Our Medicaid Budget: Are We Just Putting Lipstick on an 800 lbs. Pig?

Too often, I have heard an analogy about the Medicaid budget and a pig wearing lipstick. Normally it goes like this: “Are we just putting lipstick on an 800 lb. pig?”…and the Medicaid budget is the 800 lbs. pig, not the lipstick.

For those of you who do not know, I own a pet pig. She is a micro pig. Not a pot belly pig; those get to be 150 lbs. Oh, no. A micro pig; those stay very small. Our Oink is only 21 pounds.

Here is a picture:

Kissing Oink

Notice she does not have lipstick on. So when someone says, “Are we just putting lipstick on an 800 lbs. pig?” I think, “Is that so bad?”

I understand that saying to put “lipstick on a pig” is a rhetorical expression. An expression used to demonstrate that making a superficial or cosmetic change is a futile attempt to disguise the true nature of a product. However, Oink and I take offense, because she is so much more beautiful than the Medicaid budget (and much smaller).

Although my Oinky-Oink is only 21 pounds. The expression that I have heard most often involves an 800 lbs. pig. If our Medicaid budget were Oink’s size, the General Assembly would probably be home.

Seriously, here is my question on my “Pigs and Medicaid” blog:

How can we expect the General Assembly to create a “knowable” and “concrete” Medicaid budget when the Department of Health and Human Services (DHHS) cannot provide the General Assembly with accurate data?

Literally, DHHS cannot tell the General Assembly how many people are enrolled in Medicaid. Legislatures are being told to guesstimate. Guesstimate???

Between 2009-2012, North Carolina exceeded its approved Medicaid budget by 5.4 billion. In the last decade, our Medicaid spending has increased by more than 90%.

Not to mention DHHS has difficulty filling and retaining employees. Attrition is prominent. As of June 1, 2014, a quarter of the division’s 332 jobs were vacant; the average unfilled job had been open for 347 days, or nearly a year. In November, DHHS’ chief financial officer sent out a cry for help. The Medicaid office “does not have adequate staff with the necessary experience and skills to properly manage the … program,” Rod Davis wrote to the state budget office.

To compensate for too few employees, DHHS gave a no-bid contract to Alvarez & Marsal to help create a Medicaid budget. We all know how that turned out.

With the help of Alvarez & Marsal, DHHS proposed to tax the then-10 managed-care organizations (MCOs) that manage Medicaid services for mental health, developmentally disabled, and substance abuse. But we needed approval by the feds.

It was DHHS’ hope that the extra funds would be the catalyst for a federal match twice that size. Once we got the federal match, DHHS would refund the taxed dollars to the MCOs and use the federal money to pay for programs. Maybe I’m wrong, but the idea sounds like a “bait and switch.” Analogously, I have a client pay me $50,000 on January 31, 2015, the end of our fiscal year, only to refund it February 1, 2015. I would get credit for collecting the $50,000 in fiscal year 2014, but it was not a real collection. It was fake.

And the feds knew it. The answer was, “No.”

Sen. Bob Rucho, R-Mecklenburg, said the information presented Wednesday should have been made available months ago, and he noted that it’s still not detailed enough for a forecast.

“When will we get the numbers that we need to have so that we can have a good budget number?” asked Rucho. And his question is not an anomaly. He is not alone.

“I’ve asked them every time I’ve had the opportunity, and I’m astounded that a $13 billion organization does not have budget numbers,” said Sen. Tommy Tucker (R-Waxhaw), one of the more outspoken members of the Joint Legislative Oversight Committee on Health and Human Services.

Medicaid Chief Financial Officer Rod Davis told Senator Ralph Hise that his department has an idea of how much they’ve paid to providers, but that they can’t forecast what’s to come.

“Would it be like saying we know what checks we wrote, we just don’t know what we’ve paid for,” Hise asked.

Going back to my question:

How can we expect the General Assembly to create a “knowable” and “concrete” Medicaid budget when the Department of Health and Human Services (DHHS) cannot provide the General Assembly with accurate data?

Are we putting too much pressure on the General Assembly and not on DHHS?

The General Assembly is responsible for creating a Medicaid budget. But how can we hold the General Assembly to create an accurate Medicaid budget if the “single state agency,” DHHS, charged with managing Medicaid cannot provide the General Assembly with accurate data???

Here is my political soapbox: We have a Republican General Assembly and we have a Republican governor. Shouldn’t the General Assembly and the governor be on the same side???? Perhaps it’s more than politics. Perhaps it’s more than a donkey and an elephant.

Otherwise with a Republican General Assembly and a Republican Governor, there should be no tension between the “balance of the powers.” Yet there is.

Let’s put lipstick on a pig:

Lipstick pig

By the way, whoever created the saying “Are we just putting lipstick on an 800 lbs. pig?” obviously did not own a pig. Because Oink did NOT enjoy getting lipstick on her snout. In fact, she squealed like a pig.

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on July 11, 2014, in "Single State Agency", Accountability, Aldona Wos, DHHS, Division of Medical Assistance, Federal Government, General Assembly, Health Care Providers and Services, Joint Legislative Oversight Committee on Health and Human Services, Legislation, MCO, Medicaid, Medicaid Attorney, Medicaid Budget, Medicaid Costs, Medicaid Funds, Medicaid Providers, Medicaid Spending, Medicare, Medicare Attorney, NC, North Carolina, Tax Dollars, Taxes, Taxpayers and tagged , , , , , , , , , , , , , , , , , , . Bookmark the permalink. 6 Comments.

  1. The fundamental question is whether it is Clinique or Estee Lauder lipstick. When we answer that, we will truly be getting to the heart of the Medicaid problem…..

  2. I think the lipstick should be on Oink’s lips, not her snout! No wonder she was so upset!

  3. Very good analogy! Thank you Knicole – and I love, love, love the pig! Provider agencies are managed to the 1/4 hour and expected to account for each person, goal, Task Analysis as in how many times did you verbally prompt the individual to “grasp the fork” etc. We are monitored, accredited, audited, home visited, reviewed …… We would be shut down if we could not or did not comply. What’s good for the goose must not be required for the gander.

  4. I think it’s becoming all too obvious that Aldona Vos must be replaced. Coming up with a viable budget really is not rocket science. It feels like they’re not only confused about the expenditures, but want to keep it vague to protect themselves. Fraud kills.

  1. Pingback: CMS Ramps Up Medicare Audits: A Pig and Pony Show? | medicaidlaw-nc

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