Mike Klein Online

Georgia Physician Shortage Just One Among Many Challenges

Mike Klein

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.”

(Mike Klein is Editor at the Georgia Public Policy Foundation)

July 30, 2012 Posted by | Uncategorized | , , , , , , , , | Leave a comment

Governor Deal: Major Health Policy Decisions “In a Holding Pattern “

Mike Klein

Governor Nathan Deal expressed displeasure with the U.S. Supreme Court decision on federal health care reform during a Thursday afternoon news conference, describing it as “the largest tax increase in the history of the United States, at least $500 billion and perhaps significantly more.”  The Governor also admitted he was surprised by the decision because he thought the Court had given “pretty strong signals” that it had problems with the individual mandate.

The Governor appeared alone when he spoke to reporters and a large crowd that assembled in mid-afternoon inside the State Capitol.  Deal said the state will likely hold off making decisions on several questions until after the November national elections.  Presumptive Republican Party Presidential nominee Mitt Romney has vowed to dismantle the health care law if he is elected.

Deal said Thursday morning’s Supreme Court’s decision does appear to leave states with some flexibility, in particular, whether they will be forced to expand their Medicaid eligible populations.  “There was at least an area of indication that it was not an absolute mandate,” Deal said.  “The discretion for a state to participate in the expansion of Medicaid was a door that was left open.  The Court has said that would have been an unconstitutional mandate on states.”  (Click here to watch Governor Deal’s news conference on YouTube.)

Georgia estimates its Medicaid eligible population would increase by 620,000 in 2014 based on requirements in the Patient Protection and Affordable Care Act.  On Thursday, Governor Deal said that increase would cost $76.3 million additional state dollars in 2014, and it would result in 24.2 percent of all Georgians being Medicaid eligible.  The current number is 17.6 percent.

Governor Nathan Deal

“As you know, the original legislation (said) that if you did not accept the mandate for expanding the Medicaid coverage up to, in our case 138 percent of the federal poverty level, that you would have lost your federal participation in your existing Medicaid program,” Deal said.  “The Court has ruled that leverage and that coercion was not appropriate.”

Because the law was upheld, Georgia faces a mid-November decision about whether it will create some version of a state health insurance exchange or default to a federal exchange.  Deal said that decision also will likely not be made before the November election.  “We probably are going to be in a holding pattern until we see what the events of November bring us,” he said.

A special committee that considered health insurance exchange models last fall reported to the Governor that while it preferred no exchange, a Georgia created exchange would be preferable to one imposed by the federal government.  The Georgia model could be a state-operated exchange or, the committee recommended, a largely private model with some state oversight.

Responding to a question from the Georgia Public Policy Foundation, Governor Deal acknowledged that a regional, multi-state health insurance exchange “is an idea worth exploring.”  The Governor noted, however, that the state passed a law that would allow insurance companies licensed by other states to offer policies in Georgia but, “No company has taken us up on that offer.”

Governor Deal said decisions that need to be made this year – in particular, whether to expand Medicaid eligibility and what kind of exchange to create – should not require a Special Session of the Georgia General Assembly.  However, he thinks one might be necessary next year.

“We’re probably going to be finished with our 2014 budget before we know the answers to those questions that only Congress and the White House can provide,” the Governor said.  The 2013 General Assembly will likely conclude in late March or April, possibly well before Washington has given clear guidelines to states if there is a new administration.  Deal said that could require bringing lawmakers back to Atlanta.  “I will do everything in my power to avoid that,” he said.

The Governor opposed and fought against President Barack Obama’s federal health care reform law during the last of his nine terms as a congressman from Georgia.  “I was surprised by the decision,” Deal admitted.  “I honestly felt that the issue of the constitutionality of the individual mandate was one that the Court had given pretty strong signals that they had problems with.

“It is somewhat ironic to me that it is now constitutional not because it is a proper exercise of the power of federal government under the commerce clause but that it is appropriate only because of the federal exercise of taxation authority over the states and over its citizens.  That’s why I said, if we really want to know what the largest tax increase is, we have just now been given that opinion by the Supreme Court.  It is this piece of legislation that, ironically, is called the Affordability Act.”

(Mike Klein is Editor at the Georgia Public Policy Foundation)

June 28, 2012 Posted by | Uncategorized | , , , , , , | Leave a comment

History Up Close at U.S. Supreme Court Health Care Arguments

Mike Klein

Monday morning millions will pay attention via media reports but only a few dozen will be inside when the U.S. Supreme Court begins three days of hearings that will decide the constitutionality of President Barack Obama’s federal health care reform law.  Georgia Attorney General Sam Olens will be among those few who have a seat in the Court where history will begin to unfold.

“We won’t know the opinion until the end of June,” Attorney General Olens said this week when he discussed the case before Georgia Public Policy Foundation members and guests.  The lawsuit that reached the U.S. Supreme Court is just one of several filed nationally that all had the same goal: Throw out the Patient Protection and Affordable Care Act and start over.

Georgia is among 26 plaintiff states that are challenging the law before the Supreme Court.  U.S. District Court Judge Roger Vinson ruled the individual mandate unconstitutional in his January 2011 decision.  Vinson further ruled that the mandate is the essential component of the entire law and, therefore, he declared the entire law unconstitutional.

The federal government appealed to the 11th Circuit Court of Appeals in Atlanta.  Last August the appellate court upheld Judge Vinson’s individual mandate decision by a 2-1 margin but the three-judge panel also ruled that the mandate could be severed from the entire Act, so the remainder of the law could stand.  “We didn’t like that part of the ruling,” Olens said.

That is a very condensed version of how this case got to the Supreme Court.  As the Attorney General outlined, six hours of arguments over three days will be conducted as follows:  Monday the Court will consider whether legal challenges are premature or whether challenges must wait until after the law takes full effect in January 2014.  Individual mandates will be argued Tuesday and Medicaid expansion Wednesday.

Georgia Attorney General Sam Olens

Olens explained the question-at-hand for Monday.  “The issue is simply that you cannot file a lawsuit on the imposition of a tax before the tax is collected,” the Attorney General said.  “Since the tax, or penalty, is not collected, until January 2014 the theory goes this case has been prematurely brought and you would have to re-file it after January 2014.”

The individual mandate section to be argued Tuesday has generated the most headlines since the Obama administration began to pursue health care reform legislation.  It would require that every adult American – “with minimal exceptions,” Olens said — must obtain health insurance or pay a penalty to the federal government starting in 2014.

This raises the question: can the federal government force citizens to purchase any product, and if they choose to not purchase the product, can the government then impose a fine?  The U.S. District Court in Florida and the Appellate Court in Atlanta both said no.  Other courts have issued different rulings, causing confusion and requiring a Supreme Court final decision.

Medicaid expansion under this law – without federal funds to support the expansion – is the Wednesday discussion.  Olens said Georgia’s Medicaid-eligible population could swell by 650,000 to 750,000.  The reason is the bill establishes Medicaid eligibility at 133 percent of the federal poverty level starting in 2014.  Medicaid is a shared federal – state partnership but states increasingly are being forced to absorb expanded costs even before this new law takes effect.

“We already know that (fewer) doctors will accept Medicaid,” Olens said.  “What happens when we have a 35 percent increase in the number of Georgians that are then on Medicaid?  It is an additional $2.5 billion cost (to Georgia) over the decade.”

Attorney General Olens also said the federal health care law will require large employers that include state governments to offer a minimum level of benefits, as decided by the federal government.  “They are telling us what coverage we need to provide to state employees,” Olens said.  “That ought to be your decision, not the federal government’s decision.”

(Mike Klein is Editor at the Georgia Public Policy Foundation

March 23, 2012 Posted by | Uncategorized | , , , , , , | Leave a comment

Senator Greg Goggans: Blame Me for Trauma Care Amendment Defeat

Georgia state Senator Greg Goggans said Thursday he feels personally responsible for the defeat of a constitutional amendment to ensure dedicated funding to statewide trauma care.   “I take the blame for this,” Goggans told the Georgia Public Policy Foundation.  “I don’t think I did enough to make people understand early on what this was all about.”

Goggans was the principal architect of Senate Bill 277 that placed trauma care on Tuesday’s ballot.  The amendment question asked, “Shall the Constitution of Georgia be amended so as to impose an annual $10.00 trauma charge on certain passenger motor vehicles in this state for the purpose of funding trauma care?”  Supporters expected to raise up to $80 million annually.

With 36 hours to reflect after Tuesday’s defeat, Goggans said “impose an annual $10 charge” might have been poorly worded.  “In hindsight, maybe impose was a terrible word,” Goggans said. “People looked at it as a tax.”

He is not hopeful the General Assembly will identify new funding this winter.  Goggans said last month’s mental health services negotiated agreement between Georgia and the U.S. Justice Department is a significant reason for that likely outcome.

Georgia agreed to comply with a 1999 U.S. Supreme Court decision that people with mental illness and developmental disabilities have a right to community treatment programs rather than segregation in state hospitals. In return, the federal government will not control state services.

But compliance will carry a steep cost.  Goggans estimated $15 million must be added to mental health services in the current year amended budget and $60-to-$65 million in the Fiscal 2012 budget.   “We have no reserves,” Goggans said, “and our one-time funds are gone.”

The trauma care amendment was not soundly rejected.  It lost by 135,000 votes from 2.5 million cast with 1.2 million voting yes.  But the amendment lost in 145 of 159 counties and rural county Georgians routinely voted no.  Goggans represents nine counties in deepest southern Georgia.

“There was a lot of push-back in rural Georgia that Atlanta would get all this money, that we would never get a trauma center in south Georgia,” Goggans said.  “I never could get it across, even to some of my personal friends.  I had friends say, if you could show me that we’re going to get a trauma center in Waycross or in Douglass, then I’ll vote for it but there’s no guarantee.

”I guess the last two or three weeks, when people started early voting, that’s when everything started to hit me; Yeah, people really have an issue with this and they don’t understand it,” Goggans said, “but I guess it was just too late.”

Mike Klein is Editor at the Georgia Public Policy Foundation.

November 4, 2010 Posted by | Uncategorized | , , , , , , | Leave a comment