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Obama’s Executive Order, Its Impact on Health Care Costs, and the Constitutionality of Executive Orders

Pres. Barack Obama will address the nation tonight at 8 pm (Thursday, November, 20, 2014). He is expected to discuss his executive order that will delay deportations of up to 5 million migrants.

What does an executive order on immigration have to do with Medicaid? Well, you can bank on the fact that almost none of the 5 million people has private health care coverage….which means, there is a high likelihood that most, if not all, the people would qualify for Medicaid.

With the expansion of Medicaid in many states, adding another 5 million people to the Medicaid program would be drastic.  Think about it…in NC, approximately 1.8 million people rely on Medicaid as their insurance.  5 million additional Medicaid recipients would be like adding 3 more North Carolinas to the country.

So I looked into it…

The Kaiser Family Foundation website states that even immigrants who have been in America over 5 years are sometimes still barred from getting Medicaid and those people would remain uninsured.  The Kaiser website states that under current law “some lawfully present immigrants who are authorized to work in the United States cannot enroll in Medicaid, even if they have been in the country for five or more years.”

By law, only immigrants who have green cards are entitled to enroll in Medicaid or purchase subsidized health care coverage through the ACA. Usually those immigrants with green cards are on the course to become citizens.

Regardless of whether Obama’s executive order tonight will or will not allow the 5 million people Medicaid coverage (which it will not), the executive order absolutely will greatly increase health care costs

The truth is that, with or without Obama’s executive order, the government already funds some health care for undocumented immigrants. We have an “emergency Medicaid” program and it pays hospitals to provide emergency and maternity care to immigrants if: 1) he or she otherwise would be Medicaid eligible if they weren’t in the country illegally or 2) he or she are legally present in this country for less than 5 years.  (Which is the reason that ER wait times are so long…if you have no health insurance and you get sick, the ER is precisely where you go).

However, with the additional 5 million people living within the borders of USA, it is without question that the “emergency Medicaid” funds will sharply escalate as hospitals provide more emergency care. ER waits times will, inevitably, increase. Health care costs, in general, surge as the population increases.  And the addition of 5 million folks in America is not a “natural” increase in population.  It will be like we added additional states.  Overnight and with the stroke of a pen, our population will grow immensely.  I guess we will see whether we get “growing pains.”

An act of Congress will still be required before the undocumented immigrants impacted by the executive order would be allowed to participate in the Medicaid programs and the Children’s Health Insurance Program (CHIP) coverage.

As to the Constitutionality of executive orders…

Executive orders are not specifically mentioned in the Constitution.  Many people interpret the nonexistence of executive orders in the Constitution as barring executive orders.

Article I Section I of the Constitution clearly states that all legislative powers reside in Congress. However, an executive order is not legislation. Technically, an executive order is a policy or procedure issued by the President that is a regulation that applies only to employees of the executive branch of government.

Nonetheless, our country has a vast history of president’s issuing executive orders. Abraham Lincoln issued an executive order to engage military in the Civil War, Woodrow Wilson issued an executive order arming the military before we entered World War I, and Franklin Roosevelt approved Japanese internment camps during World War II with an executive order.

Regardless of your political affiliation, in my opinion, it is very interesting that Obama would initiate an executive order regarding immigration given his past statements over the years complaining about past presidents’ executive orders being unconstitutional.

In 2008 campaign speeches, Obama regularly emphasized the importance of civil liberties and the sanctity of the Constitution.

In fact, in speeches, Obama stated, “most of the problems that we have had in civil liberties were not done through the Patriot Act, they were done through executive order by George W. Bush. And that’s why the first thing I will do when I am president is to call in my attorney general and have he or she review every executive order to determine which of those have undermined civil liberties, which are unconstitutional, and I will reverse them with the stroke of a pen.”

Whether or not people believe that executive orders are constitutional, it is indisputable that presidents on both sides of the aisle have issued executive orders.

Reagan and Bush issued executive orders. Although there is an argument that those executive orders came on the heels of congressional bills, as adjustments. Neither Reagan nor Bush simply circumvented Congress.

Going back to tonight’s anticipated executive order allowing 5 million migrants to remain in America…

While the executive order will not allow the 5 million people immediate access to Medicaid and other subsidized health care, it will allow 5 million more uninsured people to exist in America, which will, undoubtedly, increase health care costs and ER visits. And, eventually, the additional 5 million people will be eligible for Medicaid, subsidized health care, and all other benefits of living in America.

Obama Voices the Need for Access to Mental Health Care: Medicaid Recipients, Too?

Two days ago, Obama voiced that gun control and mental health care reform is on the horizon.  Since the terrible massacre at Sandy Hook Elementary School, people, especially politicians, have been talking about gun control.  The thinking behind this is that if the shooter at Sandy Hook did not have access to guns, the murders would not have happened.  Agreed.

But think of this:  If a child puts his or her finger in a light socket and gets electrocuted, do we cut off the power to the entire house forever? Or do we educate that child so he or she does not do it again?

Personally, I opt for the latter:  Educate.

If the child is incapable of understanding the concept of getting electrocuted by placing his or her finger in a light socket (i.e., the child has mental health issues), then, as a parent, I would seek mental health services for my child.  I still would not opt to cut off the power in the house.

Mental health services are vital.  Mental health services are important for all people. But since this is a Medicaid blog, I will focus on mental health services for Medicaid recipients.  Medicaid recipients need access to quality mental health services. Quite possibly, in the world of Medicaid, mental health services may be the most needed and least provided to recipients (maybe dental and specialities in medicine are also in the top most needed and least provided, but I will cover those topics in another blog).

I’m not talking about mental health services for the autistic children or children suffering from an easily diagnosed and highly recognizable mental health illness. These children obviously need mental health services.  In my opinion, most people would agree as to the need for mental health services to these children.  No, I’m talking about the thirteen year old girl who has so much anger built up inside that she begins to cut herself, torture animals and scream at her teachers. Or the 14-year-old boy, who was sexually abused by his uncle and is now exploring the sexuality of the 6 and 7-year-old boys in the school  bathroom. The 12-year-old boy who has no friends, is isolated at school, and is publicly ridiculed until he begins to think he has no reason to live and begins fantasizing about killings, both of himself and others…the ones who ridicule him.

Would wonderful access to mental health services for Medicaid recipients have stopped Sandy Hook from happening? Probably not. But future tragedies can be stopped by providing quality mental health services to all, especially to Medicaid recipients.  According to Obama’s recent speech, Obama agrees that quality mental health care needs to be accessible to all people.  But does that also mean Medicaid recipients? Medicaid recipients must meet criteria to receive therapy (after a certain number of visits).

Medicaid recipients rely on the Medicaid system for mental health services. I don’t mean to state the obvious, but think about it. People with private health insurance have choices about therapists. I can say, “I’m feel like my depression is overwhelming.” And schedule a psych visit for the next week. Not Medicaid recipients. Medicaid recipients need (for the most part) prior authorization. Which means if a Medicaid recipient feels low…really low…as in, needs a psychiatrist low, they need permission from the State.   A State-contracted agent must review the documents and determine it is medically necessary for that Medicaid recipient to receive therapy.  Although, for Outpatient Behavioral Services,

This is the criteria for a Medicaid recipient to receive Outpatient Behavioral Services:

Entrance Criteria

ALL of the following criteria are necessary for admission of a beneficiary for outpatient treatment services:

a.   A Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,Text Revision (DSM-IV-TR) (or its successors) Axis I or II diagnosis.

b. Presentation with behavioral, psychological, or biological dysfunction and functional impairment, which are consistent and associated with the DSM-IV-TR (or its successors) Axis I or II diagnosis.

c. Does not require a higher level of care.

d. Capable of developing skills to manage symptoms, make behavioral changes,and respond favorably to therapeutic interventions.

e. There is no evidence to support that alternative interventions would be more effective, based on North Carolina community practice standards (e.g., Best Practice Guidelines of the American Academy of Child and Adolescent Psychiatry, American Psychiatric Association, American Board of Addiction Medicine).

Medicaid beneficiaries under 21 and NCHC beneficiaries are allowed 16 unmanaged visits; adults are allowed eight unmanaged visits per calendar year. All visits beyond these limitations require prior approval.

More than eliminating guns (or cutting the power off in the house), Medicaid recipients need somewhere to go to receive quality health care with no judgment and not all this criteria. If a Medicaid recipients wants to attend weekly therapy sessions, shouldn’t the Medicaid recipient be able to go to therapy without needing an Axis I or II diagnosis? Why does a Medicaid recipient need to be diagnosed with an Axis I or II diagnose in order to receive outpatient therapy?

So now Obama has publicly announced that, along with gun control measures, he plans to tackle the issue of mental health care.  I ask, “How?” and “Does this include access to therapy for Medicaid recipients?” The fact is that Medicaid recipients can see a therapist 16 (if a child) and 8 (if an adult) times. But then, the Medicaid recipient must show medical necessity in order to receive therapy. Is this quality mental health care? Is this access to quality mental health care for ALL?


NC Medicaid: Post-Election: “To Expand or Not to Expand.”

When President Barack Obama and Democrats in Congress authored the 2010 Affordable Care Act, they required that all states expand their Medicaid programs for the poor and disabled. But when the U.S. Supreme Court handed Obama what was hailed as a victory for the health insurance law, the justices dealt the administration one setback. The court ruled that states would have the option of expanding their program but couldn’t be forced to do so.

Pat McCrory has not publicly announced whether he is in favor of Medicaid expansion (Well, actually, at the beginning of his campaign, he stated decidedly that he would not take federal money to expand Medicaid. Toward Election Day, he changed his position to a more grey stance). McCrory stated that he would conduct more research on expanding Mediaid. McCrory was elected to governor. But, technically, Perdue is still governor until January 2013.

In the short term, the state must decide by Nov. 15 whether to apply for federal grant money to plan the law’s implementation. More importantly, states were going to have to decide by Nov. 16 how the state will handle the so-called health exchange – a marketplace where those who do not have employer-provided coverage but are too wealthy to be covered by Medicaid can buy coverage.

Late Friday, the U.S. Department of Health and Human Services extended the deadline for that decision by three months. The deadline is now Feb. 15.

So, now, it will be Gov.-elect Pat McCrory who will make the decision. DHHS took the decision out of Gov. Perdue‘s hands.

A generic government health exchange (where the state works with the federal government) would be a bumpy transition. This state’s Medicaid rules don’t mesh exactly with federal guidelines, meaning there could be confusion over whether someone should be sent to the exchange or apply for Medicaid. Also, the state has a new benefits application system getting ready to go online that could make applying for health coverage through and exchange easier. That system wouldn’t be used if a generic federal approach comes about.

So how will McCrory decide? McCrory said he doesn’t have enough information to make a decision yet.  “There’s total confusion,” McCrory said Thursday of the federal health care law. “Nobody understands the bill or its implementation.”

We have 3 months, folks, to study up. Feb. 3, 2012, is decision day.