In The World According to Jay Greene, public education should mirror how we live, work and play. Much of what we do in every day living is done by choice. We can choose preschools. We can choose universities. But between kindergarten and through public high school most students attend schools based on where they live. No choice.
“The idea of choice and competition is pervasive in our society,” Greene said. “The burden really ought to be on supporters of a bizarre system that is so totally different from other aspects of our lives. There may be historical reasons why we started that way but it’s very hard to justify why if we’re starting from scratch today we would build that public school system that we have.
“The real debate is not should we have choice or not. We are already comfortable with the general idea of choice in education, particularly residential choice (choosing a school by purchasing a house in a new district). Different kinds of choice schemes will produce different regulatory schemes and could produce different outcomes.
“Our public schools can rise to the occasion,” Greene said. “They respond to competitive pressure. Achievement rises in schools when they face competitive pressure.” Click here to watch Jay Greene’s presentation on the Foundation’s YouTube channel. Click here to read Jay Greene’s education blog.
(Mike Klein is Editor at the Georgia Public Policy Foundation)
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