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Archive Monthly Archives: January 2017

Obamacare / Trumpcare: Let the arguments begin


by Len Kirschner, MD, MPH

Dear Editor, The Affordable Care Act (aka Obamacare) became law almost seven years ago in March, 2010. The battles for and against the law have continued since Day #1. There have been many ups and downs. Trips to the Supreme Court, the initial failure of and the rancorous rhetoric in the 2016 Presidential campaign have poisoned the debate.

The positives are impressive. We now have the lowest number of people without health insurance in the history of this country. Close to 200,000 Arizonans have coverage under the Exchange and over 700,000 have received coverage under our Medicaid program better known as AHCCCS.

In Washington the debate is raging about “Repeal and Replace” with no obvious resolution to the issue. A total repeal would be damaging to Arizona and a huge hit to the state budget. Hundreds of thousands of people would lose coverage and the entire population would be impacted. Much of the debate centers on the Exchange but Medicare would also be impacted. Closing the prescription drug “doughnut hole” would be canceled and the million Arizonans on Medicare would see costs increase. Hospitals would see a rise in uncompensated care and emergency department use would increase.

The House of Representatives has voted 60 times to repeal Obamacare. It was symbolic since the bill was going nowhere. Now they have the political strength to act and truly repeal Obamacare. They look like the dog who kept chasing the car and finally caught it. What do they do now?

Change is coming and the new system will be called Trumpcare. Let the arguments begin.



Len has done so much in the healthcare space its impossible to do it justice in a simple footer. Highlights include being State President of AARP of Arizona, the former Medicaid Director for Arizona, and 22 years of active duty in the United States Air Force. He is also a physician and regular on the Medicaid conference circuit. To learn more about Len, check out this bio and this bio.

This article originally appeared in a local newspaper. Reprinted with kind permission from the author.

Clay’s Weekly Medicaid RoundUp: Week of January 9th, 2017

Soundtrack for today’s RoundUp pessimist readers-

Or you can click the one for optimist readers –


WAIT A MINUTE- WHO’S SURPRISED AT THE CURRENT ACA REPEAL EFFORTS? It’s been hated by millions since day 1 (and loved by millions, especially on the left), the GOP has introduced 60+ repeal bills over the last 7 years – and now everyone is floored that one of the first things the Right does once it regains control is renew repeal efforts? The Senate took step 1 of a 10-step procedure to repeal ACA early Thursday morning. Here’s the best guide I have seen so far –


THE LAND OF OPPORTUNITY STATE PUTS APPLICATION BACKLOG TO REST- AR brought in about 250 temp workers, but they got it done. Back in June there were 100,000 “pieces of paperwork” overdue, including 34,000 or so apps that were 45 days old. At year end (just a few weeks ago – weird), there were no overdue apps. Hey AR – can you send those temp workers over to KS?


SOONER STATE MCD NEEDS ANOTHER $200M TO KEEP THE LIGHTS ON- My crystal ball says they will get it. Just look at last year- when the overall OK budget was $1.3B short, OK Mcd got $1B (which was an increase over the previous year). You silly lawmakers need to just submit to the Mcd dominance of your budgets and move on.


MAGNOLIA STATE NEEDS ANOTHER $75M NEXT YEAR- Backers of the bump point to cuts in prior years, as well as a recent $58M cut in September that addressed lower-than-expected state revenues. It is interesting that the request for more money is happening when MS enrollment is decreasing.


KUDOS TO HPP ON THE KEYSTONE WIN- Health Plan Partners was awarded new membership  in PA this week. The award will expand the HPP PA footprint into 13 more counties, home to nearly 500,000 Mcd members. Congrats HPP!


THE COPPER STATE ANTI-EXPANSION LAWSUIT MOVES FORWARD- Its only been four years of spending money on the 300,000 new bennies, but the AZ Court of Appeals has scheduled the hearing challenging whether the way the Good Guvn’r Brewer unilaterally expanded was legal in the first place.



FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Let’s start the ticker and see who wins this week’s award.  Family Care Nursing (such a wholesome name!) of Meriden, CT settled this week for $5.3M related to billing for 60 day assessments knowing it was not an RN doing the work. Aretha Derrico was arrested for billing Mcd for $57,000 of home health services not provided in Havana, FL. Randy Crowell of Henderson, NV plead guilty to a $100M Rx reverse-diversion scheme last week. Mr. Henderson had an impressive range – from Utah to NY. How did he do it? He was a licensed wholesale rx distributor, of course. Still wondering what “reverse-diversion” means (I made that up, I think)? Instead of the pills going from legit sources to the black market, Mr. Henderson acquired pills in the black market and sold them to pharmacies. Sort of like money laundering, but with oxycontin. Although the specific hit to Mcd is not enumerated, I am more than impressed with this one. There are wonderful details like the use of lighter fluid to remove labels from bottles. Mr. Henderson – you win this week’s award! I would be interested in acquiring the movie rights to your story, when you get out of the slammer.



That’s it for this week. As always, please send me a note with your thoughts to or give me a buzz at 919.727.9231. Get outside (or stay inside and order your pepper seeds. They will need 30 days to germinate, and then that’s March and you want them strong when you put them out in May, right?) and keep running the race (you know who you are).


FULL, FREE newsletter: . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Pitā sēva dha varlḍa dīkarānī

Truth and “Entitlements”

Dave Mosley

by Dave Mosley

For the minority of Americans that are judicious in attempting to access and digest the news relating to our economy, there is a term that is often frustrating and misleading: entitlement.

One often hears that entitlements are dooming our economy and that spending must be curbed.

However, one also hears the argument that individuals have paid into Social Security and Medicare, so, in fact, they are not entitlements, unlike Medicaid, for which those receiving the benefit, paid nothing directly toward the benefit.

Regarding Social Security each person who receives benefits has contributed to that fund throughout their working life. Moreover, if a person is self-employed the annual contribution is doubled. Thus, to classify such a program as an “entitlement” is false. Yes, there is a right to benefits specified by law, but individuals have paid for their benefits. The average person comes very close to paying for (while working) his/her Social Security benefits (while retired).

Medicare benefits are different, in that the average individual, retiring this year will likely receive more than 3x the total dollars in benefits than he/she has paid into the program. For this reason, one might argue that Medicare is an entitlement. The government receives approximately 1/3 of the amount from an individual that the government will pay out on behalf of said individual.

For Medicaid, there is zero correlation between what an individual pays in to the program, versus the benefits one receives. Yes, various taxes are used to create the funding sources from which the Federal, state, and even local governments pay for Medicaid. However, again, there is no correlation between payment and benefit. In fact, the majority of individuals on Medicaid have never paid taxes at all.

Also worth noting is the fact that across our Nation individuals believe that Medicare, Medicaid, and commercial insurance are very similar health insurance platforms. Many presume that the primary difference between these payers is that the Feds pay for old folks, employers pay for working folks, and Medicaid pays for poor folks.

In fact, while Medicaid was created as a parallel program to Medicare – – addressing care based upon medical necessity and sufficiency criteria – – nearly one-half of all Medicaid payments are made for services that Medicare does not cover and never has covered.

Medicaid’s benefit package, in every state, far exceeds the benefits available through commercial, Medicare, VA, TRICARE and any other type of health insurance. Nearly one-half of Medicaid services provided to beneficiaries are neither curative nor restorative. Unlimited nursing home days (or home-based care), occupational therapy, hearing aids, eye glasses, orthodontics, and a plethora of other services are all covered by Medicaid and only Medicaid.

As the next budget cycle comes around, let’s not only listen to those crafting and adopting both Federal and state budgets, let’s listen in an informed manner.

Perhaps it would be beneficial if neither elected officials, nor the media, endeavored to paint all “entitlements”, or all health insurance, with the same brush?

It is disingenuous, at best, when the 24/7 news lumps Medicaid coverage in with any other coverage available in the Nation. Medicaid is far more than “health insurance”. We, as a Nation, can certainly afford to care for the most fragile members of our society; however, let’s do so through in a manner that affords transparency and clarity.

Dave Mosley is a Managing Director and the State Practice Leader for Navigant’s Government Healthcare Solutions (GHS). He assists Medicaid, human services, and elected leaders to navigate regulatory channels and to apply best practices to improve organizational performance. He is a recognized public speaker, has been published in trade journals, and is frequently called upon as a resource to elected officials at the state and Federal levels.


For more about Dave, check out his LinkedIn profile.


Article reprinted with kind permission from author.

Medicaid Industry Who’s Who Series: Shannon McMahon

Medicaid Who’s Who: Shannon M. McMahonDeputy Secretary, Health Care Financing with Maryland Department of Health and Mental Hygiene

Shannon M. McMahon, MPA, was appointed the Deputy Secretary of Health Care Financing at the Maryland Department of Health and Mental Hygiene in February, 2015. In this role, she is responsible for the operation of the state’s Medicaid program, which serves over 1.2 million Marylanders.

Previously, Ms. McMahon was the Director of Coverage and Access at the Center for Health Care Strategies (CHCS) where she lead Medicaid eligibility, benefit design and purchasing implementation efforts and learning collaboratives for states and the federal government. Prior to CHCS, she worked in executive and management-level roles in Minnesota Medicaid, most recently as the Chief Administrative Officer, where she oversaw finance and operations for Minnesota’s three public health care programs.

Ms. McMahon also spent several years working on health policy issues as a non-partisan analyst at the Department of Legislative Services in Annapolis and also held the position of senior budget and policy adviser to the Secretary and Principal Deputy Secretary of Maryland’s Department of Health and Mental Hygiene.

Ms. McMahon has a bachelor’s degree in justice from American University, Washington, D.C. and a master’s degree in public administration from Northeastern University, Boston, Massachusetts where she was a recipient of a full tuition public policy fellowship. She is a member of the board of directors of the National Association of Medicaid Directors.

Shannon McMahon is the featured panelist in the upcoming State Spotlight Webinar on Feb. 6th at 2pm EST. Learn more and register for free here.

  1.  What is your current position and with what organization?

Deputy Secretary, Maryland Department of Health and Mental Hygiene/Medicaid Director   

  2.  How many years have you been in the Medicaid industry?

 I’ve been working in health care policy/operations and consulting for 19 years; my focus has always been on the public sector, and Medicaid in particular.

  3.  What is your focus/passion? (Industry related or not)

My passion is making the government side of health care (enrollment, access) more person-centric.  I love Lean and business process re-design.

  4.  What is the top item on your “bucket list?”

Snuba the great barrier reef

  5.  What do you enjoy doing most with your personal time?

International travel with my family; I think that foreign travel is the greatest gift you can give kids, as it imparts two key business and life skills: organization and resilience.

  6.  Who is your favorite historical figure and why?

Eleanor Roosevelt; I’ve always admired her commitment to public service and her ability to problem solve in the most politically charged environments.

  7.  What is your favorite junk food?


8.  Of what accomplishment are you most proud?

The recent Section 1115 waiver that we secured for Maryland Medicaid is a very big step to begin addressing the social determinants of health at the local level while also expanding access to substance use disorder services in the State.  The partnership forged between the State and local governments, as well as the support from the provider and advocacy community made it possible.  The amazing team in Maryland Medicaid worked hand and glove with our federal CMS counterparts to get ‘er done.

  9.  For what one thing do you wish you could get a mulligan?

I have a knack for calling people by the wrong name, and have done so with some pretty senior people in both government and the provider community. 

  10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months? 

In Maryland, we are coming off the recognition of the 50th anniversary of Medicaid in 2016.  Our  two big focuses for the next six months are

(1) Implementing the SUD expansion under the 1115 waiver which includes a physical health-behavioral health integration component;

(2)  Developing a new payment and delivery system for individuals dually eligible for Medicare and Medicaid.

(3) Potential changes to the ACA will be of particular interest to Maryland as well, and as a member of the NAMD board, I have had the opportunity to engage with the key executive and legislative branch leaders on potential changes.  


The Fairness of Medicaid Expansion Under the ACA

Ted Calvert

by Ted Calvert


As Congress and the new administration try to figure out what to do with the Affordable Care Act (ACA), it’s important to highlight one particularly impactful provision that’s often overlooked: Medicaid expansion. Keeping kids on their parents plans until they are 26 is also terrific, but it’s insignificant in comparison.

Of the approximately 25 million individuals who gained insurance coverage due to the ACA, almost half have been through Medicaid expansion. Those are, of course, individuals in the 29 states that decided to expand – an easy choice for many states since it meant billions of dollars in federal spending with comparatively small state outlays. Although Medicaid eligibility rules remain far too complex, the ACA brought some simplicity, elegance, and I think fairness to at least part of the criteria: all individuals below the poverty line are now eligible. It has always been more politically acceptable to provide government sponsored health care to poor children and their mothers, or even fathers in low-income families, but the pre-ACA rules excluded the poor who were not eligible in some other categorical way. As a result of the ACA, many more childless adults (most of them men) are now eligible for free health care. It always struck me as unfair that they were not previously eligible, and apparently the authors of the ACA agreed.

With the future of the ACA uncertain at best, I worry most about this group of individuals who earn less than $16,390 per year losing their health care coverage. In California, that’s almost three million people that are now covered due to the ACA, double the approximately 1.4 million that gained coverage through the Covered California plans. It’s not cheap – roughly $5,000 per person or $50 billion in federal spending nationwide, but we probably should have been doing it all along, at least if we believed in subsidized health care for the poor. If we don’t have the money, let’s reduce the spending in some other way, but let’s do it in a way that more evenly impacts all low-income individuals.

Ted Calvert is the owner of Ted Calvert Consulting (TCC). Ted has more than 30 years experience in the healthcare industry, and assists clients with program management, analytics, large-scale IT system oversight and standards adoption. Learn more about TCC by visiting Learn more about Ted by checking out his LinkedIn profile.

Clay’s Weekly Medicaid RoundUp: Week of January 2nd, 2017

Soundtrack for today’s RoundUp pessimist readers-

Or you can click the one for optimist readers –

BONUS Optimist Song:


SOMEBODY TELL THE GOOD GUVN’R HE’S WEARING LAST YEAR’S FASHIONS: Perhaps the protracted battle with the outgoing Guvn’r has left NC Good Guvn’r Roy Cooper a little confused. He is talking about expanding Mcd in the Tarheel State, seemingly unaware that expansion is yesterday’s news. He promised to submit a state plan amendment by this Friday to expand under ACA rules, which have to be approved by CMS. This is either a PR stunt only, or the new Guvn’r is more clueless than the average bear.


NOW THERE’S AN IDEA: AK ASKS TO KEEP ACA CASH FLOWING BUT WANTS MORE CONTROL ON LIMITING ELIGIBILITY THAN ALLOWED BY MASTERS IN THE DISRICT (CAN I USE 2 COLONS IN A HEADLINE?): The Good Guvn’r Hutchinson has been in talks with the new cabinet members about letting AR tighten eligibility requirements for its expansion bennies. He may end up getting what he’s been begging CMS for for years after all. Amazing the difference a new king (er, President) makes.


AND SO IT BEGINS- One half of the country seems to be moving into the next phase of grief. The denial phase was like watching a train wreck- fascinating (Stein’s stratagem and the attempts at electoral mutiny), terrifying (Fake News pots calling kettles black) and pitiable (b-b-but the Russians did it!) all at the same time. We are now witnessing the negotiation and acceptance phases best I can tell. I now see Op Eds discussing how block grants may not be that bad (as long as its tied to healthcare inflation) and detailed analysis of the expected GOP battle plans to repeal the sacred cow of ACA (as opposed to the previous stance of “but they can’t do that).


KS ELIGIBILITY APPS: STILL LATE- 2 years and counting for the backlog. State officials did get it down to 1,400 or so in September (from a high of 15,000), but its climbing again. The latest number is 2,247 apps at least 45 days old.


MCO TIDBITS: Item 1) WellCare completed its acquisition of Care1st of AZ this week, adding 115,000 lives to the ledger. Item 2) Iowa newspapers are now reporting they have obtained secret documents showing MCOs calling the Iowa program “drastically underfunded” and a “catastrophic experience.” Sensing that these documents reveal a disconnect between what is being said publicly and privately, Mr. Pin Ochio has stepped in with new evidence that Oceania hacked the Iowa Medicaid agency. He insists we ignore the contents of the documents and focus on the manner of their discovery.


FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Let’s start the ticker and see who wins this week’s award. There’s actually just one this week: Abe Freund, operator of Acacia Mental Health Clinic, LLC in Milwaulkee has been charged by the feds with stealing as much as $7M from Medicaid. Acacia was billing $474 for drug tests that should have been paid at $20. At the end of the feeding frenzy, 99% of all Wisconsin substance abuse counseling payments were going to Acacia. Acacia payments surged from $300k to $3M over a few years. Lesson learned (?)- when you see 99% of your SA payments going to one provider that’s grown tenfold in a few years, maybe you should have something in place to stop paying that provider number before it gets to that point?


That’s it for this week. As always, please send me a note with your thoughts to or give me a buzz at 919.727.9231. Get outside (enjoy the snow! One Yankees nuisance is a Southerners magical experience) and keep running the race (you know who you are).


FULL, FREE newsletter: . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: o Patéras ésteile ton Yió gia na sósei ton kósmo