March 8

In Battle Over Future of Veterans’ Care, Moderation Wins, for Now


WASHINGTON — In an administration rife with intramural fights, the battle over the Department of Veterans Affairs has stood out, not only for its vitriol but also for its consequences. At stake is the future of the nation’s veterans health care system.

For now at least, it appears moderation has prevailed, with the Veterans Affairs secretary, David J. Shulkin, thwarting a pitched conservative push to drive him out.

“It’s my job as secretary to get the organization singly focused on making the V.A. work better for vets,” the secretary, a physician and holdover from the Obama administration, said in an interview on Monday, after the latest in a string of meetings with the White House chief of staff. “I’ve been making it clear to the organization that we will not be distracted as we have in the last couple weeks.”

“People need to get on board with that or need to leave,” he added.

For weeks now, Dr. Shulkin, a political moderate who was confirmed by the Senate 100 to 0, has been locked in a bitter and unusually public battle with a band of Trump administration officials who he said were out to overthrow him. The plotters included White House officials and the two men charged with safeguarding the secretary’s public image — who instead worked to undercut it, according to loyalists of the secretary.

Offstage lurked Concerned Veterans for America, part of the constellation of political groups funded by the billionaire libertarian-leaning activists Charles G. Koch and David H. Koch, in this case to push the department away from government-run veterans’ care and toward private care subsidized by the government.

Dr. Shulkin forced the fight into the open, running a one-man media operation via his own cellphone while betting that the White House would eventually offer reinforcements. On Monday, after meeting with the White House chief of staff, John F. Kelly, Dr. Shulkin signaled that his gamble had paid off.

He said in an interview that President Trump and Mr. Kelly supported his making changes at the department, including the removal of any staff members who did not support him. Mr. Kelly made no mention of finding a new secretary, Dr. Shulkin said, and the White House press secretary, Sarah Huckabee Sanders, publicly expressed her support.

Staff changes could be announced on Wednesday, Dr. Shulkin said, without providing details. Whether he can prevail in actually firing the officials — rather than just having them transferred elsewhere in the government — remains to be seen. Political appointees serve at the pleasure of the president, and it was not clear whether Mr. Kelly or Mr. Trump would back their ouster.

At the root of the dispute is a long-running battle over how to deliver health care to the nation’s veterans. The department, the federal government’s second largest, operates more than 1,200 hospitals and clinics across the country where about nine million veterans receive treatment at little or no cost. In limited cases, it pays for veterans to see private doctors.

Policymakers in both parties argue that offering veterans unrestricted choice between the public veterans health care system and private medical providers would be too expensive and lead to the dismantling of the Veterans Affairs system. They have generally favored a more measured approach that would allow the department to approve the use of private care when waiting times are too long at veterans’ hospitals or when veterans live too far from the department’s facilities.

Enter the Trump administration: Mr. Trump has promoted greater choice as a top priority and surrounded himself with several conservative advisers supportive of greater privatization. Darin Selnick, a former senior adviser to the Koch-funded group, serves as the veterans affairs adviser for the White House’s Domestic Policy Council.

Dr. Shulkin, who led the department’s health care system under President Barack Obama, has aligned himself with the more moderate position. As more conservative officials see it, that has put him out of line with the White House view on the department’s most pressing policy issue.

In addition to the two top communicators — Curt Cashour, Dr. Shulkin’s press secretary, and John Ullyot, the assistant secretary responsible for communications — Dr. Shulkin is likely to target several officials close to the White House. They are Jake Leinenkugel, the White House senior adviser on veterans affairs, and Camilo Sandoval, a former data manager for the Trump campaign who was given a political post at the department.

Mr. Leinenkugel, a former brewery executive, wrote an email to Mr. Sandoval in December outlining his falling out with Dr. Shulkin over policy issues. Mr. Leinenkugel proposed using a then-continuing inspector general investigation to oust Dr. Shulkin’s chief of staff; replacing the deputy secretary, Thomas G. Bowman, with Mr. Leinenkugel; and replacing Dr. Shulkin with a “strong political candidate” with ties to the Koch-based group.

The dispute boiled over last month when the department’s inspector general released a scathing report on a business trip that Dr. Shulkin took to Britain and Denmark last year. The report found “serious derelictions” related to the trip and concluded that the secretary spent much of it sightseeing and improperly accepted a gift of Wimbledon tickets. It also accused Dr. Shulkin’s chief of staff at the time of altering an email to justify the department’s paying the airfare of Dr. Shulkin’s wife.

Political appointees trying to wrestle away control of the department seized on the report to force the secretary’s ouster. Shortly after its release, Mr. Cashour and Mr. Ullyot called a prominent House staff member to ask for backup, according to a Republican congressional aide familiar with the call. Mr. Ullyot told the staff member, Jonathan Towers, that Dr. Shulkin would be gone by the weekend and asked if House Republicans would advocate the secretary’s removal, the Republican aide said.

Mr. Towers, who works for the chairman of the House Veterans Affairs Committee, Representative Phil Roe of Tennessee, told Mr. Ullyot “no” on the spot, the aide said, and pointed out that Mr. Roe had released a statement of support for the secretary just a day before.

Mr. Cashour and Mr. Ullyot have disputed that account. The purpose of the call, they said, was to warn Mr. Towers that doubts raised about the inspector general report by Dr. Shulkin were unfounded. Tiffany McGuffee Haverly, a spokeswoman for Mr. Roe, said on Monday that the chairman continued to have confidence in Dr. Shulkin.

Dr. Shulkin, meanwhile, disputed the report’s conclusions and went around his press office to personally reach out to the news media and publicize concerns that appointees in his office were “trying to undermine the department from within.”

There were other examples. In recent months Dr. Shulkin began to use a new, more inclusive motto for the department, changing the phrase “To care for him who shall have borne the battle and for his widow, and his orphan” so that it included female veterans, a former department official said.

Mr. Ullyot, carrying out orders from the White House, reversed the decision, and Dr. Shulkin relented.

The secretary has not spoken directly with Mr. Ullyot in three weeks, since the report’s release. His critics within the administration said he had isolated himself and become paranoid.

Allies of Dr. Shulkin have suspected that the same faction could be behind ominous-sounding reports that have appeared in the press saying that the inspector general was on the verge of releasing another damaging report, this time about Dr. Shulkin’s use of his in-house security detail — a report that could provide a final blow to the secretary. A spokesman for the inspector general did not reply to a request for comment.

Asked about Monday’s meeting, Mr. Cashour replied with a seemingly unrelated statement. “President Trump tasked Secretary Shulkin with reforming the V.A. so it could better serve the men and women who sacrificed to protect our country,” Mr. Cashour said. “Many reforms have already been enacted, many more are still needed, but nothing will distract the president, the secretary and the department from finding the best ways to provide care and benefits to our country’s heroes.”

March 8

Sanders says new health-care plan shows Dems moving toward ‘Medicare for all’

By Peter Sullivan via The Hill

Sen. Bernie Sanders (I-Vt.) said Monday that he thinks a new health-care plan from a Democratic think tank shows that the party is moving toward his position on health care.

Asked if he thinks the plan from the Center for American Progress (CAP), which comes very close to Sanders’s signature idea of “Medicare for all,” shows the Democratic Party is moving his way, Sanders told The Hill, “Yes, I do.”

The plan released by CAP, a group with close ties to Sanders’s former primary opponent Hillary Clinton, is not quite single-payer in that it still allows for employer-based insurance as an option. But it otherwise provides Medicare for all people, something very close to Sanders’s vision and a leftward shift from previous major Democratic plans.

Sanders alluded to the fact that the CAP plan does not go as far as his own, but called it a “step.”

He pressed his calls for universal coverage and said “I think that the most cost-effective way to do that is by expanding Medicare, eliminating the private insurance companies, and then saving tremendous amounts of money in administrative costs.”

“I believe in a Medicare for all, single-payer, but to the degree that people are talking about guaranteeing health care to all people, it’s a step.”

The CAP plan, called Medicare Extra for All, provides for a government-run health insurance plan modeled off Medicare for all, with the exception of those who choose to remain in employer-based coverage.

That is further than previous plans from Clinton or former President Obama, which largely called for a government-run “public option” that would compete alongside private insurers.

March 6

Willing and able: Disabled workers prove their value in tight labor market

By Paul Davidson via USA Today

Julie Propp landed her first-ever job about 18 months ago — at age 55.

A part-time retail helper at a Kwik Trip convenience store in Marshalltown, Iowa, Propp cleans and ensures coffee cups and other items are well-stocked. She previously loaded boxes in workshops run by agencies that help disabled people but never had a traditional job because of a developmental disability.

She prefers her current gig. “It’s more money down there and more hours,” says Propp, who earns $10.90 an hour and will soon get a bump to $11.25. “Some customers are so nice.”

With the low 4.1% unemployment rate making it tougher for employers to hire and retain workers, more are bringing on Americans with disabilities who had long struggled to find jobs. Many firms are modifying traditional interviews that filter out candidates with less-refined social skills and transferring some job duties to other staffers to accommodate the strengths of people with disabilities.

“In a tight labor market, employers who usually might not hire some of these people are reaching (deeper) in the queue,” says Harry Holzer, a public policy professor at Georgetown University.

Kwik Trip launched its program to place people with disabilities in retail helper jobs in 2013. About half of the company’s 634 stores in Iowa, Minnesota and Wisconsin have such workers. Turnover for retail helpers was just 9% last year compared to 45% for all part-time employees, says Joalyn Torgerson, Kwik Trip’s return-to-work coordinator.

Propp is “always looking for more stuff she can do,” store Manager Sheila Earney says.

Advocates for people with disabilities say recognition of their value in the workplace is long overdue, and they hope employers’ current hiring need spurs a more enduring shift. The share of working Americans who are disabled was still small at 3.2% last year, but that was up modestly from a range of 2.9% to 3.1% from 2011 to 2016, according to the Labor Department.

“There’s a growing cadre of companies that look at people with disabilities as an untapped talent pool,” says Carol Glazer, CEO of the National Organization on Disability. “When people spend their entire lives solving problems in a world that wasn’t built for them, that’s an attribute that can be translated into high productivity in the workforce.”

The portion of working-age disabled Americans who are employed averaged 29.3% last year, up from 26.8% in 2013, figures from the Labor Department and Moody’s Analytics show. That’s still far lower than the 73.5% of non-disabled Americans who were working, though the latter has not increased as sharply. The unemployment rate for disabled people is 8.8%, down from 16.9% in 2011, but more than double the U.S. jobless rate.
Shrinking Social Security

The return of many disabled workers to the labor force has helped shrink the Social Security disability rolls, which swelled during and after the recession as many people with less severe infirmities applied for benefits after their unemployment insurance expired. The past three years, the number of people on disability has steadily fallen to 8.7 million from 9 million and the ranks of those leaving has exceeded those joining, notes Moody’s economist Adam Ozimek.

Meanwhile, hundreds of companies have launched programs to recruit people with disabilities in recent years, partly in response to the 1990 Americans with Disabilities Act, which bars discrimination against job applicants and requires “reasonable accommodations” in the workplace. Now that job candidates are scarcer, many firms are ratcheting up those efforts. With millions of employees job hopping for higher wages, companies such as CVS, Microsoft and PricewaterhouseCoopers find people with disabilities are often more reliable and loyal. And those with conditions such as autism can be more detail-oriented. Microsoft has hired 50 people with autism the past three years, mostly as software engineers.

CVS hires hundreds of disabled people annually under an initiative it began about 20 years ago, but the company has ramped it up amid the tight labor market, with the number of recruits doubling in 2017.

“We have to get creative” to fill job openings, says David Casey, CVS’ vice president of workforce strategies. Its program “is a competitive advantage. We’re getting access to a talented pool that a lot of other companies are overlooking.” Retention rates for disabled workers are double that of CVS employees overall, Casey says.

Several years ago, the company joined with state and local agencies to open “mock pharmacies” brimming with CVS products, prescriptions and signage to train disabled job candidates. In nine weeks, students learn how to run the cash register, place products on shelves, complete paperwork and deal with customers.

Kaylee Merrick, 24, who lives in Stafford, Va., and graduated high school in 2014, got her first job through the program nearly two years ago. She has anxiety, post-traumatic stress disorder, depression, memory loss, attention-deficit disorder and attention-deficit hyperactivity disorder. In previous job interviews, “I was like — Oh, no, what if they don’t hire me? I start fidgeting really bad. I have tics.” With CVS, she says, “they teach you.”

Merrick, who works up to 30 hours a week, rings up purchases, stocks shelves, cleans and helps customers. “I’m basically running around all day,” she says. “I love dealing with people, even the grumpy ones. … And when I clean something, it’s clean.”
Opportunities at Microsoft

The number of disabled people in white-collar jobs is also growing. Microsoft long has hired people with autism for software developer and data scientist positions as part of its normal recruitment. But the company realized many qualified candidates were screened out during phone interviews, says Neil Barnett, Microsoft’s director of inclusive hiring. Skilled computer programmers are coveted, with Microsoft perennially struggling to fill hundreds of openings.

So the software giant overhauled its selection process for autistic candidates, stretching a typical one-day interview and testing regimen to 4½ days. Candidates are interviewed, but the conversations are spaced out and emphasis is on tasks that show how well they help co-workers and take leadership roles.

Hiring managers are told to downplay such things as whether an applicant makes eye contact. And if he or she simply answers a question with a “yes,” or “no,” the manager is instructed to follow up.

“We’re finding tremendous talent,” Barnett says. “We feel we have the types of roles that would be a good fit.” People with autism tend to pay more attention to detail and are quick to spot patterns, he says.

Joey Chemis, 30, a Microsoft data scientist who previously worked minimum-wage jobs despite degrees in applied math and statistics, says prior hiring managers “found me a little intense.” Microsoft “let us spend time on campus getting acclimated.”

PricewaterhouseCoopers, the big accounting and consulting firm, has learned that workers with autism focus intently on repetitive duties required in positions such as tax managers, says Brad Hopton, who oversees the firm’s disability inclusion programs.
Special solutions for special needs

Some companies have been hesitant to hire disabled workers because of concerns about safety and liability, says Glazer and Janet Bruckshen, head of Washington Vocational Services, which places and trains disabled workers. Remedies are widely available. Smartphones with voice recognition help deaf grocery store workers talk to customers. Standing desks aid workers with attention-deficit disorder who find it hard to sit for long periods.

Robert Holder, 31, who has multiple sclerosis and recently got a part-time job at the welcome desk of a YMCA in Mauldin, Mass., has asked for a phone headset and a special keyboard. “You feel like you’re getting back to society,” says Holder, 31, who had searched eight months for work.

Some businesses are going further, modifying job requirements. Shannon Goodall, 31, of Edmonds, Wash., hunted fruitlessly for a job for five years. She has a learning disability that makes multitasking and interacting with customers difficult. But Papa Murphy’s, which makes pizza and other food to cook at home, hired Goodall about a year ago, allowing her to prepare food while shifting her customer-service duties to co-workers.

“I was looking for a job that wasn’t secluded,” says Goodall, adding that she was isolated from customers and co-workers in previous positions.

Noting that many staffers are college students who quit after a few months, her manager, Taylor Allcock, says, “It’s really nice having someone around who I can depend on.”

March 2

Trump’s Social Security budget offers more work, less staff, longer waits

By Joe Davidson via The Washington Post

or the elderly and disabled who complain about poor Social Security assistance now, these might be the good old days.

President Trump’s proposed fiscal 2019 Social Security Administration (SSA) budget would cut staffing, a recipe for long waits in agency offices and on the telephone for those trying to navigate the often-difficult world of old-age, disability, survivor and Medicare benefits. Retirement and survivor benefits would not be hit.

Declining service is nothing new, but under Trump, there would be fewer federal employees to deal with an increasing number of people of retirement age. His budget request calls for almost 1,000 fewer full-time-equivalent work years in 2019 than this year. A full-time-equivalent work year is the amount of work a person toiling full time would do in one year. The amount of overtime allowed staffers to keep up with demand would be less than a third of that in 2017 and just over half the 2018 estimate.

The advocacy group, National Committee to Preserve Social Security and Medicare, provides these stats to illustrate the problem: About 10,000 baby boomers hit retirement age every day. The increase in workloads coupled with a decrease in staffing led to a 627-day wait for disability applicants’ hearings in 2017. The three-minute telephone wait that callers had for SSA’s 800 number in 2010 was six times longer last year. Despite SSA attempts to direct traffic to its website, there were 2 million more field office visits in 2016 than 2015. “More than 16,000 visitors were forced to wait more than hour for service each day in August 2017,” the committee said.

Promising to become “more efficient and effective” for the 71 million people who receive monthly benefits, Social Security Administration statements say Trump’s budget “will allow us to support our front line operations, such as our field offices, processing centers, and National 800 Number, by providing some critical hires and expanding our additional service delivery channels and online service options.”

Sure, there will be support, but at what level? The support was too low even before Trump’s proposed 2019 cuts.

At a Senate briefing last month, Julian Blair, a 70-year-old Silver Spring resident, spoke about the hardships that service cuts cause.

“I accompany a 92-year-old neighbor to the Social Security,” Blair said. “He’s not computer literate … so I’m going with him. We had to go three times before he could get the service he needs because the lines were so long, and he’s disabled he can’t stand there all day. There was no seats for him.”

He went on to talk about how his daughter “almost gave up and cried because she just could not get the service in a timely manner” for her son’s survivor benefit after his father died. “That’s a shame that should not happen.”

“I have a brother that worked 34 years, became disabled,” Blair added. “It took him two and a half years (to get a claim processed). What happens in that two and a half years? Savings gone, unemployment gone. So real people, this affects for real people.

“But it’s … more than just services. To us, it’s a continued effort to dismantle Social Security.”

The administration wants to push more recipients to the Internet, saying “most Social Security services do not require a visit to an office” and noting the many things that can be done online. But many elderly, like Blair’s 92-year-old neighbor, don’t do business online. And the availability of Web-based services hasn’t prevented long lines at Social Security offices.

Sue Bird, 66, of Wellington, Nev., told of driving 80 miles to a Social Security office in Reno. When she arrived for a 10 a.m. appointment, she estimated 20 to 30 people were standing outside, waiting to get in. Once she got in, she saw almost 150 waiting inside.

“The room was packed with people,” she said by telephone. “I was shocked.”

Blair doesn’t blame the employees.

“It’s not anyone’s fault who’s working there,” he said. “It’s just busy.”

He’s right. The blame is not on Social Security employees. But it is somebody’s fault. The staffers are too busy, and the waits are too long, because elected leaders aren’t providing enough money for the service the elderly and disabled deserve.

Declaring the Social Security Administration to be “in a dire state,” Witold Skwierczynski, president of the National Council of SSA Field Operations Locals, Council 220, of the American Federation of Government Employees, said “the FY19 budget request would cause further deterioration of service. More calls on the 800 number will result in busy signals and those who got through would have lengthy wait times. It will take longer to get appointments in field offices and walk in customers will wait longer for service and, in many cases, be sent home without obtaining service. SSA processing time for claims and appeals will increase.”

That’s not all that will increase. Expect a rise in staff strain.

“Employees stress levels will increase, and service will suffer,” Skwierczynski added, “since SSA employees will be forced to use short cuts to process claims that will likely disadvantage the public.”

March 2

Tens of thousands of Medicaid recipients don’t pay their premiums

by Phil Galewitz, Kaiser Health News

When Arkansas lawmakers debated whether to renew the state’s Medicaid expansion in 2016, many Republican lawmakers were swayed only if some of the 300,000 adults who gained coverage would have to start paying premiums.

This “skin-in-the-game” provision — endorsed by conservatives in Washington and in many statehouses — is designed to make Medicaid recipients value their government health insurance more and lead healthier lives.

It’s “to encourage more personal responsibility,” Arkansas Governor Asa Hutchinson told reporters in 2016. “We want to incentivize better, healthy living.”

Yet few enrollees are paying the $13 monthly premiums, which apply only to Medicaid recipients whose earnings surpass the poverty level. In 2017, just 20% of the 63,000 Arkansas enrollees paid. For now, Medicaid enrollees in Arkansas don’t lose coverage for lack of payment.

Arkansas is not the only state where Medicaid recipients who gained coverage under the Affordable Care Act disregard the new premiums. Tens of thousands of Medicaid enrollees in four other states that added premiums during the past four years— Indiana, Michigan, Iowa and Montana — have also opted not to pay, according to state records.

Under the ACA, states received millions of federal dollars to cover everyone with incomes under 138% of the federal poverty level (about $16,700 for an individual today). Previously, Medicaid mainly covered only low-income children, disabled adults and parents.

Premiums, which are routine obligations in private health insurance and Medicare, were not a part of Medicaid until that expansion in 2014. But in these five states, conservative lawmakers were hesitant to expand the federal-state program unless they secured fees from nondisabled adults.

Kentucky has received approval to add premiums in 2018.

“We believe the premiums are important to prepare these beneficiaries for what would be required of them if they move up the economic ladder and get coverage through an employer or the federal marketplace,” said Arkansas Medicaid spokeswoman Amy Webb. “It’s a small amount, especially considering the benefit they are receiving. Under an employer or at the marketplace, they would lose their coverage for failure to pay.”

Advocates for Medicaid say it is not surprising that significant numbers of Medicaid enrollees fall behind on their payments.

“Families have to make tough choices every day about whether they buy food, pay the electric bill, their rent, or pay premiums,” said Rich Huddleston, executive director of Arkansas Advocates for Children and Families. He notes that even the state’s $13 monthly premium is burdensome.

Still, the experience in the five states shows converting conservatives’ “skin-in-the-game” mantra into practice has many administrative challenges.

Michigan requires Medicaid enrollees with incomes above the poverty level to pay 2% of their income in monthly premiums, though the amount could be decreased if they engage in so-called healthy behaviors, such as getting a flu shot or trying to quit smoking.

A survey of enrollees last year in Michigan found nearly 88% said the amount they had to pay was “fair,” and 72% said they agreed that they would “rather take some responsibility to pay something for their health care than not pay anything.”

But from January through August last year, fewer than half of Michigan Medicaid recipients who owed a premium — about 77,000 of 175,000 — paid it.

And premiums were not the only new obligation that many these enrollees are failing to meet. The state’s Medicaid expansion also required them to fill out a health risk assessment form with their doctor and promise to improve their health. In return, members could lower their premiums or gain a $50 gift card.

Of the 900,104 beneficiaries who have been enrolled in Medicaid for at least six months, 19% have completed this chore, according to state records.

For most enrollees this is voluntary. But enrollees with incomes above 100% of the poverty level could lose Medicaid coverage if they don’t fill out the form to attest they will try to improve their health. Michigan, in particular, is getting tough: In February, it mailed letters to 13,550 beneficiaries informing them that they failed to meet this requirement and they will be moved off Medicaid. They will have to choose a private plan on the Obamacare insurance marketplace or will be automatically enrolled in one in June.

Dr. Renuka Tipirneni, a researcher with the University of Michigan Institute for Healthcare Policy & Innovation, said it’s unclear if these enrollees will be worse off in the private plans since many will get subsidies to help cover their premium costs. But they may face a larger cost-sharing portion or have to change doctors.

Michigan officials last year also sent 68,000 Medicaid enrollees who owed premiums a notice that they would garnish any state income tax refunds or lottery winnings. That led about 7,000 recipients to pay. The state last year collected premium money from 19,400 through their tax refunds and another 59 from their lottery winnings, according to a state report.

Arkansas officials also plan to intercept state tax refunds to recoup unpaid premiums, but not until 2019.

Other states have mixed records on collecting Medicaid premiums, according to state reports:

— Indiana is the only state to lock enrollees out of Medicaid for six months for failure to pay — and about 10,000 recipients fell into that category in 2016. Kentucky recently received federal permission to add a similar lockout provision this year.

— Iowa disenrolled more than 14,000 Medicaid enrollees from January 2016 to September 2017 for failure to pay a $10 monthly Medicaid premium, though they could re-enroll at any time. More than 40,000 Medicaid enrollees with incomes over 50% of the poverty level were subject to a premium in September 2017 and about three-quarters of them had not paid nor completed a health risk assessment form that would have waived the fee.

— Montana’s Medicaid program dropped 2,884 adults with incomes over the poverty level in 2017 for failing to pay a premium. The state charges 2% of the enrollee’s monthly income. Montana allows those dropped to re-enroll at any time without paying.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

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