Thursday, June 28, 2012

Will Texas expand Medicaid coverage under Obamacare to include prisoners' hospital costs?

The Internet today, naturally, is abuzz with commentary about the US Supreme Court's ruling upholding most of "Obamacare" but giving states the right to opt out of the Medicaid-expansion piece without losing federal funds they already receive. Now that the court has ruled, Grits thought it worthwhile to iterate the questions raised implicating Texas criminal justice spending. Specifically, will the now-optional state Medicaid expansion happen in the Lone Star state, and will it include hospital care for Texas prison inmates?

The answers could determine whether the Texas Lege can reduce the line item for prison health spending in the next biennium, or if they must increase it by a nine-figure sum. Here's how described the new option to cover state prisoners' hospital bills under the federal Affordable Care Act:
most state prisoners (currently) do not qualify for Medicaid. That's because all but a few states limit Medicaid  to low-income juveniles, pregnant women, adults with disabilities and frail elders.  The majority of people in lock-ups are able-bodied adults who do not qualify, even on the outside.  In 2014, however, when Medicaid is slated to cover some 16 million more Americans, anyone with an income below 133 percent of the federal poverty line will become eligible. Since most people have little or no income once they are incarcerated, virtually all of the nation’s 1.4 million state inmates would qualify for Medicaid.

As a bonus to state corrections agencies, most inmates would be considered new to Medicaid, making them eligible for 100 percent coverage by the federal government between 2014 and 2019. After that, states would be responsible for only 10 percent of their coverage. In addition, state health insurance exchanges—which are required to be functioning by 2014—would make it easier for corrections departments to sign inmates up for the program.
So the question arises: Will the Texas Legislature expand Medicaid in 2014, or will the state thumb its nose at the new law and abstain from accepting additional federal healthcare money? Given that the feds would pay 100% of the costs until 2019, not to mention the fact that expanding Medicaid would allow the state to pawn off a great deal of prisoner healthcare costs on the feds, there will be terrific fiscal temptation to accept the subsidies. OTOH, Governor Rick Perry, Attorney General Greg Abbott, and many Republican legislators have staked out extremist positions against Obamacare, and the state could choose to reject the money on principle. That's a bit like cutting off one's nose to spite one's face, since Texas taxpayers would then be in the position of subsidizing healthcare in other states while failing to receive any of the benefits, not just in expanded coverage for free-world Texans but in reduced state prison health costs.

Though the feds will substantially up their subsidies in 2014, covering inmate hospital care through Medicaid is something some states are already doing. Reported, "Dr. Gloria Perry, the chief medical officer for the Mississippi prison system, says her agency heard about the cost-cutting measure from a health care vendor looking for business in the state. The agency then verified the legality of the procedure with the state Medicaid office and quickly created a reimbursement program. No state laws or appropriations were required."

Given the US Senate's filibuster rule, where 60 out of 100 votes are needed to pass legislation, I don't see the federal healthcare law being repealed even if Mitt Romney is elected President and Republicans reclaim the US Senate, despite a great deal of chest pounding to the contrary on the campaign trail. The battle over implementing federal healthcare legislation has now shifted inexorably to the states.

Whether Texas will accept billions in federal subsidies to expand Medicaid as envisioned under Obamacare will be one of the biggest political debates of the 83rd Texas Legislature. And at the end of the day, Grits wonders whether the deciding factor won't be the new law's effect on prisoner health care costs. 

RELATED (6/29): In the Fort Worth Star-Telegram, columnist Bud Kennedy had some kind words to say about this item. "Of all the blog posts and blather Thursday on both sides of the Supreme Court case, one of the most incisive comments came from Austin criminal justice blogger Scott Henson," he wrote, concluding, "I give him credit for thinking before shouting."

Regrettably, though, there was an error in Kennedy's recitation of the effect of Medicaid expansion on state prison healthcare costs. He declared that "the federal government would pick up 90 percent of the state's nearly $500-million-per-year prisoner healthcare costs." In fact, as Grits understands it, the Medicaid expansion would only cover hospital costs for prisoners, not in-prison clinics or other health services delivered on-site. That would still be a quite-large sum, but Medicaid would not cover all prisoner health costs.

According to a state auditor's report (pdf) published in 2011, hospital services account for about $16% of Texas prison health costs - roughly $150 million per biennium. Also, Texas runs its prison pharmacy through UTMB-Galveston's hospital system, but Grits can't tell without more research whether pharmacy costs would be covered by Medicaid under that scenario: It's possible. Notably, Texas underfunded prison healthcare in the current biennium by more than $100 million, so while Medicaid wouldn't pay for all prison health costs, it would plug the state's short term prison health deficit. Otherwise, the only way to reduce prison health costs in the state budget is to reduce the number of people Texas incarcerates.

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Don Dickson said...

I wouldn't think there's a snowball's chance of Texas expanding its Medicaid program. Really?

Gritsforbreakfast said...

If they do, Don, the feds pay 100% of the costs from 2014 to 2019, and 90% of the costs thereafter. Plus, they'd save nine figures in the prison health budget.

Think about the impact of the uninsured on hospital emergency rooms: There will be a lot of constituencies - including some traditionally aligned with Rs - clamoring for taking the federal dollars.

Maybe they won't, but from a fiscal perspective it'd be foolish not to.

Prison Doc said...

I agree with Grits, I think there is not much chance of Obamacare being reversed by Congress--even if a Republican supermajority were elected.

I believe that healthcare under Obamacare will be very much like current prison health care under UTMB-CMC. That is, a broad range of very basic medical services; treatment for chronic conditions with old, well-known (read: cheap) medications. There will be decent care for catastrophic problems such as cancer, HIV, etc. Probably no definitive care for non-urgent, non-life threatening conditions like bum knees and back pain.

Anyone who thinks the government is simply going to pick up the tab for the high quality care that a majority of Americans are accustomed to is probably in for a rude awakening. It is not going to be a windfall for correctional care either--probably worse than the present, with the added bonus of being able to blame the Feds.

Whether or not Medicaid coverage is used for Texas inmates, it is important to remember that Medicaid only covers a small fraction of the costs that physicians and hospitals need to be paid in order to stay in business. That's why most doctors don't want to accept Medicaid. OTOH, considering that UTMB has been laboring with a sub-Medicaid reimbursement rate for years, maybe Medicaid would look like a pot of gold. But I doubt it.

Anonymous said...

Where's the fed going to get the money from for that 100% of the cost?

Hook Em Horns said...

Don Dickson speaks the truth about the political reality that IS the Texas legislature.

Anonymous said...

Why does Grits think that passing the cost of prison care to the Feds in whole or in part will put tax paying Texas ahead? It will still have to paid for. What does it matter to the tax payer if the money is taken from him at the state level or at the federal level. In the end there is no free lunch.

Why is it the argument always seems to center on who will pay rather on how to reduce costs - other then just blindly reducing payroll?

The cost of auditing medical care in the prison system vs the cost of giving that care is one area in which cost could be reduced or at least focused on the actual treatment of patients.

In the battle over the cost of prison health care I have never heard anyone articulate how the cost of the constant auditing effects the bottom line. I have spent many years in correctional nursing and most of those years were spent in a position as a director of nursing at a unit level. In all that time it has amazed me how much manpower, money and time was wasted proving the medical departments at the prison units give good care instead of giving that care.

The special interest groups that are constantly after TDCJ to improve what they are sure is inadequate medical treatment of offenders have no idea that the care they seek to improve is in part undermined by the pressure they bring to bear.

One of the results of their constant badgering is that it forces the legal department of TDCJ to suggest preemptive polices and audits to make sure these polices are being carried out by UTBM. The collective result over the years has been a steady increase in the number of detailed polices and procedures and audits to monitor their compliance.

The problem is the time taken up by these polices and audits demand as many man hours as the actual patient care. Today's climate, (created by the Texas Ledgislature's descision to under fund prison health care), has created a man power shortage at the unit level. This shortage has left the medical staff at the unit level with a descision to make. Spend man power giving real patient care or spend time detailing what care can be given so it can be tracked to prove the care was given in the first place. The audit demands that are made on the units are made worse by the constant bickering that goes on between TDCJ and UTMB as they fight over the contract that they have as yet to come to any agreement on. The effect is that the staff at unit level spends as much or more time proving they give good care as they do giving that care. This situation is far from being cost effective. Right now, (with their new found power of holding the purse strings), Dr. Linthicam and Dr. Williams of TDCJ Medical are responsible for most of the over the top requirements placed on UTMB at the unit level and it's increasing.

Nurseypooh said...

Well said Anon 0558

Anonymous said...

They kept telling us it wasn't a tax. It is a tax. It is the biggest tax in U. S. history.

Anonymous said...

SACRAMENTO, Calif. — Stockton has filed for Chapter 9 protection, making it the largest American city ever to declare bankruptcy.

Stockton is leading the way. This is the model for us all. Just spend whether the money is there or not.

Anonymous said...

Woo Hoo! Free crack for everyone from Obama!!! It's partaaaaaayyy time!

Gritsforbreakfast said...

"What does it matter to the tax payer if the money is taken from him at the state level or at the federal level"

5:58, it doesn't necessarily make a difference to taxpayers like you and me. I PROMISE you it makes a difference to legislative budget writers because the state must balance its budget and the feds can run a deficit.

I'm not saying that's necessarily a good thing, but that's the way it is. All the legislators who want to say they "cut spending" will take every chance they can to pawn off costs on the feds, counties, cities, etc., and pretend it's "savings." Twas ever thus.

Anonymous said...

Unless Obamacare caps the costs of medical costs this will prove to be an exercise in futility.

Medical profession is licking their lips and I would bet they have already have a plan in place to double the price of all their services.

Just look at how much more expensive the cost of service is right now if you have insurance versus walking in an paying all the costs in cash out of pocket.

Surely this is not available to any and everyone who just walks across our borders?

Anonymous said...

@ 8:17..."Surely this is not available to any and everyone who just walks across our borders?"

Yes it will, with or without ID or as some on here like to call it, "papers."

Anonymous said...

Only if he can figure out away to get their vote.

Anonymous said...

@ 8:38...He's already got it figured out. Just like public education, it will be guaranteed under the equal protection clause of the 14th amendment.

Anonymous said...

"The state must balance its budget and the feds can run a deficit."

If enough voters can be bought off by new dollars that the government just prints, then the government will keep printing money no matter the consequence.

If enough voters can be bought off by money we borrow from China, the government will keep borrowing no matter how bad it is for us in the long term.

Gritsforbreakfast said...

Just to clarify some of the absurdist misinformation put out by anons on this string:

8:17, delivering services through Medicaid does cap costs.

8:26, according to Fox News, "Illegal immigrants are not entitled to the new insurance coverage under the law, and will remain one of the biggest groups uninsured."

As for the "largest tax increase in history" schtick, according to Politifact, the tax hike is "smaller than tax increases signed into law by President Ronald Reagan in 1982" as well as four other US tax increases since 1940.

Everybody's entitled to their own opinions, but not their own facts.

texasred said...

Just a small aside in reference to medical insurance, a family member recently demanded an itemized accounting of the charges submitted to the insurance carrier after a short hospital stay...3.25 per aspirin, two dollars per pair for disposable surgical gloves(new pair any time staff entered her room for any reason.). Maybe this burden would not be so heavy if Obamacare put a cap on how deeply ins.companies are allowed to gouge the healthcare providers. Just asking...

Anonymous said...

8:26, according to Fox News, "Illegal immigrants are not entitled to the new insurance coverage under the law, and will remain one of the biggest groups uninsured."

Wait and see ostrich.

Gritsforbreakfast said...

Yeah, 12:09, Fox News really has their head in the sand on the whole immigration question, huh?

Anonymous said...

You keep on believing it. The equal protection clause, just as it did in Plyler v Doe, will trump the notion that illegal aliens don't qualify.

Or does Obama get to pick and choose what they qualidy/don't qualify for? You can't have it both ways.

I say if under the 14th amendment we have to provide education, we have to provide access to healthcare. What's that word; discrimination?

Gritsforbreakfast said...

"You keep on believing it."

If you want anyone NOT to believe it, cite a single documentable source supporting your view, or point to any credible person who says so who's willing to sign their name to their opinion as opposed to anonymously trolling blog comments.

Again, you're entitled to your own opinions, but not your own facts.

Anonymous said...

@ 8:17.....
Surely this is not available to any and everyone who just walks across our borders?

You decide.............

Gritsforbreakfast said...

You realize, don't you 2:45, that people using those clinics DON'T HAVE INSURANCE? So they won't get coverage under Obamacare. Sorry to let reality rain on your pity party.

Anonymous said...

Grits, 2:45 isn't really upset that illegal immigrants might be covered under the Affordable Care Act, since as you pointed out, they won't. And as I'm sure you also know, illegal immigrants got care at federally qualified health clinics under Bush, Clinton, Reagan. Nothing new there. That person is upset merely that illegal immigrants EXIST, and to the extent they still exist after the ACA was ruled constitutional, they'll always be angry. I don't know why you bother responding. I wouldn't have the patience.

Anonymous said...

Obama LIED: Gov Funded Health Centers for 'Migrants' Won't Check Immigration Status

HHS: Obamacare-Funded Health Centers for 'Migrants' Won't Check Immigration Status

Just check:

Anonymous said...

Medicare Fraud: A $60 Billion Crime
By CBS News
September 5, 2010

Of all the problems facing the United States right now, none are more important than health care.

At the center of both issues is Medicare, the government insurance program that provides health care to 46 million elderly and disabled Americans. But it also provides a rich and steady income stream for criminals who are constantly finding new ways to steal a sizable chunk of the half trillion dollars that are paid out each year in Medicare benefits.

In fact, Medicare fraud - estimated now to total about $60 billion a year - has become one of, if not the most profitable, crimes in America.

Medicaid fraud is equally a problem.

Gritsforbreakfast said...

11:53, the people using those clinics are not covered under Obamacare. You're conflating programs you know nothing about and at this point just embarrassing yourself.

12:50, just to be clear the VAST majority of Medicare and Medicaid fraud comes from PROVIDERS, not unauthorized patients. That has scarce little if anything to do with illegal immigration.

Anonymous said...

"Affordable Health Care Act"

How hypocritical can this government be, to suggest this is "affordable" is an absolute joke.
What is the main reason most people in this country don't have private insurance? Money.
So if you can't afford to buy private insurance because you don't have any money to do so, how in the world are you going to pay the "fine" (tax) for not having insurance? Not to mention all of the abortion money this will fund.

Anonymous said...

Big government programs result in increased fraud and theft. They cost x the first year, 2x the second year and 10x the fifth year--count on it.

Jorge Luis said...
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Jorge Luis said...
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Jorge Luis said...

Ok - so the SCOTUS says that the "individual mandate" is a tax, not a penalty or surcharge. Meaning that if individuals choose not to get health insurance, they will pay a fine, levied by the IRS.

Grits, you have been an advocate against the Texas Driver Responsibility Program. So if SCOTUS says that an individual that chooses not to have insurance will be assessed a tax, not a surcharge, does that mean that the Texas DRP is a tax, making it unconstitutional for them to collect? I do not think that the DMV is authorized to charge taxes, right?

Anonymous said...

to·tal·i·tar·i·an[ tō tàllə térree ən ]ADJECTIVE
1. centralized and dictatorial: relating to or operating a centralized government system in which a single party without opposition rules over political, economic, social, and cultural life

I think we're there. We may still have 2 parties in name - but they are essentially one party with 2 factions.