(4 hours if you are interested)

About a week before Christmas Iowa’s Senate Health Policy Oversight Committee held a hearing with the administrators of Iowa’s now privatized medicaid system. The YouTube is posted above. It runs nearly 4 hours. I will be honest, I tried to watch it but it went deep into the weeds almost immediately and I was lost.

Which to a degree may be one of the goals of the privatized Medicaid system. Instead of being clear and understandable so the customers of the system can’t possibly navigate their way through the system. Thus private companies must be employed who can apply rules set up by congresses and legislatures while seeming to act as a gateway for the customer.

This brings us to a story in this month’s Mother Jones magazine concerning a company called Maximus. Maximus is a company few have heard of yet your tax dollars are most likely paying dearly for the service they offer – that of acting as the go-between between the governmental rules and the end customer. This has become a very lucrative relationship for Maximus as means testing for nearly any governmental individual payment. The story is long but well worth the read.

Having never heard of Maximus before and being moderately familiar with Iowa’s privatized medicaid program, I was surprised to see Iowa among Maximus’s top customers:

“Across the contracts we assessed, the bulk of Maximus’ work has been in managing access to means-tested health care programs like Medicaid and the Children’s Health Insurance Program. In the last decade, Maximus has contracted for this kind of work in 28 states and Washington, DC, earning $1.7 billion. The company has also helped run cash and work assistance programs across 21 states, New York City, and the federal government; those contracts totaled $312 million for welfare-to-work, disability, and child support collection. Nearly all of Maximus’ work is in a handful of states—megacontracts in Michigan and Texas account for 46 percent of its contract values, and commitments in Iowa, Indiana, Kansas, Pennsylvania, and Tennessee account for 27 percent more. But the scale of Maximus’ activities is so large that contracts with the 37 other governments, representing just 27 percent of its overall revenue, amount to more than $557 million. Even this is an undercount; eight states provided at least one document indicating a relationship with Maximus without noting the contract value. 

<<snip>>

Indeed, Trump’s order, with its focus on self-sufficiency and fraud prevention, parallels conservative initiatives in the realms of immigration and voting. In September, the administration proposed a change that would prevent any immigrant using Medicaid, housing assistance, or food stamps from getting a green card. It’s “that theme of ‘You may have a right, you may have a benefit, but we’re going to do what we can to make you decide not to use it,’” says Andy Slavitt, an Obama-era Medicaid official who helped implement the Affordable Care Act.

Just as voters in some states are forced to suddenly produce additional identification to vote, all in the name of preventing virtually nonexistent voter fraud, recipients of social welfare are made to jump through hoops to prevent welfare theft that barely happens anyway. The thinking is, “‘We’re giving you these benefits and you’re going to have to work for it,’” says Emory University historian Carol Anderson, whose book One Person, No Vote came out last fall. “It’s the same kind of frame, and a lot of it is targeted at the same people.” The fraud in public aid programs that does exist often benefits providers and business owners more than the poor. One study of five states found that less than 0.2 percent of SNAP food stamp clients double dipped. Nevertheless, 18 states have passed restrictive “stop the scam” policies that expand fraud detection programs.”

(Note: there are some fees inside the new “First Step” prison reform bill passed and signed last week that will open up new business for the Maximuses of the world.)

Perhaps the most surprising thing about this article is that a company such as Maximus can exist and have such a profound influence over peoples’ lives – especially poor people’s lives – and few people have ever heard of them.

For those of us in Iowa it has to be a big surprise that a company such as Maximus is integrated right into the middle of one of our most controversial issues yet few have ever heard of them. Yet according to some among our leaders in Des Moines they must be doing a bang up job:

For states that have decided to teach the poor a lesson about responsibility, Maximus is a popular partner. A web­inar in December 2017 featured Michigan’s acting Medicaid director, Kathy Stiffler, who spoke glowingly of Maximus’ work in that state, where it serves as an enrollment broker for Medicaid. The state also persuaded its Medicaid insurers to contract with Maximus to help manage clients’ premium contributions, said Stiffler; the company is so trusted by the state that its officials meet with insurers without state representatives present. Indeed, when Maximus bids on contracts, its proposals include letters of reference from state governments happy with its work. In a 2016 bid for a Medicaid enrollment broker contract in Wyoming, four states—Illinois, Indiana, Iowa, and Virginia­—offered letters of support. Indiana called Maximus “a valued partner.” The other three states all noted, verbatim, that its “staff” and “work ethic…go above and beyond.”

And that is why there are so many of us out here in Iowa’s hinterlands who can’t wait for Rob Sand to get to work investigating this mess. Soon to be former Auditor Mary Mossiman delayed a report on privatized Medicaid until she could delay it no longer. She was able to delay it until after the election, which may have partially accounted for her loss. When the report was issued it really didn’t seem to look behind any furniture or look under any rugs.

Rob Sand has a reputation for diligence and honesty. Most expect he will let the evidence guide the investigation and we will get an honest assessment of the real structure and cost of this monstrosity of a privatized system that most on either side of the issue believe is doing a very poor job. I believe the report will be an eye opener for most Iowans, including Kim Reynolds.

Let us hope that the legislature and governor will then be moved to make the necessary changes to make Medicaid work for those whose lives depend on the system, not for the managed care organizations or Maximus. 

For an idea of what kind of a system America could have one only need look to our northern border and the system Canada implemented. Common Dreams looks at 25 differences between the Canadian system and the USA.