Unlikely alliances work to save Minnesota’s health-care program for the poor

Saving Minnesota’s General Assistance Medical Care program for the poor is forging unlikely alliances between police and the homeless, patients and providers, Jews and Catholics, labor groups and hospital CEOs, and liberals and a conservative or two.

Even a policy fellow at the conservative think tank Center of the American Experiment recently wrote an op-ed piece titled “Save GAMC — by raising it above lesser priorities.”

Restoring the program has spawned the Save GAMC Coalition. It represents the interests of GAMC enrollees and 40 advocacy groups serving them, including the Minnesota Coalition for the Homeless. There’s also the Safety Net Coalition, which represents 50-plus hospitals, providers and related associations like the Minnesota Hospital Association; and the GAMC Alliance, which encompasses all of the groups.

Chances are that a “Save GAMC” rally will draw this diverse crowd to the Capitol’s rotunda on Feb. 4, the day the Legislature convenes.

Why so soon in the session? Funding for the program, which serves poor single adults without dependent children, originally was scheduled to run out March 1. Just this morning the Gov. Tim Pawlenty and Department of Human Services announced there was enough money left to extend GAMC coverage until April 1. (Here is the press release.)

Lawmakers now have a few more weeks to pass a solution that will satisfy a broad spectrum of interests and the governor.

Three days before the end of the 2009 session, Pawlenty used his line-item veto to cut $381 million in second-year funding for GAMC. The DFL-controlled House of Representatives was unable to persuade any Republicans to override the veto and achieve the two-thirds majority required by law. The consequences set off a massive community effort to call attention to the needs of as many as 70,000 GAMC recipients annually and the potential impacts of lost funding on safety-net hospitals, county governments, jobs and cost-shifting to the privately insured population.

The governor’s subsequent unallotment of another $15 million further mobilized GAMC advocates. Meanwhile, the Pawlenty administration’s plan to shift GAMC enrollees to MinnesotaCare, an insurance program for low-income workers, isn’t going over well with the alliances.

A potent reminder of work ahead
So the Feb. 4 rally likely will be a potent reminder of the work left undone in the last session and what needs to be done before the end of March.

“I’ve certainly seen rallies on the first day (of the session), and I’ve seen rallies on the last day, but it doesn’t happen that often,” said House Assistant Majority Leader Erin Murphy, DFL-St. Paul.

The last time Murphy saw this degree of diverse support for a single cause was in 2008, when the Legislature voted to raise the gasoline tax to improve state highways and later overrode Pawlenty’s veto of the bill.

“The elimination of GAMC has ramifications on hospitals, on Main Street, on public safety and on individuals,” said Murphy, co-author of a joint temporary 16-month plan [PDF] crafted by DFL lawmakers to restore some funding with a mix of surcharges designed to reap higher federal reimbursements, rate reductions for services and a 10 percent share of GAMC costs from counties. “The impact is far-reaching and I think that speaks to the importance of rebuilding the program.”
 
GAMC’s advocates have turned out in droves at pre-session meetings of legislative committees, powwows with interest groups, and at rallies. Lawmakers have listened to a range of supporters, including GAMC enrollees with gripping personal stories and Minneapolis Police Chief Tim Dolan explaining how GAMC helps homeless people who need medication for mental-health issues and other ailments.

Twenty-eight percent of GAMC recipients are homeless and about 60 percent of enrollees suffer from mental-health problems, chemical dependency or both, according to the Minnesota Department of Human Services. [PDF]
 
Some advocates have demonstrated in front of the governor’s residence in St. Paul. Others have sponsored community forums, including Jewish Community Action‘s “Who Shall Live and Who Shall Die: Health Care Reform in Minnesota.” Groups like TakeAction Minnesota have gone door to door, explaining what’s at stake.

Two of the most-affected safety-net hospitals launched websites: Hennepin County Medical Center’s WillYouLose.org and HealthPartners/Regions Hospital’s FixItNowMN.org.

Unusual alliances
The alliances among unlikely interest groups are somewhat unusual, advocates say.

“I can’t offer enough praise to the constructive and focused effort on the part of so many to try and find a solution — that’s unusual,” said Murphy, who has a nursing background. “A lot of stakeholders are willing to accept a less-than-perfect solution to achieve the goal.”

Those on the ground also are marveling at the cooperation.

“We did some work together when the governor proposed cuts to public health, but this level of conversation, this level of coordination among such a broad group of stakeholders … that has been unique,” said Liz Doyle, policy director for TakeAction Minnesota, among the organizations leading the Save GAMC Coalition as well as conducting door-to-door canvassing on the issue. (Other leaders are Catholic Charities and the Minnesota Legal Services Coalition.)

So far, Murphy hasn’t seen any coalitions against GAMC funding. “I’m holding my breath but I’ve not heard of an organized alliance in opposition,” she said.

Hurdles could arise with counties, whose executives have testified that they will be hard pressed to come with a 10 percent share of the costs. HCMC’s executives also are pushing for a larger share of the available pie since they handle the largest number of GAMC enrollees in the state.

Still, what is it about the potential loss of the nearly 40-year-old GAMC program that unites liberals and conservatives?

Helping the neediest and cutting waste
Maria Hanratty, an academic who specializes in health economics and the economics of poverty, offers some observations from studying long-term homeless populations and efforts to help them.

“The story — and I’m not sure it’s completely true — that you can take people out of a very dysfunctional system, put them in a better place and yet save money sounds very appealing,” said Hanratty, an associate professor in the Hubert H. Humphrey Institute of Public Affairs at the University of Minnesota. “It appeals to liberals because you’re helping people who need the help the most, and it appeals to fiscal conservatives who say we’re wasting our resources by spending money on jails instead of on the appropriate medical care and housing. …

“It’s a public-private partnership, so there’s the effort through the faith communities, through the counties, through the state, the national level, and so many more advocates are connected to this process, and I think maybe that’s also different.”

Jewish Community Action, which has 700 households as members, decided to sponsor two forums because of the broad implications for Minnesotans if GAMC goes away, said executive director Vic Rosenthal. The issue also speaks to fundamental Jewish beliefs.

“There are specific passages in the Torah, where we get the foundation of our religion, about caring for the poor, feeding the hungry, caring for the sick,” he said. “We, as a community, have a responsibility to help. We would argue this is what we’re supposed to do — not what we should do.”

But how does a conservative end up supporting GAMC?

An opportunity to fix GAMC and the ‘budget mess’
Center of the American Experiment fellow Peter Nelson writes that he thinks a solution for GAMC invites looking at the bigger picture, i.e. the state’s $1.2 billion deficit and ongoing “budget mess.”

“As someone who wholly supports the reinstatement of GAMC,” Nelson writes, “I’m increasingly worried this effort might fail because, to date, none of the discussions at the Capitol adequately consider the state’s broader budget mess — the overriding reason why GAMC is set to end in the first place.”

Nelson also thinks the situation “unfairly paints the governor as a Scrooge willing to cut health care for the poor.”

“That’s [Nelson’s view] a new addition to the mix,” said state Rep. Jim Abeler, R-Anoka, vice chair of the House Health Care and Human Services Finance Division. “The progressives are the ones commonly arguing for more service.”

Former longtime Senate Majority Leader Roger Moe, now a lobbyist and consultant, said he has seen DFLers and Republicans come together in the past to resolve their differences around a single issue.

“I think this particular issue probably cuts a little deeper as it relates to the folks who are being hurt,” said Moe, a DFLer who spent more than 30 years in the Legislature. “I think everybody knows that these are people who really, sincerely need help. They are the poorest of the poor, and I think most people generally agree that as a collective society we have a responsibility to try to do what we can to take care of them.”

The road to consensus
How to get to consensus on a plan will be the challenge. Lawmakers from both major parties have proposals, including the Pawlenty administration’s plan to shift GAMC enrollees to MinnesotaCare. Still, they’ve been reaching across the aisles and chambers and meeting with the administration about the feasibility of their proposals.

“I think it’s good that there are a number of proposals, and I think that’s healthy for the process,” said Moe, who late last year chastised lawmakers for a lack of civil communication on the issue during a United Way forum on GAMC. “I think in the final analysis there’s going to be a bipartisan vote from both houses of the Legislature, and I think there are an awful lot of discussions going on with the administration. I think everybody’s sincerely trying to find a fix.”

While many GAMC advocates and DFL lawmakers don’t think MinnesotaCare is the best fit for this population, some Republicans think tinkering with that program would ease concerns.

MinnesotaCare requires premiums ($4 a month) and co-pays, and it caps annual hospitalization at $10,000, which means safety-net hospitals like HCMC and Regions would be on the hook for anything over that amount.

Even though the administration’s plan requires counties to pick up MinnesotaCare premiums for the first six months of the transition, GAMC advocates worry about what happens to enrollees’ health care in the long term and about draining the Health Care Access Fund.

Dealing with MinnesotaCare’s barriers
Keeping up with premiums and affording co-pays are “very significant barriers for GAMC enrollees, a lot of whom earn $200 a month,” said Doyle of TakeAction Minnesota.

“Just being switched to transitional MinnesotaCare could leave most GAMC enrollees out in the cold,” she said. “They have, at most, six months where they would receive premium assistance from the counties. Beyond that, their ability to successfully reapply is really limited.”

Another concern is “just the sustainability of MinnesotaCare,” Doyle said. The Health Care Access Fund, which is supported by enrollee premiums as well as a 2 percent tax on providers, is due to run out of money in 2011 and will require more than a $100 million infusion from the state’s general fund.

When the access fund drops below a certain amount, state statute sets up a pecking order of who gets dropped from MinnesotaCare. First in line are single adults and households without dependent children.

“People are glad that the governor is not simply closing his eyes to this completely, although, certainly, many of us wouldn’t be in this situation if he hadn’t done the unallotment in the first place,” said Rosenthal of Jewish Community Action. “The solution proposed is not a solution because it doesn’t cover enough people, it won’t last long enough and it will create unintended consequences. … It may help some people in the short term, but in the long term it may hurt more people.”

Small fixes and the bigger picture
Abeler, the ranking Republican on the health finance division, says that the MinnesotaCare premiums and co-pay issues for GAMC enrollees are “small things to fix,” given the looming state deficit and funding demands.

“The less expensive and more comprehensive way we can serve these (GAMC) folks, the more realistic it is that we can change it in my view,” said Abeler, a chiropractor. “It may be that we’re not that far away from a resolution — from serving these people in the framework of the law and maybe enhancing MinnesotaCare a little bit for the special needs of this group.”

It’s worth noting that Abeler was one of the “Override Six” who defied their party over the 2008 transportation bill.

In crafting a temporary 16-month solution, DFL lawmakers said they were looking ahead to national health reform that proposed expanding Medicaid to poor single adults and picked up the bulk of the states’ costs by as early as 2013. With national reform up in the air since Massachusetts elected a Republican to the U.S. Senate, Minnesota lawmakers will go into the session with a bigger task in front of them.

Setback in federal reform may prompt compromise
“It (the delay in federal reform) affects everything and makes the (state) dialogue more important,” Abeler said. “It should bring people to the middle and try to incorporate the best ideas of both parties. It can’t be too-hard-right and it can’t be too-hard-left. It just needs to be a sensible, workable plan that will have some enduring power beyond the end of this biennium.”

Holding pre-session legislative committee meetings on a big issue is not unusual — especially when a deadline looms for a program’s demise, Moe said.

“The strategy from day one has been to try to get this issue off the table” as quickly as possible, he said. The recent revenue forecast confirms the urgency “to get it done and get it away from full-blown debate on the budget and all of the other issues that will be on the table during the session.”

Any doubters as to the wisdom of that strategy need only remember what happened three days before the end of the 2009 session.

Casey Selix, who covers health reform and other issues for MinnPost, can be reached at cselix[at]minnpost[dot]com.