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Truchas, NM
Truchas, NM
I am director of a rural Health and Human Services in northern New Mexico; as such, I am at the front (and, geographically speaking, frontier) lines of ACA implementation.

I am tasked with simultaneously working with the state of New Mexico to successfully implement ObamaCare in our community, and standing up to them to make sure it is implemented in a manner that respects and benefits the people of our largely, pre-Mexican-American War Hispanic County.

While implementation of a new law is a policy issue, the ACA has been politicized. And, as Tip O'Neil pointed out, all politics, even the self-inflicted kind, are local.

New Mexico Sky

New Mexico's Purplish Sky

New Mexico's issues don't fit neatly into Washington memes. There is no off-ramp leading here from the information highway. And, there is a slightly purple tint to our otherwise blue mountain sky.

Medicaid Expansion in New Mexico

La Tierra Montessori School
Children at La Tierra Montessori School
New Mexico's  Governor, Susana Martinez, is an up and coming star in the Republican party. But because New Mexico, a primarily Democratic state,  is surpassed only by Texas in rates of uninsured, has more hungry children than any state in the Union, and because we have a long tradition of caring for our vecinos, rejection of Medicaid expansion was never politically viable.

Health Care Reform was always acceptable to New Mexicans. Health Care is the single largest sector of our local economy in the agricultural north, accounting for 25% of all wages in my community. Fifteen years ago, when I conducted our first-ever countywide health assessment, I learned that people in our mountain hamlets love their rural health clinics, which often serve simultaneously as community center, library, care provider and sole source of local employment.

When the SCOTUS ruled Medicaid expansion voluntary on the part of states, many of the deepest red Deep South states opted out, stranding two-thirds of the nation's poor blacks, and more than half of all low-wage workers without insurance, according to the New York Times.

All of the southern states with the exception of Arkansas rejected expansion. About half of the nation's poor Hispanics will be insured through the ACA. Many of those that won't live in Texas. Because much of Martinez' campaign financing originated in Texas, political commentators speculated Martinez would be pressured by benefactors to opt out as well.

This is not New Mexico's political reality.

But New Mexico is not a Medicaid utopia either. For the past two decades, beginning with Republican Governor Gary Johnson, worsening dramatically under the Democratic administration of Bill Richardson, and continuing under Martinez, New Mexico has heavily favored privatization.

Governor Bill Richardson's administration became infamous for "Pay to Play" schemes, awarding lucrative state contracts to campaign donors. Martinez rode into the Governor's mansion on a wave of anger at Pay to Play.

Yet Martinez also favors privatization of New Mexico's resources. She is using the implementation of the ACA as an excuse to award millions in resources to MCOs and other out-of-state entities.

With the exception of its top officers, the bureaucrats in New Mexico's Human Services Department (NM HSD) are not politicians. Most of them are lifelong public servants trying their best to bring healthcare to New Mexicans regardless of the shifting (and possibly irrelevant) patina of our sky.

A Colonized Economy?

Centennial Care Outreach Event
Centennial Care Outreach Event, Española NM
NM HSD has held several outreach events in my facility, all packed to capacity. Last Friday evening at four, the worst possible time for a public meeting, more than sixty people braved the rain to learn how to sign up. We had only expected twenty.  

As with any law, the angel and devil of the Affordable Care Act reside in the interpretation of its details. A bevy of lawyers appear to have found ways to exploit a few passages of the bill to aggressively expand privatization of New Mexico's delivery system.  Because New Mexico is less than transparent, it will be a challenge to ensure that Medicaid expansion moneys fund the actual delivery of services, and not just overhead for Managed Care Organizations (MCOs). This partially subverts the intent of the ACA, which requires large pool insurance companies (those that insure employers with 200 or more workers) to dedicate at least 85% of revenues to provision of actual services or return profit to beneficiaries in the form of a check.

It will be even more of a challenge to protect the ability of local governments and communities to determine what kind of services will be made available to them under Centennial Care, New Mexico's roll-out of the ACA.

One bi-partisan feature of the ACA is language inserted by Senator Charles Grassley (R-IA) forcing non-profit hospitals to work with local public health stakeholders to define  "community benefit," or charity care that the hospital must financially support to retain its non-profit status with the IRS. This clause was added to the ACA to prevent hospitals from defining overbilling as "unreimbursed," and thus "charity" care. It was also included to force them to work with local government and other stakeholders to strengthen the local safety net. This clause is not especially popular with Hospital Associations.

New Mexico's fiscal slight of hand should not be understood as an effort by a Republican governor to sabotage the implementation of the ACA. It is an attempt by an ambitious governor to both please voters, and insure that New Mexico's implementation of the ACA conforms to her national party's philosophy of small government to the greatest extent possible.

Where the Horseshoes Meet the Road

I have three specific areas of concern:

Sidonie Squier
1) In a surprise move a few months ago, after an audit by a Massachusetts firm called Public Consulting Group (PCG), NM HSD Secretary Sidonie Squier suddenly halted Medicaid payment to 15 providers of behavioral health services (responsible for 95% of behavioral health services in NM). PCG claimed to have found $36 million in overpayments by the state.

Asserting "credible allegations of fraud," and "a culture of corruption in New Mexico," Squier, who is from Florida and has only lived in New Mexico for a short time, used a clause in the ACA to suspend due process for the providers and justify what NM State Senator Linda Lopez referred to as a state-engineered "hostile takeover" of twelve of the agencies.  

Five Arizona firms have since been contracted to replace upper management of the NM non-profits at a cost of $17.8 million for six months in public funds. This is in addition to the $40 million per year already being paid to Optum Health NM, an out-of-state MCO under the umbrella of United Health Care, to oversee behavioral health delivery (which presumably includes as a duty the prevention of over-billing). Many line staff of the NM non-profits were terminated when Medicaid funding was cut off, and then hired by the Arizona organizations. The new organizations will conduct a review in three months.

Nobody other than Attorney General Gary King, and State Auditor, Hector Balderas, have been able to view the audit (the latter after a court battle). Balderas has called the audit deficient. State Senator Dede Feldman published an excellent overview of the entire mess (including an aneurysm suffered by an irate legislator while questioning Squier) here.

PCG was at the heart of a similarly dubious imbroglio in North Carolina. After a state auditor's audit of the North Carolina PCG Medicaid audit, only 10% of PCG's claims were substantiated.

While it is extremely important to investigate fraud, there is a normal due process that was ignored, creating precedent in the future for hostile takeover of any non-profit in New Mexico without recourse.  

Oddly, staff at New Mexico's HSD  seems surprised by the public outcry.

2) The NM HSD has announced a new plan to intercept the current county gross receipts tax dedicated to health care, removing counties' abilities to influence hospitals to provide appropriate local care, and leaving huge holes in county budgets. Private out-of-state MCO's would replace locally elected counties as the sole arbiters of services deemed locally appropriate.

At the same time, another bill has been introduced allowing counties to levy other taxes to make up for loss of revenue. The Governor is intercepting a locally imposed tax and then "allowing" counties to impose a new tax and thereby incur the anger of the voters on her behalf.

What's to prevent her from intercepting a new tax, too?

Counties are obligated to provide care to inmates by the Constitution, which forbids cruel and unusual punishment. Many counties also provide ambulance and other services through this tax. In a recent presentation to our County Commissioners, the HSD Deputy Secretary called his proposal a "windfall" for counties, but, when pressed to more fully explain his math, could not. He promised to get back to the Commissioners later with answers.

They're still waiting.

Counties have long been concerned about the opacity of HSD management of Sole Community Provider funds. The current proposal makes the funding pool even harder to scrutinize. Because it bases payment to hospitals on services rendered to MCOs rather than on the amount provided to the state by counties, it leaves open the possibility that a tax levied by local voters to support a local hospital will be diverted to another community entirely.

Needless to say, my board of commissioners remains skeptical.

3) The enrollment process for the newly implemented expansion (Centennial Care) is incredibly complex and filled with opportunities for confusion. This is not a case of anyone attempting to award lucrative contracts out of state under suspicious circumstances. It is simply a reflection of the complexity of the system and short timeline left for its implementation.

Of course, I am going to do my best to get people enrolled in New Mexico's version of the Affordable Care Act as quickly as I can. But I also intend to work to make its implementation beneficial to actual New Mexico tax-payers.

This is New Mexico.

It is not New Arizona. Yet.

Originally posted to TheFatLadySings on Mon Oct 07, 2013 at 09:11 AM PDT.

Also republished by New Mexico Kossaks.

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