The Delta of Spitzer
Only hitch: the $6.9 billion price tag. Weld suggested he'll pay for it by laying off public employees and tossing people off Medicaid.
This should, actually, be the substantive heart of the race for Governor, a job which is largely about steering huge rivers of money here and there. Tom Suozzi got a bit tangled up on NY1 last night when asked about what he would cut to reduce property taxes. (He, too, picked a big Medicaid number, and promised to explain more soon.)
And Eliot Spitzer, who downplays the easy savings from Medicaid, seems to think that he can find money on the margins. In Long Island earlier this year, he told an argument that money for cutting taxes or new spending would come from the "delta" (in the mathematical sense) between the natural increase in state revenues (natural, as long as the economy is good) and the ideally-less-rapid grown in costs.
That's at best a narrow little fiscal raft, freighted with quite a lot.
(If you want some great comparative numbers on New York State's spending, Larry Littlefield has the data, with charts, in his lesser-known online reference classic straightorwardly titled State and Local Government Taxes, Spending, Debt, Employment and Average Pay in New York City, Other Parts of New York State, and Other States: Comprehensive, Comparative Data From the Census of Governments. Great data, very clearly presented, if a couple of years old.)
the reality is that dennis rivera stopped george pataki from cutting medicaid...so weld, suozzi and spitzer dont stand a chance...compared to a 12 yr governor who couldnt get the job done.
Littlefield's stuff is great. I've seen it before. I hope he can update it at some point - I'd like to see the trends over the last few years.
Those who feel that you can find simple answers to our problems are living in a dream world. There are no simple answers, just simple people.
I have data compiled in spreadsheets from the 2002 census of governments, along with Medicaid data from the same year, but have nowhere to post it easily.
If you want it, e-mail me at vampire-state@att.net and put "census of governments" data in the title to distinguish it from spam, and I'll send it. Be sure you read the Taub piece, however, as it explains where it comes from and how it is compiled. But I'm warning you, the more data you see, the crankier you get.
We have to take a long hard look at Medicaid, but eliminating fraud and abuse aren't going to make much of a dent.
New York with 7% of the US population spends 15% of the Medicaid dollars. Largely, this is due to superb benefits. New York medicaidf has a virtually open drug formulary and very few limits on care. The care, int turn, is provided by the best doctors and facilities in the world. New York City trains something like 20% of the inerns/residents in the US. Medicaid hospital reimbursement formulas pay for a large portion of these academic programs and facilities.
In exchange for investing heavily in healthcare resources that benefit the US as awhole, Larry Littlefield points out that New York receives one of the least generous federal offsets in percentage terms in the country.
The point is that New York has made a noble commitment to healthcare for the impoverished and all New York residents receive much higher quality healthcare as a result of Medicaid spending. This is true progress.
There is no free lunch. Reduce medicaid spending and there will be higher private insurance premiums, less free care for the uninsured and lower overall healthcare quality in New York state.
"New York has made a noble commitment to healthcare for the impoverished."
Actually, New York's share of national Medicaid recipients is in line with its share of poor people. We don't cover more of the uninsured. If anyone is more likely to be served here, it is the middle-class elderly -- New York State's share of home health care and personal care expenditures is sky-high, and much of this is in New York City.
"and all New York residents receive much higher quality healthcare as a result of Medicaid spending."
If the healthcare industry is using higher Medicaid premiums to keep down private insurance premiums for CEOs, is that fair? And might the addtional funds just go for more inefficiency, or higher administrative salaries?
The health care industry has so much power in New York that not only do we not have the answers, we don't even dare to ask the questions.
While I agree that the federal matching formula is unfair to New York since it does not account for the state's high poverty rate, a lot of this spending is very hard to justify. And I say this as someone who would favor a national health care financing system to meet everyone's basic needs. We're getting robbed. And most of it isn't fraud, it's state policy.
larry-- This reasoning doesn't explain why New York spends more per capita. It also doesn't explain why a state like Massachusetts spends less per capita, but covers proportionally more elderly than in New York. Boston is not a cheap town, and there is certainly no dearth of teaching hospitals there.
(It also doesn't explain why a state like Massachusetts spends less per capita, but covers proportionally more elderly than in New York.)
The data is at home, but I believe NY covers more elderly than anyone.
Particularly notable is the very high share of the nation's home health care and personal care spending, despite an above average share (even when higher costs are considered) of nursing home spending. In other words, sky high spending on non-institutional care did not save on institutional care.
New York's dual eligibles (Medicare and Medicaid) do add a lot to our Medicaid expenditures, but I cannot imagine that there is the political will to start reducing the number of elderly on the rolls, their higher incomes notwithstanding.
Again, there isn't much to cut without seriously scaling back a successful and popular program.
I agree with Larry Littlefield that 1199 and the healthcare business has appropriated a large part of the state budget, but I do not think this is being consumed by inefficiency and administration. It's being consumed by a lot of old, sick people who recive a lot of high quality, but expensive healthcare.
(It's being consumed by a lot of old, sick people who recive a lot of high quality, but expensive healthcare.)
If we were merely spending more than Alabama (or California, whose spending may be too low) I'd agree with you. But we are off the charts compared with Mass, NJ, CT, PA and VT in spending per recipient. Are the old and the sick suffering there? Nor does NYS receive high marks for care quality.
And I can't help but think NYC's high share of the state's home health care and personal care expenditures, and low share of state school aid, has to do with the fact that in 1990 70 percent of those over 65 were non-Hispanic whites and 70 percent of those under 18 were not.
Just because it is the national average doesn't make it right, but whenever one category of expenditure is so far out of whack in either direction, that has to be justified by more than an assertion -- backed by an army of PR professionals. Really, while many if not most health care professionals may be good, I think the NY industry has been evil in its "take more and more off the top and damn the consequences for others" attitude toward the state budget. When you are grabbing more, and taxes and debts are already the highest, take responsibility for others having less.
I am certainly not defending the NYS healthcare establishment. They have made one cynical money-grab after another. I just don't see an easy answer. I don't see a good way to "starve the beast" without changing eligibility or benefit levels. I have not heard any candidate talk about taking on 1199, VNS, GNYHA or HANYS (big healthcare organizations) by substantivel changing reimbursement formulas, and I don't think we will.
I have a great deal of sympathy for your proposal to ration medicaid-provided skilled nursing facility care. We can agree that there is a serious moral hazard problem here as indicated by the paltry percentage of NYS residents carrying LTC insurance.
I take issue with the reimbursement reduction proposal. In your anti-price discrimination argument, you seem to at least implicitly acknowledge that private third party payers reimburse at levels above those of medicaid and medicare. If private reimbursement approaches competitive levels, where is the room for accross-the-board reductions in medicaid reimbursement? You always hear about cost shifting to private payers due to underreimbursement by medicaid and medicare. Doesn't your proposal put more pressure on private payers?
I suppose if you prohibited price-discrimination outright, it might work, but I'm not sure that this would be pro-competitive in the private payer market over long-run.
Shifting discretion over reimbursement and benefit levels to localities is a recipe for a race to the bottom. I can imagine more generous counties becoming quickly inundated with nursing nome patients.