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KH trustees split on Medicaid expansion

Posted: March 28, 2013 5:38 p.m.
Updated: March 29, 2013 5:00 a.m.

Most members of the KershawHealth Board of Trustees voted Monday to pass a resolution to support expanding Medicaid in South Carolina. It was not a unanimous vote, however, as seven trustees voted in favor of the resolution, one voted against and one abstained.

KershawHealth President and CEO Donnie Weeks said Medicaid expansion is part of the Patient Protection and Affordable Care Act, commonly known as Obamacare. Weeks said the U.S. Supreme Court ruled that the Act is constitutional but that states can elect not to expand their Medicaid programs.

“With expansion of Medicaid, over a seven year period of time, it will bring an additional $7 billion into the state of South Carolina … which of course stimulates the economy. It would have not only an impact on preserving jobs but creating jobs, so it has economic implications,” Weeks said. “It also has ramifications for access to healthcare for those that have a Medicaid card that would qualify under this program with the expansion for those who wouldn’t qualify otherwise. So, we feel that the quality of health to the citizens of South Carolina including Kershaw County would be increased by the Act. Then, specifically for KershawHealth, it has significant financial ramifications, too, over that seven-year period of time.”

Trustee Dr. Tallulah Holmstrom, who ultimately voted against the resolution, called the Medicaid expansion, as written, an unfunded mandate.

“The opinion of our state Medicaid officials regarding expansion -- it is my understanding that they do not support it,” Holmstrom said, specifically mentioning S.C. Health and Human Services Director Tony Keck. “It would appear that the initial contribution from the federal government would be favorable, but that -- rapidly, just within a few years -- it ramps up state contributions, and that it could be burdensome to the states and could be quite problematic.”

Holmstrom said she knew she might be “going out on a limb” but needed to “take a political risk in order to take a principled stand” and that Keck, who administers Medicaid, has said the expansion is a temporary fix that will rapidly become unsustainable on the state level.

“Every day I see people who don’t have access to healthcare. Believe me, I’m all for and all in favor of finding any solution that is truly sustainable in providing healthcare to all South Carolinians. I’m not going to be supportive of this resolution because my own medical society, the S.C. Medical Association, is not supportive of this. The majority of our medical staff did not seem particularly supportive of this because it’s unsustainable in a very short period of time,” Holmstrom said.

Weeks said that during the first three years of the program, the expansion is 100 percent paid for by the federal government. According to Medicaid.gov, the government’s official Medicaid website, coverage will phase down to no less than 90 percent federal funding in subsequent years. However, Weeks said there is “uncertainty” after seven years.

“But there’s an investment of 10 cents for a dollar drawn down from the federal level bringing an infusion of capital into the state. I think it is a mistake to turn down federal funds that would come into the state if it can be used for the benefit of the citizens,” Weeks said.

He acknowledged attending the medical staff meeting Holmstrom had referred to, but said that since no vote was taken, he did not know whether a majority of the medical staff is for or against the idea of expanding Medicaid.

Holmstrom went back, however, to saying Keck has been “very vocal” about his concerns and reiterated that she would not support the resolution.

Weeks said the resolution would be sent to members of Kershaw County’s legislative delegation and S.C. Hospital Association (SCHA). He also said that as KershawHealth’s CEO, he is concerned about the short run of the organization’s viability and access to healthcare for citizens.

“Yes, we think about seven years out, 15 years out, if we don’t sustain this healthcare system financially,” Weeks said, referring to KershawHealth itself, “we won’t have a future seven years out. We also want to impact the health of individuals. I personally think this has a potential to impact individuals by providing more access.”

Trustee Bobby Jones, with confirmation from the board’s attorney, said if the state decided to go forward with expanding Medicaid, it had the option of withdrawing from the expansion after seven years.

“If you get something free for three years, and then pay (10) percent … the figures I looked at, you’re making money and then can get out after seven years,” Jones said. “It doesn’t cost the state anything. You get billions and billions of dollars and it gives you an option out after seven years. So, if it does cost us something after the third year … if we made enough the first three years to cover all the losses for the fourth through seventh years, you’re still a winner.”

“But then you’re faced with telling all those people you have expanded the coverage to ‘good-bye, adios,’” Trustee Derial Ogburn said.

Trustee Paul Napper said he respected Holmstrom’s opinion, but said if South Carolina continues to “turn this money down” that it would go to other states with taxpayers paying the difference.

In response to a question from Holmstrom, Weeks said that without the expansion of Medicaid in South Carolina, KershawHealth could experience a $30 million hit to its bottom line over a seven-year period. He said if, however, South Carolina reversed course and did expand Medicaid, KershawHealth would have about a $9 million gain during that same period of time.

“So, really, it’s a $39 million swing,” Weeks said, noting that is an estimate provided to the hospital by the SCHA.

At one point during the discussion, Board Chair Scott Ziemke said trustees should view themselves differently on the issue and not bring in personal politics. Holmstrom took offense and said she had only spoken from a business perspective that the expansion is unsustainable. Ziemke later withdrew his comment.

“I find it difficult to support Medicaid expansion when you have people who are public health policy experts and Medicaid experts who are telling us Medicaid expansion does not at this moment appear, as it’s currently written, to be an appropriate decision for South Carolina. So, it’s a business decision you and I may disagree on,” Holmstrom said. “I know all the cool kids are willing to accept the Medicaid expansion because its free. I’m sure you understand like I do, there’s not anything that’s free. And I’m the one in the white coat everyday who’s seeing people struggling getting access to care. I just simply don’t think, in the long run, this is wise.”

Trustee Don Witham noted that on the back of each trustee’s nameplate at the table is KershawHealth’s mission and vision statements.

“It says, ‘to improve the health and well-being of the residents of Kershaw County.’ In my mind, this is one way to do it, at least for seven years,” Witham said. “Why would we not do this?”

Jones then asked if Keck was appointed by Gov. Nikki Haley. Weeks said that was the case.

“And she’s been against it before it ever came along,” Jones said. “So, if she’s against it and she appoints him, my God, he’s not a fool, he has to be against it. That probably has something to do with why he’s against it. I don’t know, but he would be a fool if he didn’t. He wouldn’t have a job.”

At that point, Ziemke called for the vote. Jones, Napper, Witham, Ziemke and fellow trustees George Corbin, Karen Eckford and Steve Holliday Jr. voted for the resolution. Holmstrom voted “no,” while Derial Ogburn abstained.

Late in the meeting, trustees also found themselves divided on its own rules of order and by-laws. In previous meetings, some trustees had lamented the fact that the board had no written rules of order governing meeting procedures. Ziemke said he had created a draft of written rules -- given to trustees ahead of Monday’s meeting -- based on unwritten ones the board has followed for many years. He said he was not seeking a vote, but wanted to open the floor for discussion.

Ogburn suggested the board operate under Robert’s Rules of Order. Robert’s Rules were developed in 1876 by Henry Martyn Robert, a South Carolina native from Robertville, who rose to the rank of brigadier general in the U.S. Army.

The full board is looking at creating rules of order for itself since it disbanded its governance committee earlier this year.

Ogburn noted that Robert’s Rules is a “huge volume of rules, 99 percent of which is never used.” He said boards he has served on before have used the other 1 percent and that they are very simple.

“You end up using a motion, a second, a discussion and a vote, and that’s about it. You move to adjourn, and you raise points of order. That’s generally enough to get everything done,” Ogburn said.

Eckford said she could bring a simplified version of Robert’s Rules to the board.

Ogburn also brought up how the board should handle the public comment portion of its meetings. He suggested the board follow the same rules as the Kershaw County Board of School Trustees. Since not every KershawHealth trustee had a copy of those rules, Ziemke asked that a vote be deferred until the board’s next regular meeting. He also said he was trying to have other public hospitals contacted to see how they handle public comments.

Ogburn said the school board’s rules on public comment allow people to request to speak using a sign-up sheet. Only one person from any particular group may speak, he said, and that school board trustees do not respond to any comments. Speakers are limited to five minutes and can only speak to issues, not individuals, Ogburn said.

Camden City and Kershaw County councils follow similar rules.

“I think this provides us with a good structure to operate under. If it’s good enough for the school board, it’s good enough for me,” Ogburn said.

Weeks said research conducted by Vice President of Marketing and Community Development Joseph Bruce showed that other public hospital boards do have public comment periods. However, he said none of them allowed speakers to sign up at the meetings, instead requiring them to sign up some time in advance.

Ogburn said he saw no reason to require speakers to give advance notice. Corbin, however, said he would like to see that.

“I, for one, don’t want to be involved in a 10-hour meeting,” Corbin said.

That set off an argument between the two men over how many people might take advantage of the opportunity to speak at any given meeting. Ogburn said that the public comment period could be limited to 30 minutes. He went on to claim Corbin wanted to “control things,” which Corbin denied.

Ziemke ended the debate by saying there were other arguments for having a waiting period.

“It ensures the possibility that when you have somebody who’s gotten mad that afternoon with the hospital and wants to come up here and spout off they have a cooling-off period to think about what they are really doing and what they want to say in this forum,” Ziemke said, who asked again that a formal vote on the matter wait until April’s meeting.

Ziemke then turned to the procedures used to amend the board’s by-laws. Currently, they can only be amended with a two-thirds vote of trustees and not a simple majority, and only with 20 days written notice ahead of the vote.

Holliday spoke on the matter, after first agreeing that the board should adopt Robert’s Rules of Order. He then read a letter he addressed to Ziemke, beginning with a reference to the agendas used by the board for its meetings. Holliday thanked Ziemke for coming up with a version of an operating agenda, but said it was not without flaws, including on the issue of public comments.

“To my knowledge no other county entity is required to give prior notification of subject matter to comply with administrative policies other than signing up prior to the time allotted for public comment,” Holliday said. “Quite frankly, this practice can easily be construed as defensive posturing. Upon being selected to serve on this board … I committed to use my talents, experience and education to aid in the success of KershawHealth and to provide transparency in my dealings and service as a board member.”

In regards to Freedom of Information issues, patient privacy and contractual matters, Holliday said he felt board members would not jeopardize such important issues.

“However, the current system does not allow for relevant issues to be brought forth and discussed by board members for resolution,” he said.

Holliday said there are no provisions during either regular or finance board meetings for discussion or questions about items outside what he called the “pre-formatted” agendas. It was his opinion that some issues require more than one-on-one resolution with Ziemke or administrators.

That brought him to his second item: by-law revisions. Holliday reiterated his desire for the by-laws to be reassessed since the board decided to dissolve several of its committees at the end of February. He said there were no provisions to create an ad hoc committee to deal with “outdated or conflicting by-laws issues” keeping the board from exercising its full authority or its mission to improve the health of Kershaw County citizens.

“The by-laws are the rules we operate under and if the rules are outdated how can we effectively achieve success?” Holliday asked.

He said more emphasis should be placed on the board’s rules of order and that they should be less restrictive or expanded to incorporate Robert’s Rules. Holliday said he would be happy to submit his findings -- including eight items resulting from the dissolution of the executive, finance and governance committees -- but also wanted to hear what other issues trustees have.

“I believe in strength in numbers and I’m sure a collective effort to resolve these two subjects will provide more positive results,” he said. “That is my point: if we don’t collectively get together then we’re working against ourselves.”

At Ziemke’s request, an ad hoc committee was formed to review the by-laws and recommend any changes. It will be comprised of Eckford, Holliday, Holmstrom and Ziemke.

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