A4 Thursday, August 15, 2013
OPINION
Can we make sense of the behavioral health crisis?
If you are confused about the behavioral health crisis, you’re not alone. Whichever way you see it, it’s terrible. Medicaid funds are being withheld from 15 nonprofit behavioral health providers. Except for a few confusing revelations, the public still has only vague allegations about what these nonprofits may have done. If the providers really made fraudulent use of public dollars, it’s shameful. However, it’s terrible for these organizations to be under a cloud without specific charges being revealed; equally, while investigations are ongoing, it might be terrible if their reputations were ruined by having the unproven allegations made public. Some of them will go out of business because they can’t afford to operate without their Medicaid funds. The fragile network of local providers will be damaged. These organizations provide services to people who really need help,
EDITORIAL
MERILEE
DANNEMANN TRIPLE SPACED
such as autistic children and adults struggling with addiction or mental illness. The services are provided at taxpayer expense both because they help the clients and because they benefit the rest of us. Treatment of behavioral health issues makes it possible for the clients to function in society, keeping them (we hope) out of prison or hospitalization — which would be much more costly than outpatient treatment — and in some cases keeping the public safe from them. We all have a stake in maintaining the programs at a high level of quality. We are also hearing allegations
against the state Human Services Department, and these are equally serious. One charge is simply incompetent management. New Mexico provides Medicaid behavioral health services through a managed-care model and is paying a company called Optum Health $42 million a year to manage the program, so why didn’t Optum find these problems earlier and correct them through less drastic measures? At the recent Legislative Finance Committee hearing, I lost count of the number of times Senate President Mary Kay Papen repeated, “Fortytwo million dollars!” The total budget for Medicaid behavioral health is around $380 million, according to Karen Meader of the Human Services Department. A more serious allegation is that HSD’s action represents a deliberate attempt to dismantle the existing system of community-based nonprofits and allow for-profit com-
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panies to replace them. Sen. Jerry Ortiz y Pino, D-Albuquerque, said it publicly in a recent interview on the online New Mexico Compass (nmcompass.com) and pointed to the upcoming planned restructuring of the entire Medicaid program from Salud to Centennial to support his argument. He is a social worker with a 40year local career and knows the system very well. Why, he asked, take such a drastic step when provider contracts will expire anyway in a few months? We can hope this charge is proven wrong, just as we can hope that the combined investigations of the attorney general and state auditor find little or no wrongdoing by the providers, and that somehow the system will be restored. New Mexico supports home-based small business, does it not? A similar situation is unfolding in North Carolina. The state hired Public Consulting Group, the same company that conducted the New
Mexico audit, to audit small behavioral health providers. After the dust had cleared, most of the audit findings were not substantiated, but lots of providers were put out of business when their checks stopped coming. Knicole Emanuele, a North Carolina Medicaid specialist attorney (who blogs at medicaidlawnc.wordpress.com) represents several local companies that were financially damaged by the audit. She told me she is at work on a lawsuit against the state, PCG, and possibly other parties, to recover the financial damages her clients suffered. This could cost the state millions of dollars if the plaintiffs win – money that could have been better spent helping people. We can’t afford that in New Mexico. Let’s hope it’s not necessary. Contact Merilee Dannemann at www.triplespacedagain.com. © New Mexico News Services 2013
Think tanks defy senator’s intimidation
Dick Durbin is a hypocrite. In the wake of revelations this spring that the Internal Revenue Service had red-flagged conservative groups for extra scrutiny, the Illinois Democrat and Senate assistant majority leader, declared, “It is absolutely unacceptable to single out any political group — right, left or center — and say we’re going to target them.” The IRS’ actions were “unthinkable,” Durbin continued. “That goes back to some of the worst days of Richard Nixon.” Given the Illinois lawmaker’s remarks, we imagine it was quite the unpleasant surprise for leaders of two free-market think tanks — John Allison, president and CEO of the Cato Institute, and Darcy Olsen, president of the Goldwater Institute — when they received letters from Sen. Durbin, asking if their organizations “served as a member” of the American Legislative Exchange Council or “provided any funding” to ALEC this year. The lawmaker said he plans to convene a hearing in September of the Senate Judiciary Committee’s subcommittee on the Constitution, Civil Rights and Human Rights to examine so-called “stand your ground” laws, which detail reasons for killing in selfdefense. Durbin attributes the 2012 shooting death of Trayvon Martin to Florida’s standyour-ground statute (though it played no role in the recent trial of George Zimmerman, acquitted in Martin’s death). He wants to know if the Cato and Goldwater institutes (and other putative ALEC sympathizers) support stand-your-ground legislation “that was adopted as a national model and promoted by ALEC.” It is abundantly clear to us that Sen. Durbin has targeted Cato and Goldwater because they are libertarian-conservative public policy organizations. It also is clear he is trying to quiet ALEC, whose members are preponderantly conservative Republican state legislators, working to promote the principles of free-market enterprise, limited government and federalism. We are pleased that neither Allison nor Olsen was intimidated by the Senate assistant majority leader’s letter, which demanded a response by Sept. 1. Oh, they responded all right. But almost certainly not the way Sen. Durbin expected. “We would be glad to provide a Cato scholar to testify at your hearing,” Allison wrote, “to discuss the unconstitutional abuse of power that your letter symbolizes.” “‘Have you no sense of decency?’” wrote Olsen. “That was the question posed by attorney Joseph Welch that historians credit with ending Sen. Joseph McCarthy’s witch-hunt.” We find it shameless of Durbin to use the death of Trayvon Martin to flay organizations with which he politically disagrees. We also find it chilling that the Illinois lawmaker thinks his abuse of power acceptable, his witch hunt justified.
A win for some can mean a loss for energy “An economy in distress, vast natural resources locked up with no plans to put them to use, and a regulatory regime that inhibits the development of resources and the creation of jobs.” Sound familiar? These words were written by William Perry Pendley, who served in the Interior Department under Ronald Reagan. They describe the America that Reagan encountered in 1981. But, they could be about 2013. In his new book, “Sagebrush Rebel: Reagan’s battle with environmental extremists and why it matters today,” Pendley points to the similari-
Doonesbury
MARITA NOON
ENERGY MAKES AMERICA GREAT INC.
ties of the economic climate that both Reagan and Obama had to take on at the start of their presidencies. In a Jan. 15, 2008, interview, candidate Obama correctly observed the outcome of the Reagan era: “I think Ronald Reagan changed the trajectory of America ... He put us on a fundamentally dif-
ferent path because the country was ready for it. ... Gover nment had grown and grown but there wasn’t much sense of accountability in terms of how it was operating. I think he tapped into what people were already feeling. Which is we want clarity, we want optimism, we want a retur n to that sense of dynamism and entrepreneurship that had been missing.” In the same interview Obama said he shared personal similarities to Reagan. While he does like to compare himself to Reagan, the contrast on energy policy couldn’t be more stark. Pendley
explains that Reagan adhered to the “human exceptionalism paradigm” — which asserted that “human technological ingenuity can continually improve the human situation.” Coming before Reagan, Carter embraced an “environmental paradigm” — that placed environmental limits on growth. Carter’s America is the one about which Obama stated: “... we want optimism, we want a return to that sense of dynamism and entrepreneurship that had been missing.” Yet, Obama has followed Carter’s direction, not Rea-
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The Orange County Register
DEAR DOCTOR K: I use a vaginal estrogen cream for vaginal dryness. Does it have the same risks as hormones taken orally or by skin patch? D E A R R E A D E R : H o r mo n e therapy (HT) is estrogen taken alone or with other female hormones to treat the symptoms of m e n o p au s e. “ S y s t e m i c ” H T involves hormones that enter the blood and travel throughout the body. It is the most effective treatment for postmenopausal hot flashes and vaginal symptoms, including vaginal dryness. S y st e mi c H T is m e d i ci n e taken by mouth or through the sk i n b y a s ki n pa t c h o r g e l . From those locations, it enters into the blood. But systemic HT carries with it a small risk of se v er a l s er i o us c on d i ti o n s : h e a rt a tt ack s , s t r o ke , b l o o d
ASK DR. K UNITED MEDIA SYNDICATE
clots and some cancers. To find out if there are similar risks associated with vaginal estrogen, I checked in with my c ol l e ag u e D r. C e le st e Ro bb Nicholson, editor-in-chief of the Harvard Women’s Health Watch. She pointed out that vaginal estrogen acts mostly in the vagina. It relieves vaginal symptoms, including vaginal dryness, burning, and pain with sexual
intercourse. It does not relieve hot flashes. (One exception is a vaginal ring, called Femring. It delivers so much estrogen in the v agin a t hat som e o f it is absorbed into the blood and therefore has effects throughout the body.) Low-dose vaginal estrogen is a vai lab le i n s e ve ral f or m s: creams, tablets and other kinds of vaginal rings. Vaginal creams are applied to the vulva or in t he v ag in a . Vagi nal ta bl et s (Vagifem) are inserted in the vagina. And a flexible vaginal ring, called Estring, is wor n continuously and replaced every few months. The Vagifem tablet contains the lowest amount of estrogen. Estring delivers just a bit more. Vaginal estr ogen cr eams ar e more concentrated; the amount
o f est r ogen t h at a w om an absorbs varies. Vaginal application releases little estrogen into the bloodstream. As a result, it has less risk of side ef fects than systemic estrogen. So far, no welldesigned clinical trials have evaluated systemic risks, such as breast cancer or blood clots, of low-dose vaginal estrogen. But it’s likely that if there are s uch r is ks , t h e y ar e m u ch smaller than the risks related to systemic estrogen. On e co mp licat ion of menopause that women don’t often think of is recurrent urin ar y t ra ct in fect ion s (UT Is). Vaginal dryness not only causes vaginal symptoms such as discomfort during sex, but also encourages the growth of certain bacteria around the ure-
thra — the tube that carries urine from the bladder to the vagina. If those bacteria get into the urethra, and then into the bladder, a UTI can start. A p ar t fr om t h e h igh - dose Femring, vaginal estrogen is probably safe even over the long t er m . A n d if you r m ain menopausal symptoms are vaginal symptoms, vaginal estrogen is just as effective as systemic HT and less risky. But talk to your doctor about the risks and benefits before you start — particularly if you have a history of breast cancer. (Dr. Komaroff is a physician and professor at Harvard Medical School. To send questions, go to AskDoctorK.com, or write: Ask Doctor K, 10 Shattuck St., S ec on d F loor, Bost on , MA 02115.)