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$7 Billion Hidden in Small Type

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John Lindstrom, Gongwer News Service, December 9, 2011

So much commentary on government focuses on headline issues, the ones easily chewed and spun into bumper stickers and soundbites. Let us consider something else, something that those who know the newspaper industry know might be stuck in the agate columns.

If one massed about 220,000 people in Michigan into one spot, it would be a pretty sizeable fondue of flesh. It would, in fact, qualify as the second largest city in the state.

If one spent the 2010 Michigan per capita income of $35,597 on each person in this entire group of 220,000, about $7.8 billion would be spent. A tidy sum indeed.

That being the case, the $7 billion the state and federal governments actually spend on this group of 220,000 seems a relative bargain. Then again, maybe itís not a bargain. Maybe we can spend the money better and more cheaply. Maybe we can do that and make sure none of the 220,000 people is harmed. Maybe.

This is not a theoretical group of 220,000 people. There are actually about 220,000 people in Michigan who are eligible for both Medicaid and Medicare. And it is them, and the amount of money being spent on them, that is at the heart of one of the more complex, potentially important and largely unknown stories ongoing in state government. As was said, to find it you have to read the agate columns.

This group also represents two of the essential elements government must wrestle with constantly: money and personal well-being. It must wrestle with the two issues, yet somehow not quite win on either count.

It is also one of the big hidden issues of government. Hidden not so much because government or anyone else is trying to hide it. Itís hidden because itís complicated, because it is difficult to reduce to a bumper-sticker. One would have to be willing to stretch adhesive paper across the entire bumper to fit Justice For Dually Eligible Medicaid/Medicare Recipients or Hell No, I Wonít Pay For Dually Eligible Medicaid/Medicare Recipients!. Itís hidden because it is weighted down with jargon and no dictionary yet exists to make sense of what people are saying.

And itís hidden, probably, because it deals with people whom we are uncomfortable acknowledging. This issue deals with the old and the poor, and the disabled and poor, and the mentally ill and poor. It deals with, in fact, people we could all one day become.

This also is the kind of issue government ends up dealing with a lot. It is not the kind of issue that outraged groups create social media sites for and hold rallies with tri-corn hats and bullhorns, insisting they alone know the true meaning of the constitution. It is not the kind of issue reporters tend to spend a lot of time following. This reporter knows, since he has been about the only reporter following the story.

But it also shows how despite cries from so many critics from both sides that fixing government ought to be easy, it is often anything but easy.

As backdrop, recall that Medicare, which pays for the medical care of the elderly and many disabled persons, is entirely federally funded.

Medicaid, which pays for medical care for the poor, is a joint federal/state program with both paying for care.

For years now, states have clamored for the federal government to do something about dually eligible recipients. Those tend to be older, poorer people who often are in nursing homes. Tend to be older and poorer. Many are not so old, but they suffer from multiple disabilities. Many struggle to be heard because they struggle to even speak. They are in wheelchairs. They fight off mental illnesses.

They are the people any one of us could one day become. We all will be older, we could well be poorer, we could find ourselves disabled and ignored.

They are the people whom even the most strident anti-government opponent agrees need help to live. Admittedly, the most strident anti-government advocate might say that help should come from families or churches. To others this is one reason why government exists, to care for those who truly need care.

States, including Michigan, have pushed for the federal government to pick up the costs of those individuals as a way of easing their own budget struggles.

That, the federal government has not done.

But the federal Centers for Medicare and Medicaid Services did call for the states to propose ways of consolidating and coordinating those services. Doing so would make them more efficient, possibly even save some money. Hard to argue against that.

Could consolidation and coordination also help ensure that recipients get as good or maybe better services at less money? Always that is the Holy Grail of any government restructuring: doing more with less.

Michigan applied for and received federal funds to help set up a coordinated system for dually eligible recipients. And at a hearing this week on the issue, Rep. Matt Lori (R-Constantine) said finding a way to coordinate the services in hopes of saving money ó $7 billion is on the table, after all ó definitely interests him.

It was in its proposal to the federal government, however, that alarm bells, warning sirens, watchdog yowls, blowing whistles and frightened screeching set the care industry ó and by that we mean community mental health agencies, agencies for the aging, organizations that care for the developmentally disabled and others ó on the warpath against the proposal.

That proposal called for ďa single contractual relationship between the payers (Medicare and Medicaid) and the entity responsible for service delivery and quality.Ē Separately, managed care organizations on the local levels would be contracted to actually provide the care, but it would come through this one proposed entity.

And that proposed scared the living breathing guts out of every person involved in the issue. Local directors warned their agencies would be shut down, that patients would have to get care through a centralized agency. Patients and their families were terrified. A level of fear and anger that surpassed even that seen over the proposal to tax pensions was evident among this population.

Candidly, the state was stunned at the reaction, and has had to bend anyway it can find to bend to assure those individuals it wasnít trying to ram anything through, that itís first consideration was always patient care, and that all affected persons would be part of the discussions on setting the program up. The state added more public hearings, so affected individuals could talk about the issue. It live-streams meetings of different workgroups on the different facets of the issue so people across the state can see how the discussions are proceeding.

None of this seems to have assuaged the critics, who before Mr. Lori this week urged the state go slower in developing its proposal (which it now intends to take to the federal government in spring), and to be sure the work they do is included in whatever proposal is made.

In its own way this issue triggers so many catch-phrases we have heard on a federal level applied now to the state. Is this an example of ďone size fits allĒ governing? Will patients be able to ďkeep their own doctor (or therapist, or case worker)?Ē Isnít this an overreach by a centralized government against local control?

One cynically could also say these agencies are simply trying to keep their piece of the pie, no matter what the state does.

What is indisputable though is the genuine worry by recipients and their families that their care will be dramatically and drastically affected by whatever changes are made. The changes the state makes wouldnít amount to a set of inconveniences. Those changes could trigger a massive change of life for some of these recipients.

It is also indisputable that the state workers drafting these changes understand that. Get this wrong, hurt too many people, and they can count on political blowback hitting them harder than a hurricane.

All that makes this the really tough work of governing, the kind of work that goes on all the time though usually over less personally pressing issues. It is also the hard work that goes on outside of public view, mostly because the public is preoccupied elsewhere.

The public is preoccupied even though everyone in the public could be affected by the decisions made on this issue. So much of the agate stuff is exactly that, important but unnoticed.

This issue may never reach major headline size. Itís a sucker bet to say most of the public will have any idea about this in a year or more.

But itís important. One should pay attention. It should at least be bumped out of the agate columns and stuck in among the crosswords.

John Lindstrom is publisher of Gongwer News Service. For nearly 50 years in Michigan, Gongwer News Service has provided independent, comprehensive, accurate and timely coverage of issues in and around Michiganís government and political systems. For subscription information, including a free trial, visit Gongwer online.


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