Paul Thissen: Innovation in Action

Unkindest cut may come back to haunt

By Lori Sturdevant, Star Tribune, May 23, 2009

No one who watched the failed veto override attempt last Sunday in the Minnesota House will soon forget Gov. Tim Pawlenty’s veto of funding for health care for the poorest of the poor.

Memorable moments were many in the eerily hushed chamber that day. There was the choked voice of ordinarily stoic Rep. Lyndon Carlson, as he spoke of friends who died too soon because they lacked health insurance. There was Rep. Jeremy Kalin’s warm regard for the man he unseated, Rep. Pete Nelson, R-Lindstrom, whose life was saved after a butcher shop accident by Regions Hospital — an institution set to lose $46 million in fiscal 2011 because of the veto.

There was the silent witness in the gallery of three jobless men whose treatment for multiple mental and physical disorders depends upon the vetoed program. With it, the men said, they have hope of recovering and working again. One dreams of joining the Navy. Without it? They sadly shrugged.

And there was the GOP response: Charity isn’t government’s role. (Was that an echo from the 19th century?) People who make bad choices should feel the consequences. (If the mentally ill don’t get medicine, who bears those consequences?) The program wouldn’t be in jeopardy if DFLers had spent less elsewhere. (Then why didn’t the governor veto those lower priorities instead?)

The debate was riveting — for the few Minnesotans who caught it on a lovely springtime Sunday afternoon.

But to those who weren’t listening that day, the May 14 veto of General Assistance Medical Care likely came across as something about a troubled car finance company with a similar acronym. GAMC pays for no-frills health care for about 34,000 people per year whose annual incomes fall below $7,800. More than 70 percent of them are either mentally ill, chemically dependent or both.

Many, before Minnesota went out of the state hospital business, would have resided in such places. Many are just as invisible today as if they did.

Sunday’s outcome foreshadowed the session’s finale: a party-line vote; override fails; Pawlenty wins. By the morning after adjournment for the year, Pawlenty’s health care veto was already melding into the end-of-session blur. It didn’t come up at a gubernatorial press conference.

But later that day, I spoke with someone determined to keep that veto in public view. Rep. Paul Thissen, a leader in the Legislature’s health policy brain trust, is running for Pawlenty’s job.

Thissen is far from a household name, so permit an introduction: He’s 42, a Bloomington native, four-term legislator from south Minneapolis, and a Harvard and University of Chicago-educated attorney (he used to play pick-up hoops with a skinny new U of C professor named Obama). He’s a smart, serious, un-flashy fellow.

It’s too early to assess where he stands in the big DFL gubernatorial wannabe pack. But this much is clear: When the candidates at forums are asked to contrast themselves with the incumbent, Thissen will take aim at Pawlenty’s veto. Here’s a sample:

“That veto was absolutely wrong, for two reasons,” Thissen said. “We are breaking a promise that we’ve had in Minnesota for generations, that we are going to take care of those least able to take care of themselves.

“The other thing is, it’s a clear example of short-term thinking. It’s thinking we can solve problems by not paying for them, or just moving them off of government’s books. That’s just not true.”

“What the governor is doing with GAMC in marquee style puts up the fundamental debate we’ve been having for the past decade. We’ve had this notion put before us that we can keep the Minnesota we’ve always known without paying for it. That’s tied to a notion that we’re all on our own, and should be able to take care of ourselves.

“The pendulum is swinging back to the idea that we do owe obligations to each other. That is what the next election is going to be about.”

Lori Sturdevant is a Star Tribune editorial writer and columnist. She is at lsturdevant@startribune.com.

Health Care in the Budget Cross Hairs

By Warren Wolfe and Chen May Yee, Star Tribune, May 9, 2009

Minnesota’s hospitals, nursing homes and community clinics — already reeling from the worst recession in nearly three decades — are bracing for a new round of cuts from the state’s biggest single purchaser of health care: state government.

As legislators and Gov. Tim Pawlenty struggle to close a $4.6 billion deficit in the state budget, they are looking to trim between $400 million and $1.8 billion from projected state payments to hospitals, health plans, nursing homes and other providers.

With just a week left in the legislative session, the size of the cut was still in play as budget deliberations continued over the weekend. But with health and human services accounting for about 27 percent of the state budget — second only to K-12 education — no one doubts that excruciating cuts are in store.

“We got battered by budget cuts in 2003 and we still haven’t recovered,” said Patricia Coldwell, policy analyst at the Association of Minnesota Counties. “There is no low-hanging fruit left.”

If the worst cuts materialize, providers say:

Residents of Stearns County could see St. Cloud Hospital close its Diabetes Center, eliminating exercise and nutrition programs, and close some dialysis centers.

Uninsured residents of the Twin Cities area, unless they live in Hennepin County, could find themselves turned away from Hennepin County Medical Center, which ordinarily provides uncompensated care to hundreds of patients from surrounding counties.

Aged and developmentally disabled residents in the Duluth area could see reduced services if St. Louis County loses nonprofit firms that serve those populations.

Even Minnesotans who have private insurance could see the effect in higher premiums or larger deductibles, because unpaid costs in the public sector are often shifted to private payers.

Pawlenty and his aides say they want to limit the damage, “but the current growth in health care costs cannot be sustained,” said Human Services Commissioner Cal Ludeman. “Given our budget problems, we must act responsibly.”

Last year, the state paid roughly $7 billion for medical care and insurance, or nearly one-fourth of all health care spending in Minnesota. That $7 billion includes federal matching funds for the big public health insurance programs such as Medicaid.

Razor-thin margins

As the brawl continues in St. Paul, hospitals say they already are grappling with razor-thin margins because of fewer patients and mounting unpaid bills in the recession. More cuts, they say, mean eliminating services when they are most needed.

Since last fall, Minnesota hospitals have cut nearly 2,000 jobs, frozen or cut salaries for physicians and executives, and postponed new buildings.

Pawlenty’s proposal would directly cut $336.6 million in revenues for hospitals, according to the Minnesota Hospital Association. Indirectly, hospitals say, it would cost them another $430 million in unpaid medical bills incurred by the newly uninsured who would be dropped from MinnesotaCare but still need care. The House and Senate versions would cut between $75 million and $117.1 million from hospital payments.

Children’s Hospitals and Clinics of Minnesota, for example, would lose about $36 million over the next two years. House and Senate proposals would cut closer to $10 million. Children’s had revenue of $540 million last year, 40 percent of it from Medicaid, the state-federal program for poor and elderly patients.

“What is usually not realized is that 50 percent of Medicaid recipients in this state are children,” said Dr. Alan Goldbloom, chief executive of Children’s. “Children are the group we should be investing in. They have the biggest and longest return on investment.”

Children’s recently closed an exercise medicine program for children with chronic illnesses and cut school outreach programs. Other support services — interpreters, social workers and chaplains — would be at risk with future cuts.

For HCMC, areas at risk are mental health, dental care, HIV care and clinics, said CEO Lynn Abrahamsen.

As a safety-net hospital, HCMC derives 43 percent of its revenue from Medicaid patients. To save money after the 2003 budget cuts, it closed a therapeutic pool and a Minneapolis clinic that served mostly Hmong patients, and stopped offering dental services in Richfield.

As it is, hospital executives say, Medicaid pays only about 80 percent of the actual cost of delivering care. Hospitals make up the loss by charging private insurers and their enrollees more.

In the past, hospitals could negotiate higher prices with insurers, who would then raise premiums. But as more consumers use high-deductible insurance plans in an effort to control their premiums, they’re the ones who will face higher bills as a result of cost-shifting.

When consumers can’t pay, hospitals see bad debt rise. “That shell game has fallen apart,” said Allina spokesman David Kanihan.

Pressure on nursing homes

Nursing homes can’t shift costs to other payers because state law forbids it. A recent survey of nursing homes showed that more than one-fourth had 2008 operating margins of minus 5 percent or worse “and it will be worse this year,” said Gayle Kvenvold, CEO of Aging Services of Minnesota.

Medicaid payments for the poor are the main source of income for nursing homes, and they are likely to remain flat next biennium, although some other nursing home payments are likely to be cut.

Just as hospitals fear that health care cuts will result in more people getting care in emergency rooms, nursing homes worry that likely cuts to home-care programs will push frail people out of their homes and into nursing homes.

Said Coldwell, the analyst for the Minnesota counties group, “Some people get all upset about welfare moms. They ought to realize that — in terms of dollars and number of people — the welfare mom is your grandma in a nursing home.”

Damage to reform?

Hospital officials also worry that budget cuts could derail Minnesota’s much-touted reform efforts, passed by the Legislature in 2008. The wide-ranging reforms include coordinating care for people with chronic conditions and other services that keep them healthy and out of the hospital.

Yet those services, such as phone calls from nurses to check on patients, may not happen if finances get tighter.

Fairview Health System is working with Medica at its Eagan clinic to change the care model, breaking a large clinic into teams of doctors, nurses and aides who care for groups of patients. Fairview has committed $10 million a year over five years to reform efforts, said Fairview CEO Mark Eustis. That money is now at risk.

Despite their best arguments to legislators and the governor, health and human service providers recognize that they must endure painful cuts. The question is how damaging they will be.

For the state to cut programs that provide preventive medical care, said David Wessner, CEO at Park Nicollet Health Services, is akin to “treating diabetes by getting very good at amputation.”

New Legislation for Retiring Baby Boomers

PREPARING FOR THE BOOM

By Charley Shaw, St. Paul Legal Ledger, May 18, 2009

Gov. Tim Pawlenty last week signed bipartisan legislation that addresses how communities can help their older residents stay active and engaged.

House Health Care and Human Services Policy and Oversight Committee Chair Rep. Paul Thissen, DFL-Minneapolis, said the so-called “Communities for a Lifetime” legislation is an attempt to make up for lost time in addressing the impending wave of retiring baby boomers.

“We have not as a Legislature or as a state taken the kind of action we really need to take to solve the problem that’s going to overwhelm us. This is a small step we can take in a tough budget year to start people rethinking and reframing (the issue),” Thissen said.

Communities for a Lifetime will be partnerships of cities, counties and townships that provide a list of supportive services and opportunities to their residents age 65 and older.

The bill lists several things that the partnerships should “extend” to seniors:

* Ways to contribute through volunteer service.

* Ways to participate in paid work force.

* Ways to socialize, recreate and participate in wellness activities.

* Ways to grow older where they live with access to affordable housing.

* Access to quality long-term care.

* Transportation options such as public transit.

The communities should also have health care services such as remote medical technology, nutrition programs and high-quality assisted living facilities.

The bill requires the state Board of Aging to report recommendations to the Legislature on ways communities can obtain the designation.

“It sets up a framework for defining what a community that would be livable for older people looks like in terms of housing, in terms of transportation, in terms of access to health care, in terms of volunteer activities,” said Thissen, who is planning to run for governor next year.

The Senate version of the bill was sponsored by Sen. Kathy Sheran, DFL-Mankato. Co-sponsor Sen. Julie Rosen, R-Fairmont, noted that coordinating services for the aging population in her rural district is an important way to help the overall community. The largest city in Rosen’s southern Minnesota district has 11,000 people. As much as 26 percent of the population in her area is 65 or older.

“Something like this will actually insure all the resources are working together. Instead of having a resource here and a resource there,” Rosen said.

Thissen emphasized that communities need to have some coordination in their approach to serving the aging population.

“We really aren’t doing what we need to do to start planning. Part of it is just awareness-raising for people about the implications of a rapidly aging population. And part of it is to spread best practices from community to community. There is some planning go on, but there is no coordination of it,” Thissen said.

In the future, Thissen plans to continue to press for legislation that addresses issues with the aging population.

Thissen introduced legislation this session that would create a long-term care trust fund. Thissen’s bill, which didn’t advance this session, would offer long-term care benefits similar to the federal Social Security system.

“Basically right now our system (makes you) spend yourself into poverty and we need to change that,” Thissen said.

MPR on Democratic Push to Reach a Budget Deal

CLOCK TICKING AS DEMS AIM TO FINISH MINN. BUDGET BILLS ON TIME

By Tom Scheck, Minnesota Public Radio, May 12, 2009

Democrats in the Minnesota House and Senate say they hope to pass the rest of their budget related bills as early as today. With six days to go before the constitutional deadline for the Legislature to finish its work, state lawmakers and Gov. Tim Pawlenty still haven’t reached an overall agreement on how to erase a $4.6 billion budget deficit.

St. Paul, Minn. — Democrats in the Legislature are working down a path to finish on time. It’s just a question of which roadmap they use and whether Gov. Pawlenty puts up roadblocks with his veto pen.

On Monday, Democrats said they plan to pass the remaining budget bills with a placeholder for $1 billion in new revenue. The question is whether that revenue is new taxes – which Governor Pawlenty opposes – or other options like borrowing and shifts, which the governor prefers.

DFL House Majority Leader Tony Sertich said Democrats in the Legislature are reserving the right to try to override vetoes if they aren’t close to a budget deal.

“By the end of the week, if there’s not an agreement, I believe that we definitely should provide choices and options for legislators,” Sertich said. “If the governor isn’t willing to be a part of the solution for the end of session, then legislators should take it upon ourselves.”

On Monday, the House and Senate took action on several budget bills not knowing whether they’re acceptable to Governor Pawlenty. For example, the Senate passed a public safety bill that Republicans say doesn’t spend enough.

Republican Sen. Bill Ingebrigtsen of Alexandria said the state should spend more on prisons.

“I think we need to send this back to the drawing board and pull the money that we need to satisfy this deficit from someplace other than public safety,” Ingebrigtsen said.

Republicans say that someplace else is from Health and Human Services programs. They complained that the DFL agreement to fund hospitals, nursing homes, subsidized health insurance for the poor and welfare doesn’t cut enough. But DFL Rep. Paul Thissen of Minneapolis said their plan cuts too much already – $500 million over the next two years.

“The reality is in this bill there are deep cuts. There are cuts to people with disabilities,” Thissen said. “There are cuts to hospitals. There are cuts to nursing homes. No one is denying that. The fact of the matter that we have to keep coming back to though is that the other choice is to make the cuts even deeper.”

Gov. Pawlenty’s spokesman, Brian McClung, said the governor doesn’t support the Health and Human Services budget bill. He also criticized Democrats for moving forward with a budget plan that relies on $1 billion in unspecified revenue.

“It seems like leaving blanks in bills during the last week of session is not very open, not very transparent,” McClung said. “If they want to raise taxes, they should tell us that they want to raise taxes and try that. The governor will veto it. A wiser approach is to work with Governor Pawlenty and find some common ground.”

Pawlenty tried to find that common ground by making a budget offer on Monday. His plan would reduce his level of borrowing to $500 million, would increase the size of the payment delay to schools and holds off on building up a rainy day fund. Democrats flat-out rejected the idea.

Meanwhile, Democrats are also moving forward with a backup plan that would keep government services running in case a budget deal isn’t reached. The bill would fund government services at current levels through July first of 2010. DFL Sen. Larry Pogemiller said the bill is only “precautionary” in case Pawlenty vetoes the budget bills.

“Depending on what he chooses to do there, we would want to be in a position to make sure that agencies don’t close down in case he vetoes a bill,” Pogemiller said. “We want to make sure we have all options open to ensure that there’s a nice, orderly conclusion to the legislative session.”

The Senate passed the “lights on” bill 45 to 19. Several Republicans, including David Hann of Eden Prairie, said Democrats were giving up by passing the legislation.

“This sends a bad signal to the state, and if anything, we want to make every effort to get all of the budgets completed on time and this is sort of an out that we’re premature in enacting,” Hann said.

Senate Republicans are also ramping up the rhetoric over a possible special session. A caucus staffer handed out buttons to reporters that said “Special Session costs over $40,000 every day. Get the work done now.” Lawmakers have until next Monday to accomplish that goal.

SD 60 DFL Committee Meeting

Rep. Thissen speaking at the March 18 Senate District 60 DFL Committee meeting.