Thursday, September 20, 2007

Go to the Back of the Bus!

We received an interesting email from my son's school today:

Regulations Proposed to Eliminate Federal Medicaid Reimbursement to Schools

After years of fighting back the federal government’s threat to eliminate schools’ reimbursements for certain services provided to Medicaid-eligible students, school districts throughout the nation were dealt a severe blow that could have a significant impact on their budgets. On August 31, 2007, the Centers for Medicare and Medicaid Services (CMS) formally released proposed regulations to eliminate reimbursement for Medicaid expenditures for school-based administrative activities and special education transportation services, thus marking the first step in the federal rulemaking process.
The September 7, 2007, Federal Register posting of the proposed regulations (CMS-2287-P ) indicates the proposed rule is estimated to reduce federal Medicaid outlays by $635 million in Fiscal Year (FY) 2009 and by $3.6 billion over the first five years (FY 2009–13). If adopted, California stands to lose more than $130 million annually in federal reimbursements for administrative responsibilities and certain home-to-school transportation services to students with disabilities (See August 18, 2007 Fiscal Report Article entitled, “Fight Continues on Proposed Federal Medicaid Regulations). The proposed rule would become effective October 1, 2008.
The CMS, under the umbrella of the federal Office of Health and Human Services, has consistently argued that the program is fraught with fraud and abuse, citing examples in New York and Michigan . Those claims have been strongly disputed by school agencies in those states. In response, President Bush eliminated the funding in his 2008 Federal Budget, and CMS started developing the regulations. However, the President’s proposed cuts have been rejected by the Democratic Congress, which has supported legislation to tighten up program requirements instead. The battle now moves to Congress; it will need to get language into a “veto-proof” bill to prevent the regulations from being implemented.
The comment period has begun and will end on November 6, 2007. CMS is charged with reviewing the comments and preparing a final rule. California and national education groups are preparing comments for submission and school agencies are also being encouraged to submit comments. Comments can be submitted in one of three ways:
1. Electronically. Submit electronic comments on specific issues in this regulation to Click on the link ‘‘Submit electronic comments on CMS regulations with an open comment period.’’ (Attachments should be in Microsoft Word, WordPerfect, or Excel; however, they prefer Microsoft Word.)
2. By regular mail. Mail written comments (one original and two copies) to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS–2287– P, Mail Stop S3–14–22, 7500 Security Boulevard , Baltimore , MD 21244 . Please allow sufficient time for mailed comments to be received before the close of the comment period.
3. By express or overnight mail. Send written comments (one original and two copies) to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS–2287–P, Mail Stop S3–14–22, 7500 Security Boulevard , Baltimore , MD 21244 .
A copy of the proposed regulations can be found at:
While doing so in a typically obfuscating way, what this document is saying is simply this: The Federal Government will no longer continue to subsidize school districts' expense of transporting students to and from school.
The original justification for covering the cost of medicaid-eligible (this definition covers many special needs kids) students' school transportation was that, since IDEA dictates that Medicaid must reimburse schools for costs incurred by meeting the requirements of that student's IEP, then transportation costs to and from the location of the school (in this translation, School = Medicaid Provider) are implied to be included in that reimbursement. The result of this is that most special needs students automatically are offered transportation to and from not just their own local school, but also (speaking from personal experience) to any other specialized schools or educational programs that are specified in the IEP.
Different people will draw different conclusions on this whole thing. Here are some of my thoughts:
  • -Students with special needs already have a number of cards stacked against them. Their families do too, in many cases, including financial and time constraints. It seems wrong to me to cut back services for this particualr population.
  • -Is it ultimately the school district's responsiblity to provide transportation for special education students, and they have pawned off that responsibility to the federal government through a Medicaid-based loophole? If so, any anger directed toward CMS for this would be better oriented toward the school districts to begin with.
  • -Notice the wording of the document we received. In quintessential, uber-liberal, teachers-union-backed form, the author implicates the Republican administration as the culprit, and the Democratic congress as the potential savior. Puh-lease - this is not a partisan issue, and if the power roles were reversed then precisely the opposite scenario would prevail. I grow incredibly weary of the insertion of partisan political gamesmanship into issues such as this, when basically the entire government is at fault. It is astounding to me that, considering the taxes collected by the government for just the activities of my one family - including sales tax, vehicle tax, property tax, income tax, captial gains tax, etc, etc, etc - the school district cannot afford to transport one of my three kids back and forth to school. It boggles the mind and offends the intellect. And it transcends political party. And the political discussion would be incomplete if it did not also include the educators' various unions.
  • -If you take the time to read the linked document, you may come away with the feeling, as I did, that the CMS may have a legitimate beef with the way schools are billing Medicaid. It says:
    "CMS has long-standing concerns about improper billing by school districts for
    administrative costs and transportation services. The U.S. Department of
    Health and Human Services Office of the Inspector General and the Government
    Accountability Office have identified these categories of expenses as
    susceptible to widespread fraud and abuse ... In fact, examining
    State-reported expenditure related to schools reveals that, in certain years, a
    number of States' reported school-based administrative expenditures approached
    or even exceeded their reported school-based direct medical service
    expenditures, which is clearly evidence of improper claiming in this area."
    So let me get this straight. Because the school districts improperly (fraudulently) claimed excessive administrative costs (does anyone doubt the truth of this?), we are now facing a situation where transportation could be cut off for special needs kids? My family will work around it if indeed it happens this way - other families may not be as blessed as mine. Other kids have disabilities requiring much more complex and expensive transportation considerations than mine. Other kids may be being raised by a single parent who has work schedule conflicts. Some families may not have the financial means to own a vehicle to get their kid to school (in which case they probably should have waited until better financial times to have a child, but that is a rant for another day). I hope the administrators who robbed the system lose at least one night of sleep over the results of their actions. But its not likely they will.
  • -Is there not a better way to distribute these funds? In other words, any given dollar that is collected from a taxpayer that eventually ends up being spent on Special Ed transportation is passing more desks, obviously, than is necessary. The money, apparently, is going from the Federal general fund to the State general fund, from there to the Medicaid general fund, then to the school district general fund, where it is appropriated to transportation costs. How many pennies are sucked out of each dollar at each step of the way? Is the tax-collected dollar worth, in your estimation, 90 cents of transportation? 43 cents? 7.5 cents? I have no idea, but I'm guessing 7.5 is closest to accurate. If I ran my business like this system is being run, I'd have to close up shop tomorrow.

If there is one thing I love about blogging, it is finding out via comments how many people agree or disagree with me.

Also, please note that the proper means to submit comments are included at the end of the school's email. If you would like to have input on this, this is your chance. The comment period lasts until November 6.


Another Voice said...

Glad to see you are on this Steve. People need to E-Mail their objections to CMS during the rule making process. Objections that refer to discrimination against a minority class of citizens, removal of rights guaranteed by law and injustice to people with disabilities may get more attention than a simple “please don’t do this”.

The staff at CMS get their marching orders from the president, and frankly he doesn’t give a damn any more. He just wants his final budget to look good.

I will try to find more addresses for objections.

Club 166 said...

CMS may or may not have a legitimate beef here. They always scream "fraud and abuse" at the drop of a hat, whenever they want to decrease payments to anyone.

I would also send a letter to your US legislators detailing what CMS is proposing, and why you think it is a bad idea. Be sure to reference the specific rule change that is proposed. This has helped sometimes in the medical arena.

And yeah, there's no place for public communications becoming obviously political.


Club 166 said...

By "public communications" I mean official communications of public agencies.


Patrick said...


First, its not the 'whole' government. Obviously someone like vets affairs is not culpable, though I'm not here to pick nits.

I caught the partisan thing on the first read too, and think that deficient wording needs to be pointed out to the authors of the notice, or their bosses.

I think that accountability IS at issue here. Just like IRS requires receipts for itemized taxes, the CMS should require the actual receipts from the States, districts, etc. right down the line. Then those that appear to be 'outliers' can be called into question or audited. Perhaps transportation contractors or states or individual districts are price gouging in certain parts of the country, or have inefficient or expensive upkeep problems.

But just throwing the benefit out, shortly after establishing it, does not make sense to me.

In my opinion 'Government' spends a lot of money on unnecessary things. Like sports complexes for the professionals/leagues that should really be able to afford to pay for their own Stadiums/Racetracks with their luxurious multi million dollar player salaries and box office intakes.

Caring for our neighbors needs to start here, in this country, fixing some of our own problems, before trying to fix others' problems. But I won't ramble on about things that the liars up the hill would try to justify or deny too long.

Is there head up there for the Warmth? (Though I think its up there due to greed.)

Another Voice said...

I agree with sending alerts of this change to elected officials. However, I do not feel that the CMS or the Office of the Inspector General can use “fraud and abuse” as a reason to discontinue a program. Part of their mission is to detect and combat fraud and abuse.

If the Office of the Inspector General and the Government
Accountability Office have identified these categories of expenses as susceptible to widespread fraud and abuse, the only question that needs to be answered is what are you doing about it?

Discontinuing a service because they can not control abuse is, in my opinion, wrong.

Steve D said...

AV -
Any additional addresses for objections would be appreciated.
And your comment about "fraud and abuse" being an unjustifiable reason to end the program is absolutely correct.

Club 166 - I did not realize that this was a common occurrence with CMS. That sheds a bit of new light on the issue, to be sure.

Patrick - My term 'whole government' was a poor choice of words - what I really meant was 'both parties'.
I appreciate your comment, though I must mention that I disagree with your position on, to use your example, sports complexes.
I absolutely agree that things like inefficiencies in transportation cost outlays can be just as responsible for what would seem to be cost overruns, as opposed to willful fraudulent behavior by the school districts (assuming that was one one element of your point). If that is the case, fixing those problems seems a much better solution than ending a needed program.

Navi said...

one thing:
"(in which case they probably should have waited until better financial times to have a child, but that is a rant for another day)"

I'm interested in what that rant for another day would be. This statement has been bugging me. I didn't initially comment, because, well it was a rant for another day... and I must admit, rant is the appropriate term.

because, it is soooooooooooo much more complicated than that.

Statements like that, without clarification, are tantamount to marginalizing the poor in a manner similar to the way others marginalize those with disabilities.

I realize, it was probably to buffer any arguments against your argument that some people can't afford to transport their children to school, but frankly it sends the wrong message.

Steve D said...

Navi -
I understand your point, and I agree that my statement, unqualified, is inappropriate. I apologize, and would like to explain my statement to you in private. Please send me an email so we can discuss.