Thursday, June 10, 2010

Jindal's Hack Attacks

Alan Levine was billed as the "Department of Health and Hospitals Secretary" when he appeared at the Baton Rouge Press Club on Monday. But as anyone who caught his presentation (PDF) on the impact of healthcare reform on Louisiana immediately grasped, the cabinet secretary title is a cover for Levine's true role as Jindal's most ardent partisan hack.

From attacking healthcare reform to barring DHH employees from talking to legislators about policy to calling for investigations to try to stifle opposition to privatization, Alan Levine is the tip of the spear on the governor's effort to use healthcare policy to shrink state government and give more power (and money) to private contractors.

Levine is continuing the work that Jindal started as Mike Foster's DHH secretary just over a decade ago. The difference is that Levine actually knows something about healthcare policy (if Jindal knows anything about it, he learned it after he left DHH) and has not (at least not yet) displayed the kind of unbridled political ambition that Jindal personifies.

Still, Levine came to the job after finding his place in Florida politics in Jeb Bush's second administration. He came to Louisiana after taking over a struggling hospital system for Bush, privatized much of it (some of it using no-bid contracts) and rode that success to his job with Jindal.

Man On A Mission

Levine came to Louisiana in 2008 on a mission. That mission was to radically restructure the delivery of healthcare in Louisiana in a way that would help propel Jindal's Republican political ambitions.

First on the agenda was a complete makeover of Medicaid, the jointly funded healthcare program that provides care to women, children and the disabled. Levine had run a pilot program in Florida that set up a managed care approach to running Medicaid there. The idea was to limit spending by restricting access to care. The restriction would come through the management of care by third-party entities who had a similar role in the scheme to that of HMOs. There was a fixed pool of money. The managed care provider would negotiate a package deal with providers to provide care for Medicaid patients. The managed care provider would get paid out of the existing pool of funds.

It is classic conservative Republican approach to policy: make the dollars go further by cutting back on the amount of services delivered and make some company rich in the process.

Levine hit the ground running in Louisiana, but there were complications with the calendar. Jindal and Levine wanted to get a Medicaid waiver approved by the Center for Medicare and Medicaid Services (CMS) while the Bush administration was still in office. This should not have been an issue seeing as Jindal had served in that administration and Levine had served in the administration of the President's brother who was the governor of Florida.

There were complications.

The first factor was that the move could not begin until the new state budget for Fiscal Year 2008-2009 was in place. Louisiana fiscal years begin on July 1. It took Levine a couple of months to organize an advisory committee whose purpose was ostensibly to provide input on the development of a Medicaid waiver request.

The panel was barely in place when the first of what has become a seemingly unending series of Medicaid budget shortfalls was discovered in late September of 2008. Shortly after that happened, Levine christened his Medicaid waiver "Louisiana Health First" and the generally genial discussions with the so-called advisory panel continued.

Things blew up when Jindal and Levine announced the plan fully-formed in November 2008 and committed to filing with with CMS in the waning days of the Bush administration. Members of the advisory committee went public with criticism of Levine for a lack of transparency in the process they were allegedly supposed to be participants in. It certainly appeared to the members of that group that they had been used by Levine to provide a patina of legitimacy to a plan that Levine had developed without their input or knowledge.

It was two days before Christmas, 2008, before Levine got his waiver request to CMS — the Legislature had to sign off on it and there were questions. By this time, all the DC Bushies were either too busy packing or had already left the nation's capital seeking new opportunities in what was no longer a Republican town.

Louisiana Health First came to naught, though it did poison Levine's credibility among Medicaid providers — a distrust that informs his relations with them today.


The first big challenge for the Jindal administration on the privatization front was the question of what to do with Big Charity Hospital in New Orleans, which had been rendered useless by the post-Katrina flooding.

Governor Kathleen Blanco had somehow convinced a recalcitrant Louisiana Legislature to approve planning dollars for three new LSU hospitals in the wake of the storms of 2005 — Big Charity, Earl K. Long Medical Center in Baton Rouge, and Huey P. Long Medical Center in Pineville.

The initial impulse of the administration was to scrap all three hospitals, but the pressure to build a new hospital in New Orleans was too important to the post-Katrina recovery narrative for Jindal to ignore. Combined with a commitment from the Veterans Administration to build a new hospital in New Orleans, the project constitutes a nearly $2 billion investment in post-Katrina New Orleans.

Levine became the point man on what became very clearly a quid pro quo between the administration and LSU. The deal came down to this: LSU could get a hospital in New Orleans but it could not get a hospital in Baton Rouge, too. Sort of a "nice hospital you've got there, LSU. It would be a shame if anything happened to it." The new Pineville hospital was dead on arrival.

In the dance that ensued, LSU ended up negotiating a deal with Our Lady of the Lake Regional Medical Center thereby enabling the closure of Earl K. Long. Some of the capacity served by that hospital will be replaced by a large outpatient clinic near Earl K. Long. Our Lady of the Lake agreed to take some of the Medicaid patient load (at a higher-than-average reimbursement rate) and to become home for LSU's medical training program in Baton Rouge. They'll also get a Tier 1 trauma center, courtesy of the state.

Cerise told the Times-Picayune after the deal was struck that the cost of shifting care from Earl K. Long to OLOL will actually drive up Medicaid costs in the Baton Rouge area. So, this example shows that cost savings is not the intent of the Jindal/Levine privatization effort. Instead, the goal is to dismantle public healthcare infrastructure ranging from public hospitals in the LSU hospital system to the state's three mental health hospitals in Mandeville, Pineville and Jackson.

This clearly is privatization for privatization's sake. It will have two immediate impacts. First, it will remove hundreds (ultimately thousands if carried to its end) of workers from the state payroll. Second, it will create lucrative contracting opportunities for private sector firms who move in to operate the remaining operations which is the plan for the mental health hospitals.

The question of the quality of care given to patients was raised in one legislative hearing by a family member of a resident in one of the state mental health institutions. It is apparently not relevant to Jindal and Levine as it is not quantifiable as a budget item.

Jackson: A Deal Too Far

Levine's effort to privatize the state's mental health hospitals has sparked a surprising bi-partisan rebellion in the Legislature against the move. The plan to privatize the East Louisiana State Hospital at Jackson was apparently the deal too far.

East, as it is known, is located in East Feliciana Parish. The move to privatize jeopardizes hundreds of jobs in that rural parish and that brought employees and the business community together in opposition to the plan. It led to a confrontation in the Legislature where the normally Jindal-friendly House voted to require legislative oversight of the privatization process.

Levine, apparently seeking to crush the rebellion at ground zero, called on the inspector general to review employment records at the three facilities — East, Central Louisiana State Hospital in Pineville and Southeast Louisiana Hospital at Mandeville — to check what he suggested were abuses of the family leave policies at the facilities.

Attacking Healthcare Reform

Jindal and Levine were early critics of President Obama's attempts to reform the nation's healthcare delivery system, and they have not relented since 2009.

Levine was called to Washington by congressional Republicans to deliver highly partisan attacks on the Democratic initiative dating to its infancy. No matter the shape of the reform at any given time during the arduous legislative journey to becoming law, Levine could be counted on to take up the Republican talking points against the plan.

Once the bill became law in April, Levine became the in-state point man of Republican efforts to fight the implementation of the law.

Levine testified before the Louisiana House Insurance Committee on April 20 in support of Representative Kirk Talbot's constitutional amendment to have the state nullify the provisions of the Affordable Care Act. Levine, like Talbot, put the fight within the context of states' rights.

Well, any excuse would do, wouldn't it.

In late May, when the non-partisan Kaiser Family Foundation published a state-by-state assessment of the impact of the Affordable Care Act on extending coverage to low-wage individuals and families, Levine lashed out with a partisan harangue that focused only on the cost side of the law and the analysis. Nowhere in his response could Levine bring himself to acknowledge any benefit being derived —economic, community, social or otherwise — that would result from extending healthcare coverage to a broad swath of Louisiana's large number of uninsured residents.

That inability to acknowledge any positive aspect in a policy or program being opposed is the trademark of an ideologue.

And it was Levine the ideologue who took the podium at the Baton Rouge Press Club on Monday and delivered a presentation that is so blatantly political that it raises questions regarding how public funding can be used to produce such a clearly political document (PDF).

Lies, Damned Lies, and Levine's Statistics

Like Jindal, the only thing that has value in Levine's view of healthcare is money. If a program costs dollars, then it must be bad.

How else can one assess a 32-page presentation on a piece of landmark social legislation that never mentions any social benefit but focuses exclusively on the cost of the program — and inflates those costs to cast the legislation in the worst possible light?

Levine's intent is to show as large dollar costs to the state as he can possibly imagine. He projects 13 years out to come up with a projected increased cost to the state of $7 billion, and he has to use a premise of private sector employers dropping coverage for their workers and dumping them on the Medicaid rolls to get there.

Like Jindal, Levine assumes that state revenues will never increase again. Therefore, the prospect of the state actually having the revenue to pay for he increased costs that the program will actually bring are beyond his capability of imagining. One is left to assume that the idea of state revenues increasing would be considered a nightmare scenario in the world of Jindal/Levine.

Levine completely ignores the reality that the current system of employer based healthcare is not sustainable without reform. The Affordable Care Act maintains private sector insurance, imposes some requirements on companies and requires individuals to buy coverage. It provides tax credits to businesses to provide coverage and it provides subsidies to individuals and families to enable them to afford coverage. It will improve access to care for nearly all Louisiana residents, which will go far to address our chronic disease problems. It will inject billions of dollars into the care provider community, putting hospitals, clinics and individual providers on better financial footing.

Levine cannot bring himself to mention — much less admit — any of this.

This kind of distorted take on healthcare reform could be expected from the kind of partisan hack that Levine clearly is. But, he should stop hiding behind his title as cabinet secretary in his pursuit of his partisan agenda. Alan Levine is a suitable political operative for Bobby Jindal, but he is abusing his office as secretary of the Department of Health and Hospitals at this critical juncture in our state's history.

Serving in that capacity involves a public trust. Levine's loyalty should be to his oath and to the public. It is clear that his loyalty is to Jindal and his ideology.

If he had any decency, he'd resign.

Again, if he had any decency.

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