Editorials of The Times

Posted June 6, 2018 10:35 p.m. EDT

Medicaid’s Nickel-and-Dime Routine

D’ashon, a Texas toddler with severe birth defects, needed 24/7 nursing care to keep his breathing tube clean and to prevent him from pulling it out.

His foster mother asked Superior HealthPlan, the insurance carrier that provides Medicaid services to the state’s 30,000 foster children, for additional nursing hours, according to a Dallas Morning News investigation. Superior said no, even after D’ashon’s doctors and nurses said that it was a matter of life or death.

Bind his arms with a soft splint to keep him from removing his breathing tube when no nurse was on duty, the company suggested to D’ashon’s foster mother. The insurance carrier finally agreed to provide round-the-clock nursing care — after D’ashon choked while no nurse was on duty and lapsed into a permanent vegetative state.

As a wealthy and politically powerful company gambles lives for profit, Texas officials look the other way, the Morning News reporters tell us. This is the sorry state of what passes for good-enough care for patients who depend on Medicaid, among the most vital safety nets for the American poor and disadvantaged, in the second most populous state.

Elsewhere, officials are striving to make it harder for people to get Medicaid at all.

Last week, Arkansas became the first state to require some Medicaid recipients to work in order to keep their health insurance. Three other states have secured federal permission to do the same, and several others have similar requests pending with the Centers for Medicare and Medicaid Services.

Proponents of work requirements say the goal is not to punish the poor, but to lift them out of poverty by nudging them into the workforce. But decades of experience with similar social experiments tell us that it will not play out that way. The welfare-to-work strategies of the 1980s and 1990s succeeded at getting people off government rosters — but without alleviating their poverty.

The current Medicaid proposals are likely to have the same effect: The Urban Institute has found that in Arkansas (to take one example) nearly 80 percent of Medicaid enrollees who would be subject to the new work requirements face limitations that include significant health problems, a seriously ill family member, no vehicle or a lack of education. These barriers would make it difficult to impossible for many of them to meet the new rule’s monthly reporting requirements, even if they managed to secure the required 80 hours of work each month.

If only such scrutiny were applied to Medicaid insurers. But even as more Medicaid beneficiaries — including those with complex medical conditions — are shuttled into cost-saving managed care programs, very little is being done to guard against abuses like the ones that left little D’ashon with permanent brain damage. The Centers for Medicare and Medicaid Services began a “scorecard” program on Monday to track the performance of Medicaid providers, but participation is voluntary and participants will face no penalties for poor performance.

“Conservatives love to claim that public program fraud is driven by the people utilizing the programs,” says Frederick Isasi, executive director of Families USA, a health care advocacy group. “But it’s actually corporations, providers and carriers that perpetrate most of it.”

After an investigation, Texas health officials advised the state to fine Superior $345,000 for its negligence. But a company spokeswoman told The Dallas Morning News that it was not aware of any such penalty. Meanwhile, even as Texas let insurers nickel-and-dime children like D’ashon, its rejection of federal funding for Medicaid expansion under the Affordable Care Act helps it retain its distinction as the state with the highest rate of uninsured residents.

Of course egregious insurance denials are not unique to Medicaid. Accounts of life-or-death requests denied or dangerously delayed by private insurers occur every week. But Medicaid covers our most vulnerable citizens, including children in foster care, the permanently disabled and the elderly — people we have a special duty to protect.

In 2018, that duty to protect requires the Centers for Medicare and Medicaid Services to reject state work requirement waivers, including any currently pending. It demands that the U.S. District Court side with Medicaid enrollees in Kentucky who filed a lawsuit arguing that such waivers are illegal. And it should lead states seeking similar work requirements to abandon these plans, and shift their attention and resources away from policing the neediest people to strengthening oversight of insurers.

Medicaid expansion has now been implemented in 33 states, signifying that most citizens understand and accept this responsibility. But to fully meet it, funding and oversight need to be in the right places.

Trump’s Man in Berlin

His confirmation as ambassador to Germany took a while, but when Richard Grenell arrived in Berlin in May he wasted no time riling up his new hosts. On his first day on the job, he tweeted that German companies doing business in Iran should “wind down operations immediately" because President Donald Trump had decided to unilaterally withdraw from the painstakingly negotiated nuclear deal with Iran.

Germans were not amused by an ambassador telling them what to do, but that hardly deterred our man in Berlin. What he did next was to give an outrageous and insulting interview over the weekend to Breitbart, summarized thus by the alt-right mouthpiece: “Trumpian U.S. Ambassador to Germany Richard Grenell has expressed great excitement over the wave of conservatism in Europe, saying he wants to ‘empower’ leaders of the movement.”

Trump was no doubt highly pleased by his envoy, a former United Nations spokesman, Mitt Romney campaign aide and Fox News contributor, whose confirmation was long held up by congressional critics over his history of provocative tweets, including several derogatory of the appearance of prominent women.

But ambassadors do not represent a president; they represent a state, and they are not supposed to go around “empowering” nationalist movements or far-right ideologies in other countries. The Germans were furious. The new ambassador is behaving “not like a diplomat, but like a far-right colonial officer,” fumed Martin Schulz, the former European Parliament president.

In true Trumpian fashion, Grenell insisted he had been misinterpreted. “Don’t put words in my mouth,” he tweeted. “The idea that I’d endorse candidates/parties is ridiculous. I stand by my comments that we are experiencing an awakening from the silent majority — those who reject the elites & their bubble. Led by Trump.”

Indeed, Breitbart is not known for accuracy in reporting. But just selecting Breitbart, a professed platform for the alt-right and all of its falsehoods, biases and conspiracy theories, for an interview raised serious questions about Grenell’s judgment. He knows full well that when Breitbart speaks of “conservatism” it does not mean the Christian Democratic Party of Chancellor Angela Merkel, the head of the government to which he is accredited. In case that was not clear, Breitbart said the ambassador expressed a deep respect and admiration for the young Austrian chancellor, Sebastian Kurz, saying: “Look, I think Sebastian Kurz is a rock star. I’m a big fan.”

Now Kurz, at 31 Austria’s youngest chancellor, leads a nationalist government in coalition with the far-right, pro-Russian Freedom Party and has been sharply critical of Merkel for her willingness to accept Muslim immigrants. The German equivalent would be Merkel’s nemesis, the far-right Alternative for Germany. Adding insult to injury — and violating protocol — Grenell invited Kurz to lunch when the Austrian chancellor visits Berlin next week.

It may be anachronistic to expect politically appointed American diplomats to fully abide by traditional European standards of diplomatic correctness. And it may be unrealistic to expect that the hand-picked envoy of a president who has so totally debased political discourse could be respectful or wise in his utterances. But Grenell does not, and should not, represent the United States.

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