More on New York and Medicaid

Following up on the last post, which got heavily side tracked about two minutes into writing it requiring a change of course, this post is on what I originally intended to discuss.

First home home care:

Care delivered at home by health aides trained to handle minor medical tasks grew by 90 percent per recipient from 2003 to 2009, to reach more than $15,500 a year. Personal services delivered by nonmedical attendants, such as assistance with dressing and bathing, grew by 38 percent, to reach almost $30,000 a year. Right now this care is mostly delivered on a fee-for-service basis with hours of care determined primarily by the providers who have an incentive to run up the bill with more and more services.

 If I was at work I'd have an excellent article to quote from on this, however I don't have it so this will be more general.  An issue I have with this is that there is a huge discrepancy between these kind of benefits through most of the state and these benefits in New York City.  The article I alluded to looked at 24 hour nursing care in the rest of the state compared to New York City, New York City had more than a magnitude difference in proportion of people receiving 24 hour nursing care relative to population compared to the rest of the state.

There is of course a good reason for part of this, care in facilities is higher in New York City than in the rest of the state so there is a larger group where the marginal cost of providing 24 hour care is still lower than the cost of care in a facility.  Still, this doesn't explain the entire discrepancy by a long shot.  So an examination of how these programs are run could easily find savings to be had by simply making the local bureaucracies adhere to in state best practices (though it should be noted that areas in the rest of the state would probably benefit by providing 24 hour care more frequently since this would often be cheaper than institutional care, savings can be had on both ends).

The Market and Health Insurance Sales Across State Lines

The New York Times this morning had a short piece on New York Medicaid cuts.  It's a decent overview, there are just a few bits I'd like to add my 2 cents to.  This post is a bit of a tangent, it deals with a concrete reason for why I oppose cross state sales of health insurance, given current institutions.  New York is the state with the most generous state health benefits so it provides an excellent example for how an integrated market forces democratic decision making up to the national level because decision making done at the state level imposes decisions made in one state on others, which is arbitrary and undemocratic from the point of view of the other 49 states.

To frame this, the high cost of long term care in New York, and that mental illness is a portion of this.

In 2009, the latest year with audited data, New York covered more than 300,000 patients — the elderly, chronically ill, patients with mental illness, substance abuse and other difficult problems — at a cost of $23.1 billion or almost half of the state’s total Medicaid spending that year.

And this is essentially why I'm opposed to cross state sales of health insurance.  New York has chosen to be the most generous state in the nation as far as medical benefits go. Whether or not any individual agrees with this, it is our democratically chosen decision.  As a result of this, mental health parity laws are a very big deal here, they mean that private insurers pick up some of the tab for those patients with mental illness rather than the state, without this those with expensive conditions would fall back on the state for benefits while private companies only paid for the cheap stuff (or at least for this one condition, though this could be extended to other areas of health care New York is generous in).  Many states do not have mental health parity laws and their private health plans offer little, if any, benefits to patients with mental illness, which results in throwing them back on state services. 

Letting insurance be sold across state lines would pose major problems to a state like New York.  Maintaining the level of services to the mentally ill that we currently provide would become far more difficult if people started opting for HSAs that were cheaper in states without mental health parity and then developing schizophrenia in their 20s or 30s (I'm choosing mental health for this topic because the population it impacts is the one most likely to opt for inexpensive health insurance with minimal coverage, which is problematic because it's also one of the most expensive long term conditions).  This isn't so costly for those states that give less benefits, for us, it would put additional strain on our mental health system, which is already under substantial strain with or without the budget crisis.

We Won't Imprison People Just to Give Jobs to a Few

Andrew Cuomo's speech today had several bits that I quite liked, we'll see how much of it comes to past.  Overall, what impressed me the most was that Cuomo is representative of the essentials of Progressivism, an emphasis on professionalizing and reforming government and rationalizing state policy.

What excited me the most was when he talked about the juvenile detention system.  Once I find the full text I'll update this with an exact quote, the gist of it was that we have to stop imprisoning people just so that some people have jobs.  Political constituencies in favor of a tough on crime approach are very powerful however, I'm worried that we're going to see the closure of a handful of the most egregious facilities without the broad overhaul that we need, I'm hopeful but recognize the political reality of the strength of the rural areas dependent on these facilities.  His plans to streamline government also make me hopeful, many of our institutions are antiquated and need serious rebuilding, the civil service system not least of all.

What worries me is the anti-tax rhetoric.  The reality is that reorganization takes a great deal of money and investment up front to work, although it saves huge amounts down the road.  Investing today for the long term can save a great deal of money but this requires more money today, which I don't see how we can get without temporary tax raises or a budget windfall from divesting unnecessary assets, all of which I believe New York has already divested itself of simply to meet operating expenses in previous years.  Reorganization is going to mean buying people off with earlier settlements, temporary contracting, investment in new infrastructure, particularly computers, etc.  We'll see what happens but I'm worried Cuomo's plans will be defeated because of his promise to cap taxes, I simply can't figure out where the money for restructuring is going to come from if not taxation.

Also, I thought it was really funny that all the bragging about the biggest use of technology ever in a state of the state speech amounted to a bunch of Power Point slides.  Though the one about ships passing in the night, with the Governor's, House Speaker's, and Senate Speaker's heads visible on them, pretty funny.

Randomized Trials and Social Assitance

The NY Times has a very interesting article on how New York City is using randomized trials and follow up to discover whether the Homebase program is fulfilling its goal of keeping people out of shelters.  There's a lot of opposition to this, which would make sense if the program had previously approved everyone.  However, this isn't the case.  The program already had a limited budget and had to refuse people.  What's different now is that some good is coming of this, we're becoming more able to assess a program's success which should improve homelessness prevention programs in the future.  I do of course understand the emotional aspect making people angry which happens when there is a change in the programs.  But is it really any better to be denied because of an opaque bureaucratic process than it is to be denied because of a lottery understood beforehand?  When you get past the emotion, that seems to be what the two options are, opaque bureacracy or lottery.  The lottery has the added advantage of being able to assess the program.

We need more of this if we're going to trim government effectively and make government better able to fulfill its goals.  I do need to add a note of caution however.   Since there are many different programs out there to combat homelessness to assess things correctly this has to be done one program at a time.  While I don't think there will be a big rush to do more of these studies, especially when the emotional response is considered, since good government movements sometimes come in waves I feel the need to note in advance that if people are bouncing from program to program getting denied as a result of randomized trials you're just going to mess up the results of all the tests.  I know the bureaucracy understands this, I'm less sure about politicians.

A Positive Interfaith Message On a Subject That Has So Far Inspired Little but Acrimony

I'm sick of the topic of the mosque too.  Still, there's been so much negativity surrounding the issue that I was glad to see a positive message on the topic that makes no mention of the negativity.  I thought I'd share with those that haven't come across it independently.

Message from the New York State Council of Churches:

The New York State Council of Churches, which represents Protestant denominations with more than 6,000 congregations in New York State, released a statement today supporting the planned Community Center at 51 Park Place in Manhattan. The Council also voiced support of Imam Feisal Abdul Rauf, whom they characterize as “a religious leader allied with the best of both our traditions,” who has “repeatedly denounced Islamist terrorism and has admonished members of his congregation to be, both good Americans and good Muslims.”


The Council pointed to the planned Park51 Community Center as an opportunity for America to demonstrate to the world that it stands up for its principles of religious freedom.

Pointing out that those “seeking to build The Community Center at Park51 in lower Manhattan lost family members in the September 11th tragedy also,” the Council praised the project as “a tribute to the American way of life,” in that “those whose faith is often blamed for the sins of extremists that happen to claim the same religious label, wish to turn this place into one that is life-giving for the community. Bringing life to an area still physically and economically depressed by the events of nine years ago will show extremists that the spirit they sought to eradicate still thrives and that new vitality will grow here.”

[Hat Tip: Capitol Confidential]

We Need This Article For Every State

The advantage of living in NY state is that you have a paper like the NY Times that can publish your foibles for everyone to see. I wish it had more effect but I'd guess in many states few people even have the opportunities to read articles detailing some of the bad bills going through their state legislature, unless those people are in the increasingly small segment that doesn't get their news online and reads their local paper closely. Here in NY, we at least don't have the excuse that the information is too hard to get.

It does make me that much more sceptical that information matters in public policy though since we're so exceptionally dysfunctional. The increased scrutiny hasn't led to any particularly postive impacts that I can detect.