Alaska Health Policy Review

Dear Reader:

Lately I have been thinking a lot about the idea of Medicaid as a revenue source for communities, a "jobs bill" if you will. We almost always hear of it as an expense for the state, but we rarely hear of it as a major economic contributor to just about every Alaska community. I did a little research, which transported me to the sunny climes of the deep south. The South Carolina Department of Health and Social Services has a web page titled, "The Transparency Reporting of Medicaid." The contents are described in this way:

This information is designed to give the public an overview of how tax dollars are spent in support of the Medicaid program. It is not intended to detail each health care service individual Medicaid providers deliver to patients, nor do listed payments reflect the actual salaries of individual providers. We hope information presented here will prompt discussions and lead to a better understanding of our agency's mission.

The main web site, in turn, links to another page titled, "Transparency Reporting of Medicaid Provider Payments for State Fiscal Year 2010." This is where you find the meat and potatoes.

The first column in this spreadsheet-like table is "Provider Type." Over 30 provider types are listed such as "Durable Medical Equipment" or "Physicians."

The next column is entitled "# of Providers" which indicates, for example, that in FY 2010, 1,014 dentists received Medicaid Payments.

The next column is entitled "Payment for Billed Claims." It indicates that, in the case of dentists, they collected a total of $124,094,130 in FY 2010.

The fun does not stop there. Going back to the first column, "Provider Type," each provider category has a link associated with it. For example if I click on the link associated with "Clinics," a list of 759 clinics pops up with the following key information listed for each clinic:

County (Wouldn't work for Alaska. How about legislative district? Note: I am only partly kidding here)

Beneficiaries (i.e. number of Medicaid patients)

Number of patient visits

Payment for billed claims

Average cost per billed claim

Best of all, the entire data base is searchable! Take a look at the site yourself and think of the possibilities. If a comparable website
were established here in Alaska with a little more detail, you could pose questions such as, "I live in town 'X' in Alaska. How much of an economic impact does Medicaid have in my town? About how many small businesses and workers do Medicaid expenditures support in my town?" Then, of course, you would want to inform your elected representatives.

Lawrence D. Weiss PhD, MS

Editor, AHPR

ldweiss@acpp.info

Important Information About this Newsletter

The formatting of this electronic version of Alaska Health Policy Review may be degraded due to variations in Internet service providers, browsers, and email applications. To ensure that you are reading a complete and properly formatted version of the publication, please click on "For the most readable copy of the newsletter please click here" located just above the banner at the top of the newsletter.

Back to top

Introduction to Guest Commentaries

Three weeks ago, federal court Judge Roger Vinson added his ruling to the growing roster of judges and their decisions about the constitutionality of the Affordable Care Act (ACA), the federal legislation that reforms health care in the U.S. Judge Vinson ruled for the plaintiffs -- 26 states including Alaska, the National Federation of Independent Business, and two private citizens. He held that the ACA is unconstitutional based on his conclusion that the individual mandate to purchase insurance exceeds the regulatory powers of Congress under the Commerce Clause of the Constitution.

In response to Judge Vinson's ruling, Governor Parnell turned to John Burns, attorney general-designee at the State of Alaska Department of Law. Burns advised Governor Parnell that Judge Vinson's ruling is binding in Alaska and the governor is following the Department of Law's advice. However, Burns' determination that Alaska need not abide by federal health care legislation is at odds with the opinion of policy watchers around the nation.

One of those policy analysts is Jane Perkins of the National Health Law Project, who reports in Say Ahhh! A Children's Health Policy Blog, that the decision reached by Judge Vinson in Florida represents only one judge and one opinion. Perkins maintains that states should continue "carefully paving the way for health reform in 2014." We reprint her commentary below.

Following Perkins' commentary is a reprint of Governor Parnell's Compass article, published in the Anchorage Daily News on February 19, 2011. Governor Parnell expresses his belief that the state should not implement an unconstitutional law. Parnell also discusses his decision not to apply for the health planning grant by the application deadline of February 18 and what actions the state will take instead.

Together, the two articles are a representative example of the divergent opinions about the judges' decisions in regard to the Affordable Care Act.

Just a few days ago, on Tuesday, February 22, 2011, a federal judge in Washington, D.C. dismissed a suit challenging health care reforms. Senior U.S. District Judge Gladys Kessler declared the individual insurance mandate a "critical element in Congress's comprehensive plan to reduce the spiraling health care costs that this country has experienced and is expected to experience in the future."

Judge Kessler's decision is the fifth to rule on the constitutionality of the Affordable Care Act legislation; it is the third to find the Affordable Care Act constitutional.

Back to top

Guest Commentary: ACA Ruling is Surprising and Confusing

By Jane Perkins, National Health Law Project

[On Monday, January 31, 2011], Florida district judge Roger Vinson issued his decision in one of the most closely watched cases challenging the constitutionality of the Affordable Care Act (ACA). At least 24 such cases have been filed in federal district courts around the country. The Florida case is different from all others because of the large number of plaintiffs--which include elected officials from 26 states (Judge Vinson allowed six newly elected officials into the case in January). The decision has four major elements:

Judge Vinson holds the individual responsibility requirement (to have minimum insurance coverage) unconstitutional because the Commerce power does not allow Congress to regulate economic "non-activity" - i.e, the choice not to buy health insurance. He says the requirement could result in the government requiring us to buy broccoli. This ruling (including the broccoli reference) was not surprising based on his earlier statements and questioning throughout the case. This decision matches the Virginia case involving Judge Henry Hudson, but stands in contrast to two other Federal Court decisions (now on appeal to the 4th and 6th circuit courts of appeal).

By contrast, Judge Vinson rejected the state officials' arguments that the ACA's Medicaid expansion was unconstitutional because the states were being coerced to participate. This was excellent news and was somewhat foreshadowed by some of the Judge's statements in the past months.

Judge Vinson decided, in contrast to even the prior Virginia decision and reasonable expectations, that the individual mandate could not be separated from the rest of the ACA, legally speaking the provision was not severable and, because that part was unconstitutional, the entire ACA was void.

Judge Vinson only declared the provision was unconstitutional. He denied a request to enjoin further ACA implementation. He indicated that he was opting not to rule for the injunction because his declaration that the ACA is unconstitutional should be sufficient to bar any Federal official from implementing the law.

The most surprising aspect of the decision concerns the ruling on severability. The individual responsibility requirement is not in effect and it won't be until 2014. Moreover, the Judge's order is not a model of clarity, and it is not certain whether the declaratory relief is actually intended to stop all federal implementation efforts. To avoid the risk of being seen as noncompliant with a judicial order, the Federal government may well seek to stay this aspect of the decision. Pursuant to Federal rules of procedure, the ordinary course is for the request to be made first to the district court (before asking the court of appeals). While it may seem counterintuitive, district courts will sometimes stay their own rulings where, as here, complex or sensitive matters are being raised. At any rate, the hope is that, if requested, a stay would issue promptly, thus clarifying that implementation can continue while the case is appealed. Barring a request for expedited review being made to and granted by the Supreme Court, the case would be heard by the Eleventh Circuit Court of Appeals and then the Supreme Court if it has not already accepted one of the other cases already making their way through the courts of appeal.

Meanwhile, the severability ruling is causing a lot of confusion. Until the situation is clarified, the following question will be asked: Should the state continue implementing health reform in light of the Florida decision. Here are five reasons to say, "Yes." (For five more reasons, go to our website):

The decision is being used to stir up confusion. Let's not add to that confusion by changing the status quo away from the careful path of review and implementation that is underway.

The judge did not rule against any state. His ruling only applies to the federal government. States can and should continue what they are doing: carefully paving the way for health reform in 2014--activity that is and will be matched by significant federal matching funds.

Judge Vinson is only one judge and this is one decision. So far, at least six federal district courts have dismissed cases that sought to have the ACA declared unconstitutional. Two courts have found the ACA individual responsibility mandate to be constitutional, and two have found it unconstitutional.

Judge Vinson is at odds with the only other decision holding the ACA individual responsibility provision to be unconstitutional. Virginia Federal District Judge Hudson declared the provision to be unconstitutional but easily found it to be severable from the remainder of the ACA. As he noted, the provision is not to be implemented until 2014.

Judge Vinson began his own analysis with the following observation: "Severability is a doctrine of judicial restraint." Opinion at 64. The remainder of the opinion should be looked at with skepticism because he did not exercise restraint.

[Source: Say Ahhh! A Children's Health Policy Blog; reprinted with permission]

Back to top

Please Respect Our Copyright

Alaska Health Policy Review is sent to individual and group subscribers for their exclusive use. Please contact us for information regarding significant discounts for multiple subscriptions within a single organization. Distributing copies of the Alaska Health Policy Review is prohibited under copyright restrictions without written permission from the editor; however, we encourage the use of a few sentences from an issue for reviews and other "Fair Use."

We appreciate your referral of colleagues to akhealthpolicy.org in order to obtain a sample copy. The Alaska Center for Public Policy holds the copyright for Alaska Health Policy Review. Your respect for our copyright allows us to continue to provide this service to you.

For all related matters, please contact the editor, Lawrence D. Weiss, at health.policy.review@gmail.com.

Back to top

Guest Commentary: Consider Context of Insurance Decision

By Alaska Governor Sean Parnell

As a trained (and recovering) lawyer, I have deep respect for the rule of law. And when I took the oath of office, I swore to uphold the U.S. and Alaska Constitutions as governor of Alaska.

For this reason, I firmly believe our state cannot implement a law that the courts have ruled unconstitutional, no matter what the law is.

Some state legislators have urged me to violate a court ruling -- a judge's decision that is effectively an injunction halting implementation of federal health care legislation. Judge Vinson explained in detail in his 78-page ruling that a mandate that requires Americans to purchase a product, in this case health insurance, is a violation of the Constitution.

The court's authority for judicial review has been settled since 1803 in Marbury v. Madison.

I sought legal advice on this matter from our attorney general, and he agreed that we could not implement a law that was ruled unconstitutional.

In this specific case, it's important to consider the full context.

My decision was forced by the Feb. 18 deadline to apply for federal grant funding for a health insurance exchange created by the immense federal health care reform law.

Alaska waited to make a decision on federal funding until the deadline so all the facts would be known beforehand. Florida and the other states jumped early at the bait of federal funds -- well before the federal government's deadline and before this court ruled that federal health care mandates are unconstitutional. Florida has since chosen to return the grant funds it had accepted to implement health care exchanges.

Alaska is a party to the Florida case, with 25 other states, where the judge gave us what we sought -- a declaration that the individual mandate is unconstitutional and barring implementation of the federal health care law. Alaska is bound by the decision.

Alaska can't decide to toss aside the plain language of the judge and move forward because some other jurisdiction to which we were not a party has a different case holding. That is not how the law works.

If the law is found to be constitutional, then we will reconsider our actions and implement the law. If the unconstitutional ruling is upheld on appeal and ultimately decided by the Supreme Court, then our state will continue what it's already doing: seeking ways to increase accessibility and improve affordability for health care for Alaskans and their unique needs.

For example, our state government, without federal dollars, was already reviewing opportunities for a state health insurance exchange. Specifically, we're evaluating data and software opportunities to create an Internet portal for Alaskans to get better insurance information and health care access. That work will continue, but without all of the onerous requirements of the federal health care law and without the shiny-but-poisonous apple of federal dollars and mandates that create federal dependency and control.

I have directed my commissioner of Health and Social Services to work with providers on chronic care management and primary care access for our most vulnerable citizens -- our elders and children. He will work to streamline and ease the enrollment processes for existing public assistance programs and leverage technologies like telemedicine and electronic health records.

The state of Alaska will pursue lawful, citizen-oriented, market-based solutions to make health care more affordable and accessible. Our state will not pursue unconstitutional activities.

Upholding the rule of law, as the chief executive of our state, is an important responsibility that I take very seriously. Playing crass political games -- that I will leave to others.

[Source: Anchorage Daily News Compass article published February 19, 2011; reprinted with permission]

Back to top

HHS Recovery Act: Alaska Highlights

Since the enactment of the Recovery Act in 2009, the U.S. Department of Health and Human Services has made $558.4 million in stimulus funds available in the State of Alaska for community health centers, universities and other institutions in the state to provide fiscal relief, improve and expand access to health care, provide child care and other social services for its most vulnerable citizens, establish the infrastructure for health information technology, and conduct scientific research.

Download the full document for more details.

[Source: HHS Recovery Act: Alaska Highlights]

Back to top

Health Policy Calendar

This calendar of health policy-related meetings is current as of February 23, 2011, at 2:30 PM. Please visit the Alaska State Legislature's committee schedule for the most current legislative information, as the schedule is subject to change.

Friday, February 25, 2011 8:00 AM

What: House Health and Social Services Standing Committee

Where: Capitol 106; Juneau

Other information: Final closeout, teleconferenced

Friday, February 25, 2011 1:30 PM

What: Senate Judiciary Standing Committee

Where: Beltz 105 (TSBldg); Juneau

Other information: SB 11 Hate Crimes; SB 17 Synthetic Cannabinoids; teleconferenced

Wednesday, March 9, 2011 3:30 PM

What: House Health and Social Services Finance Committee

Where: Beltz 105 (TSBldg); Juneau

Other information: Other topics of interest to the committee not covered previously, Q&A, Governor's Budget Amendments, testimony by invitation only, final closeout, teleconferenced

Sunday, March 13, 2011 6:30 PM Reception/7:00 PM Discussion

What: Toxic Trespass: Chemicals in our Environment and Effects on Reproductive Health

Where: Loussac Library Wilda Marston Theater

Other information: Sandra Steingraber, PhD. is an ecologist, author, and cancer

survivor who is recognized internationally as an authority on the environmental

links to cancer and human health. Join Dr. Sandra Steingraber for a discussion on the links between human rights and the environment, including an exploration of issues of concern to Alaskans such as large-scale development projects in Alaska and the global transport of toxics to the Arctic.

Tuesday and Wednesday, March 15 and 16, 2011

What: Alaska Primary Care Association Member Meeting with Lawmakers in Juneau

Other information: APCA Advocacy Staff arranges appointments, talking-point

bootcamps, debriefing sessions and meals, and lodging discounts for Juneau Hill

Visits. Contact Regan Mattingly at 907-929-8115 for more information and to member RSVP.

Wednesday through Sunday, March 23 to 27, 2011

What: Alaska Primary Care Association Member Visit to Washington, D.C.

Other information: Contact Shelley Hughes at 907-929-2728 for more information and to member RSVP.

Bill Watch: Bills on the Move