Medicaid

Marilyn Tavenner recently was confirmed by the U.S. Senate as the administrator of the U.S. Centers for Medicare & Medicaid Services (CMS).

It’s a big job, made even bigger by the Affordable Care Act, which is set to be fully implemented in January.

The 91-to-7 Senate vote showed bipartisan support for Tavenner, who had been principal deputy administrator at the agency.

A former HCA executive who began her career as a nurse, Tavenner came to Atlanta on Wednesday and spoke to a conference sponsored by the Georgia Chamber.

She also met with GHN for an exclusive interview, in which she discussed the law’s requirements, the individual states’ decisions on Medicaid expansion, and the challenges ahead as CMS gears up for health insurance exchanges to begin enrollment Oct. 1.

Q: Many states, including Georgia, have decided not to expand Medicaid. How does that impact the overall effectiveness of the Affordable Care Act?

A: When the Supreme Court ruled that the expansion was optional, or up to states, we started to re-project our numbers. It certainly decreases the number of people who will have coverage. But inside each state . . . we’ve tried to meet each state where they are.

If folks want to do a partial expansion, we’re still willing to do that under the old rules. It wouldn’t be at a 100 percent federal match; it would be at the traditional state match.

We’ve tried to send the signal that if you’re willing to do this in stages, we want to be there, we want to help. But there’s no doubt, in the states deciding not to expand, those below 100 percent [of the federal poverty level] will be missing [from coverage expansions].

I think the important thing for us is we have the federal marketplace available in those states, so at least we can pick up folks 100 percent and up, such as [in] Georgia, Louisiana and others, that have elected not to expand.

Fortunately, we have a strong regional office here in Atlanta. Atlanta probably has more of the pressure, because they have responsibility over several states that are not expanding.

With the [health insurance] navigator work, we’ll be working with not-for-profits and other partners to get the word out. We will insure everyone we can.

One of the unintended benefits is that when we start talking to folks, even some of the people currently eligible for Medicaid as it exists today in Georgia will get picked up [for coverage].

Q: Some states are talking about doing an expansion of Medicaid through the private market, with private insurers. What’s the administration’s position on that? 

A: Several states have talked about it. There’s actually one state that’s moving forward – that’s Arkansas. Although it’s still a Medicaid expansion, they’re using premium assistance. It’s been around and available, but it’s never been used on a wide-scale basis. So this will be our first waiver, our first demonstration. It will be on a statewide basis. We are actively working with Arkansas. To be honest, we have not seen any showstoppers. We think it will be the first demo to do premium assistance. This will entitle folks to all the Medicaid benefits and protections. It allows them to do the expansion.

Q: What is premium assistance?

A: Instead of having the Medicaid fee-for-service model, all these individuals will go into some type of private insurance plan.

Q: Many people have expressed doubts that the health insurance exchange will meet its deadlines and will be ready to go as scheduled. 

A: The GAO [Government Accountability Office] had a report out today as well [on exchanges possibly missing the open enrollment deadline Oct. 1].

It’s speculation. We will be ready. Now, will we make modifications as we go along? Certainly. But so far, we have met our deadlines. We have perhaps three regulations to get out. They’ll be coming out – some soon, some over the summer. We’re pretty much on schedule with that. We’re actively testing [systems]. . . .

I’ve just finished a series of calls, talking with each Medicaid director and each exchange director. I’ve got four or five more to go. I’m very encouraged that everybody is meeting deadlines.

Q: Will the exchanges provide a competitive market for insurance?

A: Here’s my honest opinion about that. Today, Atlanta is a classic example – Atlanta will remain competitive. We will have good premiums, and we will have the additional protections of the Affordable Care Act – no pre-existing conditions [that can bar coverage], no lifetime limits. It will have a better product at a competitive price.

There are some marketplaces that are not competitive. In my opinion, this project may take two, three, four years to change a non-competitive market into a competitive market.

But it will allow consumers to start getting educated about what’s available in their market. People start understanding what they’re paying for, what they’re receiving.

I think there will be some large insurers that will come in slower. But I think we’ll see more and more competition.

It’s really very much a private-based model. We’re using private insurers. It will grow over time. But I don’t think noncompetitive markets will become instantly competitive. It will take some time.

Q: There’s a tremendous effort ahead in educating people about the law’s requirements. What are the biggest challenges in this area?

A: Because of all the political theater over the last couple of years, the Supreme Court decision, the election last fall, there was a lot of back and forth. It’s really only been, in my opinion, in the last two months that we’ve had a really clear field about starting to get the message out about the Affordable Care Act and what it does.

Quite honestly, I try not to say the ‘Affordable Care Act,’ because it creates this feeling about whether it’s good or bad. But if I go one step below, about what we’re trying to do, people get interested. Most people want health insurance, they want some protection. They understand the importance of prevention.

I think we spend between now and September talking about what’s beneath the Affordable Care Act – what we’re trying to do – to increase access, improve quality and deal with costs.

In September, we change to ‘You’re John Smith, we want you to sign up for insurance.’ Then it becomes very targeted.

Q: Then it becomes about enrolling people. How will you accomplish that?

A: There are several ways to approach it. The navigators are one. We just put out a $50 million funding opportunity across the federal exchanges. The state exchanges have their own funding pool. There are people who will train. There are associations that naturally will gravitate to this and want to do this. We’re in the process of reviewing those applications now.

The second avenue is the website [www.healthcare.gov]. If you and I want to go to the website and sign up, and check to see what we qualify for, we will be able to do it without a navigator, so you can do it independently.

We’ll have a 1-800 call center similar to Medicare numbers today. We have different levels of training and skill sets. If you have a basic question, or if you want to really start to dig into your account, we have different levels of training.

Q: How will you get basic information out to consumers – what they need to pay attention to?

A: We actually started some of that last week. States have started their television and media campaigns . . . State-based exchanges have a great deal of independence.

We’ll be doing that – TV, radio, print. We’ll being doing it through the call center, and through the website.

Q: There are employers trying to get out of some of the law’s mandates. Such as hiring people to work under 30 hours a week, who won’t be considered full-time employees; keeping a workforce under 50 full-time employees, so the company doesn’t have to offer insurance; providing bare-bones plans and driving people into the exchanges. What’s your response to these moves? 

A: For large employers, they had a lot of grandfathering protections. So for them, I won’t say it’s business as usual, and there were certain things they had to add, such as insuring [dependent children] up to age 26.

There are some things that are different for them, but as I remind them, they should also see the cost benefit. We’ve seen the lowest cost increases [during] the last three years. First, folks said it’s the economy [holding the costs down], but now most economists are saying that we can’t say it’s the economy. I’ve tried to make the point that for large employers, I’m not seeing this desire to get out of the business [of providing insurance].

I’m sure they’re looking at the 30-hour issue. That’s a real issue – I’m not making light of that.

If you have less than 50 employees, you don’t have to offer health insurance. We hope you do, but there’s no penalty; you are exempt. That’s the majority of startup businesses.

What we are trying to do is make marketplaces competitive so you want to offer insurance as a recruitment tool, as the right thing to do for the employee, and the employee’s family.

There’s a lot of misconception about who has to pay the penalty. The folks who will have to pay are the people who are above 50 [employees] and choose not to offer insurance, and who have someone who actually goes to the exchange.

That’s a small population of employers. Most employers are either below 50, or fall into those who traditionally offer insurance.

So I think a lot is being made about a very small segment of the market.

Q: You were here recently speaking to large employers. What was discussed?

A: We had a closed meeting at Grady Hospital, and I met with large employers. We had this very good debate back and forth. I was talking with one of them in the hallway [today], and he said, ‘I’m surprised you came back. We gave you a hard time.’ And I said, ‘I was surprised to be invited back.’

I’m OK with getting a hard time. I actually think it was a good dialogue. I wanted to hear from them about kind of the cost trends they were seeing, and they were good. But they did have concerns about the Cadillac tax [on expensive benefits plans] and covering [people's children] up to age 26. It was an open dialogue at what we need to look at long term, where we can make improvements. It was a give and take.

Q: What do you want to emphasize about all these changes?

A:  I would like to emphasize the points I made about access, cost and quality. Access is one big piece of it, and obviously it’s the part we’re rolling out in the fall. But we’re really trying to look at all three areas.

Folks have been complaining bitterly about health care for years. Everyone complains, but no one really offers a long-term solution. This is an attempt at a long-term solution to a problem this country has recognized for years. Is it perfect? No. Will it have to be modified over time? Absolutely.

But it’s a step forward. We can’t do it without industry support, without advocacy support. I’d like to emphasize we’re all in this together. I want to work together with folks.

Oct. 1 is a big milestone for the Affordable Care Act.

That’s when open enrollment begins for the ‘‘marketplaces,’’ the insurance exchanges where individuals and small businesses will get health coverage under the 2010 law.

Renard Murray is well aware of the upcoming calendar.

Murray is the regional administrator for the Centers for Medicare & Medicaid Services in both the Atlanta and Dallas (Texas) regions.

He will be in charge of the federally run insurance marketplace in Georgia and six other states in the Southeast. And Murray, who hails from Louisiana, will be working with the exchanges in the Dallas region, which consists of Texas, New Mexico, Louisiana, Arkansas and Oklahoma.

Georgia Health News interviewed Murray recently about the planning for the marketplaces, the public perception of the Affordable Care Act (often known as Obamacare), possible problems with its implementation, and the South’s health challenges.

Q: You’re in charge of the exchanges in two regions now?

A: With the Affordable Care Act, it’s basically region-based. So in the Atlanta region, we are running federally facilitated marketplaces in seven of eight states. The executive person in each region is basically running the marketplace for that region –– open enrollment, quality, and its operational components. I’m running the Atlanta region marketplaces.

I’m supporting the Dallas region as well, but not really leading it. It’s still a lot of work.

Texas has the largest number of uninsured among states with federal facilitated marketplaces, and Florida is second. It keeps us busy. But it’s exciting work, because when you think about the mission of getting the uninsured people insurance that they’ve never had before, it’s keeping us excited. Individuals with pre-existing conditions who were denied coverage can now get coverage. That keeps us excited.

Q: Which states in your region are running their own marketplaces?

A: The only one running its own [in the Atlanta region] is Kentucky –– they have a state-based marketplace. We stand ready and available to provide support, assistance, guidance, recommendations to Kentucky as well, even though they’re operating their own marketplace.

Q: And the Dallas region?

A: The only one in the Dallas region running its own marketplace is New Mexico.

Q: How’s the planning for the marketplaces going?

A: It’s going very well. We’re partnering with our federal partners [such as] the Department of Labor, the Department of Education. They have similar interests in getting people insured. There’s overlap.

The Department of Labor operates the COBRA benefit. Individuals are becoming unemployed, but may not afford COBRA coverage, but they qualify for the marketplace. From the federal perspective, we are working with more than a dozen of our federal partners.

We are also working with stakeholder groups –– the hospital associations, the geriatric associations, the various associations that deal with individuals who might be uninsured. We’re trying to get them to understand what the marketplace is.

We are driving people to our website, Healthcare.gov, which has posters, pamphlets, YouTube videos, self-help things –– things that can educate your constituencies in terms of what the marketplace means. We’re developing it in Spanish as well. We want to reach all populations.

Q: Are you working with health insurance companies as well?

A: This is work we recognize we have to do. We haven’t really started engaging insurance companies directly at the regional level. I’m not saying it hasn’t happened nationally at the headquarters level. Here, we have had several conference calls and trainings already, and I’m sure insurance company members have participated.

We’re trying to get people more interested in becoming [insurance] navigators to ask questions and be informed on what the navigators will be doing. We’re giving stakeholders information on what to expect with education, what the marketplace means. We want to make sure that we’re getting it right. We’re asking stakeholders to give us ideas and information that will help us build this correctly.

Q: Will the information technology to launch the marketplaces in October, or definitely by January, be ready?

A: I would say yes. There’s been a lot of work that has been going on with states. There’s been testing in building that [IT] hub. In addition to that, we’re also developing a network of call centers that can help individuals, so a person can call, speak to a counselor who can help them.

I’m pretty confident that our IT infrastructure is going to be pretty solid so that we’ll be able to facilitate marketplace enrollments beginning October 1.

Q: There’s a lot of confusion among consumers about how this marketplace is going to work –– questions such as: Am I eligible for credits? How is this going to help me? Am I going to lose my insurance?

A: Let me use an analogy for you. Fifteen to 20 years ago, we’d go to a travel agent to take a trip. The travel agent would come up with options, you’d pick a flight, you’d go there, you’d have a good time.

The marketplace will be very similar to the transition of moving from travel agents to Travelocity or the other sites [that offer travel assistance via the Internet]. Individuals who would normally go to insurance companies to shop for insurance will go now into a marketplace.

At a one-stop location, they can decide which health plan is the best option for them. Their children can be eligible for CHIP through the marketplace, or Medicaid. Individuals with incomes less than 400 percent of the federal poverty level will also quality for a tax credit.

It sounds like it’s overwhelming, but nonetheless, it puts at the fingertips of consumers the ability to choose a plan that works the best for them. Just like it did for Medicare Part D. There are gold, silver, bronze, platinum plans –– they can choose which coverage is best for them in the marketplace.

It sounds it may be a little bit overwhelming, but they’ll have more ability to manage my own choice health care, instead of going to an agent.

Q: You mentioned Medicare Part D, the prescription drug benefit that debuted in 2006. There were hiccups when that started. Do you anticipate similar glitches?

A: Yes, there were a few hiccups along the way in Part D, but the good thing is we learned a lot of lessons.

We’re applying those lessons to the marketplace . . . We’re looking at our processes now so when people apply October 1, we have procedures and processes already developed [to help them] based on lessons we learned from Part D.

Q: Many of the states in your regions are not expanding Medicaid programs. How much of a problem will that be?

A: Let’s look at it historically. When the law was signed in the ’60s [establishing] Medicaid, several states said, ‘We’re not going to do Medicaid.’ Maybe less than a handful of states said they weren’t going to do it. Here we are [nearly] 50 years later, and we have Medicaid programs in every state. I can’t predict what states will do, [but] Medicaid expansion may follow the same path.

Q: So you believe states will eventually expand their programs?

A; It depends on the Legislature of a state and what they decide to do. I think states will start to re-examine their options, realize the availability of federal funds, and then decide what’s best for the state, based on whatever the governor and Legislature decides to do.

Q: Many critics of the ACA say it’s too costly for states to expand Medicaid.

A: I can’t speculate what a governor is looking at in terms of cost, because what he or she may be using for analysis may be based on some other types of decision points. On the point of reimbursement for Medicaid expansion, all I can tell you is that in the first three years, we’re looking at 100 percent federal reimbursement. The plan has been laid out in terms of Medicaid reimbursement rates for expansion over the next 10 years.

Governors are making a decision based on what he or she anticipates is going to be the growth of cost of the Medicaid program over that time.

Q: Opponents also question whether the federal government can deliver what it’s promising, given the current budget crunch.

A: I’ll use another analogy. You buy a car, you expect it to last five years with a five-year warranty. You have a major breakdown in the fourth year. The warranty is still there; it hasn’t expired. The regulation [says Medicare expansion] will be 90 percent [federally funded] 10 years down the road, and it will be 90 percent.

Q: You’ve heard a lot of criticism of Obamacare. What are the biggest misconceptions about it?

A: The biggest misconception is people basing their comments and decisions on what they’re hearing from a neighbor or someone else who hasn’t read the regulations and doesn’t know what’s going on. I try to debunk the myths and direct people to Healthcare.gov, the official site.

Don’t base what you’re hearing from a media outlet. Base it on what you’re hearing from the federal government. If you have questions, you can contact the Department of Health and Human Services, the Centers for Medicare and Medicaid Services, or if you have a tax question, contact the IRS. . . . We have a team here at CMS that can address those questions.

Healthcare.gov gives information on not just how the marketplace will work but how the Affordable Care Act itself works, how it affects women, affects seniors, affects Asian-Americans . . .

We also have a mobile app, so that individuals can access [the marketplace] from their smartphones, and people can sign up for information. When the marketplace website is launched, you can access it . . . and start the enrollment process.

Q: The states in your region have physician shortages. There are fears that the ACA will aggravate these shortages.

A: I’m not that concerned about that. I hear the comments and the rhetoric about not having access.

Some of the things we’ve done [include] HRSA, with the Medical Service Corps, looking to expand the availability of primary care positions in medically underserved areas.

In Medicaid, we’re reimbursing primary care physicians at the Medicare rate, enhancing more primary care for Medicaid recipients because we tend to have a gap there.

We’re getting more advanced practice nurses out there.

We’ll see a lot of people hopefully accessing primary care, instead of [going] to the ER . . . We’re developing medical homes that will provide primary care and coordinate care. Medicare is developing accountable care organizations. There’s telemedicine.

I think we’re going to have adequate access to services over the next several years.

Q: The South has many health needs and health disparities, along with high poverty and uninsured rates. How important is the ACA in addressing these problems?

A: It’s extremely important. States in the Southeast are among the highest in uninsured rates.

We’re working on other models. There’s a pilot project taking place in Alabama to focus on heart [care]. A lot of people in Alabama have congestive heart failure. African-Americans as well as [Hispanics], we’re targeting those ethnic groups [so they] get more informed about some things that can help prevent heart attacks and strokes.

Q: Do you hope the ACA will help solve these health problems?

A: It’s not going to be solved, but we’re going to make a tremendous dent in it. A lot of the things we’re focusing on, telling African-Americans, Asian-Americans, this is how the ACA can help you to deal with some of the health issues you’re having.

Each state has an office of minority health. There are connections with those state offices. We’re working with them to deal with some of the health disparities.

Q: Anything else you want to emphasize?

A: Even though the marketplace is upon us, we’re still going to administer the Medicare program, the CHIP program, the Medicaid program. We know the natural connections between those programs.

If you walk around the halls at CMS, you’re probably going to see some pretty exhausted people –– they’re doing both things at once. Nevertheless, we’re excited about the work coming from the Affordable Care Act.

Georgia's Attorney General

From his opposition to the Affordable Care Act to his prosecutions of Medicaid fraud, Georgia Attorney General Sam Olens has been very involved in health care issues in the state.

Georgia Health News recently sat down with Olens in an exclusive interview regarding his views on health care.

He discusses his fight against “pill mills,’’ his views on health reform and its regulations, and his office’s anti-fraud work, including a current case involving abortion.

Olens also touches on rural hospitals’ challenges, tort reform, and his campaign for lawyers to collect food for poor children in the state.

Q: Fighting against ‘‘pill mills’’ is a legislative priority of yours. Talk about what needs to be done with the problem of these prescription drug sales.

A: Florida had a huge problem, and about two years ago, they passed legislation that significantly reduced the number of medical providers who were selling large quantities of oxycodone.

Ever since Florida’s improvement, many of those bad actors have moved into our state. It is expected that once Georgia passes legislation, those bad actors will move into the next state.

We have the blessing and the curse of such a great [transportation] infrastructure here, between Hartsfield-Jackson [Atlanta's international airport] and I-75 and I-85 and I-20. So it’s easy to transport Class II and Class III drugs [controlled substances].

The legislation seeks to provide the medical board and pharmacy board the necessary authority to wipe out those bad actors.

We’re not trying to stop reputable doctors who treat intractable pain from doing so. We want those patients to have the appropriate medical and pharmacy care.

But when you see a place that’s renting by the month, [where cars in the parking lot have] predominantly out-of-state plates, when the doctors are not really issuing many prescriptions, they’re having a cash business inside the building – we want those actors out of our state.

Q: There’s legislation on this currently introduced in the Georgia House.

A: House Bill 178. The chief sponsor in the House is Tom Weldon, and it has approximately 45 co-sponsors. The bill specifically provides for the medical board to license and regulate providers [of pain management clinics].
Q: Last year, a similar bill failed to pass. What’s different this time?

A: [Last year’s] bill was ready for passage, but it was the last week of the [legislative] session. There was an education component and it was necessary to hold meetings to bring everyone together – the medical community, the pharmacy community.

And the rush is not to pass a bad bill. The push is to pass a good bill.

We frankly ran short of days to accomplish that. It wasn’t for lack of effort. It was for lack of time.

The bill, as filed this year, is exceedingly similar to the last version from the session. We certainly have very optimistic expectations that the bill will pass this year.

Q Is it similar to the pill mill law in Florida?

A: Yes. There are differences in our states’ constitutions that mandate differences in the legislation. But as a general statement, yes.

Q: Your administration seems to place a high priority on fighting Medicaid fraud, based on the number of press releases on prosecutions we get from your office.

A: I would suggest to you that some of that is simply the difference in [information policy] of administrations. By that I mean our office puts a lot out on the website. When I was running for AG, one of the typical questions was, ‘‘What does the AG do?’’ I think part of the way I respond to what the AG does is through these press releases, on pleas, trials, convictions.

From a process perspective, I think we have placed a higher emphasis on the Medicaid fraud unit. But that should in no way, shape or form say that prior Attorney General Thurbert Baker did not put an emphasis on it, too. We’re putting more out there because we think the public learns from that information.

I think frankly it also has a deterrent effect on bad actors, in telling them we’re going to take [their offenses] seriously and we’re going to take appropriate action, whether it’s a civil recoupment or criminal conviction.

Q: Do you think fraud is currently being contained, or are the prosecutions uncovering just the tip of the iceberg?

A: I think it’s the tip of the iceberg. And I think it’s the case nationally. You can get many quotes from the Department of Justice and HHS on the massive amounts of Medicare fraud. I think the same can be said for Medicaid fraud. We work closely with our three U.S. attorneys in the state, with our federal and state law enforcement partners, and I think there’s more we can and should do.

Q: There’s a Medicaid fraud case involving abortion that’s getting headlines. You’re prosecuting that case, even though a state administrative law judge found the physician had not committed fraud. Why are you pursuing that case?

A: Let me answer in general, because it’s a pending matter.

There are two prosecutions, not one. [Also,] we didn’t represent DCH [the Department of Community Health, the state’s Medicaid agency] in the administrative hearings referred to in these cases. We are involved in the criminal context, not the administrative context.

This is not a political case in any way, shape or form. It’s a Medicaid fraud case. The Hyde Amendment is very clear on the use of Medicaid dollars [prohibiting the use of federal dollars for abortion].

These cases didn’t originate in my office. They didn’t originate at the Medicaid fraud unit. They originated at DCH, the state agency …

These cases are generally referred from the state agency or other sources, and moved to the Medicaid fraud unit.
Q: In your mind, there were Medicaid funds spent for abortion?

A: Let me rephrase the question. We allege that Medicaid funds were spent in violation of federal law.

The issue is not abortions. The issue is compliance with federal law relating to Medicaid.

Q: So it could have been anything – Medicaid funds being used to pave roads, for example?

A: We’re treating this case as we would treat any Medicaid fraud case. There’s nothing special or different about this matter than anything else in the Medicaid fraud unit. It’s not a higher priority or a lesser priority.

Q: You were very much out front in your opposition to the Affordable Care Act, the health reform law of 2010, and led the state’s legal fight against it. Talk about the legal reasons for your opposition.

A: When the country was first founded, the first constitution was the Articles of Confederation, which was very weak on national power and gave predominant power to the states.

Thereafter came our current Constitution. And there was a dispute at that time about whether the federal government had paramount power, or the states, which led to the Bill of Rights.

Never before had Article 1, Section 9, of the Constitution, the Commerce Clause, been used regarding failure to buy a product, and call it commerce [the ACA’s mandate for most individuals to obtain health insurance or face a financial penalty].

So I would suggest to you that while your interest area is health care, and that’s the purpose of your publication, the objection from the [state] attorneys general was not specifically about health care, it was federal overreach of the Commerce Clause.

Now we were told we were going to lose on the Commerce Clause and lose on the spending clause about the expansion of Medicaid and that we would win on the tax clause because the president and Democratic leadership in Congress denied it was a tax because they wouldn’t have the 60 votes in the Senate.

Of course the exact opposite transpired. We won on the Commerce Clause and the spending clause but lost on the tax clause when Chief Justice Roberts opined, because principally [he reasoned] if the individual mandate did not carry with it criminal penalties, it could still be viewed as a tax.

We were involved in the case not due to health care, but due to the fact that we felt the president and Congress had exceeded the powers given to them in the federal Constitution.

And many of us think for decades that states have looked the other way and not maintained or sought to maintain state sovereignty.

Having said that, there are still numerous issues. There are thousands of pages of forthcoming regulations still due to the Affordable Care Act. There are significant issues related to the default federal health insurance exchange in regard to the state. There are significant issues on how HHS will deal with the ability of states to not accept expansion on their terms . . .

You have had Governors Jindal [of Louisiana} and Perry [of Texas] opine that if [Medicaid] was given as a block grant, they would be much more inclined to take the expansion.

Q: Governor Deal has also supported Medicaid block grants.

A; That’s true. There are numerous legal issues remaining both on the employer mandate as well as the expansion of Medicaid. As we read forthcoming regulations, it will determine how many if any additional lawsuits [will be filed] by the same states that filed the initial lawsuit against the Affordable Care Act.

Q: So this issue is not going away?

A: Look, the majority of the court held it was constitutional. The president was re-elected. So the Affordable Care Act is a reality. I believe strongly in the rule of law. It is a law in our country, one that I need to follow, like all other laws.

At the same time, there are other elements of that law where federal regulations are still forthcoming. Depending on those regulations, there may be additional disagreements with HHS that merit litigation.

Q: Your position appears to be one of monitoring the [health reform] law.

A: We’re closely monitoring all of the regulations. We frankly did not agree with HHS on the religious liberty issue [mandating most employers to offer free contraception].

. . . I was recently at Clayton State University, and former Gov. Roy Barnes and I were on a panel, and Barnes [a Democrat] disagreed with how [the Obama] administration was handling that issue, too. Folks of very different backgrounds had large concerns with the regulations on the issue.

Q: Will you join in the lawsuits against the employer requirement on birth control?

A: Potentially in the form of amicus briefs.

Q: Did the president’s recent compromise on the contraception issue change anything?

A: It was a little broader than the first version, and I think many folks are now trying to chew on it, and to decide whether further action is necessary. Clearly from a perspective of a business such as Hobby Lobby, the change did not affect them at all. So I expect their appeals to continue.

Q: Certificate of Need — the state regulatory process of health care facilities — has been controversial at the very least. The Republican Party stands for less government regulation. What are your thoughts about CON?

A: To be honest, I’m reluctant [to discuss it] because there’s pending legislation across the street [at the Capitol], and depending on what they pass, I’m there to defend it, whether I like it or not.

Clearly there’s a lot of litigation between various providers at the moment that we can all agree isn’t healthy.

We can also agree that we have too many hospitals in danger of closing. And I think there is a very valid concern that the increased cost of the president’s health care act is adversely affecting those rural hospitals and their ability to stay in business.

And one of the things that concerns me as the state’s lawyer is the fact that we have areas of the state that have insufficient trauma and labor and delivery services now. An unintended consequence of the ACA [may] make it worse.

Q: If the state doesn’t expand Medicaid?

A: We’re in a state where we’re 45th in the country in number of doctors per 100,000 people. We’re in a state where only 42 percent of our doctors accept Medicaid now. There are already estimates of an additional 100,000 enrollees to Medicaid due to the Affordable Care Act — separate and apart from the expansion — [which will have] an estimated cost, according to the governor’s office, , in excess of 1billion over the next decade.

And many state budgets are being cut to balance this year’s Medicaid budget.

I don’t think the public understands how much money Medicaid costs.

One of the reasons we won on the spending clause in the U.S. Supreme Court was that on average, Medicaid is 10 percent of a state’s revenues.

When you talk about K-12 [education], technical colleges, colleges and universities, and Medicaid, it’s really tough for states before you even get to law enforcement on balancing a budget. We don’t get to do what Washington unfortunately does – give massive amounts of debt to our children and grandchildren. I think we’re getting to a crucial point where the states are having trouble funding the essentials.

Q: What are your thoughts about having special arbitration panels resolve medical malpractice allegations?

A: I think it would be very interesting to seek to do that in the form of a pilot [project]. Where everyone would have the benefit to see how it worked on a voluntary basis, before it was potentially made mandatory. By doing so, you may get a buy-in from both sides during that pilot project.

Q: You’ve taken an interest in food donations to the poor. How did your drive to get lawyers to collect food for the poor come about?

A: At the national attorneys general meetings, we try to cover best practices, and best practices may not be limited to how to win a lawsuit, [but also] what’s worked well for your community.

At one of the first meetings I attended, the attorney general for Virginia talked about how his predecessor, now the governor of Virginia, started this food drive. As a result the lawyers in Virginia collect approximately 1.2 million pounds of food every year.

Georgia’s now about the fourth state to do it. Since we’ve done it, one or two other states are now doing it.

The first year we collected the equivalent of 620,000 pounds. The goal this year is 750,000 pounds.

It’s a great way for lawyers to use their contacts in their local communities to collect food and money that goes straight to the local food bank. The food and money don’t come to Atlanta, and are thereafter spread throughout the state. They immediately go to one of the seven regional food banks where [people] live.

The scary fact for me is that 60 percent of our public school children are eligible for free or reduced lunch. That number is alarming. We have specifically timed our two-week food drive so that those children who get free or reduced lunch during the school year may have a healthy lunch over the summer. The food banks are using these donations to help them in neighborhoods where they know there are many poor children over the summer months.

Q: Many kids go hungry during the summer.

A: No one really thinks of what they do in the 10 to 12 weeks over the summer. We overtly encourage them to reach out to the Rotary, Civitan, Kiwanis, Chambers [of Commerce], bring a box and get food from everyone in their community.

With this recession, the demand is only greater, the state’s poverty rate is only higher. It’s a great opportunity for lawyers to provide additional value to their community. ..

And the winners are the children. . . . If part of the bully pulpit that comes with being the state’s lawyer is providing healthy food to our schoolchildren, so much the better.

Dr. Jaquelin Gotlieb examines a new patient, Jada Smith, 5, at her Stone Mountain office as Jada’s brother Jaylan looks on

Drs. Jaquelin and Edward Gotlieb, a husband-and-wife pediatric team, have practiced in the Stone Mountain area for 36 years.

Over that time, the two pediatricians have seen their percentage of Medicaid patients rise — while the income from their practice drops.

The government Medicaid program in Georgia pays much less than Medicare, which itself pays less than private insurance. And currently, two of every three children coming to the Gotliebs’ practice are on Medicaid or PeachCare, another government program that pays a similar amount.

But starting in 2013, the Gotliebs’ financial arithmetic will begin to improve.

That’s because physician Medicaid rates will be raised next year to the Medicare payment level, the result of a little-known provision in the Affordable Care Act. For a “sick” office visit, the pay for a physician is estimated to rise from about $40 to nearly $70.

“It will help tremendously financially,’’ Jaquelin Gotlieb says.

The pay bump will mean more Medicaid reimbursement for services by family physicians, internists and pediatricians, and for vaccinations, with the extra money supplied by the federal government. The pay hike is for two years.

A survey of 1,400 physicians in Georgia found half of them do not accept new Medicaid or PeachCare patients. Pay is a major reason for those doctors’ decision. In an economy that has been weak for years, some doctors have to make hard choices to stay in business.

That, in turn, makes it harder for many low-income people to find doctors who will see them. In the overall effort to improve access to care in Georgia, low doctor pay from Medicaid has been a major obstacle.

Vocal opposition to hike

The pay hike is considered good news for doctors and patients. Yet its link to the Affordable Care Act caused some dissent last week at a meeting of the board of the state Department of Community Health. The opposition arose despite the fact that the additional reimbursement is paid for entirely with federal funds.

Jerry Dubberly, the state Medicaid chief, presented the pay raise proposal to the agency board for initial adoption of a public notice of the change.

But Community Health board member Clay Cox commented that the state had no real choice, and called the pay raise move “just disgusting.’’

Dubberly said there would be administrative costs to the state with the change. “It’s significant staffing time,’’ he said.

The initial adoption of the public notice of the pay hike was approved by the Community Health board, with Cox the only “no’’ vote.

The pay raise won’t pertain to PeachCare. Still, groups representing primary care physicians say it’s a much-needed boost.

“In rural areas, it will help sustain the practice and keep it open,’’ says Dr. Mitch Cook of Athens, president of the Georgia Academy of Family physicians.

The commissioner of Community Health, David Cook, said the pay hike may have an impact on the supply of doctors taking Medicaid patients. But Cook also said, “Physicians know this is a temporary measure.’’

He questioned whether doctors will make a long-term financial decision on expanding their Medicaid practices, given the uncertainty over the federal budget.

And Jaquelin Gotlieb notes the administrative burden that physicians deal with in treating Medicaid patients.

The pay hike “will help doctors who have the dedication to stay on Medicaid,’’ she says. “I don’t think it will attract new doctors.’’

The Medical Association of Georgia also backs the pay increase, noting that “Medicaid physicians in Georgia are paid at a rate that is less than the cost of delivering the service.”

The group cites the significant shortfall that Medicaid faces.

“It is imperative for Georgia to find a way to adequately fund the Medicaid program in a permanent and sustainable way to ensure that the state’s neediest residents have access to the medical care they need.’’

Losing money on some patients

A Lithonia internist, Dr. Clyde Watkins Jr., says he stopped seeing new Medicaid patients four years ago.

“It was purely the reimbursement,’’ says Watkins, a member of the Georgia chapter of  the American College of Physicians. “It doesn’t cover the cost of delivering the service. My practice loses money when seeing Medicaid patients.”

Watkins points out that the reimbursement change will help physicians who take care of “dual eligibles’’ – people who receive both Medicaid and Medicare insurance.

He says current Medicaid reimbursement is so low that it does not cover the 20 percent co-insurance amount for dual-eligible patients. So, under current payment structure, doctors basically lose that payment.

But starting next year, Medicaid would pay that often missing 20 percent amount.

“We would no longer lose money with existing Medicaid patients,” Watkins says.

Every dollar spent now for medical care will save money in future health costs, he adds. “It will help make Georgians healthier in the future.”

After smoking on and off for more than 12 years, Atlanta native Katie Moore may have finally kicked the habit for good.

How did she do it? By moving 880 miles away, to New York, where the state tobacco tax is the highest in the country — $4.35 a pack, nearly $3 more than the national average of $1.46. In New York City, where Moore now lives, smokers pay an additional $3.10 tax on top of the state tax. In some parts of New York, a single pack of cigarettes can cost as much as $14.50.

Because of high cigarette prices, Moore said, smoking ceased to be an option when she moved to the Big Apple for her job. In fact, the 30-year-old associate financial representative admitted that the high price of cigarettes was the only reason she ditched her three-pack-a-week habit.

“If I still lived in Atlanta, I probably would have never stopped,” she said. “Cigarettes were so cheap, so the incentive to quit just wasn’t there.”

Testimony from people like Moore proves why Georgia should raise its tobacco taxes, said Sarah Balog, government relations director for the American Heart Association in Atlanta.

“Every price increase has a documented and proven effect to reduce youth and overall smoking rates,” Balog said.

According to data from the Campaign for Tobacco Free Kids, every 10 percent increase in the cost of tobacco means a drop in youth smoking rates of about 7 percent and a decrease in adult smoking rates of 4 percent. Those numbers may seem small, but in Georgia, where the tobacco tax is the 48th-lowest in the nation, and more than a dollar less than the national average, a small decrease in the number of smokers could translate into a significant decrease in state health care spending.

But efforts to raise the tobacco tax have gone nowhere during recent sessions of the Georgia General Assembly, including this year, when health advocates backed an additional tax of $1 per pack of cigarettes.

The year before, the same dollar-a-pack increase died in the Legislature after opposition by the Georgia Association of Convenience Stores. Georgia’s current tax is 37 cents per pack.

Advocates of a tobacco tax increase point to the dangers of youth smoking as a major reason to make a change. The Bump It Up a Buck coalition says that in Georgia, 95,900 high school students smoke and 22 million packs of cigarettes are bought or smoked by kids each year.

But the issue goes beyond young people. “Currently, . . . [Georgians pay] out of pocket a half a billion dollars a year for smoking-related illnesses [covered by Medicaid],” said Rep. Ron Stephens (R-Savannah), who was lead sponsor of a bill to increase tobacco taxes in 2009 and 2010. Keeping tobacco prices low forces hardworking Georgians to subsidize Medicaid costs for smoking-related illnesses, he said.

If Georgia’s tobacco tax went up by one dollar a pack, as Stephens proposed two years in a row, the state would take in $350 million more to defray these health care expenses. Though that still would fall short of the half-billion that Stephens said is needed, the current tax brings in far less — $150 million each year.

The last time the state tobacco tax was increased was in 2003, when Sonny Perdue had just taken office as governor. He signed a bill to raise the tax from 12 cents to 37 cents a pack. The change was not very big by national standards, but the state brought in an additional $100 million the following year.

In the period since then — with Perdue serving eight years in the governor’s office and Nathan Deal succeeding him in 2011 — there has been no further increase in the state tobacco tax. Efforts to get another increase through the Legislature haven’t come close to success.

A clash of political wills

Advocates of an increase point to evidence of strong public support for the idea. In a poll conducted in 2010 by Glen Bolger, a Republican strategist and co-founder of Public Opinion Strategies, 72 percent of self-identified Republicans and 76 percent of self-identified Democrats in Georgia favored a tobacco tax increase.

But the anti-tax movement is a political force to be reckoned with in Georgia, and the campaign for a tobacco tax increase has run up against it.

Stephens said many conservative legislators in Georgia shy away from his proposal for fear they will be labeled “tax increasers” and lose their seats. In an especially trying economic climate, legislators see supporting any tax increase as risky, even if the majority of citizens support it, he said.

Stephens also said that a prominent anti-tax political think tank, Americans for Tax Reform, has kept some Georgia representatives from sponsoring the tobacco tax by promoting a “no new tax” pledge. Once legislators sign the pledge, they must stick to their word and oppose all new tax proposals or jeopardize their reputations as being truly “anti-tax,” said Stephens.

But Joshua Culling, Georgia’s state affairs manager for Americans for Tax Reform, said Stephens’ perspective is the one that is shortsighted. Raising the tobacco tax is not the solution to Georgia’s problems, Culling said. A total reform of the current health care system is what is really needed, he said, and until that happens, a tax increase will only hurt the economy.

“Raising taxes to cover health care costs suggests that the system is OK and that there’s just not enough money currently to sustain it,” he said. “But it’s a broken system that needs to be addressed, and until our legislators understand that point, we’ll never fix the problem.”

Culling said raising the tobacco tax would put on an unfair burden on a small segment of the population to solve a statewide problem, which is why so many legislators oppose the idea.

In 2012, roughly 23 percent of Georgia’s state senators and 20 percent of its state House members, the majority of whom are Republicans, have taken the anti-tax pledge — including key leaders such as House Speaker David Ralston. Governor Deal, a Republican, has also taken the pledge.

Not all Republicans in Georgia oppose a tobacco tax increase. Three of the five co-sponsors on tobacco tax legislation are conservative Republicans. These sponsors understood the long-term financial benefits to Georgia taxpayers of increasing tobacco prices, said Rep. Mary Margaret Oliver of Decatur, one of the two Democratic co-sponsors of the bill.

“Bottom line, we should not be encouraging people to smoke tobacco, because our taxpayers have to spend more money on smoking-related illnesses,” she said.

Oliver applauds Stephens, the most high-profile GOP advocate of the tobacco tax, for taking “a real economic view” on taxpayer dollars, even if it’s an unpopular stance among some Georgia legislators.

“State representatives cannot avoid issues of preventive health care,” she said, “and [Rep. Stephens] as a pharmacist and someone who works in the health care profession, understands the potential financial and health benefits of raising tobacco prices, even if that means supporting a tax.”

Gov. Deal has said that raising the tobacco tax would harm convenience stores near the border with other states.

Unable to make any headway with the governor and legislative leaders, Stephens has temporarily shelved his campaign to increase the tobacco tax.

“There is no need to waste my energy and the energy of other representatives if leadership support isn’t there,” said Stephens. “It’s going to take a shift in mindset, and an understanding that we are subsidizing Medicaid on behalf of the working public. Until that point is made, no one will touch it.”

What about retailers?

Some blame the prevailing attitudes in the Legislature on Big Tobacco.

The millions of dollars given each year to the Republican National Committee by tobacco companies keep Georgia Republicans from cutting ties and implementing a harsher tax, said Eric Bailey, Georgia grassroots advocacy manager for the American Cancer Society.

But for tobacco-tax opponent Jim Tudor, president of the Georgia Association of Convenience Stores, it’s not a matter of loyalty to tobacco companies. It’s all about loyalty to small retailers.

“Legislators are well-meaning people, but they are not retailers and they don’t have to compete with other stores,” Tudor said.

Raising the tobacco tax by a dollar may drive Georgians living in border counties to cross state lines to stores where cigarettes would then be about 20 cents cheaper, he said.

“It’s a pennies business, and we can’t afford to lose any business for reasons of tax policy,” Tudor said. “This may not affect states without a large border population, but that’s certainly the case in Georgia, and it will hurt small businesses.”

Culling agrees with Tudor, calling the tobacco tax an “unstable” method to raise revenue because of cross-border sales.

Convenience stores rely on tobacco sales for a third of their yearly profit, so a tax increase that helps competitors will certainly hurt Georgia’s small business owners and the economy, he said.

Culling also cited an ATR-funded study that found Georgia’s cigarette sales increased by nearly 1.3 million packs six months after South Carolina raised its excise
tax rate in July 2010.

But Balog said Culling’s and Tudor’s argument doesn’t hold up.

“This fear of cross-border sales is the biggest boogeyman in the argument against raising the tobacco tax,” she said. “The idea that someone is going to drive across the border to save pennies on cigarettes when the gasoline prices are so high just doesn’t make sense.”

Evidence from four neighboring states – South Carolina, Tennessee, Alabama and Florida – shows that sales in counties that border Georgia have not taken a hit even though their tobacco prices currently exceed those in Georgia, Bailey said. A report from the economic consulting firm Orzechowski and Walker illustrates that Georgia’s tobacco tax revenue actually declined 5 percent after Florida raised its tax by $1 in 2009 to match the national average, he said. At the same time, Florida saw a 193% increase in revenue, collecting $1.2 billion in 2010 versus $429 million in 2009.

Advocates for the tax in Georgia are not giving up despite recent setbacks.

Raising the tobacco tax, and hopefully encouraging some people to stop smoking, will not only benefit the state financially but also help its image, Balog said.

“Georgia is known for so many things – great golf, sports, music, food, beaches,” said Balog. “Do we really want to make cheap cigarettes and high incidence of smoking-related illnesses one of them? I don’t think so.”

This article is the latest in a series developed by the Public Health News Bureau, a project funded by Healthcare Georgia Foundation. The bureau is staffed by graduate students from the Health and Medical Journalism Graduate Program of the University of Georgia’s Grady College of Journalism and Mass Communication.

Robyn Abree earned her undergraduate degree in journalism and master’s in health and medical journalism at UGA’s Grady College.