Health Reform and Oversight, Ombudsmen, and Obfuscation

“Iowa has two ombudsmen to investigate and advocate for the 560,000 poor or disabled recipients on the (Medicaid) program.”

—The Des Moines Register, February 28, 2016

I salute Jason Clayworth, the reporter who wrote the Des Moines Register article from which the above quote is taken, as well as Tony Leys, another Register reporter, and the Des Moines Register editorial staff. Their tireless efforts to investigate and comment on the upcoming transformation of the Iowa Medicaid program to a for-profit managed care model has brought some clarity to the issue as well as exposed some potential flaws. Iowa is only the fourth state in the country to completely adopt this new model across its various Medicaid programs.

As I write this post I note that the movie Spotlight won the Oscar for best picture, edging out The Big Short, an examination of corporate greed in America. Spotlight chronicles the Boston Globe’s investigation of sexual abuse by priests in the Catholic Church. I commend the Register’s efforts to spotlight the many issues associated with the Iowa Medicaid program and its transition to for-profit managed care.

While lauding the journalists at the Register, I regret citing a continual error in their collective reporting on the topic of Iowa Medicaid managed care. As a member of the Medicaid Assistance Advisory Council (MAAC) — mandated by federal law and further established in Iowa Code—for over ten years, I have confirmed again and again that the two ombudsmen noted in the above quote only serve recipients in long-term care (generally nursing home care) Medicaid programs; the other more than half a million patients with Medicaid have no dedicated ombudsmen to serve their needs. Further, I have been told that the State Ombudsman Office does not want to deal with or assist Medicaid patients. The above quote then becomes even more egregious because of the total lack of ombudsmen to represent Medicaid patients who are not in long-term care programs.

Twice delayed by U.S. Center for Medicare and Medicare Services (CMS), the Medicaid Modernization Program begins April 1.  As I have written in previous posts, the oversight process for this new program consists of a “three-legged stool,” according to the Iowa Department of Human Services: a legislative oversight committee, MAAC, and ombudsmen.

Obfuscate means to darken, confuse, bewilder, or to stupefy. With this definition in mind, I address the following concern specifically to Iowa State Senator Amanda Ragan, Iowa State Senator Liz Mathis (who some years ago attended journalism classes with my wife at the University of Iowa), Iowa State Senator Linda Miller, and Iowa State Representative Dave Heaton. I also submit this issue to the MAAC executive committee.

The Medicaid Assistance Advisory Council works now in consultation with the MAAC Executive Committee to make recommendations to the Medicaid program. I was outraged two weeks ago when making a motion to the Chair of MAAC at a meeting. I was told that motions and recommendations could not be made or voted on from the floor without the motion or recommendation being included on the agenda for that meeting. My motion was for MAAC to support efforts to create a sufficient number of ombudsmen to serve the general Medicaid population. This motion was not even allowed to have a second.  Motions and recommendations have been made from the floor and voted on during meetings since I joined the Council. The current situation, as I understand it, fits neatly in a scenario that Joseph Heller wrote about in his World War II novel, Catch 22. The Medicaid  Assistance Advisory Council is to advise and make recommendations but can now only do so if such motions and recommendations appear on the agenda of that particular meeting. Consequently, neither information nor shared ideas learned at a given meeting can be used to create timely recommendations during that meeting. Catch 22!

Given that the next MAAC meeting is scheduled for May, which will occur after the Legislature adjourns, this obfuscation by MAAC means the Legislature will not hear nor act on the recommendations of MAAC.  I have serious concerns about MAAC’s ability to be a viable oversight option. I hope the Legislators who are currently reexamining the oversight process take note of my concerns and give them serious consideration. Oversight needs to be viable, transparent, timely, informed, and patient-centered. Oversight should protect, enlighten and educate. Our current oversight process is simply not adequate. It will put all Medicaid patients in jeopardy.

In the end, Iowa needs a sufficient number of ombudsmen for general Medicaid patients and needs a fully functional, responsive, and responsible MAAC. I will continue to raise these concerns in conversations, meetings and via this blog.

An addendum: Republicans in the 1980s and 1990s touted the Patient’s Bill of Rights as a way to protect patients from the often greedy practices of Health Maintenance Organizations (HMOs). I am mystified by Governor Branstad’s administration and the Legislative Republican’s refusal to help an even more vulnerable population of patients who will now be asked to deal with for-profit Managed Care Companies (MCOs) for their health care. This is particularly concerning since we learned Sunday that the MCOs are starting their own medical clinics. These profit-driven medical clinics will put both Medicaid patients and the clinic’s own physicians and other providers at risk of being manipulated and exploited by the MCOs.