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The House budget includes a requirement that the position of Medicaid Director be subject to confirmation by the North Carolina General Assembly. Here’s some of the language:

4         APPOINTMENT AND CONFIRMATION OF MEDICAID DIRECTOR
5         SECTION 12H.36.(a) Effective July 1, 2014, and applying to Directors of the
6         Division of Medical Services appointed on or after that date, G.S. 108A-54 is amended by
7         adding a new subsection to read:
8         “§ 108A-54. Authorization of Medical Assistance Program; administration.
9         …
10       (e) The Medicaid Program shall be managed by the Director of the Division of Medical
11       Assistance (Medicaid Director), who shall be recommended by the Secretary of Health and
12       Human Services and appointed by the Governor, subject to confirmation by the General
13       Assembly by joint resolution. [...]

This provision should raise many questions and concerns. The legislature does not have appointment authority over any other position that is so central to carrying out the policy agenda of the Governor. If, for example, the legislature is bent on limiting access to Medicaid while the Governor wants to streamline enrollment, then the conflict will likely shut down any ability to get a Medicaid Director in place.

And while there is a clear process to appoint a Director if the Governor does not forward a nomination, the budget does not spell out what happens if the legislature refuses every nominee from the Governor. What would most likely occur is that the Governor would have to wait until the legislature is out of session and then appoint a temporary Medicaid Director.

If all of this sounds familiar it’s because this is how the process works in Washington, DC, where politics clouds every decision and ties up the basic functions of government. Instead of fostering bi-partisanship and stability, Congress has caused major disruptions in the running of Medicare and Medicaid by refusing to approve presidential nominees.

The same is likely to happen in Raleigh.

The Governor, who is elected statewide, should be able to appoint his or her preferred Medicaid Director to carry out the policies that he or she was elected to enact. If this confirmation requirement survives negotiations between the House and the Senate then leadership elected in select pockets of the state will have veto power over how the Governor runs one of the most important agencies of the executive branch.

ICYMI, be sure to check out this editorial in Raleigh’s News & Observer entitled “Gov. McCrory’s Medicaid plan should prevail.” As the editorial notes:

“McCrory’s plan, developed over months of consultations with North Carolina providers, would make quality care its first goal, but it would also produce savings through preventative care and more efficient delivery of medical services.

McCrory’s plan would replace the cost-inflating, fee-for-service approach now in use and instead pay providers for making people well and keeping them from getting sick.

The foundation for this approach is already in place through North Carolina’s nonprofit Community Care program. Now it needs to be refined and expanded.

The governor has done well to listen to doctors about improving Medicaid. Now let’s hope he can get the General Assembly to listen to him.”

Read the entire editorial by clicking here.

/www.newsobserver.com/2014/06/05/3914338/gov-mccrorys-medicaid-plan-should.html?sp=/99/108/#storylink=c the entire piece by clicking here.

common-coreIf you missed it yesterday, be sure to read Lindsay Wagner’s story , “State Board of Education’s authority weakened with legislation that replaces Common Core,” over on the main Policy Watch site. It’s an extremely informative piece that explains the latest developments in North Carolina’s never-ending political game of legislative micromanagement of public schools.

As Wagner reports, lawmakers are poised to repeal the state’s involvement in the Common Core State Standards because of the standards’ supposed widespread unpopularity amongst parents and educators. (There was more action today.) Notwithstanding the fact that the proponents are likely wrong — at least about the attitudes of educators — here’s the part of the story that especially deserves to be highlighted:

It is not Common Core that’s really causing the widespread unrest being felt in many public schools these days as students, teachers and parents deal with the explosion of high-stakes tests. This from Wagner’s story: Read More

Lindenmuth

Lindenmuth

If there’s one news story about North Carolina state government that you don’t want to miss this morning it’s NC Policy Watch reporter Sarah Ovaska’s new investigative report on the McCrory administration’s “jobs czar,” Richard Lindenmuth. As Ovaska reports, the man charged with overseeing the privatization of the state’s business recruiting efforts (something that former Republican governor Jim Martin calleda “dumb and dangerous idea”) has some controversies and questions in his own background in private industry. This is from the report:

“N.C. Policy Watch investigation into Lindenmuth’s background uncovered federal court records showing that controversy has marred his career in recent years. He placed his Raleigh consulting company, Boulder International, into bankruptcy in 2010 and had his fiduciary abilities called into question by a federal bankruptcy judge in a separate incident.

U.S. Bankruptcy Judge Barbara Houser, the chief bankruptcy judge for the Northern District of Texas, found that Lindenmuth improperly overcharged expenses by nearly $117,000 while consulting for a home décor company undergoing bankruptcy, a situation she found ‘very, very troubling’ and potentially criminal.

‘[T]his appears to violate the criminal violations of the Bankruptcy Code, and I mean this is not right,’ Houser said, according to a hearing transcript.

Court records don’t show that law enforcement ever pursued the situation, and Lindenmuth denied any wrongdoing in court records and to N.C. Policy Watch. He did, however, agree to return $250,000, nearly half of what he was paid for seven months of work at the company.”

Click here to read the rest of the story including more of Judge Houser’s scathing characterization’s of Lindenmuth’s actions. It will be interesting to see if Gov. McCrory stands by the appointment given the numerous controversies already swirling around his administration’s economic development efforts.

Since assuming office Gov. McCrory has throttled the theme that Medicaid is broken and must be reformed. He began by offering a radical proposal of dismantling our current system and selling it off to private insurance plans. He has since backed away from that idea and now wants a more modest expansion of what currently works in Medicaid.

The House, in a bipartisan bill filed this session, clearly agrees with the Governor’s new approach. The legislation, spearheaded by Rep. Nelson Dollar, would build Accountable Care Organizations (or ACOs)  in Medicaid. These provider led ACOs would move us toward greater integration of care and away from fee-for-service medicine. Medicare is using the ACO model as are many private insurers. In fact, Medicaid is one of the only payers in the state not moving to this method of organizing care.

In its budget, the Senate flatly rejects this approach. That chamber wants Medicaid to move to full capitation. In other words, legislators want to provide a set budget to Medicaid. The insinuation is that the Senate prefers the Governor’s original plan to pay private insurers to care (or not care, as the case may be) for our most vulnerable citizens.

The Senate also engages in some fantasy by pulling Medicaid into a freestanding department that will engage the nation’s best health care minds in this ambitious reform effort. At least that’s how Sen. Louis Pate described the proposed process. The trouble, of course, is that the nation’s best health care minds consider North Carolina’s Medicaid program to be an important model and they aren’t interested in helping to dismember it. The nation’s best health care minds also aren’t interested in coming to our state and spending time tearing apart care for low-income people as the legislature reduces services, limits eligibility, and slashes the budget. We are, in short, engaged in the opposite of innovation.

Rep. Dollar is a smart chap and likely realizes that his ACO bill isn’t going anywhere as a piece of legislation. That means he will need to stick the proposal into the House budget to give it a fighting chance. Hence, the showdown mentioned in the title of this post.

Certainly the House is moving in a better direction. But it’s a good time to reflect that Virginia is having its own budget battle over Medicaid right now. Except instead of fighting over how to fiddle with (or blow up) a program that is working, Virginia’s leaders are having a serious discussion about using federal funds to expand Medicaid coverage to 400,000 people. If that happens it means that our tax dollars will help boost Virginia’s economy, bolster its rural hospitals, and support its citizens.

That will certainly be charitable of us, but not wise.