ACO's & MSSP: Berwick's 1994

Dr. Don Berwick spoke to health care leaders and providers on health reform in 1994.  He cited the willy-nilly responses to managed care, including mergers, acquisitions, layoffs, shuffling CEO's, and price cutting, He likened it to an anthill that had been trodden upon, lots of scurrying with an unclear purpose.  Berwick shared:

One CEO said "my overhead is killing me.  I want to improve but don’t have the time.  I've never been so scared in my life."  Underneath confident deal makers, CEO’s who end up on top of mergers have no clue what to do.  This is crazy.  Everybody's running around, but no one knows what to do.  All we know is doing nothing is unacceptable.  We're afraid of being left out. There's never been a time when common sense is so uncommon.

Ironically Berwick heads the Centers for Medicare/Medicaid Services, which implements the current version of health reform.  Managed care has been rebranded Accountable Care Organizations, capitation renamed "bundled payment".  CMS released rules for Accountable Care Organizations, causing heath care leaders and providers to scurry around frantically. 

Huge hospital systems in Texas are talking merger to increase the size and scale of ACO operations.   Health care systems look beyond state lines for merger partners.  As in any corporate combination, layoffs are required to achieve cost savings.

ACO rules are Rube Goldberg complexification.  Medicare's Shared Savings Program leverages one horrific management practice, the splitting of "savings" with a contract group.  I never understood what an organization already being paid to do good work, to manage well, needed another incentive.

Extrinsic motivators work best for simple processes, generally under the control or one person.  They distort behavior in systems that require cooperation.  Incentive programs can drive short term behavior change, but come with cheating and fraud.  Nearly 30% of executives backdated stock option grants over a decade to maximize incentive compensation.

Health care costs need to be cut in a hurry, to legitimize PPACA.  OMB Chief Peter Orszag, an architect of health reform, told the Washington Economic Club he would "throw things against the wall to see what sticks." 

Accountable Care Organizations and Medicare's Shared Savings Programs may stick, with what odor?  What does it mean wihen the feds have to incentivize ACO's to even apply?  Don Berwick once called pay for performance a "toxic daisy chain."  Yet, he combines two bad practices, P4P and shared savings, in one deform effort.

Berwick's pushing this version of anthill scurrying makes it more bizarre.  Health care providers no longer have good work to do.  Just like corporate CEO's, they need complex, inane incentive schemes to do their torturous jobs.  That's the precisely wrong leadership transformation.

Do we have White House Health Czar Nancy Ann Deparle, an ex-private equity underwriter (PEU), to thank for this mess?  Now that Uncle Sam is advancing start up ACO capital, PEU's should have the scent.

"Will they ever learn?"--Dr. W. Edwards Deming

Greed will not save health care.  God help us to remember what we've forgotten.

Update 9-3-12:  Berwick's 1994 resurfaces.

Update 8-6-16:  After years of insanely high health insurance premium increases the public is concerned about affordability, according to several of the highly conflicted people who helped create PPACA.  After reforming healthcare Nancy Ann Deparle returned to private equity as founder of Consonance Capital which specializes in health care.

Update 3-15-18:  Skyhigh healthcare prices differentiate the U.S. from the rest of the world.  Cost curve definitely not bent by PPACA.

Update 9-25-18:   Former UN Secretary General calls U.S. healthcare system morally wrong.

Update 4-16-20:  A coronavirus pandemic revealed America's broken healthcare system and PPACA's many shortcomings. How many  22 million newly unemployed  can afford the premiums?  How many of these will get COVID-19 and die at home without proper care?  

Texas Politicans Produce Medicrud

U.S. Representative Mike Conaway (R-TX) announced at his Health Care Open House that 23% of uninsured Texans qualified for Medicaid but weren't enrolled.  He suggested Texas didn't need national health reform, that existing programs could address a large chunk of the problem.  Despite identifying a glaring need in his district, Conaway never went town to town signing up constituents for coverage. 

The Texas Legislature sees this pool of uninsured Texans as a flock of golden geese.  House Bill 13 wants the federal government to give Texas matching Medicaid funds (FMAP) based on:

A modification to the formula prescribed by federal law for determining this state ’s FMAP to achieve a formula that would produce an FMAP that accounts for and is periodically adjusted to reflect changes in the following factors in this state:
(1) the total population;
(2) the population growth rate; and
(3) the percentage of the population with household incomes below the federal poverty level.

For twelve years the State of Texas mostly sat on its backside regarding its legions of uninsureds.  Now it wants federal money for low income people it hasn't bothered to cover. 

HB13 aims to gain control over Medicaid "disproportionate share" and "upper payment limit" funds.  Fitch Ratings said Shannon Medical Center received $15.5 million in DSH/UPL payments in 2010.  Major tampering with this funding stream could jeopardize Shannon's safety net hospital role for the Concho Valley.  First, who would be covered under the Legislature's alternate methods, which:

(1) provide flexibility to determine Medicaid eligibility categories and income levels; 

I expect Texas, with the highest percent of uninsured citizens, to continue underachieving by setting bare bones eligibility categories and income levels.  The bill will also:

(2) provide flexibility to design Medicaid benefits that meet the demographic, public health, clinical, and cultural needs of this state or regions within this state;

Texas redefined public health in 2000, dropping "access to primary care" as an essential public health service.  How will they redefine other needs to the state Treasury's advantage?

The bill goes on to identify coverage elements under Medicaid's alternative methods.  Low income people can expect:

(3) encourage use of the private health benefits coverage market rather than public benefits systems;
(4)  encourage people who have access to private employer-based health benefits to obtain or maintain those benefits;
(5) create a culture of shared financial responsibility, accountability, and participation in the Medicaid program by:

(A) establishing and enforcing copayment requirements similar to private sector principles for all eligibility groups;
(B)  promoting the use of health savings accounts to influence a culture of individual responsibility; and
(C) promoting the use of vouchers for consumer-directed services in which consumers manage and pay for health-related services provided to them using program vouchers

Ignore that Texas legislators favor private health insurers, responsible for distortions making coverage nearly unaffordable for many.  The above language has local implications.  The City of San Angelo sent 200 people from the ranks of the insured with draconian premium sharing for early retirees and dependents.  Oddly, the City participated in a program encouraging employers to maintain affordable health coverage for early retirees.  The City did the exact opposite.  How would reformed Medicaid "encourage" low paid COSA workers to obtain or maintain health insurance benefits?

Cost sharing mechanisms, copayments, health savings accounts and vouchers, mean more work for Shannon's Business Office.    Recall that Medicaid is already a notoriously poor payor to hospitals.  Add the 8% hospital payment cut in the Texas budget and Medicaid becomes a larger deadbeat.

Reformed Medicaid would have hospitals chasing low income people for copayments and distributions from likely empty HSA's,  Hospitals would compete for low income consumers and their likely measly payment vouchers.

Let's hope the following fable doesn't come true, although it's entirely predictable:

Once upon a time hospitals existed to serve all people, providing high quality health care regardless of ability to pay.  Then the Legislature privatized everything, with pay for performance permeating the system.  Intrinsically motivated organizations and workers found themselves under Rube Goldberg financial complexification, which killed their internal desire to do good work. They eventually said, "You can't pay me enough to deal with this crap." So, they quit or sold out to for-profiteers.

That's when the heart of health care died and was replaced by a mechanical version.  Should the fable come true, be sure to thank the system's deformers, your elected representatives.

Darby Claims Credit for Bone Crushing Budget

Rep. Drew Darby spoke to school funding and the overall budget passed by the Texas Legislature

"I'm going to support it because we have no choice, this is how much money we have, and we have to reallocate the resources within the existing available funds," said Darby, who helped write the budget as a House Appropriations subcommittee chairman.  "The reality is, every part of Texas is having to take a hit."

"The overall budget is down about 8 percent," he said. "We've made almost $15 billion in cuts. I think it reflects priorities. I think we've restored funding in education to a level that is appropriate for right now."

Will Lady Justice pay attention to a Texas Legislature living within its meanness?  Will Medicaid recipients, university students and parents of public school kids line up to vote in the next election?

They'll have a choice, as did this year's Legislature.  Will their priorities align with Rep. Darby's?  Time will tell.

Great Texas Ex-Perryment to Go National?

Texas Governor Rick Perry gave his best "aw shucks" in reference to a possible Presidential bid. Here's the evolution of Perry's thinking on running "Just Say No to Washington, D.C."  Six months ago:

Perry said he would not consider running for president because he had "the best job in the world."

 One week ago Perry focused on cutting health care and firing educators:

When asked earlier this week if he had "ruled out" a bid, he said he would remain focused on the legislative session.

 With the session closing in sight, Perry suddenly became open to a Presidential run:

Gov. Rick Perry has said that he will consider running for president after the state legislative session ends Monday. "I'm going to think about it," Perry said Friday morning

The Texas Legislative session seemed thematically orchestrated to give Perry his conservative bonafides.  He can load up his privatization pack with voter ID, sonogram, bone crushing budget cuts, no new taxes, no rainy day fund, and ride with his gang to Washington.  He needs to get out of Dodge before September 1.  That's when his Great Texas Ex-Perryment officially begins,with its $15 billion hole.

While this has aspects of the Wayback Machine, which gave us a "no fly zone" to reign in a heinous dictator, an unprecedented radiation disaster and the prospect of a government shutdown , it's not the second coming of George W. Bush.  Bush actually worked in a bipartisan fashion during his time as governor.  W. jettisoned it outside the D.C  Beltway.

Perry wants to run the federal government he so readily derides?  Might he use trillions in federal funds to share loot to his friends?  Highly likely. 

Who will ride with Perry, should he get the Republican nomination?  Sweet Sarah Palin, with her rugged Perry-like husband, could ride sidesaddle.  That's be the prettiest pair of gun-totting politico's America has seen in years.  When will America stop offering caricatures for office and run real people?

Update 5-29-11:  Others noticed the Legislative set up for a Perry Presidential run.

Update 6-12-11:  Rumors have Newt Gingrich's campaign staff jumping to the Rick Perry Presidential ship.

Rallo Cites Gift Aid as Recruitment Tool

Angelo State University President Joseph Rallo isn't letting $1 billion in state budget cuts for higher education cloud his vision.  Rallo cited a key recruitment tool in reaching 10,000 students, gift aid.  Money comes courtesy of the Robert G. Carr and Nona K. Carr Scholarship Foundation's corpus of $86 million.

Students will need all the help they can get, considering the Legislature plans to cut Texas scholarships by 30,000 students and ASU's "up to 9.9%" tuition and fee hike.  Fall '10 saw 86.1% of full time undergraduate students receiving any form of financial aid.  ASU's statistics show funding of $16.4 million in state scholarships/grants (includes Texas and all states).  Funding cuts and rising tuition could become a financial storm for some ASU students.

Despite headwinds, Rallo projects student enrollment to be 7,000 this fall, up from 6,155 in Fall 2010.  That's after letting go many professorial extenders, instructors and lecturers.  Fewer educators will teach more students, which translates to larger class sizes, in person and online. ASU's retention rate isn't stellar to begin with.  It's graduation rate is even worse.

A mass move to online teaching frequently brings problems with student engagement and retention. It will be a dicey fall for ASU.  The faculty to student ratio should soar from the advertised 20:1.  ASU may get more students, but how many will stay Rams?

Click on the image below to make it bigger:  The graph shows ASU's retention and graduation rates for the last five years.

Update 6-23-11: ASU's tuition hike came in at the maximum 9.9%

Legislature Cuts Residency Funds for Family Docs

The primary care shortage isn't going away anytime soon, courtesy of the Texas Legislature.  (The projected national shortage is the gap pictured above.)  Texas Tribune reported:

State funding for the family practice residency program will drop more than 70 percent, from $21.2 million in the current biennium to $5.6 million in 2012-13 — a cut of roughly $10,000 per student. The primary care residency program will be zeroed out entirely. These cuts come on top of 10 percent formula funding cuts for medical schools, and Medicaid rate cuts at the hospitals that train these med students.

Both San Angelo hospitals and Esperanza Clinic have struggled at times to add primary care physicians.  Two Texas family practice residency programs closed in the last four years.  Legislators made it more challenging for the Esperanza's of the world to recruit new doctors.

The physician education loan repayment program, which pays the medical school bills of new doctors who agree to practice in underserved communities, is losing 76 percent of its funding — a $17 million hit over the next two years.

San Angelo is finding more water to grow.  Texas plans to have millions more people.  Who will take care of them, insured or uninsured?  The Texas Legislature doesn't care.

Shannon's Exposure to Texas Budget Cuts

Medicaid is taking the biggest hit from the Texas legislature's bone crushing budget cuts.  Hospitals will receive 8% less in funding from Texas Medicaid.  Shannon Medical Center, the area's safety net provider, provides care for people regardless of ability to pay.  Fitch Ratings cited Medicaid as comprising 10.6% of Shannon's patients.  For the year ended 2010 Shannon had roughly $230 million in revenue, with $24.4 million Medicaid related.  An 8% decrease in reimbursement would cost Shannon $2 million over a two year period.The hospital's $4.4 million profit margin would be dinged, but Shannon could survive this cut.

Fitch cited a deeper concern, Shannon's Disproportionate Share (DSH) and Upper Payment Limit (UPL) payments.

Shannon Health System anticipates that a constrained state budget will negatively impact Medicaid reimbursement, and could also impact DSH/UPL payments. SHS received $15.5 million in DSH/UPL payments in fiscal 2010, equating to approximately 4.9% of net patient revenues. SHS's future profitability is extremely vulnerable to changes in state and federal reimbursement methodology given the hospital's exposure to governmental payors.

DSH/UPL payments are funneled through the state for federal matching funds.  Tom Green County Commissioners recently pushed forward $1 million in UPL payments to ensure a higher match. 

The devil is in how Texas cuts DSH/UPL and how much they choke from Washington, D.C.  Let's say those funds are cut a third.  Shannon's two year hit grows from $2 million to $12 million.

Shannon's profit margin of $4.4 million comes after Trust funding of $6.2 million.  A major cut in DSH/UPL could push Shannon Medical Center to shop for a buyer.  For-profit hospitals are salivating over the current environment.  For-profiteers are cold calling and e-mailing hospital CEO's.  The last time health care had such uncertainty, Community Medical Center sold out to Columbia/HCA.  Health reform is back to the future in more ways than one.

The Texas Legislature's budget will have second order effects that could swamp Shannon.  The City of San Angelo sent over 200 people to the ranks of the uninsured from City budget moves.  State cuts could cause thousands of Concho Valley residents to lose health insurance.

ASU communicated with its 767 employees on future job loss, although it's not clear how many positions will be cut through direct layoff or contract non-renewal.  SAISD is playing the same word game.  Both hospitals will likely cut staff due to Medicaid cuts.  Four major employers will drop positions with health insurance benefit.  How many dependents will lose coverage as well?  The spinoff will smack Shannon's payor mix.  Watch "self pays" rise from 8.9% to what, 12%, 15% of patients?  That's another $9 million to $18 million hit.  Will price increases to Shannon's remaining paying patients fill the holes?   Maybe, maybe not.

Throw in beds stacked with patients ready for discharge to a nursing home bed, yet none are available and Shannon's cost per case rises.  Fleeting revenue, costs exploding?  A sickly green storm is brewing over Shannon, courtesy of the Texas Legislature.  I hope Shannon survives as a nonprofit community hospital.

Update 5-24-11:  HCA's provision for doubtful accounts rose to 8.1% of revenue, up from 7.5% a year ago.   A recent SEC filing stated "Same facility uninsured admissions increased 4.7 percent in the first quarter compared to the prior year and comprised 6.5 percent of total admissions compared to 6.3 percent of total admissions in the first quarter of 2010."  PPACA's foot dragging is even hurting For-Profiteers.  HCA's investor presentation cites low unemployment in their hospital service areas and an improving acquisition environment.

Texas Legislature to Live within its Meanness

The Texas Legislature agreed upon a $80.6 billion two year budget, a decrease of $15 billion from the amount spent in the last budget cycle. NECN reported:

Hospitals will see their reimbursement rates for Medicaid patients cut 8 percent, early childhood intervention will lose $40 million and the Federal Women's Health Program will be eliminated.

Lawmakers have also slashed programs to make sure the state is prepared for natural disaster or epidemics and funding for HIV and sexually transmitted disease prevention, while abstinence education remains fully funded. Chronic disease prevention has been cut more than 50 percent and family planning funding may be cut 80 percent, according the budget board documents.

To pay for the programs that are left, the Legislature has made it a priority to capture the maximum number of federal dollars while spending as few state dollars as possible.

The Texas legislature loves federal money.  They've lived off supplemental federal Medicaid funding under Obama's Stimulus Bill.  Texas Governor Rick Perry did not say "No to Washington," taking the raised federal percent, 78% for two years.  It's gone, thus Texas will only get 60% in federal Medicaid funding.

Gov. Perry, an expert at accounting gimmicks, will get a bill that puts off the projected Medicaid shortfall to January 2013, when the Legislature reconvenes. The legislature has a hold on any spending bills the first month of the session.  Will Shannon Medical Center survive until February 2013 as an independent safety net hospital?  Even with the ample resources of The Shannon Trust, the hospital could easily be in jeopardy.

The last time our country faced a health care upheaval (over managed care), San Angelo Community Medical Center sold out to Columbia/HCA.  It was spun off to Triad Hospitals, which later was acquired by Community Health Systems.  Does Shannon Medical Center face a similar for-profit future?  Time will tell.

The title of this piece came from a poll on the Texas Legislature's bone crushing cuts.  "Live within its Meanness" came in second.  The winner:  "Medicaid recipients don't vote, not a one."

It seems other state legislators noticed.  (The image above can be seen here)

Update 5-24-11:  The Dallas Morning News used the "mean" theme to describe the budget deal.

Rick Perry Knows Accounting Gimmicks

Texas Governor Rick Perry knows accounting tricks, despite his call to forego financial manipulations.  The Texas Tribune reported:

Gov. Rick Perry sent out a press release that stated he is against using any kind of "accounting gimmicks" to balance the budget. 

Perry used funny numbers to justify Vought Aircraft Industries receipt of $35 million from his Texas Enterprise Fund.

State of Texas grant monies

$35.0 million

Vought promised 3,000 new jobs for Texans by 2010.  When that date arrived, Vought hadn't added any jobs.  It cut 35 positions, $1 million in Texas taxpayer subsidy per job eliminated.

Using economic impact gimmicks, Perry claims Vought provided 29,377 jobs for Texans, when Vought reported 3,315 Texas jobs.  His office overstated reality by 25,992 jobs.  When in trouble change the metric or lie like hell.  Rick Perry did both.

Gov. Perry secretly renegotiated the Vought deal, while under the ownership of The Carlyle Group, a politically connected private equity underwriter (PEU).  Vought booked a refund of $2.1 million liability relative to the grant.  It paid $900,000, courtesy of the Governor's largess.

Triumph's financial statements are opaque on the Texas grant.  However, two items likely refer to the TEF grant:

Repayment of governmental grant

-----($1,695,000)

)

Deferred grant income

--------$31,417,000

Carlyle/Vought had $35 million in Texas taxpayer money for six years and added not one job. Triumph/Vought purchased the liability from Carlyle, which aims to cash in via a 2.5 million share public offering at $92.75 a share. Carlyle's $232 million in proceeds is more than enough to make Texas taxpayers whole. Yet, they'll pay up when Rick Perry gives an honest accounting. Likely, never.

Update 6-1-11: The Legislature tightened Perry's two corporate slush funds. They gave him nearly $300 million to work with in 2012, Perry's likely Presidential year. 

Rallo Reinstates Honors Program

“A strong honors experience at ASU remains an important aspect of our academic strategic planning process."--Dr. Joe Rallo, President-Angelo State

In other words, ignore leadership's recent tire squealing, smoke-belching skid and 180 degree turn. Three novice VP's obviously had no appreciation for ASU's strong honor. 

Speaking out makes a difference, according to Rallo.

I have been approached by several individuals who have expressed keen interest in helping to support and sustain an honors experience at the university.

Dr. Rallo didn't give credence to the many students, faculty and community members who spoke out on behalf of the program or dissected leadership's logic (or lack thereof).  I have to believe some offered support, or threatened to remove existing support, based on the passionate reaction of people involved.

The end result:  the program is saved, until August.

“The Honors Program, including its curriculum, scholarships, staffing and physical location, will be immediately reinstated.”

I wonder how many staffers and students ASU lost in the period of management indecision?  It remains to be seen what Honors "looks like" come Fall.

Update 5-8-12:  ASU's Rampage gave an update on the Honors Program   President Rallo stated "There were very few real honors classes, [but] mostly research.  Research is good, but that's not what the Honors Program is all about."  Later the article offered,  "Rallo said the Board of Regents approved $1 per student-credit-hour per student, which will pay for undergraduate research opportunities for all students on campus who choose to engage in research.  The money will be administered by the Honors director, but will benefit everyone."

ASU Officially "Torching Tomorrow"

The State of the Division poll closed on ASU's restructured motto, just as Dr. Rallo hit the airwaves on expected budget cuts. There is a remarkable degree of alignment on the impact of the Texas Legislature.  Poll results show:

ASU will leap over "Torching Tomorrow," moving to "From Here, It's Possible."  Only "here" is somewhere in the digital universe.  "From hell, it's digital."

ASU's Rallo: "Too Early" to Weigh in on Guns in Classrooms

The Texas Senate moved concealed weapons closer to college classrooms.  The bill would allow concealed handgun license holders to carry weapons into public college buildings.  ASU President Rallo sashayed away from a firm position.  GoSanAngelo reported:

Angelo State University President Joseph Rallo said it's too early to take a position, but points out that the bill still has hurdles to clear before becoming law and may change in the process or face other obstacles.

"As a public university, we will do whatever the Legislature says," Rallo said in a phone interview Monday.

Too early?  There are only three weeks left in the session.  It's darn near too late.

Rallo implied he would weigh in after hearing from students.

Joseph Rallo, ASU's president, declined to offer his personal position on the issue at this point, noting that it was an "evolving process."

"Every campus in Texas is basically asking the same question, and that is 'What is the student perspective?'"

Students spoke loud and clear.

In the third poll on the issue, 67.4 percent of ASU students chose to not allow concealed handguns on campus. 

ASU's police chief is against the bill.  Rep. Darby will receive ASU student feedback and then make up his mind.  I thought Rallo would eventually take a stand, but that's looking doubtful. 

There are only three weeks left in the Legislative session.  Typically, its finals days are an orgy of bill passing, where many things are concealed.

Earlier on Monday, senators voted to allow themselves to carry concealed handguns into places the rest of the public cannot, such as churches, restaurants and sporting events.

Who thought America would have different laws for the ruling class?  It's Texecutive Privilege.

Poll's Open on Texas Budget

The Texas budget for 2012-13 is much worse than "bare bones."  The Senate version is bone breaking and the House's limb separating, which leads to our latest poll:.

Why will the Texas legislature impose bone crushing budget cuts?.

1.  To live within their meanness.
2.  Have to wait for a real rainy day to use the Rainy Day Fund
3.  It's an actual scorched earth budget, not an exercise.
4.  Disruption creates opportunity, especially for donors.
5.  Medicaid recipients don't vote, not a one

To participate look for the box to the right of this blog's latest post.  You may choose more than one answer.  As always, pray for rain. 

House Budget Cuts for West Texas

House budget cuts for Rep. Drew Darby's District 72 total $135 million. Here's the projected breakdown:

Cuts to Medicaid comprise 75% of the total in District 72.

. . Total cuts (millions $) 135 . Medicaid 102.3 . Public School 19.3 . ASU 11.9 . Howard College 1.5

District 72 consists of four counties, Coke, Mitchell, Scurry and Tom Green. The four counties have 18 school districts, five hospitals and numerous nursing homes.  In addition ot ASU and Howard, Darby represents Western Texas College in Snyder.  WTC is slated to lose $500,000 in prior funding.

Given Tom Green County's status as the trade center for the Concho Valley, Darby's focus should be broader than District 72.  However, he is directly accountable to voters in those four counties.  Come September Darby will no longer represent Mitchell and Scurry.  He'll retain Tom Green and Coke, adding Concho, Runnels, Glasscock, Howard, Irion, Reagan and Sterling counties.

The Texas Senate passed a bone crushing budget vs. the House's limb severing version. The two chambers will reconcile the bills. The final product will spread lots of pain, directly and indirectly. Let's hope it's not the memory destroying kind.  Voters, especially those impact by the jobs decimator,  need to recall who spoke out and who remained silent.

What if QEP Studied Texas Budget Cuts?

Angelo State University's Quality Enhancement Program (QEP) will focus on "community-engaged active learning," a process that involves involves students, faculty, staff, administration and community members in learning

What if ASU students and faculty worked hand in hand with the community to assess the impact of state budget cuts?  The timing is good, given QEP's embarking on two years of research this fall.  That's when Texas budget cuts, anywhere from bone breaking to limb separating, will begin.

Students and faculty could work alongside nursing home, hospital, and clinic staff to see the impact of Medicaid budget cuts on citizens and providers.  They could track MHMR's efforts to meet growing demand with dwindling resources. They could watch and record as employers and the state walk away from health insurance commitments, while the federal government drags its knuckles until 2014.

Students could help the City of San Angelo file for federal ERRP reimbursement, thereby preventing another round of 34 to 58% health insurance premium increases for employee/retiree dependents.  They could ask City Council why there has never been a public presentation on ERRP, even though the city qualified for the program in August 2010.

ASU students could monitor the impact of the job decimator on the Concho Valley.  When people lose employment, they lose benefits like health insurance.  Job elimination isn't the only method of growing the area's uninsureds.  The City of San Angelo drove nearly 200 people from health insurance rolls via unbearable premium sharing.  How many more will lose coverage at ASU, SAISD, Shannon Medical Center, San Angelo Community Medical Center and beyond, either through job loss or making insurance unaffordable?  The number could easily be in the thousands, adding a double punch of misery to safety net providers.. 

Might students get a straight answer to questions, like:  Why wouldn't City Council use a portion of projected ERRP funding to meet commitments to early retirees?  Why won't the Texas legislature fundamentally address the state's health insurance crisis, now a decade old?  Instead, it will exacerbate it, growing our legions of uninsureds.  

Would knowledgeable students and faculty remain "responsible citizens" if they challenged elected or local leaders?  ASU leaders' response to state budget cuts indicate the only appropriate question for students is:  "Thank you, sir.  Can I have another one?"  It might help students' chances of gainful employment.

Use theory, study something...  Will it be for justice or "just us?"

Texas Senate Budget Cuts: Majority to Come from Medicaid

The Senate passed its budget bill with $11 billion in cuts from the current biennium.  Over $6.6 billion or 60% will come from Medicaid.

It's up to a joint committee to find a compromise between the House and Senate versions.  It means pain to Concho Valley health care providers accepting Medicaid.  The question is how much?  Rep. Drew Darby's House guts $115 million, while Senator Duncan's body slashes over $55 million. 

Medicaid comprises 11.5% of Shannon Medical Center's payor mix, according to Fitch Ratings.  Representative Mike Conaway's handout at his 2009 health care "open house" stated 23% of those without health coverage qualified for Medicaid, but weren't enrolled.  Conaway never led a town to town barnstorming tour to sign his constituents up for Medicaid.  The Legislature's cutting Medicaid will stress local safety net providers, maybe to the point of breaking.  Sellout, that's one local angle.