Fellow wonk Ezra Klein looks at the vast differences in state Medicaid programs and proposes a plan for simplification: set eligibility at 250% of the federal poverty line “with states able to use state money to expand categories or add services”. Well, that’s basically how it works now. Minnesota has devoted billions of dollars to expanding Medicaid eligibility and providing a multitude of services that are considered “optional” under Medicaid law. To make things even more confusing, states can seek waivers from the federal government to provide an expanded set of Medicaid services to a defined population, like people with developmental disabilities or people who have complex medical conditions. On the one hand, this flexibility gives states the freedom to tailor Medicaid to the needs of their populations. On the other, it creates an environment where one state can offer many more services than the state next door. Klein’s solution wouldn’t change that situation.

Here’s what I would do if I was ruler of everything. Require every state to offer a common menu of Medicaid services that are funded using existing federal matching rates. If a state wants to provide additional services, the feds should provide an enhanced matching rate for those extras. Yes, it will cost more at the federal level, but the alternative is an unpredictable cycle of service expansions and draconian cuts; a wasteful process that devours billions of administrative dollars at the state level.

And we can fund all this by nationalizing Citibank and Bank of America. Viva la revolucion.

The state Legislative Auditor released a report yesterday heavily criticizing the Medicaid-funded personal care assistance service (summary and full text available here). The PCA program provides assistance to people with disabilities and the elderly with the ordinary tasks of daily living: eating, bathing, dressing, etc. The report several structural problems with the program, such as workers being paid for more than 24 hours of service in a day and home care agencies providing insufficient supervision for workers.

Before I go any further, I should make a disclaimer: the views expressed here are my own and not those of the Minnesota Department of Human Services.

The report makes a few points that deserve further discussion:

• Workers being paid more than 24 hours in a day: Fraud and abuse undoubtedly occurs, but the some of these billing irregularities can be attributed to shortcomings in the Medicaid reimbursement system. Every PCA worker is required to have a unique provider number. But the backlog for issuing provider numbers is several weeks long and, in the meantime, agencies need to fill shifts for their clients. So agencies might use an existing provider number to bill for those hours until the new provider number is issued. I’m not excusing the practice, but it’s one created by external factors. 
• All PCA consumers should have professional supervision of their workers: I have mixed feelings about this. I understand the need for supervision, especially in cases where the individual is particularly vulnerable. But plenty of people are capable of supervising their own workers and sending in a professional would simply be a waste of time and money.
• Some PCA workers are working more than 40 hours a week, raising questions about quality of care: Well, if you earned only $9-$11 an hour with few benefits, you might be inclined to pick up extra shifts. And I don’t sense the same collective hand-wringing about physicians and nurses working overtime in hospitals. Finally, I’m not sure that raising amorphous concerns about quality–without presenting any supporting data–is either helpful or particularly insightful.

The Legislature is sure to pass several policy fixes for the PCA program and many of them are overdue. But it’s worth remembering that the vast majority of PCA recipients are using the service to meet basic needs and, in its absence, they would be placed in institutions.

A word of advice for proprietors of bars, taverns, pubs, and other drinking establishments. If a potential customer calls to inquire whether your business is accessible, take a good look around. If one entrance has three steps and the other entrance is behind a foot-high curb, you are not, by any stretch of the word, accessible and you should answer accordingly. You should not answer with a chipper “Sure!” because said caller will incorrectly assume he can enter your establishment without the assistance of a small crane or a squad of bodybuilders, neither of which he has on hand.

You have no idea how long I have waited to use that header.

President Obama (it’s a bit surreal to write that) gave a good speech, although probably not a great one. It contained few, if any,  lines that will echo into the future. And that’s okay. Obama has already proven his skill as an orator and the unspoken symbolism of the day was more powerful than anything he could have said. But the speech’s content left no doubt that a new governing philosophy is in ascendancy. I can’t imagine Bush bothering to recognize nonbelievers in any public address. This passage leaves little doubt that Obama has fundamental differences with the previous administration:

As for our common defense, we reject as false the choice between our safety and our ideals.  Our
Founding Fathers, faced with perils we can scarcely imagine, drafted a
charter to assure the rule of law and the rights of man, a charter
expanded by the blood of generations.  Those ideals still light the
world, and we will not give them up for expedience’s sake. 

But this nonbeliever thought the most graceful moments of the ceremony came during Reverend Joseph Lowery’s benediction. It struck an optimistic chord while also being somewhat melancholy, as if he was trying to make us appreciate the blood price of so many lives lost in the long struggle culminating in this moment. And it was corny, but in a sweet way that you only find in the words of charming old men who have witnessed much.

Bush is really gone, right? He doesn’t have some super-secret skeleton key that will let him sneak back into the Oval Office tonight and smear Vaseline on all the drawer handles? Because I wouldn’t put it past the guy.

My brother is on his way to Washington D.C. to join a few million others in the Inauguration festivities. I’m counting on him to send me photos from his iPhone on Tuesday, or else I’m going to be linking to the same YouTube videos that a bazillion other bloggers will be linking. And I might put in a request for a cheap souvenir (I could probably accomplish the same thing just by going on eBay, but that feels like cheating). I’ll be working on Tuesday, but I hope to watch the proceedings out of the corner of my eye via one of the many streaming video options available.