E-Newsletter – National and Industry News Florida Council January 20, 2013

E-Newsletter – National and Industry News
Florida Council
January 20, 2013
experts provides the training. They include fellow
police officers, mental health professionals, family
members and people who live with mental health
conditions. In addition to clinical information, and
learning about community resources (and how to
link to them), trainees hear personal stories, acquire
de-escalation skills and put knowledge into practice
through role play. Officers and people who have
had their own crises act out a number of no-holdsbarred, real-life scenarios. They also get a sense of
what it's like to experience extreme mental health
symptoms, such as hearing voices. It's not always
pretty to watch or listen to, but the outcomes of the
CIT training show great promise. Research shows
that when CIT trained officers respond to a call
there are myriad benefits. The use of physical
restraints goes way down, as do injuries to people
in crisis and to officers. People are less likely to be
arrested and taken to jail. And because officers
know how to connect people to community services,
the need to use the most expensive emergency
services can sometimes be avoided.
Equally
valuable is the goodwill that CIT engenders.
Officers report greater satisfaction in knowing how
to help people, and citizens report greater trust in
their police. If cities as large as Philadelphia and
Houston and rural communities such as New River
Valley in Virginia and Cambria County, Pennsylvania,
can institute CIT, why aren't there teams in every
community? Of course it costs money to pull
officers off the street, to train police dispatchers, to
pay for materials and for costs associated with using
community buildings.
Grants from government
entities and foundations can at times help to offset
these costs. And much of the training is done by
volunteers. While the basics of the training program
remain the same, it must be tailored to each
locality.
Therefore, more than anything else
instituting a CIT program takes commitment and
coordination. This usually begins with a person, or
small group of people, building a coalition of
community stakeholders.
How many fewer
tragedies might there be if more people stepped
forward to become CIT champions? (CNN, 1/10/14)
How To Stop Tragic Shootings
Of Mentally Ill
By Debbie F. Plotnick
It breaks my heart to read about the death of Keith
Vidal, the North Carolina teenager who, his family
says, suffered from schizophrenia, and who was
shot and killed after police arrived to help with a
crisis last Sunday. Many details of the case are still
unclear, and it's hard to know who or what is
responsible.
Tragically, incidents such as this
appear over and over again in the news. The
scenario goes something like this: Police are called
to assist with a person who is experiencing a mental
health crisis. There is an escalation in tensions,
perhaps the introduction of a real or imagined
threat, and this leads to someone getting hurt, or
worse, killed. And it's not always the person in
crisis; sometimes it is the police officer.
Debbie Plotnick
Another all too common outcome is that the person
in crisis ends up not at the hospital, but at the jail.
Police officers, families and certainly people with
mental health conditions don't want this to happen.
And it doesn't have to. There is a time-tested, well
researched way to lessen the likelihood that calling
the police for assistance will end badly. In 1988, an
approach was developed in Memphis, Tennessee,
that has been slowly — too slowly — making its way
throughout the country. It's called Crisis
Intervention Team Training, usually just referred to
as CIT. Here's how CIT works: A team of police
officers (or other first responders) from one
department or jurisdiction, or from a coalition of
neighboring
departments,
undergoes
a
comprehensive
week-long
(40-hour)
training
program that does several things. It teaches some
basics about mental illnesses, substance abuse
disorders and developmental disabilities, and it
explains how to recognize and interact with
someone with these conditions that is crisis. News
reports indicate that the detective who was put on
administrative leave after the Keith Vidal shooting
had not completed the CIT program, though others
in the Southport Police Department, where he
served, had. If true, we can't know whether this
would have changed the outcome, but it most
certainly could have helped. A cadre of community
http://www.cnn.com/2014/01/10/opinion/plotnickteen-shooting/index.html?hpt=op_t1
Mental Health Technicians In Demand
San Jacinto College's certificate comprises 33 hours
of courses and is intended to take a year to
complete -- fall, spring and summer. More and
more people are seeking psychiatric services to help
manage or solve issues ranging from stress at work
or ongoing depression to anxiety disorders and
substance abuse. As the demand for psychiatric
services continues to grow, so too will the need for
qualified mental health technicians.
In fact,
1
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
employment of mental health technicians - also
known as psychiatric technicians or psychiatric aides
- is expected to increase 15 percent from 2010 to
2020, according to the U.S. Bureau of Labor
Statistics. The BLS also notes that "there is likely to
be an increase in the number of people with
cognitive mental diseases, such as Alzheimer's
disease. Demand for psychiatric technicians and
aides in residential facilities are expected to rise as a
result." Those hoping to become mental health
technicians need postsecondary education and some
degree of on-the-job training before they may start
working without direct supervision.
Local
community colleges, such as San Jacinto College,
provide the education and training to pursue a
career as a mental health technician. San Jacinto
College's mental health services program is
designed to train these technicians. The mental
health technician training program prepares
students to care for mentally impaired or
emotionally
disturbed
individuals
following
physician's instructions and hospital procedures.
"Our program provides a one-year certificate that
comprises 33 hours of courses and is intended to
take a year to complete - fall, spring and summer.
It encompasses eight courses that deal with the
various elements and skills a mental health
technicians will need," said Alfred Lara, director of
San Jacinto College's mental health services
program. "These include abnormal psychology,
assessment, group therapy, basic nursing skills and
other relevant courses culminating to a capstone
course of a practicum, where we send students into
a psychiatric hospital setting for a semester to put
into practice the concepts learned, and get training
from experienced mental health technicians and
counselors." Lara said San Jacinto College also
maintains partnerships with community centers and
psychiatric hospitals that allow students to immerse
themselves at their facilities and benefit from the
additional practicum experience.
"Oftentimes,
students are hired by these facilities at which they
have completed their practicum, and this is the best
source for them to be hired. For those not hired on
at their practicum site, our practicum coordinator
assists each graduate in finding proper placement
for employment," Lara said. Houston Community
College also offers a Human Service Technology
program, designed for students interested in the
field of human services.
The program equips
students for employment as technicians in a range
of human service facilities, including those seeking
to become mental health technicians. "The Human
Service Technology Program offers classes in basic
counseling, orientation to social services, counseling
theories, family interventions, assessment, group
counseling and co-occurring disorders," said Richard
Rosing, a mental health associate for Human Service
Technology at Houston Community College's
Coleman College for Health Sciences.
"The
complete associate degree takes two years, with
specialty areas being able to complete in either one
semester or one year." (Houston Chronicle,
1/10/14)
http://www.chron.com/news/article/Mental-healthtechnicians-in-demand-5132102.php
Teen Homelessness: An American Disgrace
In the US, children under 18 represent one-third of
the US homeless population. 2.8 million American
children have at least one episode of homelessness
every year, while 1.35 million are permanently
homeless. Sadly it’s not a new problem. Seattle
first became concerned about their homeless teens
in the 1990s. In 1999, shortly before moving to
New Zealand, I worked in a community clinic with a
special outreach program for homeless teenagers.
Prior
to
the
2008
economic
meltdown,
approximately ten percent of homeless teens had
access to state and city-run shelters. Over the last
five years, chronic state and city budget deficits
have forced most of them to close.
US Teen Homelessness Rivals the Third World
In third world countries, homeless children are
called “street kids.” The US government prefers to
call them “unaccompanied minors.” Giving it a
fancy name on it doesn’t hide the fact that rate of
homeless American children per capita is worse than
some third world countries. Among countries who
keep a count of homeless children under 18, India
has the highest rate of street children per capita,
with 1 homeless child per 61 residents. Egypt is
next with 1 per 110, then Pakistan (1 per 120),
Kenya (1 per 133), Russia (1 per 141), and Congo
(1 per 148).
The per capita rate of child
homelessness in the US is 1 per 245 residents. This
is worse than the Philippines (1 per 360), Honduras
(1 per 370), Jamaica (1 per 419), Uruguay (1 per
1,000), and Morocco (1 per 1066). Germany, in
contrast, has 1 homeless child per 4,100 residents.
Why American Teens Become Homeless
Approximately fifty percent of homeless teenagers
wind up on the streets due to conflict with their
parents. Another twenty percent are there due to a
breakdown of their foster care placement. Others
are homeless because their parents are homeless.
Of teenagers made homeless by family conflict,
forty percent are lesbian, gay, bisexual or
transsexual teens whose parents refuse to accept
their sexuality (25% of LGBT teens are rejected by
their parents). Another large proportion are victims
of physical, sexual and/or emotional abuse. Forty
percent of homeless teenagers report being beaten.
Twenty-five percent report a history of sexual
2
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
abuse.
Forty percent have parents who are
mentally ill or who have substance abuse problems.
Ten percent have run away because they’re
pregnant. Some leave home because of alcohol and
drug problems of their own. Many homeless teens
work at minimum wage jobs that don’t pay enough
for an apartment. However faced with a (true)
unemployment rate over 20%, most face long term
unemployment.
legislative advocacy director for the National Alliance
on Mental Illness. "This is a key protection. It's a
cornerstone of what has made the benefit work for
people with mental illness." Sperling said that
patients with mental health issues often have to try
a variety of drugs before they find the right one for
their condition. He questioned whether the change
would help crack down on the problem of
improperly prescribed antipsychotics, saying it
amounted to a blunt instrument. The National
Kidney Foundation also voiced worries. Legislative
policy director Tonya Saffer said transplant patients
often depend on combinations of medication, so
having the broadest possible choice is crucial.
"Covering all immunosuppressant drugs is very
important for the patient and very important to
protect the transplanted organ from rejection,"
Saffer said. The proposal could lead to "patients
having to go through multiple channels to try and
get a drug," which would put patients at risk, she
added. In the proposal, the administration said the
new policy was developed after careful consultation
with a broad range of experts. The three other
types of drugs that have protected status — for
cancer, HIV/AIDS and preventing seizures — would
remain protected. If adopted in the coming months,
the new policy could take effect as early as 2015.
The administration estimates it could save the
taxpayers a total of $720 million by 2019.
Beneficiaries may also be able to save. That's
because the drug plans can drive a harder bargain
for manufacturer discounts when a drug is not
protected. "The circumstances that existed when
this policy was originally implemented have changed
dramatically in the more than seven years the
program has been in operation," the Centers for
Medicare and Medicaid Services said in its proposal.
"We are concerned that requiring essentially open
coverage of certain classes and categories of drugs
presents both financial disadvantages and patient
welfare concerns ... as a result of increased drug
prices and overutilization," the proposal added. A
leading industry analyst said the proposal would
represent a significant change for Medicare's
prescription benefit, which is highly popular with
beneficiaries. "It is a weakening of a patient
protection," said Dan Mendelson, CEO of Avalare
Health, a market analysis firm. "I'm not sure that
Medicare saves money from this kind of a change,"
he added. "Other elements of the program may
have a cost increase if people are not using
medications in the right way." (New York Times,
1/11/14)
Good links regarding teen homelessness:
http://en.wikipedia.org/wiki/Street_children
http://www.psychologytoday.com/blog/teenangst/201101/homeless-teens
http://globalgeopolitics.net/wordpress/2011/03/31/u
-s-budget-cuts-threaten-handful-of-beds-forhomeless-youth/
http://www.shelterhouse.on.ca/article/youthhomelessness-147.asp
http://www.dosomething.org/actnow/tipsandtools/b
ackground-11-causes-teen-homelessness
(Salon,
1/10/14)
http://open.salon.com/blog/stuartbramhall/2014/01/
10/teen_homelessness_an_american_disgrace
Proposed Medicare Drug
Change Stirs Access Worries
In a move that some fear could compromise care for
Medicare recipients, the Obama administration is
proposing to remove special protections that
guarantee seniors access to a wide selection of
three types of drugs. The three classes of drugs —
widely used antidepressants, antipsychotics and
drugs that suppress the immune system to prevent
the rejection of a transplanted organ — have
enjoyed special "protected" status since the launch
of the Medicare prescription benefit in 2006. That
has meant that the private insurance plans that
deliver prescription benefits to seniors and disabled
beneficiaries must cover "all or substantially all"
medications in the class, allowing the broadest
possible access. The plans can charge more for
costlier drugs, but they can't just close their lists of
approved drugs, or formularies, to protected
medications. In a proposal published Friday in the
Federal Register, the administration called for
removing protected status from antidepressants,
antipsychotics, and immunosuppressant drugs. The
proposal said that status it is no longer needed to
guarantee access, would save millions of dollars for
taxpayers and beneficiaries alike, and could help
deal with the problem of improperly prescribed
antipsychotics drugs in nursing homes.
But
advocates for patients are strongly criticizing the
idea, saying it could potentially limit access to
critically needed medications for millions of people.
"We are disturbed by this," said Andrew Sperling,
http://www.nytimes.com/aponline/2014/01/11/us/p
olitics/ap-us-medicaredrugs.html?ref=aponline&_r=0
Weather Swings Can Hurt
3
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
headaches, migraines, arthritis, joint pain, and sinus
and inner-ear problems. But in an unexpected
seasonal twist, Mississippi State University
meteorologist Grady Dixon said suicide rates drop
during the winter. The peak season for suicides is
June, he said, but the reason remains a mystery.
"Usually the thing people are most interested in or
surprised to hear is that while people have
depression in the cold, dark winter months, suicides
around the globe, with no exception, most
commonly occur during the late spring and early
summer," he said. "It's the broken-promises effect.
If you are clinically depressed and have seasonal
affective disorder, you expect spring to be better.
But if you are clinical ill, you probably won't get
better in the spring when you expect to feel better.
It's not a weather effect but the lack of a weather
effect that causes the suicide." January does bring
the year's highest mortality rate, likely due to higher
rates of infections, including influenza deaths and
other weather impacts on people, especially the
elderly.
The National Weather Service said
temperatures will climb to the lower 40s today, then
to the low 50s on Saturday before dropping back to
the low 40s on Sunday. The weekend will feature
drizzle, rain, freezing rain and snow, which won't
accumulate, with total precipitation of a half to
three-quarters of an inch. Hendricks said this
winter's weather extremes are occurring because
we're in a transition between el nino and la nina
weather patterns, which are nearly yearlong
weather trends involving the heating and cooling of
the north and northeastern Pacific Ocean. Despite
the temperature extremes, with more likely to
come, winter highs and lows will average near
normal by winter's end. We've also had more than
double the normal snowfall for the season, with
30.3 inches through Wednesday, as compared to
the normal of 13.5, he said. Temperatures are
expected to return to normal by Wednesday.
Weather and climate psychologist Alan E. Stewart of
the University of Georgia said men and women react
differently to severe weather. Women are more
cautious than men.
Maximizing reproduction
requires caution, with a slight tendency for
expectant mothers to spend their final trimester
during late spring and summer months before giving
birth in August or September. Winter weather
historically has posed harsh challenges for moms
and babies to stay warm, find food and avoid
infections. CDC statistics showed that 9 percent of
all babies in 2010 were born in August with 7.5
percent born in February. OK, the numbers aren't
dramatic, but the trend holds. Men are a different
story. "Men take more weather-related risks than
women, including driving across roadways that have
water flowing, or being outside during thermal
extremes, or not taking cover when thunder is
heard and lightning is seen, or not sheltering when
Physical, Mental Health
Biometeorology — the study of weather's impact on
living organisms including humans — uses different
terminology but concludes that weather itself, but
specifically dramatic shifts in weather, can impact
physical and even mental health. The good health
news?
Experiencing such horrible stretches of
weather better prepares us for what National
Weather Service meteorologist Lee Hendricks said is
a strong likelihood of another cold snap this winter.
The so-called polar vortex, blamed for the sub-zero
temperatures, could send us into another mental
and physical vortex before spring. "It's a huge
swing
physiologically,"
Jennifer
Vanos,
a
biometeorologist and assistant professor of
atmospheric science at Texas Tech University, said
about Tuesday's record low of minus 9 degrees
Fahrenheit sandwiched by unseasonable highs in
the 50s. "People were not prepared. Physiologically,
adapting is a tough thing to do when you are used
to certain weather day after day." But if another
cold snap occurs, "people will be prepared," she
said, especially for those 20 and under who never
experienced such sub-zero temperatures. "They will
know what to do, how to dress, and it won't be as
stressful." Long airplane rides usually are necessary
for such swings in temperature. It's like flying
round trip from Myrtle Beach, S.C., to the Yukon.
The Associated Press reported 21 deaths nationwide
from the cold snap, most in the Midwest. The
normal high locally for early January is 36 degrees
with a low of 21. In the week ending Saturday, if
the forecasted high of 52 holds true, the region will
have experienced a 61-degree swing. Last Sunday
alone saw a temperature swing of 57 degrees -- 50
to minus 7, Hendricks said. Along with potential
dangers of extremely low temperatures, including
hypothermia, frostbite and blood vessel constriction
leading to heart attacks, quick shifts in barometric
pressure, high or low, represents an unsuspected
health villain.
Vanos said people are most
comfortable with barometric pressure of 30 inches
of mercury (inHg). When it quickly rises to 30.3
inHg or higher, or drops to 29.7 or lower, the risk of
heart attack increases. High barometric pressure
constricts blood vessels, which hinders blood flow,
while low pressure expands blood vessels, making it
more difficult for the heart to pump blood. The
highest prevalence of heart attacks occurs within 24
hours of swings of that magnitude in barometric
pressure, she said. "That effect is strongest in the
fall and winter," she said. It's not yet known
whether the rate of heart attacks increased this
week.
Jack Boston, senior meteorologist at
AccuWeather.com, said barometric pressure rose
from 29.77 inHg at 7 a.m. Monday to 30.36 inHg by
7 a.m. Tuesday.
Vanos, among others, says
changes in barometric pressure also cause
4
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
there's word from the National Weather Service of a
storm or tornado," said Stewart. (Austin American
Statesman, 1/10/14)
at age 11, by their teachers as being diligent,
focused, patient, academically successful and strong
in social skills. We followed these young people
until they were 19 and studied their mental and
physical health, focusing on depression, drug use,
aggression and criminal behavior.
As in past
studies, those who were rated positively at age 11
had relatively few of these problems when they
were 19. When we looked beneath the surface,
though, these apparently resilient young people
were not faring well. Compared with others in the
study, they were more obese, had higher blood
pressure and produced more stress hormones.
Remarkably, their health was even worse than peers
who, at age 11, had been rated by teachers as
aggressive, difficult and isolated. They were at
substantial risk for developing diabetes or
hypertension down the line. We continued studying
these youths as they grew into adults. Perhaps not
surprisingly, the lower-income youths who made it
to college used fewer drugs and drank less alcohol.
To be academically competitive with their
classmates, they had to stay focused on their
schoolwork. As in the first study, though, their
resilience was only skin deep. At age 20, the lowerincome college kids had greater obesity, higher
blood pressure and more stress hormones than
those who did not make it to college. (Their health
was also worse than that of peers in more affluent,
educated neighborhoods.) These patterns mesh
with other social-science findings, which suggest
that upward mobility does not always provide the
expected return on investment when it comes to
health. If we look at the life expectancy associated
with a college education, blacks gain about four
fewer years from bachelor’s degrees than do whites.
What is it about upward mobility that undermines
the health of these young Americans? In our
studies, most participants are the first in their
families to attend college. They feel tremendous
internal pressure to succeed, so as to ensure their
parents’ sacrifices have been worthwhile. Many feel
socially isolated and disconnected from peers from
different backgrounds. They may encounter racism
and discrimination. Some young people respond to
the pressure by concentrating on character
strengths that have served them well, cultivating an
even more determined persistence to succeed. This
strategy, however, can backfire when it comes to
health. Behaving diligently all of the time leaves
people feeling exhausted and sapped of willpower.
Worn out from having their noses to the grindstone
all the time, they may let their health fall by the
wayside, neglecting sleep and exercise, and like
many of us, overindulging in comfort foods. What
can we do to mitigate these negative health effects?
To start, schools and colleges that serve lowerincome students could provide health education,
screenings and checkups as a part of their
http://www.mystatesman.com/news/ap/health/weat
her-swings-can-hurt-physical-mental-health/ncjN9/
Can Upward Mobility
Cost You Your Health?
Americans love a good rags-to-riches story. Even in
an age of soaring inequality, we like to think that
people can still make it big here if they work hard
and stay out of trouble. The socioeconomic reality
of most of the last four decades — stagnant wages,
soaring income and wealth inequality, and reduced
equality of opportunity — have dented, but not
destroyed, the appeal of the American dream.
Those who do climb the ladder, against the odds,
often pay a little-known price: Success at school and
in the workplace can exact a toll on the body that
may have long-term repercussions for health.
Among American children, there are wide
socioeconomic gaps on many dimensions of wellbeing: school achievement, mental health, drug use,
teenage pregnancy and juvenile incarceration, to
name just a few. Despite the risks that lowerincome children face, we also know that a
significant minority beat the odds. They perform
admirably in school, avoid drugs and go on to
college. Psychologists refer to these children as
resilient, because they achieve positive outcomes in
adverse circumstances. They do so in part by
cultivating a kind of determined persistence. They
set goals for the future, work diligently toward
them, navigate setbacks, stay focused on the long
term and resist temptations that might knock them
off the ladder to success. Several years ago, we
began studying these resilient young people, trying
to find out if their success stories also translated
into physical health benefits. We reasoned that if
disadvantaged
children
were
succeeding
academically and emotionally, they might also be
protected from health problems that were more
common in lower-income youths. As it turned out,
the exact opposite was true. These young people
were achieving success by all conventional markers:
doing well academically, staying out of trouble,
making friends and developing a positive sense of
self. Underneath, however, their physical health
was deteriorating. Our first hints of this pattern
came from a study of 489 rural African-American
young people in Georgia, whom one of us, Gene
Brody, has been tracking for more than 15 years.
Most came from families who were working but
poor. In 2010, their average family income was
about $12,000 a year; about half lived below the
poverty line. We found a subgroup of resilient
children who, despite these obstacles, were rated,
5
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
curriculum. Second, schools and clinics could offer
stress management programs, targeting lowerincome, higher-achieving young people. Finally, we
could develop programs to help these young people
blow off steam in productive ways, pairing them
with mentors who have navigated similar life
challenges. Policymakers should do everything they
can so that those young people who overcome so
much to live the American dream have the health to
enjoy the fruits of their efforts.
that has engulfed outgoing governor Robert F.
McDonnell, will be filed next week. Following a path
set by McDonnell (R), lawmakers from both parties
have filed measures to restore voting rights for
nonviolent felons. The social issues that have
dominated past sessions are largely absent from the
agenda this year. There are multiple bills from
Democrats
hoping
to
repeal
the
state’s
constitutional ban on same-sex marriage and roll
back the mandatory ultrasound that passed amid
great controversy two years ago, but these
measures stand little chance in a House dominated
by conservatives. At the same time, Republicans
aren’t on the offensive. Only one Republican has
filed any bills related to abortion or birth control this
session: Del. Robert G. Marshall (R-Prince William),
an aggressive and reliable conservative on social
issues. And he’s only got a few in the hopper. While
Marshall says he’s not backing down “in the least,”
he acknowledged that his party leadership is not
interested in joining the fight. “Maybe they think
they’re mother hens, protecting their Republicans
from I don’t know what,” he said. “Laying down
and playing dead; I find that disgusting and
obsequious.” One Republican House bill would
allow religious expression in public schools, and a
bipartisan measure would compensate people who
were involuntarily sterilized by the state — both top
priorities of the influential Family Foundation. The
latter initiative failed last year, with opponents citing
a lack of funds. Sen. Thomas A. Garrett Jr. (RGoochland) has taken flak from liberal blogs for a
bill that would clarify the state’s anti-sodomy
“Crimes Against Nature” law, ruled unconstitutional
in 2013 by a federal appeals court. His original bill
said only that the law did not apply to consenting
adults; he has since amended it to include
consenting teenagers. However, Garrett said, “I
draw the line at grown-ups having sex with kids.” A
former prosecutor, he said he had seen a 37-yearold convicted under that law for propositioning a 13year-old and did not want that man to be able to
appeal on the grounds of constitutionality. A bill
from freshman Del. Marcus B. Simon (D-Fairfax)
would make illegal “revenge porn,” the distribution
of revealing photographs of another person without
consent and with intent to cause distress. California
and New Jersey are the only states in the country
with laws targeting the practice. Another bill from
state Sen. Henry L. Marsh III (D-Richmond) would
ban the celebratory shooting of guns in the air, a
dangerous tradition that killed a 7-year-old in
Chesterfield County last July Fourth.
And a
bipartisan effort in the House and Senate is
underway to make sure Virginia textbooks note that
the Sea of Japan is also called the East Sea, the title
Koreans prefer. “It is not an attempt to change U.S.
policy or the name of the ocean, that’s above my
pay grade,” said Sen. David W. Marsden (D-Fairfax).
Gregory E. Miller ([email protected])
and Edith Chen ([email protected]) are
professors of psychology and fellows of the Institute
for Policy Research at Northwestern University.
Gene H. Brody ([email protected]) is professor of
human development and family studies and the
director of the Center for Family Research at the
University of Georgia. (Dallas Morning News,
1/10/13)
http://www.dallasnews.com/opinion/sundaycommentary/20140110-can-upward-mobility-costyou-your-health.ece
Medicaid Expansion, Not
Social Issues, Expected To
Dominate Va. Legislative Session
One issue will dominate Virginia’s legislature this
year above most others: the proposed expansion of
Medicaid under the Affordable Care Act.
The
measure carries huge financial implications for
hospitals and other health-care providers. But it is
also a deeply divisive issue, and its success or
failure will signal how effectively incoming governor
Terry McAuliffe can work with a Republicandominated legislature. Republicans, meanwhile, are
more interested in discussing just about anything
else with the governor, whom they have praised for
his outreach generally. “We’ve talked about areas
where I thought there was common ground,” said
House Speaker William J. Howell (R-Stafford). “If I
were governor, those are the issues I’d focus on in
my first year.” Those issues include education
reform, in which Dels. Thomas A. “Tag” Greason (RLoudoun) and K. Robert Krupicka Jr. (D-Alexandria)
are both working on overhauling and paring back
the state’s Standards of Learning tests. There’s
more disagreement over a law passed last year
creating a state district to take over failing schools;
some lawmakers hope to repeal it, while Greason
thinks the first order of business should be to make
it work. “Let’s make sure we’re not saddling the
commonwealth with an inoperable law,” he said.
Howell is planning a special committee to deal with
mental health, an issue given new urgency after the
suicide of the son of state Sen. R. Creigh Deeds (DBath). A bipartisan ethics bill, crafted before the
session began and stemming from the gifts scandal
6
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
He just wants the textbooks to reflect the
controversy, he said, which is taught on state tests.
Similar legislation has died before, but he plans to
put a major push behind it this time, along with
legislation to help teenagers given sentences of life
without parole for crimes that were not deadly.
Sen. Richard H. Stuart (R-Westmoreland) wants to
ban drilling for oil and gas on the coastal plain east
of Interstate 95, saying it’s necessary to protect the
state’s groundwater — an environmental bill that
will probably attract Democratic support. Lobbyists
and lawmakers say legislation to regulate fracking in
the state’s Northern Neck is likely to come up as
well. But any amount of bipartisan cooperation will
be overshadowed by Medicaid, especially if
McAuliffe holds to a campaign promise to ignore any
budget that does not include the expansion. “I’ve
dismissed what he said as being a freshman
mistake,” said Sen. Majority Leader Thomas K.
Norment Jr. (R-James City). Lobbyists in the healthcare industry hold out hope that a deal with
Republicans can be made. (Washington Post,
1/10/14)
War On Poverty Spurs
Political, Academic Battles
Florida Sen. Marco Rubio, who’s been working to
mend fences with his conservative base, has now
jumped into the issue of poverty and federal antipoverty programs, proposing drastic changes in the
way the government seeks to help the poor. But
Rubio’s proposals, timed to coincide with the 50th
anniversary of the start of the War on Poverty, are
based on debatable assertions about the cost and
success of that war. “Fifty years ago, President
Lyndon Johnson declared a big government war on
poverty,” Rubio said in a YouTube news release this
week. “Well, since then American taxpayers have
spent about $20 trillion on welfare and other
government programs that claim to lift people out of
poverty.”
Still, he said, there are millions of
Americans classified as living in poverty, and “in my
home state, nearly 1 in 5 Floridians live in poverty.
… Isn’t it time to declare big government’s war on
poverty a failure?” Experts on both sides of the
ideological divide say the claim of $20 trillion in
spending is overstated — and many academic
researchers are saying that the positive effects of
the war on poverty have been understated. “The
official poverty measure fails to show or correctly
identify that true poverty has fallen noticeably in the
U.S. over the past five decades,” said economist
James X. Sullivan of Notre Dame University, author
of a recent study on how to measure poverty rates.
“If you correct for well-known flaws in the official
measure, it shows poverty has fallen noticeably. ...
Done correctly, it suggests we’re winning the war on
poverty.” Rubio’s criticism of the War on Poverty, a
series of federal programs aimed at improving the
economic prospects of the nation’s poor, has been
raised by Republicans for decades. “In 1964 the
famous War on Poverty was declared, and a funny
thing happened.
Poverty, as measured by
dependency, stopped shrinking,” said President
Ronald Reagan in a 1986 radio address. “I guess
you could say poverty won the war.” In 1995,
powerful Texas Rep. Bill Archer said the United
States “has spent $5.3 trillion on welfare since the
War on Poverty began, ... and the Census Bureau
tells us we have lost the war.” In July, Wisconsin
Rep. Paul Ryan, the GOP budget guru, told his
committee that since LBJ declared war on poverty,
“we’ve spent over $15 trillion in that war. So what
do we have to show for it? Well, today 46 million
people live in poverty. ... For too many families, the
American dream is out of reach.” Ryan’s $15 trillion
figure came from a study by Michael Tanner of the
conservative Cato Institute, who added up
expenditures in 126 federal programs he identified
as aimed at combating poverty and converted the
totals into inflation-adjusted dollars.
“How We
http://www.washingtonpost.com/local/virginiapolitics/medicaid-expansion-not-social-issuesexpected-to-dominate-va-legislativesession/2014/01/10/9917de58-798c-11e3-af7f13bf0e9965f6_story.html
Telemedicine Holds Great
Promise For Children
Re “Telemedicine can help solve health care delivery
puzzle” (Viewpoints, Dec. 29): Akhilesh Pathipati is
exactly correct when he says that telemedicine is
the right solution at the right time for much that ails
our health care system. Children especially stand to
benefit, especially those living in rural and
underserved communities. And telemedicine can
bring needed health and dental services to children
at convenient locations, such as schools.
Telemedicine can also reduce travel time and costs,
while also reducing absences from school and work
to go to appointments. This can be especially
important for low-income families.
For kids,
telemedicine can treat many conditions, from
common childhood illnesses, like strep throat and
asthma, to conditions requiring specialty care in
fields like dermatology, endocrinology, emergency
and critical care, behavioral and mental health care,
and even dental care. As more children get covered
through health care reform telemedicine has a
larger role than ever to play. -- Jenny Kattlove, The
Children's
Partnership,
Santa
Monica
(The
Sacramento Bee, 1/10/13)
http://www.sacbee.com/2014/01/10/6042914/telem
edicine-closing-the-health.html#storylink=cpy
7
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
Spend Nearly $1 Trillion a Year Fighting Poverty —
and Fail,” is its title. Tanner was asked about
arguments that the official statistics overstate
poverty and thus understate the success of the war
against it. “My argument,” he replied, “is more that
you have 126 separate programs that spend this
money run by nine Cabinet departments and six
independent agencies. That’s a huge incentive for
inefficiency.” Tanner’s figure includes $3 trillion of
state spending and $12 trillion in federal spending.
He notes that the state spending is mostly money
that matches federal contributions, including
Medicaid, which must be spent according to federal
rules. According to an analysis by The Washington
Post, if Tanner’s figure of $12 trillion is correct, the
anti-poverty spending amounts to slightly less than
12 percent of federal expenditures during the
period. Tanner acknowledged his figure includes
some spending that doesn’t go just to the poor,
even though it’s intended to boost individuals’
economic prospects, including Pell grants for college
tuition. A Rubio spokesman said he thought Rubio’s
$20 trillion figure came from a Heritage Foundation
study. His staff declined to answer other questions
about the video and about a speech he made last
week outlining his proposals for revamping federal
anti-poverty efforts.
These proposals include
converting anti-poverty programs into grants to the
states and replacing the Earned Income Tax Credit
with a wage enhancement program in which the
government would subsidize the pay of low-wage
workers. In fact, $20 trillion is the figure used in a
recent study by Robert Rector of the Heritage
Foundation, known among conservatives as “the
godfather of welfare reform.” “While the material
living conditions of the poor have improved in that
time, dependence on public assistance has only
grown,” Rector wrote. Rector’s figure, however,
includes some big expenditures Tanner omitted,
including Medicaid spending for long-term and
nursing home care — about 30 percent of
Medicaid’s $415 billion in 2012. Poor people benefit
from this Medicaid program, but so can anyone who
lives in a nursing home long enough to become
destitute or uses what Tanner calls “accounting
tricks,” shifting assets to meet Medicaid’s
requirements. That can include keeping a home
worth up to $800,000, a car, jewelry, life insurance
and retirement accounts, plus assets owned by a
spouse, Mark Warshawsky of the American
Enterprise Institute wrote recently in the Wall Street
Journal. Tanner said he omitted Medicaid long-term
care from his figure because “technically the
beneficiaries are below the poverty line, ... but it’s
not intended as a program for the poor. It’s
intended for the elderly.” The hottest argument,
however, is over whether government spending has
reduced poverty. According to the official poverty
rate, the change hasn’t been great — a drop of 4.4
percentage points, from 19.5 percent to 15.1
percent, from 1960 to 2010, according to the study
by Sullivan of Notre Dame. But because it counts
only income, the official rate doesn’t include the
effect of some of the most important anti-poverty
programs, Sullivan and other researchers have said.
Those include the Earned Income Tax Credit, other
kinds of tax credits and in-kind assistance, including
food stamps. Further, use of the Consumer Price
Index to set the official poverty line yearly
overstates the number of poor because the CPI
overstates inflation, most economists now say.
Allowing for those flaws, Sullivan said, the result is a
26 percentage point drop in poverty during the
1960-2010 period, not 4.4 points. The U.S. Census
Bureau is publishing an alternative measure of
poverty that corrects some of the errors, said
sociologist Christopher Wimer of Columbia
University’s Population Research Center. He and
colleagues found a 40 percent drop in poverty since
just before the beginning of the War on Poverty, but
also found that during the Great Recession and
previous recessions, War on Poverty programs
prevented millions of people from dropping into
“deep poverty” — less than 50 percent of the
poverty level. Without those programs, Wimer said,
the deep poverty level would have been nearly 20
percent of the population in some recession years,
instead of remaining flat at about 5 percent since
just after the War on Poverty started. (Tampa
Tribune, 1/11/14)
http://tbo.com/news/politics/war-on-poverty-spurspolitical-academic-battles-20140111/
Krugman: Social Programs
Have Helped America's Poor
Fifty years have passed since Lyndon Johnson
declared war on poverty.
And a funny thing
happened on the way to this anniversary. Suddenly,
or so it seems, progressives have stopped
apologizing for their efforts on behalf of the poor
and have started trumpeting them instead. And
conservatives find themselves on the defensive. It
wasn't supposed to be this way. For a long time,
everyone knew - or, more accurately, "knew" - that
the war of poverty had been an abject failure. And
they knew why: It was the fault of the poor
themselves. But what everyone knew wasn't true,
and the public seems to have caught on. The
narrative went like this: Anti-poverty programs
hadn't actually reduced poverty, because poverty in
America was basically a social problem - a problem
of broken families, crime and a culture of
dependence that was only reinforced by government
aid. And because this narrative was so widely
accepted, bashing the poor was good politics,
enthusiastically embraced by Republicans and some
8
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
Democrats, too. Yet this view of poverty, which
may have had some truth to it in the 1970s, bears
no resemblance to anything that has happened
since. For one thing, the war on poverty has, in
fact, achieved quite a lot. It's true that the standard
measure of poverty hasn't fallen much. But this
measure doesn't include the value of crucial public
programs like food stamps and the earned-income
tax credit. Once these programs are taken into
account, the data show a significant decline in
poverty, and a much larger decline in extreme
poverty.
Other evidence also points to a big
improvement in the lives of America's poor: Lowerincome Americans are much healthier and betternourished than they were in the 1960s.
Furthermore, there is strong evidence that antipoverty programs have long-term benefits, both to
their recipients and to the nation as a whole. For
example, children who had access to food stamps
were healthier and had higher incomes in later life
than people who didn't. And if progress against
poverty has nonetheless been disappointingly slow which it has - blame rests not with the poor but with
a changing labor market, one that no longer offers
good wages to ordinary workers. Wages used to
rise along with worker productivity, but that linkage
ended around 1980. The bottom third of the U.S.
workforce has seen little or no rise in inflationadjusted wages since the early 1970s; the bottom
third of male workers has experienced a sharp wage
decline. This wage stagnation, not social decay, is
the reason that poverty has proved so hard to
eradicate. Or to put it a different way, the problem
of poverty has become part of the broader problem
of rising income inequality, of an economy in which
all the fruits of growth seem to go to a small elite,
leaving everyone else behind. So how should we
respond to this reality? The conservative position,
essentially, is that we shouldn't respond.
Conservatives are committed to the view that
government is always the problem, never the
solution; they treat every beneficiary of a safety-net
program as if he or she were "a Cadillac-driving
welfare queen." And why not? After all, for
decades their position was a political winner,
because middle-class Americans saw "welfare" as
something that Those People got but they didn't.
But that was then. At this point, the rise of the 1
percent at the expense of everyone else is so
obvious that it's no longer possible to shut down
any discussion of rising inequality with cries of "class
warfare." Meanwhile, hard times have forced many
more Americans to turn to safety-net programs.
And as conservatives have responded by defining an
ever-growing fraction of the population as morally
unworthy "takers" - a quarter, a third, 47 percent,
whatever - they have made themselves look callous
and mean-spirited. You can see the new political
dynamics at work in the fight over aid to the
unemployed.
Republicans are still opposed to
extended
benefits, despite
high
long-term
unemployment.
But they have, revealingly,
changed their arguments. Suddenly, it's not about
forcing those lazy bums to find jobs; it's about fiscal
responsibility. And nobody believes a word of it.
Meanwhile, progressives are on offense. They have
decided that inequality is a winning political issue.
They see war-on-poverty programs like food
stamps, Medicaid and the earned-income tax credit
as success stories, initiatives that have helped
Americans in need - especially during the slump
since 2007 - and should be expanded. And if these
programs enroll a growing number of Americans,
rather than being narrowly targeted on the poor, so
what? So guess what: On its 50th birthday, the war
on poverty no longer looks like a failure. It looks,
instead, like a template for a rising, increasingly
confident
progressive
movement.
(Houston
Chronicle, 1/10/14)
http://www.chron.com/opinion/outlook/article/Krug
man-Social-programs-have-helped-America-s5132203.php
ObamaCare Rule
Streamlines Medicaid Program
Federal officials on Friday issued an ObamaCare
regulation intended to make it easier for older and
disabled people to access housing benefits under
Medicaid. The Centers for Medicare & Medicaid
Services, a division of HHS, issued a final rule that
streamlines the approval process for Medicaid's
home and community-based programs.
While
Medicaid does provide health insurance that covers
doctor appointments for certain low-income families,
it also helps seniors and people with disabilities pay
for care in community-based living centers. The
rule is more of an administrative fix than anything
else. The problem with this portion of Medicaid is
that some beneficiaries who were signed up for
multiple programs were having to seek an
unnecessary number of reapprovals at different
intervals, one for each program.
This rule
streamlines the process, so they only need approval
once every five years for all of the programs. The
rule also clarifies how much beneficiaries have to
pay for the different programs. As part of President
Obama's Community Living Initiative, the program
creates new affordable and accessible housing
opportunities.
Those could include "retirement
communities" for older people, as well as at-home
care from nurses. The rule is expected to cost
taxpayers as much as $150 million this year. (The
Hill, 1/10/14)
9
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
http://thehill.com/blogs/regwatch/healthcare/19515
3-obamacare-rule-streamlines-medicaidprogram#ixzz2q6tMhhR9
exchanges. Insurers say that enrollment files sent
by the federal portal remain incomplete or incorrect,
and significant back-end parts of the system remain
to be built.
Both of CMS’s leadership
announcements Friday were to replace two top
officials who left amid much public skewering in the
wake of the site’s botched Oct. 1 rollout. Tim Love,
a 22-year agency veteran, will serve as chief
operating officer and oversee the contracts for the
federal Obamacare portal. Love replaces Michelle
Snyder, who retired at the end of last year and
whose work was scrutinized during congressional
hearings on HealthCare.gov. Dave Nelson will serve
as chief information officer, replacing Tony Trenkle,
who abruptly left in November for a private-sector
opportunity. Trenkle was the supervisor of Deputy
CIO Henry Chao, who had a leading day-to-day role
in managing the development of HealthCare.gov.
Nelson, who has been at the agency for a decade,
most recently served as acting CIO following
Trenkle’s departure. As reported Friday morning by
The Washington Post, CMS intends to hire
Accenture to replace CGI when its current contract
ends. The Post, citing a “person familiar with the
matter,” said Accenture and CMS will ink a one-year,
$90 million deal. Agency spokesman Aaron Albright
wouldn’t comment directly on the Accenture report.
“We are working with our contract partners to make
a mutually agreed upon transition to ensure that
HealthCare.gov continues to operate smoothly for
consumers,” Albright said in a late-morning
statement. “We continually evaluate our needs and
remain focused on ensuring consumers have access
to affordable, quality coverage, and more than 1.1
million already have enrolled in a private plan in the
federal marketplace.”
Accenture spokeswoman
Joanne Veto also declined to comment. “We are in
discussion with potential clients all the time, but it is
not appropriate to discuss contracts we may or may
not be pursuing,” she said. CGI’s statement said
the switch comes “at a time when HealthCare.gov is
performing well, due largely to CGI’s key role during
the ‘tech surge.’ We are proud that more than 400
CGI employees worked around the clock from
October through December to deliver a consumer
experience that works for a vast majority of
Americans.” The statement also noted that CMS
has awarded it “nearly $37 million in contracts”
since October. At the White House, spokesman Jay
Carney said he didn’t have information about the
switch and that “contracts at CMS are something
that CMS would address.” CGI was hired by CMS in
September 2011 to lead construction of the federal
enrollment website, which is serving 36 states, and
administration officials have been publicly critical of
the contractor’s work since the botched Oct. 1
rollout. CMS Administrator Marilyn Tavenner in a
late October congressional hearing singled out CGI
as the only contractor that failed to deliver on time
Federal Health Site To Get New Contractor
CGI Federal will stop its work on the troubled
federal health insurance exchange when its contract
with the Centers for Medicare and Medicaid Services
expires at the end of February, the company said
Friday. CGI was the largest contractor working on
the complex online enrollment system, which barely
functioned when the healthcare.gov website went
live at the beginning of October. The company has
played a role in the effort to repair the site. Linda
Odorisio, a spokeswoman for CGI Federal, a
subsidiary of CGI Group of Montreal, rejected
suggestions that CGI had effectively been fired by
the federal government, and said the company
decided not to take up an option to maintain the
contract for the next two years beginning in March.
"The joint decision comes at a time when
healthcare.gov is performing well, due largely to
CGI's key role during the 'tech surge,' " Odorisio
wrote in an email. A person familiar with the
situation told the New York Times that the
government will award the maintenance contract,
which is worth about $90 million annually, to
Accenture, a large consulting firm that often
subcontracts projects to CGI. Aaron Albright, a
spokesman for the Centers for Medicare and
Medicaid Services, declined to comment on the
contract, citing ongoing negotiations. (Tampa Bay
Times, 1/11/14)
http://www.tampabay.com/news/nation/federalhealth-site-to-get-new-contractor/2160629
CMS Changes Leadership,
Health Website Contractor
The agency overseeing HealthCare.gov has
overhauled its leadership team and dumped the
contractor responsible for the troubled enrollment
site, signaling a critical shift in how the Obama
administration attacks the troubles people have had
trying to sign up for health care. News of the twin
moves came Friday morning as the House was
passing a measure triggered by questions about the
website’s security. A statement by the Centers for
Medicare & Medicaid Services referred to “a
mutually agreed upon transition” between the
agency and its “contract partners.” Hours later, the
partner in question announced that its work on the
site will conclude with its contract end date in
February. Although HealthCare.gov is functioning
far better since a massive repair effort concluded in
late November, problems are still undermining
public confidence in the federal and state
10
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
— though contractors had also blamed CMS for poor
management of the project. States that tapped CGI
to build their own online insurance marketplaces
have shown increasing frustration with the firm.
Massachusetts, which hired CGI to relaunch its
existing exchange website, may sue the firm, state
Attorney General Martha Coakley said this week.
The Massachusetts exchange has hired Dell and
MITRE to fix deep technical problems that have
plagued many residents’ online enrollment
experiences since October. Vermont Gov. Peter
Shumlin’s administration has withheld more than $5
million from payments for CGI’s work on the state’s
problematic enrollment website. “The contractors
we hired to build it have underperformed at every
turn,” Shumlin said this week. On Capitol Hill on
Friday, House Energy and Commerce Chairman Fred
Upton (R-Mich.) said that the change in contractors
“does not change the sad state of this law. The
committee continues to have more questions than
the administration has answers.
Our purpose
continues to be about accountability and
transparency — two things that have been absent
from the administration when it comes to this health
care law.” Following the latest news, CGI’s stock
was down more than 3 percent Friday afternoon.
(Politico, 1/10/14)
among the 10 most frequent reasons for a short
hospital admission. Medicare officials have urged
hospital patients to find out if they’ve been officially
admitted. But suppose the answer is no. Then what
do you do? Medicare doesn’t require hospitals to
tell patients if they are merely being observed,
which is supposed to last no more than 48 hours to
help the doctor decide if someone is sick enough to
be admitted. (Starting on Jan. 19, however, New
York State will require hospitals to provide oral and
written notification to patients within 24 hours of
putting them on observation status. Penalties range
as much as $5,000 per violation. ) To increase the
likelihood of being formally admitted, “get yourself
in the door before midnight,” advised Dr. Ann
Sheehy, division head of hospital medicine at the
University of Wisconsin Hospital in Madison, Wisc. A
new Medicare regulation — the so-called “pumpkin
rule” — requires doctors to admit people they
anticipate staying for longer than two midnights, but
to list those expected to stay for less time as
observation patients. Although the rule applies
now, Medicare officials won’t enforce it until April 1,
having already pushed the deadline back. The
American Medical Association and the American
Hospital Association have called the pumpkin rule
“impossible” to comply with and have urged that
enforcement be delayed again until October. “It
doesn’t make any sense,” said Dr. Sheehy, who
studied how the rule would have affected
admissions at her hospital over an 18-month period
and published the results in JAMA Internal Medicine.
Some patients will be admitted because they came
in at the right time of day, not because they have
more complicated medical problems.” The twomidnight rule doesn’t change Medicare’s threemidnight rule, the one limiting post-hospital nursing
home coverage. Officials at the federal Centers for
Medicare and Medicaid Services declined comment
for this story because of pending litigation seeking
to eliminate observation status. If you or a family
member land in the hospital as an observation
patient and think you should be admitted, it’s better
to act sooner than later. “I would talk to anyone
who would listen to me,” said Terry Berthelot, a
senior attorney at the Center for Medicare
Advocacy, which offers a free self-help packet for
observation patients. “ Make as much noise as you
can, because it’s much easier to change your status
while you’re still in the hospital than to go through
Medicare’s appeals process later.” Ms. Berthelot
suggests asking your regular physician to speak with
the doctor treating you in the hospital about why
you need to be admitted, based on your medical
condition and risk factors. “It’s got to be a medical
argument,” said Ms. Berthelot. “You can’t say,
‘Mom will need rehab after this,’ or ‘We can’t take
her home because no one can stay with her.’” If
that doesn’t work, sometimes a strongly worded
http://www.politico.com/story/2014/01/healthcaregov-contractor-leadership102039.html#ixzz2q6uQZ7GH
Fighting ‘Observation’ Status
Every year, thousands of Medicare patients who
spend time in the hospital for observation but are
not officially admitted find they are not eligible for
nursing home coverage after discharge. A Medicare
beneficiary must spend three consecutive midnights
in the hospital — not counting the day of discharge
— as an admitted patient in order to qualify for
subsequent nursing-home coverage. If a patient is
under observation but not admitted, she will also
lose coverage for any medications the hospital
provides for pre-existing health problems. Medicare
drug plans are not required to reimburse patients
for these drug costs. The over-classification of
observation status is an increasingly pervasive
problem: the number of seniors entering the
hospital for observation increased 69 percent over
five years, to 1.6 million in 2011. The chance of
being admitted varies widely depending on the
hospital, the inspector general of the Department of
Health and Human Services has found. Admitted
and observation patients often have similar
symptoms and receive similar care. Six of the top
10 reasons for observation — chest pain, digestive
disorders, fainting, nutritional disorders, irregular
heartbeat and circulatory problems — are also
11
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
letter or call from a lawyer describing the patient’s
medical needs can be effective. In some cases,
help from a professional can make a difference.
Shari Polur, an elder-law attorney in Louisville, Ky.,
recently hired a geriatric care manager to persuade
a local hospital to admit her client. Since admission
status can change from one day to the next, the
manager, who is also a registered nurse, called the
hospital every morning to make sure the patient
was still officially admitted until she could be
transferred to a nursing home. If the situation isn’t
resolved while you’re in the hospital and you require
follow-up care at a nursing home, you’ll have to pay
the bill of often thousands of dollars up front. At
that point, Ms. Berthelot suggests, you should file
what amounts to a special doubled-barreled appeal
with Medicare. It’s not for the faint of heart: the
process is long and arduous, and it requires
beneficiaries to first receive and pay for the care —
often an expensive proposition — before seeking
reimbursement. And the legal arguments can be
tangled. The Medicare appeals process typically
addresses disputes over whether certain treatments
or services rendered should have been covered.
Observation patients have actually received hospital
coverage and services a doctor says is medically
necessary — so they don’t really have anything to
appeal, said Marc Hartstein, director of Medicare’s
hospital and ambulatory policy group, at a recent
briefing in Washington. “My limited understanding
of this is that the patient cannot appeal a decision
not to order or not to do something,” he said. But
observation patients may claim that they received
treatment usually provided to admitted patients only
in a hospital. Therefore, the hospital incorrectly
billed Medicare for an outpatient service instead of
for inpatient services. The patient should have been
admitted and therefore qualifies for nursing home
coverage. “It’s absolutely confusing as heck,” said
Michael Sgobbo, an elder law attorney in
Charleston, S.C., who recently won an appeal on
behalf of a 98-year-old woman who will be
reclassified as an admitted patient. That means
Medicare will pay her nursing home bill of nearly
$10,000.
Lawyers at the Center for Medicare
Advocacy recommend fighting observation care on
two fronts. First, follow the appeal instructions in
the Medicare summary notice, a quarterly statement
of services. Circle the charges on the statement
from the hospital and explain that these items were
inappropriately billed under Medicare’s Part B as
outpatient services. They should have been billed
under Medicare’s Part A for hospital services,
because the patient received treatment that could
only have been provided in a hospital. Mail the
statement within 120 days (from the date on the
statement) to the address provided for appeals.
Second, after challenging the hospital’s observation
designation, file a separate appeal to seek
reimbursement for the nursing home charges, said
Ms. Berthelot. To begin, ask the nursing home to
bill Medicare.
You should receive a Medicare
summary notice indicating that it did not pay the
nursing home charges because the patient didn’t
have the required three-day hospital stay. Circle
those charges, and explain that the beneficiary was
hospitalized for three days and received an inpatient
level of care. Then send it within 120 days to the
address provided for appeals. Be prepared to dig in.
If either appeal is denied, you must appeal again to
the next level, following the instructions in the
denial letters. “Both appeals can take at least a
year and are fraught with difficulty,” said Ms.
Berthelot. “The reality is that most people can’t get
through and those who do, get lucky.” Some
observation patients appeal and never get decisions,
warned Diane Paulson, senior attorney at Greater
Boston Legal Services. Some of her clients’ cases
were dismissed because they were not admitted to
the hospital — the very point they were challenging.
“You can’t appeal if you don’t have a denial,” she
said. When that happens, the case falls into “a
black hole.” But the chances of winning improve as
you continue to appeal, as Nancy and George
Renshaw, of Bozrah, Conn., discovered.
After
spending nearly four years going through the
process, a Medicare judge decided last February
that Mr. Renshaw’s father should have been
admitted to the hospital instead of classified as an
observation patient.
Medicare finally paid his
nursing home bill, and in November the Renshaws
received a refund of $4,410. “I was shocked,” said
Ms. Renshaw. “I never expected to see a penny of
it.” (New York Times, 1/10/14)
http://newoldage.blogs.nytimes.com/2014/01/10/fig
hting-observation-status/
Medical Students: Fluent In Science,
Illiterate In Health Policy
Since its inception more than a century ago, modern
medical education has undergone a series of quiet
revolutions, stretching and scaling to accommodate
advances in biomedical science.
Yet this
comprehensive expansion in one critical area masks
a relative neglect of another. Despite their
staggering scope — spanning genetics to geriatrics,
and everything in between — medical curricula
today largely omit training on health policy. The
result? Even as today’s medical students graduate
with a deep scientific fluency, they leave all but
illiterate when it comes to the health care system.
Consider, for example, the findings of a 2009 study
in the journal Academic Medicine analyzing survey
data from the Association of American Medical
Colleges. Polling nearly 60,000 graduating medical
students, the analysis found that less than half of
12
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
the respondents felt they had an adequate grasp of
health economics, managed care or health care
systems. Compare this result to the corresponding
statistic for clinical care, which clocked in at well
over 80 percent. Moreover, in a 2011 New England
Journal of Medicine survey of medical deans, almost
60 percent of respondents reported their
institution’s curriculum as containing “too little”
health policy training. I can bear witness to this
disparity firsthand. The curriculum of Stanford
Medical School, where I am a deferred first-year
student, does not incorporate a single required
course on health policy or the health care system
across four years and 249 credits of training. And
this oversight comes with consequences.
To
illustrate, recent research in JAMA Internal Medicine
found that fewer than half of medical students
nationwide understand even the basic components
of the Affordable Care Act. On a systemic level, this
illiteracy directly impedes our ability to institute
meaningful health policy reforms that tackle such
thorny issues as quality-based physician payments,
comparative effectiveness guidelines or end-of-life
care. Without willing and capable physician leaders
to guide, implement and sustain such major shifts
for the decades to come, reform efforts almost
certainly will founder. Consequently, efforts to rein
in health care costs and improve patient outcomes
must begin by modernizing medical curricula to
incorporate health policy training. For example, a
national mandate that fundamental knowledge of
health systems be a prerequisite for medical
licensing would encourage medical schools to
incorporate course work on basic principles of health
policy and economics. This teaching, moreover,
should be nonpartisan and nonideological, focusing
instead on the nuts and bolts of health systems —
akin to what law or business school students learn
about policymaking and institutional governance.
This training need not be comprehensive or allencompassing. Just as pre-clinical instruction in the
medical sciences provides a basic foundation that is
built on in later clinical training, health policy
education in medical curricula can offer a baseline
understanding that is reinforced in subsequent
years. Even ensuring just a rudimentary level of
health policy literacy could go a long way.
Furthermore, the advent of so-called massive open
online courses, or MOOCs, means that financial
concerns — the costs of expanding medical curricula
to encompass health-care policy — may be
unwarranted.
Whatever the medium, it is
imperative that we install health policy as an
integral part of the national medical curricula, lest
we continue to churn out a generation of students
who are ill-equipped to make sense of the
challenges and changes to come.
Amid the
dynamism of our 21st-century health care system,
policy fluency is at least as important as a mastery
of biomedical concepts. Rahul Rekhi, a student at
Stanford University School of Medicine, is studying
as a Marshall Scholar at Oxford University. He
served as special assistant to the Maryland secretary
of health in 2013. (Dallas Morning News, 1/10/14)
http://www.dallasnews.com/opinion/sundaycommentary/20140110-medical-students-fluent-inscience-illiterate-in-health-policy.ece
Rubio Sounds Alarm
Of "Obamacare Bailout"
U.S. Senator Marco Rubio (R-FL) today commented
on new evidence of the increasing likelihood of a
taxpayer-funded bailout of health insurance
companies under ObamaCare.
The 'evidence'
comes as insurance companies make their first
material filings to the Securities and Exchange
Commission (SEC) regarding projections for their
ObamaCare risk pools, the Herald's Marc Caputo
reports. According to Rubio, one company has
disclosed that “as a result of the December 2013
federal and state regulatory changes allowing
certain individuals to remain in their previously
existing off-exchange health plans, the Company
now expects the risk mix of members enrolling
through the health insurance exchanges to be more
adverse than previously expected.”
Rubio
concluded, “American taxpayers should not be on
the hook for bailing out health insurers, especially
because ObamaCare is not working the way it was
sold. Congress should take an ObamaCare bailout
off the table by passing legislation I’ve introduced to
repeal the so-called risk corridor provision under the
law." Rubio's position -- that Obamacare can't
survive without a taxpayer "bailout of insurers" -- is
a little misleading, according to Herald senior
healthcare reporter Dan Chang. "The risk corridors
were built into the ACA legislation, so I don't know if
it's fair to call it a 'bailout,' at least not in the sense
of TARP, or the auto industry bailout. The word
bailout implies an emergency spend for some
unforeseen circumstance," Chang said. Since the
deadline for the ACA's first enrollment year is March
31, Chang expects the real mix for the insurance
companies' risk pools won't become clear until April.
The ACA anticipated from the start that insurers
could lose money from a higher proportion of sicker
policy holders. The risk corridors provided a built-in
payment structure to offset those potential losses
for three years, to help companies gain their health
reform sea legs. The cost was factored into the
original ACA budget. A bill Rubio proposed last year
called the ObamaCare Taxpayer Bailout Prevention
Act would repeal the risk corridors. It's not really
preventing a bailout, though. It's defunding the
guts of the health reform program. 1/10/14)
13
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
http://miamiherald.typepad.com/health/2014/01/ru
bio-sounds-alarm-of-obamacarebailout.html#storylink=cpy
at their practicum site, our practicum coordinator
assists each graduate in finding proper placement
for employment," Lara said. Houston Community
College also offers a Human Service Technology
program, designed for students interested in the
field of human services.
The program equips
students for employment as technicians in a range
of human service facilities, including those seeking
to become mental health technicians. "The Human
Service Technology Program offers classes in basic
counseling, orientation to social services, counseling
theories, family interventions, assessment, group
counseling and co-occurring disorders," said Richard
Rosing, a mental health associate for Human Service
Technology at Houston Community College's
Coleman College for Health Sciences.
"The
complete associate degree takes two years, with
specialty areas being able to complete in either one
semester or one year." (Houston Chronicle,
1/10/14)
Mental Health Technicians In Demand
San Jacinto College's certificate comprises 33 hours
of courses and is intended to take a year to
complete -- fall, spring and summer. More and
more people are seeking psychiatric services to help
manage or solve issues ranging from stress at work
or ongoing depression to anxiety disorders and
substance abuse. As the demand for psychiatric
services continues to grow, so too will the need for
qualified mental health technicians.
In fact,
employment of mental health technicians - also
known as psychiatric technicians or psychiatric aides
- is expected to increase 15 percent from 2010 to
2020, according to the U.S. Bureau of Labor
Statistics. The BLS also notes that "there is likely to
be an increase in the number of people with
cognitive mental diseases, such as Alzheimer's
disease. Demand for psychiatric technicians and
aides in residential facilities are expected to rise as a
result." Those hoping to become mental health
technicians need postsecondary education and some
degree of on-the-job training before they may start
working without direct supervision.
Local
community colleges, such as San Jacinto College,
provide the education and training to pursue a
career as a mental health technician. San Jacinto
College's mental health services program is
designed to train these technicians. The mental
health technician training program prepares
students to care for mentally impaired or
emotionally
disturbed
individuals
following
physician's instructions and hospital procedures.
"Our program provides a one-year certificate that
comprises 33 hours of courses and is intended to
take a year to complete - fall, spring and summer.
It encompasses eight courses that deal with the
various elements and skills a mental health
technicians will need," said Alfred Lara, director of
San Jacinto College's mental health services
program. "These include abnormal psychology,
assessment, group therapy, basic nursing skills and
other relevant courses culminating to a capstone
course of a practicum, where we send students into
a psychiatric hospital setting for a semester to put
into practice the concepts learned, and get training
from experienced mental health technicians and
counselors." Lara said San Jacinto College also
maintains partnerships with community centers and
psychiatric hospitals that allow students to immerse
themselves at their facilities and benefit from the
additional practicum experience.
"Oftentimes,
students are hired by these facilities at which they
have completed their practicum, and this is the best
source for them to be hired. For those not hired on
http://www.chron.com/news/article/Mental-healthtechnicians-in-demand-5132102.php
Teen Homelessness: An American Disgrace
In the US, children under 18 represent one-third of
the US homeless population. 2.8 million American
children have at least one episode of homelessness
every year, while 1.35 million are permanently
homeless. Sadly it’s not a new problem. Seattle
first became concerned about their homeless teens
in the 1990s. In 1999, shortly before moving to
New Zealand, I worked in a community clinic with a
special outreach program for homeless teenagers.
Prior
to
the
2008
economic
meltdown,
approximately ten percent of homeless teens had
access to state and city-run shelters. Over the last
five years, chronic state and city budget deficits
have forced most of them to close.
US Teen Homelessness Rivals the Third World
In third world countries, homeless children are
called “street kids.” The US government prefers to
call them “unaccompanied minors.” Giving it a
fancy name on it doesn’t hide the fact that rate of
homeless American children per capita is worse than
some third world countries. Among countries who
keep a count of homeless children under 18, India
has the highest rate of street children per capita,
with 1 homeless child per 61 residents. Egypt is
next with 1 per 110, then Pakistan (1 per 120),
Kenya (1 per 133), Russia (1 per 141), and Congo
(1 per 148).
The per capita rate of child
homelessness in the US is 1 per 245 residents. This
is worse than the Philippines (1 per 360), Honduras
(1 per 370), Jamaica (1 per 419), Uruguay (1 per
1,000), and Morocco (1 per 1066). Germany, in
contrast, has 1 homeless child per 4,100 residents.
14
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
Why American Teens Become Homeless
costlier drugs, but they can't just close their lists of
approved drugs, or formularies, to protected
medications. In a proposal published Friday in the
Federal Register, the administration called for
removing protected status from antidepressants,
antipsychotics, and immunosuppressant drugs. The
proposal said that status it is no longer needed to
guarantee access, would save millions of dollars for
taxpayers and beneficiaries alike, and could help
deal with the problem of improperly prescribed
antipsychotics drugs in nursing homes.
But
advocates for patients are strongly criticizing the
idea, saying it could potentially limit access to
critically needed medications for millions of people.
"We are disturbed by this," said Andrew Sperling,
legislative advocacy director for the National Alliance
on Mental Illness. "This is a key protection. It's a
cornerstone of what has made the benefit work for
people with mental illness." Sperling said that
patients with mental health issues often have to try
a variety of drugs before they find the right one for
their condition. He questioned whether the change
would help crack down on the problem of
improperly prescribed antipsychotics, saying it
amounted to a blunt instrument. The National
Kidney Foundation also voiced worries. Legislative
policy director Tonya Saffer said transplant patients
often depend on combinations of medication, so
having the broadest possible choice is crucial.
"Covering all immunosuppressant drugs is very
important for the patient and very important to
protect the transplanted organ from rejection,"
Saffer said. The proposal could lead to "patients
having to go through multiple channels to try and
get a drug," which would put patients at risk, she
added. In the proposal, the administration said the
new policy was developed after careful consultation
with a broad range of experts. The three other
types of drugs that have protected status — for
cancer, HIV/AIDS and preventing seizures — would
remain protected. If adopted in the coming months,
the new policy could take effect as early as 2015.
The administration estimates it could save the
taxpayers a total of $720 million by 2019.
Beneficiaries may also be able to save. That's
because the drug plans can drive a harder bargain
for manufacturer discounts when a drug is not
protected. "The circumstances that existed when
this policy was originally implemented have changed
dramatically in the more than seven years the
program has been in operation," the Centers for
Medicare and Medicaid Services said in its proposal.
"We are concerned that requiring essentially open
coverage of certain classes and categories of drugs
presents both financial disadvantages and patient
welfare concerns ... as a result of increased drug
prices and overutilization," the proposal added. A
leading industry analyst said the proposal would
represent a significant change for Medicare's
Approximately fifty percent of homeless teenagers
wind up on the streets due to conflict with their
parents. Another twenty percent are there due to a
breakdown of their foster care placement. Others
are homeless because their parents are homeless.
Of teenagers made homeless by family conflict,
forty percent are lesbian, gay, bisexual or
transsexual teens whose parents refuse to accept
their sexuality (25% of LGBT teens are rejected by
their parents). Another large proportion are victims
of physical, sexual and/or emotional abuse. Forty
percent of homeless teenagers report being beaten.
Twenty-five percent report a history of sexual
abuse.
Forty percent have parents who are
mentally ill or who have substance abuse problems.
Ten percent have run away because they’re
pregnant. Some leave home because of alcohol and
drug problems of their own. Many homeless teens
work at minimum wage jobs that don’t pay enough
for an apartment. However faced with a (true)
unemployment rate over 20%, most face long term
unemployment.
Good links regarding teen homelessness:
http://en.wikipedia.org/wiki/Street_children
http://www.psychologytoday.com/blog/teenangst/201101/homeless-teens
http://globalgeopolitics.net/wordpress/2011/03/31/u
-s-budget-cuts-threaten-handful-of-beds-forhomeless-youth/
http://www.shelterhouse.on.ca/article/youthhomelessness-147.asp
http://www.dosomething.org/actnow/tipsandtools/b
ackground-11-causes-teen-homelessness
(Salon,
1/10/14)
http://open.salon.com/blog/stuartbramhall/2014/01/
10/teen_homelessness_an_american_disgrace
Proposed Medicare Drug
Change Stirs Access Worries
In a move that some fear could compromise care for
Medicare recipients, the Obama administration is
proposing to remove special protections that
guarantee seniors access to a wide selection of
three types of drugs. The three classes of drugs —
widely used antidepressants, antipsychotics and
drugs that suppress the immune system to prevent
the rejection of a transplanted organ — have
enjoyed special "protected" status since the launch
of the Medicare prescription benefit in 2006. That
has meant that the private insurance plans that
deliver prescription benefits to seniors and disabled
beneficiaries must cover "all or substantially all"
medications in the class, allowing the broadest
possible access. The plans can charge more for
15
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
prescription benefit, which is highly popular with
beneficiaries. "It is a weakening of a patient
protection," said Dan Mendelson, CEO of Avalare
Health, a market analysis firm. "I'm not sure that
Medicare saves money from this kind of a change,"
he added. "Other elements of the program may
have a cost increase if people are not using
medications in the right way." (New York Times,
1/11/14)
inHg or higher, or drops to 29.7 or lower, the risk of
heart attack increases. High barometric pressure
constricts blood vessels, which hinders blood flow,
while low pressure expands blood vessels, making it
more difficult for the heart to pump blood. The
highest prevalence of heart attacks occurs within 24
hours of swings of that magnitude in barometric
pressure, she said. "That effect is strongest in the
fall and winter," she said. It's not yet known
whether the rate of heart attacks increased this
week.
Jack Boston, senior meteorologist at
AccuWeather.com, said barometric pressure rose
from 29.77 inHg at 7 a.m. Monday to 30.36 inHg by
7 a.m. Tuesday.
Vanos, among others, says
changes in barometric pressure also cause
headaches, migraines, arthritis, joint pain, and sinus
and inner-ear problems. But in an unexpected
seasonal twist, Mississippi State University
meteorologist Grady Dixon said suicide rates drop
during the winter. The peak season for suicides is
June, he said, but the reason remains a mystery.
"Usually the thing people are most interested in or
surprised to hear is that while people have
depression in the cold, dark winter months, suicides
around the globe, with no exception, most
commonly occur during the late spring and early
summer," he said. "It's the broken-promises effect.
If you are clinically depressed and have seasonal
affective disorder, you expect spring to be better.
But if you are clinical ill, you probably won't get
better in the spring when you expect to feel better.
It's not a weather effect but the lack of a weather
effect that causes the suicide." January does bring
the year's highest mortality rate, likely due to higher
rates of infections, including influenza deaths and
other weather impacts on people, especially the
elderly.
The National Weather Service said
temperatures will climb to the lower 40s today, then
to the low 50s on Saturday before dropping back to
the low 40s on Sunday. The weekend will feature
drizzle, rain, freezing rain and snow, which won't
accumulate, with total precipitation of a half to
three-quarters of an inch.
Hendricks said this
winter's weather extremes are occurring because
we're in a transition between el nino and la nina
weather patterns, which are nearly yearlong
weather trends involving the heating and cooling of
the north and northeastern Pacific Ocean. Despite
the temperature extremes, with more likely to
come, winter highs and lows will average near
normal by winter's end. We've also had more than
double the normal snowfall for the season, with
30.3 inches through Wednesday, as compared to
the normal of 13.5, he said. Temperatures are
expected to return to normal by Wednesday.
Weather and climate psychologist Alan E. Stewart of
the University of Georgia said men and women react
differently to severe weather. Women are more
cautious than men.
Maximizing reproduction
http://www.nytimes.com/aponline/2014/01/11/us/p
olitics/ap-us-medicaredrugs.html?ref=aponline&_r=0
Weather Swings Can Hurt
Physical, Mental Health
Biometeorology — the study of weather's impact on
living organisms including humans — uses different
terminology but concludes that weather itself, but
specifically dramatic shifts in weather, can impact
physical and even mental health. The good health
news?
Experiencing such horrible stretches of
weather better prepares us for what National
Weather Service meteorologist Lee Hendricks said is
a strong likelihood of another cold snap this winter.
The so-called polar vortex, blamed for the sub-zero
temperatures, could send us into another mental
and physical vortex before spring. "It's a huge
swing
physiologically,"
Jennifer
Vanos,
a
biometeorologist and assistant professor of
atmospheric science at Texas Tech University, said
about Tuesday's record low of minus 9 degrees
Fahrenheit sandwiched by unseasonable highs in
the 50s. "People were not prepared. Physiologically,
adapting is a tough thing to do when you are used
to certain weather day after day." But if another
cold snap occurs, "people will be prepared," she
said, especially for those 20 and under who never
experienced such sub-zero temperatures. "They will
know what to do, how to dress, and it won't be as
stressful." Long airplane rides usually are necessary
for such swings in temperature. It's like flying
round trip from Myrtle Beach, S.C., to the Yukon.
The Associated Press reported 21 deaths nationwide
from the cold snap, most in the Midwest. The
normal high locally for early January is 36 degrees
with a low of 21. In the week ending Saturday, if
the forecasted high of 52 holds true, the region will
have experienced a 61-degree swing. Last Sunday
alone saw a temperature swing of 57 degrees -- 50
to minus 7, Hendricks said. Along with potential
dangers of extremely low temperatures, including
hypothermia, frostbite and blood vessel constriction
leading to heart attacks, quick shifts in barometric
pressure, high or low, represents an unsuspected
health villain.
Vanos said people are most
comfortable with barometric pressure of 30 inches
of mercury (inHg). When it quickly rises to 30.3
16
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
requires caution, with a slight tendency for
expectant mothers to spend their final trimester
during late spring and summer months before giving
birth in August or September. Winter weather
historically has posed harsh challenges for moms
and babies to stay warm, find food and avoid
infections. CDC statistics showed that 9 percent of
all babies in 2010 were born in August with 7.5
percent born in February. OK, the numbers aren't
dramatic, but the trend holds. Men are a different
story. "Men take more weather-related risks than
women, including driving across roadways that have
water flowing, or being outside during thermal
extremes, or not taking cover when thunder is
heard and lightning is seen, or not sheltering when
there's word from the National Weather Service of a
storm or tornado," said Stewart. (Austin American
Statesman, 1/10/14)
common in lower-income youths. As it turned out,
the exact opposite was true. These young people
were achieving success by all conventional markers:
doing well academically, staying out of trouble,
making friends and developing a positive sense of
self. Underneath, however, their physical health
was deteriorating. Our first hints of this pattern
came from a study of 489 rural African-American
young people in Georgia, whom one of us, Gene
Brody, has been tracking for more than 15 years.
Most came from families who were working but
poor. In 2010, their average family income was
about $12,000 a year; about half lived below the
poverty line. We found a subgroup of resilient
children who, despite these obstacles, were rated,
at age 11, by their teachers as being diligent,
focused, patient, academically successful and strong
in social skills. We followed these young people
until they were 19 and studied their mental and
physical health, focusing on depression, drug use,
aggression and criminal behavior.
As in past
studies, those who were rated positively at age 11
had relatively few of these problems when they
were 19. When we looked beneath the surface,
though, these apparently resilient young people
were not faring well. Compared with others in the
study, they were more obese, had higher blood
pressure and produced more stress hormones.
Remarkably, their health was even worse than peers
who, at age 11, had been rated by teachers as
aggressive, difficult and isolated. They were at
substantial risk for developing diabetes or
hypertension down the line. We continued studying
these youths as they grew into adults. Perhaps not
surprisingly, the lower-income youths who made it
to college used fewer drugs and drank less alcohol.
To be academically competitive with their
classmates, they had to stay focused on their
schoolwork. As in the first study, though, their
resilience was only skin deep. At age 20, the lowerincome college kids had greater obesity, higher
blood pressure and more stress hormones than
those who did not make it to college. (Their health
was also worse than that of peers in more affluent,
educated neighborhoods.) These patterns mesh
with other social-science findings, which suggest
that upward mobility does not always provide the
expected return on investment when it comes to
health. If we look at the life expectancy associated
with a college education, blacks gain about four
fewer years from bachelor’s degrees than do whites.
What is it about upward mobility that undermines
the health of these young Americans? In our
studies, most participants are the first in their
families to attend college. They feel tremendous
internal pressure to succeed, so as to ensure their
parents’ sacrifices have been worthwhile. Many feel
socially isolated and disconnected from peers from
different backgrounds. They may encounter racism
http://www.mystatesman.com/news/ap/health/weat
her-swings-can-hurt-physical-mental-health/ncjN9/
Can Upward Mobility
Cost You Your Health?
Americans love a good rags-to-riches story. Even in
an age of soaring inequality, we like to think that
people can still make it big here if they work hard
and stay out of trouble. The socioeconomic reality
of most of the last four decades — stagnant wages,
soaring income and wealth inequality, and reduced
equality of opportunity — have dented, but not
destroyed, the appeal of the American dream.
Those who do climb the ladder, against the odds,
often pay a little-known price: Success at school and
in the workplace can exact a toll on the body that
may have long-term repercussions for health.
Among American children, there are wide
socioeconomic gaps on many dimensions of wellbeing: school achievement, mental health, drug use,
teenage pregnancy and juvenile incarceration, to
name just a few. Despite the risks that lowerincome children face, we also know that a
significant minority beat the odds. They perform
admirably in school, avoid drugs and go on to
college. Psychologists refer to these children as
resilient, because they achieve positive outcomes in
adverse circumstances. They do so in part by
cultivating a kind of determined persistence. They
set goals for the future, work diligently toward
them, navigate setbacks, stay focused on the long
term and resist temptations that might knock them
off the ladder to success. Several years ago, we
began studying these resilient young people, trying
to find out if their success stories also translated
into physical health benefits. We reasoned that if
disadvantaged
children
were
succeeding
academically and emotionally, they might also be
protected from health problems that were more
17
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
and discrimination. Some young people respond to
the pressure by concentrating on character
strengths that have served them well, cultivating an
even more determined persistence to succeed. This
strategy, however, can backfire when it comes to
health. Behaving diligently all of the time leaves
people feeling exhausted and sapped of willpower.
Worn out from having their noses to the grindstone
all the time, they may let their health fall by the
wayside, neglecting sleep and exercise, and like
many of us, overindulging in comfort foods. What
can we do to mitigate these negative health effects?
To start, schools and colleges that serve lowerincome students could provide health education,
screenings and checkups as a part of their
curriculum. Second, schools and clinics could offer
stress management programs, targeting lowerincome, higher-achieving young people. Finally, we
could develop programs to help these young people
blow off steam in productive ways, pairing them
with mentors who have navigated similar life
challenges. Policymakers should do everything they
can so that those young people who overcome so
much to live the American dream have the health to
enjoy the fruits of their efforts.
my first year.” Those issues include education
reform, in which Dels. Thomas A. “Tag” Greason (RLoudoun) and K. Robert Krupicka Jr. (D-Alexandria)
are both working on overhauling and paring back
the state’s Standards of Learning tests. There’s
more disagreement over a law passed last year
creating a state district to take over failing schools;
some lawmakers hope to repeal it, while Greason
thinks the first order of business should be to make
it work. “Let’s make sure we’re not saddling the
commonwealth with an inoperable law,” he said.
Howell is planning a special committee to deal with
mental health, an issue given new urgency after the
suicide of the son of state Sen. R. Creigh Deeds (DBath). A bipartisan ethics bill, crafted before the
session began and stemming from the gifts scandal
that has engulfed outgoing governor Robert F.
McDonnell, will be filed next week. Following a path
set by McDonnell (R), lawmakers from both parties
have filed measures to restore voting rights for
nonviolent felons. The social issues that have
dominated past sessions are largely absent from the
agenda this year. There are multiple bills from
Democrats
hoping
to
repeal
the
state’s
constitutional ban on same-sex marriage and roll
back the mandatory ultrasound that passed amid
great controversy two years ago, but these
measures stand little chance in a House dominated
by conservatives. At the same time, Republicans
aren’t on the offensive. Only one Republican has
filed any bills related to abortion or birth control this
session: Del. Robert G. Marshall (R-Prince William),
an aggressive and reliable conservative on social
issues. And he’s only got a few in the hopper. While
Marshall says he’s not backing down “in the least,”
he acknowledged that his party leadership is not
interested in joining the fight. “Maybe they think
they’re mother hens, protecting their Republicans
from I don’t know what,” he said. “Laying down
and playing dead; I find that disgusting and
obsequious.” One Republican House bill would
allow religious expression in public schools, and a
bipartisan measure would compensate people who
were involuntarily sterilized by the state — both top
priorities of the influential Family Foundation. The
latter initiative failed last year, with opponents citing
a lack of funds. Sen. Thomas A. Garrett Jr. (RGoochland) has taken flak from liberal blogs for a
bill that would clarify the state’s anti-sodomy
“Crimes Against Nature” law, ruled unconstitutional
in 2013 by a federal appeals court. His original bill
said only that the law did not apply to consenting
adults; he has since amended it to include
consenting teenagers. However, Garrett said, “I
draw the line at grown-ups having sex with kids.” A
former prosecutor, he said he had seen a 37-yearold convicted under that law for propositioning a 13year-old and did not want that man to be able to
appeal on the grounds of constitutionality. A bill
Gregory E. Miller ([email protected])
and Edith Chen ([email protected]) are
professors of psychology and fellows of the Institute
for Policy Research at Northwestern University.
Gene H. Brody ([email protected]) is professor of
human development and family studies and the
director of the Center for Family Research at the
University of Georgia. (Dallas Morning News,
1/10/13)
http://www.dallasnews.com/opinion/sundaycommentary/20140110-can-upward-mobility-costyou-your-health.ece
Medicaid Expansion, Not
Social Issues, Expected To
Dominate Va. Legislative Session
One issue will dominate Virginia’s legislature this
year above most others: the proposed expansion of
Medicaid under the Affordable Care Act.
The
measure carries huge financial implications for
hospitals and other health-care providers. But it is
also a deeply divisive issue, and its success or
failure will signal how effectively incoming governor
Terry McAuliffe can work with a Republicandominated legislature. Republicans, meanwhile, are
more interested in discussing just about anything
else with the governor, whom they have praised for
his outreach generally. “We’ve talked about areas
where I thought there was common ground,” said
House Speaker William J. Howell (R-Stafford). “If I
were governor, those are the issues I’d focus on in
18
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
from freshman Del. Marcus B. Simon (D-Fairfax)
would make illegal “revenge porn,” the distribution
of revealing photographs of another person without
consent and with intent to cause distress. California
and New Jersey are the only states in the country
with laws targeting the practice. Another bill from
state Sen. Henry L. Marsh III (D-Richmond) would
ban the celebratory shooting of guns in the air, a
dangerous tradition that killed a 7-year-old in
Chesterfield County last July Fourth.
And a
bipartisan effort in the House and Senate is
underway to make sure Virginia textbooks note that
the Sea of Japan is also called the East Sea, the title
Koreans prefer. “It is not an attempt to change U.S.
policy or the name of the ocean, that’s above my
pay grade,” said Sen. David W. Marsden (D-Fairfax).
He just wants the textbooks to reflect the
controversy, he said, which is taught on state tests.
Similar legislation has died before, but he plans to
put a major push behind it this time, along with
legislation to help teenagers given sentences of life
without parole for crimes that were not deadly.
Sen. Richard H. Stuart (R-Westmoreland) wants to
ban drilling for oil and gas on the coastal plain east
of Interstate 95, saying it’s necessary to protect the
state’s groundwater — an environmental bill that
will probably attract Democratic support. Lobbyists
and lawmakers say legislation to regulate fracking in
the state’s Northern Neck is likely to come up as
well. But any amount of bipartisan cooperation will
be overshadowed by Medicaid, especially if
McAuliffe holds to a campaign promise to ignore any
budget that does not include the expansion. “I’ve
dismissed what he said as being a freshman
mistake,” said Sen. Majority Leader Thomas K.
Norment Jr. (R-James City). Lobbyists in the healthcare industry hold out hope that a deal with
Republicans can be made. (Washington Post,
1/10/14)
while also reducing absences from school and work
to go to appointments. This can be especially
important for low-income families.
For kids,
telemedicine can treat many conditions, from
common childhood illnesses, like strep throat and
asthma, to conditions requiring specialty care in
fields like dermatology, endocrinology, emergency
and critical care, behavioral and mental health care,
and even dental care. As more children get covered
through health care reform telemedicine has a
larger role than ever to play. -- Jenny Kattlove, The
Children's
Partnership,
Santa
Monica
(The
Sacramento Bee, 1/10/13)
http://www.sacbee.com/2014/01/10/6042914/telem
edicine-closing-the-health.html#storylink=cpy
War On Poverty Spurs
Political, Academic Battles
Florida Sen. Marco Rubio, who’s been working to
mend fences with his conservative base, has now
jumped into the issue of poverty and federal antipoverty programs, proposing drastic changes in the
way the government seeks to help the poor. But
Rubio’s proposals, timed to coincide with the 50th
anniversary of the start of the War on Poverty, are
based on debatable assertions about the cost and
success of that war. “Fifty years ago, President
Lyndon Johnson declared a big government war on
poverty,” Rubio said in a YouTube news release this
week. “Well, since then American taxpayers have
spent about $20 trillion on welfare and other
government programs that claim to lift people out of
poverty.”
Still, he said, there are millions of
Americans classified as living in poverty, and “in my
home state, nearly 1 in 5 Floridians live in poverty.
… Isn’t it time to declare big government’s war on
poverty a failure?” Experts on both sides of the
ideological divide say the claim of $20 trillion in
spending is overstated — and many academic
researchers are saying that the positive effects of
the war on poverty have been understated. “The
official poverty measure fails to show or correctly
identify that true poverty has fallen noticeably in the
U.S. over the past five decades,” said economist
James X. Sullivan of Notre Dame University, author
of a recent study on how to measure poverty rates.
“If you correct for well-known flaws in the official
measure, it shows poverty has fallen noticeably. ...
Done correctly, it suggests we’re winning the war on
poverty.” Rubio’s criticism of the War on Poverty, a
series of federal programs aimed at improving the
economic prospects of the nation’s poor, has been
raised by Republicans for decades. “In 1964 the
famous War on Poverty was declared, and a funny
thing happened.
Poverty, as measured by
dependency, stopped shrinking,” said President
Ronald Reagan in a 1986 radio address. “I guess
http://www.washingtonpost.com/local/virginiapolitics/medicaid-expansion-not-social-issuesexpected-to-dominate-va-legislativesession/2014/01/10/9917de58-798c-11e3-af7f13bf0e9965f6_story.html
Telemedicine Holds Great
Promise For Children
Re “Telemedicine can help solve health care delivery
puzzle” (Viewpoints, Dec. 29): Akhilesh Pathipati is
exactly correct when he says that telemedicine is
the right solution at the right time for much that ails
our health care system. Children especially stand to
benefit, especially those living in rural and
underserved communities. And telemedicine can
bring needed health and dental services to children
at convenient locations, such as schools.
Telemedicine can also reduce travel time and costs,
19
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
you could say poverty won the war.” In 1995,
powerful Texas Rep. Bill Archer said the United
States “has spent $5.3 trillion on welfare since the
War on Poverty began, ... and the Census Bureau
tells us we have lost the war.” In July, Wisconsin
Rep. Paul Ryan, the GOP budget guru, told his
committee that since LBJ declared war on poverty,
“we’ve spent over $15 trillion in that war. So what
do we have to show for it? Well, today 46 million
people live in poverty. ... For too many families, the
American dream is out of reach.” Ryan’s $15 trillion
figure came from a study by Michael Tanner of the
conservative Cato Institute, who added up
expenditures in 126 federal programs he identified
as aimed at combating poverty and converted the
totals into inflation-adjusted dollars.
“How We
Spend Nearly $1 Trillion a Year Fighting Poverty —
and Fail,” is its title. Tanner was asked about
arguments that the official statistics overstate
poverty and thus understate the success of the war
against it. “My argument,” he replied, “is more that
you have 126 separate programs that spend this
money run by nine Cabinet departments and six
independent agencies. That’s a huge incentive for
inefficiency.” Tanner’s figure includes $3 trillion of
state spending and $12 trillion in federal spending.
He notes that the state spending is mostly money
that matches federal contributions, including
Medicaid, which must be spent according to federal
rules. According to an analysis by The Washington
Post, if Tanner’s figure of $12 trillion is correct, the
anti-poverty spending amounts to slightly less than
12 percent of federal expenditures during the
period. Tanner acknowledged his figure includes
some spending that doesn’t go just to the poor,
even though it’s intended to boost individuals’
economic prospects, including Pell grants for college
tuition. A Rubio spokesman said he thought Rubio’s
$20 trillion figure came from a Heritage Foundation
study. His staff declined to answer other questions
about the video and about a speech he made last
week outlining his proposals for revamping federal
anti-poverty efforts.
These proposals include
converting anti-poverty programs into grants to the
states and replacing the Earned Income Tax Credit
with a wage enhancement program in which the
government would subsidize the pay of low-wage
workers. In fact, $20 trillion is the figure used in a
recent study by Robert Rector of the Heritage
Foundation, known among conservatives as “the
godfather of welfare reform.” “While the material
living conditions of the poor have improved in that
time, dependence on public assistance has only
grown,” Rector wrote. Rector’s figure, however,
includes some big expenditures Tanner omitted,
including Medicaid spending for long-term and
nursing home care — about 30 percent of
Medicaid’s $415 billion in 2012. Poor people benefit
from this Medicaid program, but so can anyone who
lives in a nursing home long enough to become
destitute or uses what Tanner calls “accounting
tricks,” shifting assets to meet Medicaid’s
requirements. That can include keeping a home
worth up to $800,000, a car, jewelry, life insurance
and retirement accounts, plus assets owned by a
spouse, Mark Warshawsky of the American
Enterprise Institute wrote recently in the Wall Street
Journal. Tanner said he omitted Medicaid long-term
care from his figure because “technically the
beneficiaries are below the poverty line, ... but it’s
not intended as a program for the poor. It’s
intended for the elderly.” The hottest argument,
however, is over whether government spending has
reduced poverty. According to the official poverty
rate, the change hasn’t been great — a drop of 4.4
percentage points, from 19.5 percent to 15.1
percent, from 1960 to 2010, according to the study
by Sullivan of Notre Dame. But because it counts
only income, the official rate doesn’t include the
effect of some of the most important anti-poverty
programs, Sullivan and other researchers have said.
Those include the Earned Income Tax Credit, other
kinds of tax credits and in-kind assistance, including
food stamps. Further, use of the Consumer Price
Index to set the official poverty line yearly
overstates the number of poor because the CPI
overstates inflation, most economists now say.
Allowing for those flaws, Sullivan said, the result is a
26 percentage point drop in poverty during the
1960-2010 period, not 4.4 points. The U.S. Census
Bureau is publishing an alternative measure of
poverty that corrects some of the errors, said
sociologist Christopher Wimer of Columbia
University’s Population Research Center. He and
colleagues found a 40 percent drop in poverty since
just before the beginning of the War on Poverty, but
also found that during the Great Recession and
previous recessions, War on Poverty programs
prevented millions of people from dropping into
“deep poverty” — less than 50 percent of the
poverty level. Without those programs, Wimer said,
the deep poverty level would have been nearly 20
percent of the population in some recession years,
instead of remaining flat at about 5 percent since
just after the War on Poverty started. (Tampa
Tribune, 1/11/14)
http://tbo.com/news/politics/war-on-poverty-spurspolitical-academic-battles-20140111/
Krugman: Social Programs
Have Helped America's Poor
Fifty years have passed since Lyndon Johnson
declared war on poverty.
And a funny thing
happened on the way to this anniversary. Suddenly,
or so it seems, progressives have stopped
apologizing for their efforts on behalf of the poor
20
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
and have started trumpeting them instead. And
conservatives find themselves on the defensive. It
wasn't supposed to be this way. For a long time,
everyone knew - or, more accurately, "knew" - that
the war of poverty had been an abject failure. And
they knew why: It was the fault of the poor
themselves. But what everyone knew wasn't true,
and the public seems to have caught on. The
narrative went like this: Anti-poverty programs
hadn't actually reduced poverty, because poverty in
America was basically a social problem - a problem
of broken families, crime and a culture of
dependence that was only reinforced by government
aid. And because this narrative was so widely
accepted, bashing the poor was good politics,
enthusiastically embraced by Republicans and some
Democrats, too. Yet this view of poverty, which
may have had some truth to it in the 1970s, bears
no resemblance to anything that has happened
since. For one thing, the war on poverty has, in
fact, achieved quite a lot. It's true that the standard
measure of poverty hasn't fallen much. But this
measure doesn't include the value of crucial public
programs like food stamps and the earned-income
tax credit. Once these programs are taken into
account, the data show a significant decline in
poverty, and a much larger decline in extreme
poverty.
Other evidence also points to a big
improvement in the lives of America's poor: Lowerincome Americans are much healthier and betternourished than they were in the 1960s.
Furthermore, there is strong evidence that antipoverty programs have long-term benefits, both to
their recipients and to the nation as a whole. For
example, children who had access to food stamps
were healthier and had higher incomes in later life
than people who didn't. And if progress against
poverty has nonetheless been disappointingly slow which it has - blame rests not with the poor but with
a changing labor market, one that no longer offers
good wages to ordinary workers. Wages used to
rise along with worker productivity, but that linkage
ended around 1980. The bottom third of the U.S.
workforce has seen little or no rise in inflationadjusted wages since the early 1970s; the bottom
third of male workers has experienced a sharp wage
decline. This wage stagnation, not social decay, is
the reason that poverty has proved so hard to
eradicate. Or to put it a different way, the problem
of poverty has become part of the broader problem
of rising income inequality, of an economy in which
all the fruits of growth seem to go to a small elite,
leaving everyone else behind. So how should we
respond to this reality? The conservative position,
essentially, is that we shouldn't respond.
Conservatives are committed to the view that
government is always the problem, never the
solution; they treat every beneficiary of a safety-net
program as if he or she were "a Cadillac-driving
welfare queen." And why not? After all, for
decades their position was a political winner,
because middle-class Americans saw "welfare" as
something that Those People got but they didn't.
But that was then. At this point, the rise of the 1
percent at the expense of everyone else is so
obvious that it's no longer possible to shut down
any discussion of rising inequality with cries of "class
warfare." Meanwhile, hard times have forced many
more Americans to turn to safety-net programs.
And as conservatives have responded by defining an
ever-growing fraction of the population as morally
unworthy "takers" - a quarter, a third, 47 percent,
whatever - they have made themselves look callous
and mean-spirited. You can see the new political
dynamics at work in the fight over aid to the
unemployed.
Republicans are still opposed to
extended
benefits, despite
high
long-term
unemployment.
But they have, revealingly,
changed their arguments. Suddenly, it's not about
forcing those lazy bums to find jobs; it's about fiscal
responsibility. And nobody believes a word of it.
Meanwhile, progressives are on offense. They have
decided that inequality is a winning political issue.
They see war-on-poverty programs like food
stamps, Medicaid and the earned-income tax credit
as success stories, initiatives that have helped
Americans in need - especially during the slump
since 2007 - and should be expanded. And if these
programs enroll a growing number of Americans,
rather than being narrowly targeted on the poor, so
what? So guess what: On its 50th birthday, the war
on poverty no longer looks like a failure. It looks,
instead, like a template for a rising, increasingly
confident
progressive
movement.
(Houston
Chronicle, 1/10/14)
http://www.chron.com/opinion/outlook/article/Krug
man-Social-programs-have-helped-America-s5132203.php
ObamaCare Rule
Streamlines Medicaid Program
Federal officials on Friday issued an ObamaCare
regulation intended to make it easier for older and
disabled people to access housing benefits under
Medicaid. The Centers for Medicare & Medicaid
Services, a division of HHS, issued a final rule that
streamlines the approval process for Medicaid's
home and community-based programs.
While
Medicaid does provide health insurance that covers
doctor appointments for certain low-income families,
it also helps seniors and people with disabilities pay
for care in community-based living centers. The
rule is more of an administrative fix than anything
else. The problem with this portion of Medicaid is
that some beneficiaries who were signed up for
multiple programs were having to seek an
21
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
unnecessary number of reapprovals at different
intervals, one for each program.
This rule
streamlines the process, so they only need approval
once every five years for all of the programs. The
rule also clarifies how much beneficiaries have to
pay for the different programs. As part of President
Obama's Community Living Initiative, the program
creates new affordable and accessible housing
opportunities.
Those could include "retirement
communities" for older people, as well as at-home
care from nurses. The rule is expected to cost
taxpayers as much as $150 million this year. (The
Hill, 1/10/14)
administration attacks the troubles people have had
trying to sign up for health care. News of the twin
moves came Friday morning as the House was
passing a measure triggered by questions about the
website’s security. A statement by the Centers for
Medicare & Medicaid Services referred to “a
mutually agreed upon transition” between the
agency and its “contract partners.” Hours later, the
partner in question announced that its work on the
site will conclude with its contract end date in
February. Although HealthCare.gov is functioning
far better since a massive repair effort concluded in
late November, problems are still undermining
public confidence in the federal and state
exchanges. Insurers say that enrollment files sent
by the federal portal remain incomplete or incorrect,
and significant back-end parts of the system remain
to be built.
Both of CMS’s leadership
announcements Friday were to replace two top
officials who left amid much public skewering in the
wake of the site’s botched Oct. 1 rollout. Tim Love,
a 22-year agency veteran, will serve as chief
operating officer and oversee the contracts for the
federal Obamacare portal. Love replaces Michelle
Snyder, who retired at the end of last year and
whose work was scrutinized during congressional
hearings on HealthCare.gov. Dave Nelson will serve
as chief information officer, replacing Tony Trenkle,
who abruptly left in November for a private-sector
opportunity. Trenkle was the supervisor of Deputy
CIO Henry Chao, who had a leading day-to-day role
in managing the development of HealthCare.gov.
Nelson, who has been at the agency for a decade,
most recently served as acting CIO following
Trenkle’s departure. As reported Friday morning by
The Washington Post, CMS intends to hire
Accenture to replace CGI when its current contract
ends. The Post, citing a “person familiar with the
matter,” said Accenture and CMS will ink a one-year,
$90 million deal. Agency spokesman Aaron Albright
wouldn’t comment directly on the Accenture report.
“We are working with our contract partners to make
a mutually agreed upon transition to ensure that
HealthCare.gov continues to operate smoothly for
consumers,” Albright said in a late-morning
statement. “We continually evaluate our needs and
remain focused on ensuring consumers have access
to affordable, quality coverage, and more than 1.1
million already have enrolled in a private plan in the
federal marketplace.”
Accenture spokeswoman
Joanne Veto also declined to comment. “We are in
discussion with potential clients all the time, but it is
not appropriate to discuss contracts we may or may
not be pursuing,” she said. CGI’s statement said
the switch comes “at a time when HealthCare.gov is
performing well, due largely to CGI’s key role during
the ‘tech surge.’ We are proud that more than 400
CGI employees worked around the clock from
October through December to deliver a consumer
http://thehill.com/blogs/regwatch/healthcare/19515
3-obamacare-rule-streamlines-medicaidprogram#ixzz2q6tMhhR9
Federal Health Site To Get New Contractor
CGI Federal will stop its work on the troubled
federal health insurance exchange when its contract
with the Centers for Medicare and Medicaid Services
expires at the end of February, the company said
Friday. CGI was the largest contractor working on
the complex online enrollment system, which barely
functioned when the healthcare.gov website went
live at the beginning of October. The company has
played a role in the effort to repair the site. Linda
Odorisio, a spokeswoman for CGI Federal, a
subsidiary of CGI Group of Montreal, rejected
suggestions that CGI had effectively been fired by
the federal government, and said the company
decided not to take up an option to maintain the
contract for the next two years beginning in March.
"The joint decision comes at a time when
healthcare.gov is performing well, due largely to
CGI's key role during the 'tech surge,' " Odorisio
wrote in an email. A person familiar with the
situation told the New York Times that the
government will award the maintenance contract,
which is worth about $90 million annually, to
Accenture, a large consulting firm that often
subcontracts projects to CGI. Aaron Albright, a
spokesman for the Centers for Medicare and
Medicaid Services, declined to comment on the
contract, citing ongoing negotiations. (Tampa Bay
Times, 1/11/14)
http://www.tampabay.com/news/nation/federalhealth-site-to-get-new-contractor/2160629
CMS Changes Leadership,
Health Website Contractor
The agency overseeing HealthCare.gov has
overhauled its leadership team and dumped the
contractor responsible for the troubled enrollment
site, signaling a critical shift in how the Obama
22
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
experience that works for a vast majority of
Americans.” The statement also noted that CMS
has awarded it “nearly $37 million in contracts”
since October. At the White House, spokesman Jay
Carney said he didn’t have information about the
switch and that “contracts at CMS are something
that CMS would address.” CGI was hired by CMS in
September 2011 to lead construction of the federal
enrollment website, which is serving 36 states, and
administration officials have been publicly critical of
the contractor’s work since the botched Oct. 1
rollout. CMS Administrator Marilyn Tavenner in a
late October congressional hearing singled out CGI
as the only contractor that failed to deliver on time
— though contractors had also blamed CMS for poor
management of the project. States that tapped CGI
to build their own online insurance marketplaces
have shown increasing frustration with the firm.
Massachusetts, which hired CGI to relaunch its
existing exchange website, may sue the firm, state
Attorney General Martha Coakley said this week.
The Massachusetts exchange has hired Dell and
MITRE to fix deep technical problems that have
plagued many residents’ online enrollment
experiences since October. Vermont Gov. Peter
Shumlin’s administration has withheld more than $5
million from payments for CGI’s work on the state’s
problematic enrollment website. “The contractors
we hired to build it have underperformed at every
turn,” Shumlin said this week. On Capitol Hill on
Friday, House Energy and Commerce Chairman Fred
Upton (R-Mich.) said that the change in contractors
“does not change the sad state of this law. The
committee continues to have more questions than
the administration has answers.
Our purpose
continues to be about accountability and
transparency — two things that have been absent
from the administration when it comes to this health
care law.” Following the latest news, CGI’s stock
was down more than 3 percent Friday afternoon.
(Politico, 1/10/14)
drug plans are not required to reimburse patients
for these drug costs. The over-classification of
observation status is an increasingly pervasive
problem: the number of seniors entering the
hospital for observation increased 69 percent over
five years, to 1.6 million in 2011. The chance of
being admitted varies widely depending on the
hospital, the inspector general of the Department of
Health and Human Services has found. Admitted
and observation patients often have similar
symptoms and receive similar care. Six of the top
10 reasons for observation — chest pain, digestive
disorders, fainting, nutritional disorders, irregular
heartbeat and circulatory problems — are also
among the 10 most frequent reasons for a short
hospital admission. Medicare officials have urged
hospital patients to find out if they’ve been officially
admitted. But suppose the answer is no. Then what
do you do? Medicare doesn’t require hospitals to
tell patients if they are merely being observed,
which is supposed to last no more than 48 hours to
help the doctor decide if someone is sick enough to
be admitted. (Starting on Jan. 19, however, New
York State will require hospitals to provide oral and
written notification to patients within 24 hours of
putting them on observation status. Penalties range
as much as $5,000 per violation. ) To increase the
likelihood of being formally admitted, “get yourself
in the door before midnight,” advised Dr. Ann
Sheehy, division head of hospital medicine at the
University of Wisconsin Hospital in Madison, Wisc. A
new Medicare regulation — the so-called “pumpkin
rule” — requires doctors to admit people they
anticipate staying for longer than two midnights, but
to list those expected to stay for less time as
observation patients. Although the rule applies
now, Medicare officials won’t enforce it until April 1,
having already pushed the deadline back. The
American Medical Association and the American
Hospital Association have called the pumpkin rule
“impossible” to comply with and have urged that
enforcement be delayed again until October. “It
doesn’t make any sense,” said Dr. Sheehy, who
studied how the rule would have affected
admissions at her hospital over an 18-month period
and published the results in JAMA Internal Medicine.
Some patients will be admitted because they came
in at the right time of day, not because they have
more complicated medical problems.” The twomidnight rule doesn’t change Medicare’s threemidnight rule, the one limiting post-hospital nursing
home coverage. Officials at the federal Centers for
Medicare and Medicaid Services declined comment
for this story because of pending litigation seeking
to eliminate observation status. If you or a family
member land in the hospital as an observation
patient and think you should be admitted, it’s better
to act sooner than later. “I would talk to anyone
who would listen to me,” said Terry Berthelot, a
http://www.politico.com/story/2014/01/healthcaregov-contractor-leadership102039.html#ixzz2q6uQZ7GH
Fighting ‘Observation’ Status
Every year, thousands of Medicare patients who
spend time in the hospital for observation but are
not officially admitted find they are not eligible for
nursing home coverage after discharge. A Medicare
beneficiary must spend three consecutive midnights
in the hospital — not counting the day of discharge
— as an admitted patient in order to qualify for
subsequent nursing-home coverage. If a patient is
under observation but not admitted, she will also
lose coverage for any medications the hospital
provides for pre-existing health problems. Medicare
23
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
senior attorney at the Center for Medicare
Advocacy, which offers a free self-help packet for
observation patients. “ Make as much noise as you
can, because it’s much easier to change your status
while you’re still in the hospital than to go through
Medicare’s appeals process later.” Ms. Berthelot
suggests asking your regular physician to speak with
the doctor treating you in the hospital about why
you need to be admitted, based on your medical
condition and risk factors. “It’s got to be a medical
argument,” said Ms. Berthelot. “You can’t say,
‘Mom will need rehab after this,’ or ‘We can’t take
her home because no one can stay with her.’” If
that doesn’t work, sometimes a strongly worded
letter or call from a lawyer describing the patient’s
medical needs can be effective. In some cases,
help from a professional can make a difference.
Shari Polur, an elder-law attorney in Louisville, Ky.,
recently hired a geriatric care manager to persuade
a local hospital to admit her client. Since admission
status can change from one day to the next, the
manager, who is also a registered nurse, called the
hospital every morning to make sure the patient
was still officially admitted until she could be
transferred to a nursing home. If the situation isn’t
resolved while you’re in the hospital and you require
follow-up care at a nursing home, you’ll have to pay
the bill of often thousands of dollars up front. At
that point, Ms. Berthelot suggests, you should file
what amounts to a special doubled-barreled appeal
with Medicare. It’s not for the faint of heart: the
process is long and arduous, and it requires
beneficiaries to first receive and pay for the care —
often an expensive proposition — before seeking
reimbursement. And the legal arguments can be
tangled. The Medicare appeals process typically
addresses disputes over whether certain treatments
or services rendered should have been covered.
Observation patients have actually received hospital
coverage and services a doctor says is medically
necessary — so they don’t really have anything to
appeal, said Marc Hartstein, director of Medicare’s
hospital and ambulatory policy group, at a recent
briefing in Washington. “My limited understanding
of this is that the patient cannot appeal a decision
not to order or not to do something,” he said. But
observation patients may claim that they received
treatment usually provided to admitted patients only
in a hospital. Therefore, the hospital incorrectly
billed Medicare for an outpatient service instead of
for inpatient services. The patient should have been
admitted and therefore qualifies for nursing home
coverage. “It’s absolutely confusing as heck,” said
Michael Sgobbo, an elder law attorney in
Charleston, S.C., who recently won an appeal on
behalf of a 98-year-old woman who will be
reclassified as an admitted patient. That means
Medicare will pay her nursing home bill of nearly
$10,000.
Lawyers at the Center for Medicare
Advocacy recommend fighting observation care on
two fronts. First, follow the appeal instructions in
the Medicare summary notice, a quarterly statement
of services. Circle the charges on the statement
from the hospital and explain that these items were
inappropriately billed under Medicare’s Part B as
outpatient services. They should have been billed
under Medicare’s Part A for hospital services,
because the patient received treatment that could
only have been provided in a hospital. Mail the
statement within 120 days (from the date on the
statement) to the address provided for appeals.
Second, after challenging the hospital’s observation
designation, file a separate appeal to seek
reimbursement for the nursing home charges, said
Ms. Berthelot. To begin, ask the nursing home to
bill Medicare.
You should receive a Medicare
summary notice indicating that it did not pay the
nursing home charges because the patient didn’t
have the required three-day hospital stay. Circle
those charges, and explain that the beneficiary was
hospitalized for three days and received an inpatient
level of care. Then send it within 120 days to the
address provided for appeals. Be prepared to dig in.
If either appeal is denied, you must appeal again to
the next level, following the instructions in the
denial letters. “Both appeals can take at least a
year and are fraught with difficulty,” said Ms.
Berthelot. “The reality is that most people can’t get
through and those who do, get lucky.” Some
observation patients appeal and never get decisions,
warned Diane Paulson, senior attorney at Greater
Boston Legal Services. Some of her clients’ cases
were dismissed because they were not admitted to
the hospital — the very point they were challenging.
“You can’t appeal if you don’t have a denial,” she
said. When that happens, the case falls into “a
black hole.” But the chances of winning improve as
you continue to appeal, as Nancy and George
Renshaw, of Bozrah, Conn., discovered.
After
spending nearly four years going through the
process, a Medicare judge decided last February
that Mr. Renshaw’s father should have been
admitted to the hospital instead of classified as an
observation patient.
Medicare finally paid his
nursing home bill, and in November the Renshaws
received a refund of $4,410. “I was shocked,” said
Ms. Renshaw. “I never expected to see a penny of
it.” (New York Times, 1/10/14)
http://newoldage.blogs.nytimes.com/2014/01/10/fig
hting-observation-status/
Medical Students: Fluent In Science,
Illiterate In Health Policy
Since its inception more than a century ago, modern
medical education has undergone a series of quiet
revolutions, stretching and scaling to accommodate
24
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
advances in biomedical science.
Yet this
comprehensive expansion in one critical area masks
a relative neglect of another. Despite their
staggering scope — spanning genetics to geriatrics,
and everything in between — medical curricula
today largely omit training on health policy. The
result? Even as today’s medical students graduate
with a deep scientific fluency, they leave all but
illiterate when it comes to the health care system.
Consider, for example, the findings of a 2009 study
in the journal Academic Medicine analyzing survey
data from the Association of American Medical
Colleges. Polling nearly 60,000 graduating medical
students, the analysis found that less than half of
the respondents felt they had an adequate grasp of
health economics, managed care or health care
systems. Compare this result to the corresponding
statistic for clinical care, which clocked in at well
over 80 percent. Moreover, in a 2011 New England
Journal of Medicine survey of medical deans, almost
60 percent of respondents reported their
institution’s curriculum as containing “too little”
health policy training. I can bear witness to this
disparity firsthand. The curriculum of Stanford
Medical School, where I am a deferred first-year
student, does not incorporate a single required
course on health policy or the health care system
across four years and 249 credits of training. And
this oversight comes with consequences.
To
illustrate, recent research in JAMA Internal Medicine
found that fewer than half of medical students
nationwide understand even the basic components
of the Affordable Care Act. On a systemic level, this
illiteracy directly impedes our ability to institute
meaningful health policy reforms that tackle such
thorny issues as quality-based physician payments,
comparative effectiveness guidelines or end-of-life
care. Without willing and capable physician leaders
to guide, implement and sustain such major shifts
for the decades to come, reform efforts almost
certainly will founder. Consequently, efforts to rein
in health care costs and improve patient outcomes
must begin by modernizing medical curricula to
incorporate health policy training. For example, a
national mandate that fundamental knowledge of
health systems be a prerequisite for medical
licensing would encourage medical schools to
incorporate course work on basic principles of health
policy and economics. This teaching, moreover,
should be nonpartisan and nonideological, focusing
instead on the nuts and bolts of health systems —
akin to what law or business school students learn
about policymaking and institutional governance.
This training need not be comprehensive or allencompassing. Just as pre-clinical instruction in the
medical sciences provides a basic foundation that is
built on in later clinical training, health policy
education in medical curricula can offer a baseline
understanding that is reinforced in subsequent
years. Even ensuring just a rudimentary level of
health policy literacy could go a long way.
Furthermore, the advent of so-called massive open
online courses, or MOOCs, means that financial
concerns — the costs of expanding medical curricula
to encompass health-care policy — may be
unwarranted.
Whatever the medium, it is
imperative that we install health policy as an
integral part of the national medical curricula, lest
we continue to churn out a generation of students
who are ill-equipped to make sense of the
challenges and changes to come.
Amid the
dynamism of our 21st-century health care system,
policy fluency is at least as important as a mastery
of biomedical concepts. Rahul Rekhi, a student at
Stanford University School of Medicine, is studying
as a Marshall Scholar at Oxford University. He
served as special assistant to the Maryland secretary
of health in 2013. (Dallas Morning News, 1/10/14)
http://www.dallasnews.com/opinion/sundaycommentary/20140110-medical-students-fluent-inscience-illiterate-in-health-policy.ece
Rubio Sounds Alarm
Of "Obamacare Bailout"
U.S. Senator Marco Rubio (R-FL) today commented
on new evidence of the increasing likelihood of a
taxpayer-funded bailout of health insurance
companies under ObamaCare.
The 'evidence'
comes as insurance companies make their first
material filings to the Securities and Exchange
Commission (SEC) regarding projections for their
ObamaCare risk pools, the Herald's Marc Caputo
reports. According to Rubio, one company has
disclosed that “as a result of the December 2013
federal and state regulatory changes allowing
certain individuals to remain in their previously
existing off-exchange health plans, the Company
now expects the risk mix of members enrolling
through the health insurance exchanges to be more
adverse than previously expected.”
Rubio
concluded, “American taxpayers should not be on
the hook for bailing out health insurers, especially
because ObamaCare is not working the way it was
sold. Congress should take an ObamaCare bailout
off the table by passing legislation I’ve introduced to
repeal the so-called risk corridor provision under the
law." Rubio's position -- that Obamacare can't
survive without a taxpayer "bailout of insurers" -- is
a little misleading, according to Herald senior
healthcare reporter Dan Chang. "The risk corridors
were built into the ACA legislation, so I don't know if
it's fair to call it a 'bailout,' at least not in the sense
of TARP, or the auto industry bailout. The word
bailout implies an emergency spend for some
unforeseen circumstance," Chang said. Since the
deadline for the ACA's first enrollment year is March
25
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
31, Chang expects the real mix for the insurance
companies' risk pools won't become clear until April.
The ACA anticipated from the start that insurers
could lose money from a higher proportion of sicker
policy holders. The risk corridors provided a built-in
payment structure to offset those potential losses
for three years, to help companies gain their health
reform sea legs. The cost was factored into the
original ACA budget. A bill Rubio proposed last year
called the ObamaCare Taxpayer Bailout Prevention
Act would repeal the risk corridors. It's not really
preventing a bailout, though. It's defunding the
guts of the health reform program. 1/10/14)
option for insuring those in need would be to
expand the use of high-deductible health plans in
combination with health savings accounts. This
approach provides a cost-effective vehicle for
insuring against catastrophic medical expenses while
simultaneously helping individuals defray the costs
of routine medical care. Such coverage protects
individuals from losing a lifetime of assets and from
the devastating consequence of financial bankruptcy
due to unpaid hospital and associated medical bills,
a contributor to financial stress for millions of
Americans every year. Such coverage means lesscostly insurance policies, since they cover only
major expenses and thereby reduce the bureaucracy
and expense of smaller claims. And, with high
deductibles, the hidden prices of medical care
become far more visible, a necessity for containing
costs. Price transparency coupled with greater
availability of accurate information on health
outcomes and provider quality are essential if
patients are to choose healthcare services based on
value. Combining high-deductible insurance with
health savings accounts provides a way to help
individuals defray the costs of necessary, but
routine, medical expenses. Such savings accounts
allow individuals to set aside money tax-free to buy
immediate or future medical care. Health savings
accounts in combination with high-deductible
insurance plans could also provide an excellent
method for modernizing Medicaid. States could
deposit Medicaid funds into individual health-care
accounts owned by low-income recipients. The
funds could then be used to purchase routine care
and to buy high-deductible health plans. They could
also be used to defray deductible costs. Any funds
left over at the end of each year would accumulate
to help defray medical expenses in future years.
Health savings accounts have grown rapidly in the
past 10 years, and for good reason. They should
now be made available to Medicare recipients as
well. This growth could be enhanced — and the
growth in health-care costs slowed — if the
accounts were made available to the poor and the
elderly. Another change Americans should embrace
is an increase in the supply of health-care providers.
The Affordable Care Act tries to control costs, in
considerable part, by wage and price controls. We
know from decades of experience that this approach
leads to less of whatever you try to control and
reduces overall quality. We need more, not less. To
modernize the delivery of primary care and increase
access to it, reforms must facilitate a wider
availability of clinics staffed by nurse practitioners
and physician assistants working in collaboration
with physicians. Where they exist, such privatesector clinics provide health care at lower cost,
especially for routine and preventive care such as flu
shots, blood pressure monitoring and standard
tests. The use of such clinics increased tenfold
http://miamiherald.typepad.com/health/2014/01/ru
bio-sounds-alarm-of-obamacarebailout.html#storylink=cpy
It’s Time To Rethink Health Insurance
BY GEORGE P. SHULTZ, SCOTT W. ATLAS
AND JOHN F. COGAN
Special To The Los Angeles Times
As the acute problems of the Affordable Care Act
become increasingly apparent, it also has become
clear that we need new ways of ensuring access to
health care for all Americans. We should begin with
an examination of health insurance. Insurance is
about protecting against risk. In the health arena,
the risk at issue is of large and unexpected medical
expenses. The proper role of health insurance
should be to finance necessary and expensive
medical services without the patient incurring
devastating financial consequences. Over the last
decade, however, Americans have come to expect
their health insurance to subsidize the consumption
of all medical care. Rather than simply protecting
against financial catastrophe, insurance has become
a pass-through mechanism to pay for every type of
medical service, including routine ones. This shift in
expectation has meant that health insurance stands
out as entirely different from all other types of
insurance. Ask yourself: Would you use automobile
insurance to buy gasoline?
Would you use
homeowner insurance to finance painting your
house? This wrongheaded view has played an
important role in contributing to rapidly rising
health-care costs. Patients with insurance do not
perceive themselves as paying for the cost of
routine services, nor do their physicians and other
health-care providers. The natural result has been a
more-is-better approach, with patients and doctors
embracing costly health-care services that are often
of little value to the patient. Given health care’s
crucial role in well-being, it is important to assist
individuals who can’t afford even routine medical
expenses, but it shouldn’t be done through hidden
insurance subsidies. The entire concept of health
insurance must be reconsidered. One attractive
26
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
between 2007 and 2009, according to a Rand Corp.
study, and it is continuing to grow at 15 percent
annually. Meanwhile, major hospitals are beginning
to partner with them.
Pharmacies and health
centers in retail stores — potential neighborhood
health centers — should be expanded and
transformed into clinics with broader capabilities.
Another necessary reform is to increase competition
among insurance companies. Currently, insurance
can’t be sold across state boundaries. That system
sets up archaic barriers to competition and choice.
Medical care and the research associated with it
have changed the world, not only by transforming
previously incurable diseases to treatable ones but
by enabling safer and more effective care for
millions of Americans. But to fully realize the
extraordinary promise of medical science, we must
change the way we use and finance health-care
services. Insurance is key to protecting individuals
and families from the risk of financial devastation
and to ensuring access to major medical care.
Public financing of the routine and fully anticipated
health needs of chronically ill and low-income
people is important, but insurance isn’t the proper
vehicle for accomplishing that. The first essential
step in reforming the health system is to recognize
what insurance is and what it is not. Coupling that
important understanding with a vital modernization
of the health-care delivery system is an essential
first step toward a greatly improved health-care
system. George P. Shultz was formerly secretary of
labor, state and treasury, and director of the U.S.
Office of Management and Budget. John Cogan was
deputy director of the U.S. Office of Management
and Budget. Scott W. Atlas is a physician. They are
senior fellows at Stanford University’s Hoover
Institution. They wrote this for the Los Angeles
Times. (Tampa Tribune, 1/12/14)
the most admirable, humane moral advances of the
20th century. The War on Poverty’s increase in
Social Security benefits dramatically reduced poverty
among the elderly, with few unintended social or
behavioral consequences. Nutrition programs have
fortified generations of children, while encouraging
dependence on ... food. Other efforts, such as the
expansion of Aid to Families with Dependent
Children, became political shorthand for unintended
social and behavioral consequences, leading a
Democratic candidate for president to promise an
end to “welfare as we know it.” For decades, the
federal role in improving education for low-income
children
was
a
resounding,
embarrassing,
scandalous failure. Some of LBJ’s ideas, such as
Head Start, still seem so promising that we keep
trying to get them right, even when social science
finds modest results. Political judgments on the
War on Poverty are generally little more than an
ideological Rorschach test.
But beyond simple
pronouncements of failure or success, a few things
are clear: The federal government has met some
human needs on a vast scale; it also does not know
how to conquer poverty. America, at all levels of
government, spent about $1 trillion on transfer
programs last year, while more than 40 million
people remain below the poverty line. If you were
making a judgment about the War on Poverty in,
say, 1968, it would have seemed an unqualified
success. A decline in the poverty rate seemed
closely correlated with increasing expenditures. But
progress quickly ran into economic and social
obstacles that are not addressed by transfers.
Advancing technology and globalization began
draining the country of decent-paying, lower-skill
jobs.
Many American educational institutions
proved incapable of imparting higher skills — or
basic skills for that matter. At the same time, social
trends began undermining family structure and
community health. (The tie between single-parent
households and poverty is an economic, not a
moral, assertion. Poor single parents naturally find
it harder to hold full-time jobs and invest in the
welfare of their children.) This is a type of poverty
that LBJ could not foresee: A decline in blue-collar
jobs, rooted in global trends, requiring workers to
gain skills that schools could not reliably impart,
leaving whole communities economically depressed
and isolated, while many children were deprived of
economically stable and supportive two-parent
families, leading to dangerously stalled social
mobility and creating divisions of class that are
inconsistent with the American ideal.
These
problems — which reinforce and complicate each
other — still require the effort and idealism of the
War on Poverty. But the methods will need to be
very different.
Neither traditional safety net
programs nor economic growth alone are sufficient.
A new (and hopefully renamed) War on Poverty
http://tbo.com/list/news-opinion-commentary/itstime-to-rethink-health-insurance-20140112/
For A New Fight Against Poverty
By Michael Gerson
Assessing the outcome of the War on Poverty —
announced 50 years ago — has always been
complicated by the hopes it initially inspired. After
his election in 1964, Lyndon Johnson proclaimed
that Americans were living in “the most hopeful
times since Christ was born in Bethlehem.” Which
raised expectations pretty high — and placed LBJ in
the manger. Elsewhere in the same vein, he said,
“For the first time in our history, it is possible to
conquer poverty.” The actual result — as in most
complex human endeavors — is mixed. Programs
such as Medicare and Medicaid are woven tightly
into the fabric of American life. Both are costly and
in need of serious reform — and represent some of
27
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
would require improvements in labor markets —
increasing the skills of workers and the rewards of
work, and reaching many who are entirely alienated
from the workforce.
And it would require
encouraging the norm of marriage before childbirth
and catalyzing the work of community institutions
(including religious nonprofits), which give people
the skills and values to succeed in a free economy.
Note that a comprehensive effort would require
ideological flexibility on both sides of the ideological
spectrum.
For liberals, there is a difference
between using social mobility as a unifying national
goal and employing economic inequality as a
political cudgel. For conservatives, a preference for
the work of markets and civil society can’t be used
as an excuse for inaction when civil society is
beleaguered and overwhelmed (in part) by powerful
economic trends. Recent Republican anti-poverty
initiatives have been rhetorically promising but
substantively thin. Yet given the seriousness of
persistent poverty, any president, or aspiring
president, must take the stage that LBJ mounted —
and still dominates half a century later. (Tampa
Tribune, 1/12/14)
exchanges are beyond just purchasing private
health insurance coverage for higher-income
populations: They’re also about Medicaid enrollment
for lower-income populations. This is a big step
forward in terms of one-stop shopping.” Is mobile a
wave of the future in health care like so many other
industries?
Agarwal: “I’m incredibly bullish on the potential of
mobile technologies for helping us achieve the goals
that health care has set for itself.
Mobile
technologies give us a way of really addressing one
of the persistent problems in health care, and that is
patient activation and engagement. As consumers
of health care, we have been completely disengaged
from the process of taking care of our own health,
and we rely on experts — our doctors — to tell us
what to do. “Mobile technologies I think offer the
potential to flip that equation, and essentially
through tracking, maintaining information, being
reminded what you need to do to stay healthy, we
can achieve a lot of the quality and cost goals that
we’ve set for ourselves. “If we could have a mobile
technology that engages consumers and reminds
them every once in while, motivates them, puts
them in social settings where they can compete —
all of those kinds of opportunities, I think, will bring
us to a health-care system where patients are
watching out for themselves on a daily basis, and
then meeting with doctors only when there is a
clinical encounter or clinical need that really needs
that expert intervention.” Give me one big idea that
you think that we can really help change the nature
of health care right now.
http://tbo.com/list/news-opinion-commentary/for-anew-fight-against-poverty-20140112/
Information Technology Is
Changing Health-Care System
With the implementation of the Affordable Care Act,
health care was a hot topic in 2013. Rising costs
and continued challenges make certain health care
will continue to be a big issue in 2014. Recently,
Capital Business sat down with experts from the
University of Maryland and the Arlington consultancy
Evolent Health to talk about health care and the
opportunities ahead for information technology to
improve efficiency and quality of care. Joining the
conversation were Ritu Agarwal, founder and
director of the Center for Health Information at the
University of Maryland’s Robert H. Smith School of
Business; Karoline Mortensen, assistant professor of
health services administration, University of
Maryland Public Health; and Shandy Guharoy, vice
president for information technology for Evolent
Health. Here are excerpts from their conversation
with Dan Beyers, editor of Capital Business:
Agarwal: “Personalized medicine. It’s the natural
progression and advancement of health care. It says
that all treatments, all therapies, all health care, all
health-care instructions — everything related to the
management of a person’s health — is going to be
tailored specifically for you, rather than saying these
are vast populations and we’re going to use the
same kind of treatment for them. “So how do we
get to the goal of personalized medicine? One, we
have to understand every human being’s genome,
and we’ve made remarkable progress with the
human genome project on that. Second, we have
to understand your behavioral patterns; we have to
understand the specific situation contingencies that
you live in. All of the data that’s needed to drive
personalized medicine is now in the process of being
collected, stored and digitized. “We have advanced
technologies that will allow us to discover patterns
that we’ve never seen before — so at the end of the
day, we can really take care of somebody’s health
from a personalized perspective. “That’s a very big
idea. It’s going to take us two, three, maybe even
four decades to get there, but I think all the pieces
that are needed for personalized medicine are
slowly going into place and I’m very excited about
What are some of the issues right now for
consumers — what should they be thinking about?
Mortensen: “The biggest challenge right now facing
consumers is how do you get the information about
these exchanges to that population?
Recent
surveys report that as many as 70 percent of the
uninsured responding to these surveys are not
familiar with what the exchanges are designed to
do.
And this is a critical issue because the
28
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
the future.”
How do you keep up on the
technology, and create architectures that get us to
where we need to go in the future to have
something like a personalized medical system?
Guharoy: “It’s data versus insights. The data is
already there; what is the insight from the data?
From population health management where you are
aggregating the data, you are seeing the trends in
the data, you are being able to predict and forecast.
And the next part of it is personalization. It’s a step
by step. “These are lifestyle changes. Look at how
our mobile and our cellphones that we carry with us
have changed our lives. The same thing will happen
in health care.” (Washington Post, 1/12/14)
same. Bear in mind that every budget the G.O.P.
has offered since it took over the House in 2010
involves savage cuts in Medicaid, food stamps and
other antipoverty programs. Still, can’t Republicans
change their approach? The answer, I’m sorry to
say, is almost surely no. First of all, they’re deeply
committed to the view that efforts to aid the poor
are actually perpetuating poverty, by reducing
incentives to work. And to be fair, this view isn’t
completely wrong. True, it’s total nonsense when
applied to unemployment insurance. The notion
that unemployment is high because we’re “paying
people not to work” is a fallacy (no matter how
desperate you make the unemployed, their
desperation does nothing to create more jobs)
wrapped in a falsehood (very few people are
choosing to remain unemployed and keep collecting
benefit checks). But our patchwork, uncoordinated
system of antipoverty programs does have the
effect of penalizing efforts by lower-income
households to improve their position: the more they
earn, the fewer benefits they can collect. In effect,
these households face very high marginal tax rates.
A large fraction, in some cases 80 cents or more, of
each additional dollar they earn is clawed back by
the government. The question is what we could do
to reduce these high effective tax rates. We could
simply slash benefits; this would reduce the
disincentive to work, but only by intensifying the
misery of the poor. And the poor would become
less productive as well as more miserable; it’s hard
to take advantage of a low marginal tax rate when
you’re suffering from poor nutrition and inadequate
health care. Alternatively, we could reduce the rate
at which benefits phase out. In fact, one of the
unheralded virtues of Obamacare is that it does just
that. That is, it doesn’t just improve the lot of the
poor; it improves their incentives, because the
subsidies families receive for health care fade out
gradually with higher income, instead of simply
disappearing for anyone too affluent to receive
Medicaid. But improving incentives this way means
spending more, not less, on the safety net, and
taxes on the affluent have to rise to pay for that
spending. And it’s hard to imagine any leading
Republican being willing to go down that road — or
surviving the inevitable primary challenge if he did.
The point is that a party committed to small
government and low taxes on the rich is, more or
less necessarily, a party committed to hurting, not
helping, the poor. Will this ever change? Well,
Republicans weren’t always like this. In fact, all of
our major antipoverty programs — Medicaid, food
stamps, the earned-income tax credit — used to
have bipartisan support.
And maybe someday
moderation will return to the G.O.P. For now,
however, Republicans are in a deep sense enemies
of America’s poor. And that will remain true no
matter how hard the likes of Paul Ryan and Marco
http://www.washingtonpost.com/business/capitalbu
siness/information-technology-is-changing-healthcare-system/2014/01/10/0b66e8c6-7250-11e39389-09ef9944065e_story.html
Enemies Of The Poor
Suddenly it’s O.K., even mandatory, for politicians
with national ambitions to talk about helping the
poor. This is easy for Democrats, who can go back
to being the party of F.D.R. and L.B.J. It’s much
more difficult for Republicans, who are having a
hard time shaking their reputation for reverse
Robin-Hoodism, for being the party that takes from
the poor and gives to the rich. And the reason that
reputation is so hard to shake is that it’s justified.
It’s not much of an exaggeration to say that right
now Republicans are doing all they can to hurt the
poor, and they would have inflicted vast additional
harm if they had won the 2012 election. Moreover,
G.O.P. harshness toward the less fortunate isn’t just
a matter of spite (although that’s part of it); it’s
deeply rooted in the party’s ideology, which is why
recent speeches by leading Republicans declaring
that they do too care about the poor have been
almost completely devoid of policy specifics. Let’s
start with the recent Republican track record. The
most important current policy development in
America is the rollout of the Affordable Care Act, a k
a Obamacare. Most Republican-controlled states
are, however, refusing to implement a key part of
the act, the expansion of Medicaid, thereby denying
health coverage to almost five million low-income
Americans. And the amazing thing is that they’re
going to great lengths to block aid to the poor even
though letting the aid through would cost almost
nothing; nearly all the costs of Medicaid expansion
would be paid by Washington. Meanwhile, those
Republican-controlled
states
are
slashing
unemployment benefits, education financing and
more. As I said, it’s not much of an exaggeration to
say that the G.O.P. is hurting the poor as much as it
can. What would Republicans have done if they had
won the White House in 2012? Much more of the
29
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
Rubio try to convince us otherwise. (New York
Times, 1/12/14)
campaign issue in 2014; the House plans two antiObamacare votes Friday. But in the states, the
Medicaid expansion — a giant, dangling carrot worth
billions of federal dollars to states that sign up —
has proved attractive to nearly a dozen GOP
governors, and a handful more are on the fence.
Governors like Rick Perry of Texas and Bobby Jindal
of Louisiana remain firmly in the “no way” camp.
But Pennsylvania and Tennessee are actively
working with the Obama administration to expand
Medicaid, although their efforts to squeeze policy
concessions on the GOP wish list — like requiring
enrollees to pay more — could be a dead end.
Indiana and Oklahoma are eyeing alternative
versions of expansion and were granted a one-year
reprieve by the Obama administration to extend
existing state health care programs while they think
about it. Virginia, where Democrat Terry McAuliffe
is succeeding Republican Gov. Bob McDonnell, is
considered a likely candidate to embrace expansion
this year. In Maine, Democrats in control of the
state Legislature are pressuring Republican Gov.
Paul LePage to accept the Medicaid expansion this
year, during his reelection effort. New Hampshire,
too, where only a Republican-led Senate has
blocked expansion, is considered a likely candidate
to flip this year. Governors in small, Republicandominated states like Wyoming, Kansas and Utah
say they’re keeping an open mind in 2014, despite
their hatred for the overall health law. And in every
undecided state, an unusual alliance of powerful
hospital, business and religious interests has been
leaning on Republican leaders to reverse course. In
short, the 26 states that have already approved
Medicaid expansion are likely to be joined by at
least a few more in 2014 — and the “hell no” states
could find themselves an increasingly isolated
bunch, concentrated in the South. “We really are
not taking any state for granted,” said Tim Phillips,
president of the conservative Americans for
Prosperity, which is fighting expansion efforts
around the country. He expects Republicans will
distance themselves from expansion the closer the
elections get, but says AFP won’t leave it to chance.
“We’re going to continue to run a very aggressive
grass-roots and paid media campaign,” he said, with
ads running in states on a case-by-case basis, as
they consider expansion proposals. Already, seven
states have approved expansion with the blessing of
Republican governors — including Arizona’s Jan
Brewer, Ohio’s John Kasich and New Jersey’s Chris
Christie.
Medicaid is growing quickly under
Obamacare, with an estimated 3.9 million people
determined eligible for the program in the first three
months.
Supporters say that if all 50 states
expanded Medicaid, another 5 million people would
become eligible. In general, Republican-dominated
states outside of the South aren’t taking as hard a
line against expansion as conservatives would
http://www.nytimes.com/2014/01/13/opinion/krug
man-enemies-of-thepoor.html?hp&rref=opinion&_r=0
Insurers Complain of
Slow Payments; Enrollees Wait
News outlets report on consumers struggling to
prove they have enrolled in coverage and on
insurers wondering when and if they will get paid.
The New York Times: Enrollees At Health Exchanges
Face Struggle To Prove Coverage.
Paul D. Donahue and his wife, Angela, are among
more than a million Americans who have signed up
for health coverage through the federal insurance
exchange. Mr. Donahue has a card in his wallet
from his insurer to prove it. But when he tried to
use it to get a flu shot and fill prescriptions this
week, local pharmacies could not confirm his
coverage, so he left without his medications.
Similar problems are occurring daily in doctors’
offices and drugstores around the country as
consumers try to use insurance coverage that took
effect on Jan. 1 under the Affordable Care Act (Pear
and Goodnough, 1/10).
The Wall Street Journal: Health Insurers Cite Slow
Premium Payments For New Plans.
Insurers are struggling to get their premium
payments from people who signed up for coverage
through the health-law marketplaces, leaving many
plans with fewer enrollees than expected at the
start of the new year. ... "It's been pulling teeth,"
said Shaun Greene, chief operating officer of Utahbased Arches Health Plan, a startup.
As of
Thursday, Arches had collected about 60% of
premiums for people who signed up for coverage
that took effect Jan. 1. He said Arches would urge
customers in email and phone calls to pay for at
least a few more days, even after the deadline
(Mathews and Weaver, 1/10). (Kaiser Health News,
1/13/14)
http://www.kaiserhealthnews.org/DailyReport.aspx?reportdate=1-13-2014
GOP Governors May Still Go For Medicaid
Expansion - And Cash
Republicans counting on a year of nonstop
Obamacare-bashing may be in for an unwelcome
surprise: more red-state governors ditching the
political script to take a second look at the law’s
huge expansion of Medicaid. The party plans to
make Obamacare and its early stumbles a central
30
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
prefer. Kansas Gov. Sam Brownback, who three
years ago sent back a major $31.5 million federal
grant to set up a state-run health insurance
exchange, hasn’t shut the door on expansion this
year. “Gov. Brownback is still considering whether
or not to expand Medicaid,” spokeswoman Sara
Belfry wrote in an email.
“The governor will
consider all bills passed by the Legislature this
session.” Kansas’s top hospital trade group signaled
that it’s readying a new Medicaid offensive in the
coming legislative session. Just before the holidays,
the Kansas Hospital Association hired former HHS
Secretary Mike Leavitt, who’s advising GOP states
on Obamacare implementation, to craft a Medicaid
expansion plan that its members could pitch to
reluctant state lawmakers. In deep-red Utah, state
lawmakers and a special Medicaid commission have
met over the past few months to consider
conservative approaches to the Medicaid expansion.
After winning special concessions from the Obama
administration last year for the state’s smallbusiness exchange, Utah policymakers seem poised
to once again test the feds’ health care flexibility,
say advocates closely tracking the debate. In two
legislative hearings in November and December, “it
became abundantly clear they’re going to push
beyond” reforms Obama administration said it would
allow for the Medicaid expansion program, said
Jason Stevenson, communications director for the
Utah Health Policy Project. Gov. Gary Herbert has
remained on the sidelines of the expansion debate
so far, but he’s expected to weigh in soon.
Wyoming Gov. Matt Mead also isn’t ruling anything
out. “At this time Gov. Mead is not recommending
that the Legislature go ahead with the optional
expansion. He plans to monitor the implementation
of the ACA and remains open-minded if
improvements are made to address his concerns,”
said Mead spokesman Renny MacKay. That’s not an
endorsement, but it’s not the kind of flat rejection
that governors like Perry have made. Deborah
Bachrach, a consultant who works on Medicaid, said
even more Republicans might move toward
expansion after the primary season. If they escape
intraparty challenges or win a primary, they won’t
be as scared about the politics of Obamacare, she
said. Bachrach also described an intensifying push
by hospitals and business coalitions to lean on
undecided states, which are missing out on federal
dollars every day they shun expansion. She said
this effort, combined with the opportunity for states
to propose alternative, private-sector-style Medicaid
models “lead us to believe that more states will
consider (or reconsider) and ultimately approve
expansions.” Entrenched political opposition will
likely leave the Obama administration without its
biggest Medicaid expansion prizes — Florida and
Texas, which have a combined 2 million people
expected to be eligible for Medicaid expansion.
Although Florida’s Republican Gov. Rick Scott
supported expansion last year, his GOP-led
Legislature rebuffed him, and efforts at compromise
appear to have stalemated. Scott, who is seeking
reelection, has since made efforts to distance
himself from the Medicaid expansion. “I think the
politics make the policy more difficult now,” said
Don Gaetz, Florida’s Senate president, a Republican.
“The politics have gone sour for Obamacare, and
that makes it more difficult, I think, to work out
something with the federal government to do things
their way.” Gaetz said any chance of moving
toward the Obama administration’s position slipped
away during the law’s miserable rollout in October
— and he’s relieved Florida waited to move forward.
“We have a newly elected senator who was an
infantry captain in Iraq. He reminded me that
sometimes it’s good to be the second one in the
minefield,” he said. “I think that’s a good way for
states to look at Obamacare.” Another set of
Republican states began 2014 by reaffirming their
commitments to shun Medicaid expansion. Idaho
Gov. Butch Otter, for example, said he won’t touch
expansion this year. Nor will Republican governors
in Alaska and South Dakota, despite bright-red
North Dakota’s surprise embrace of the policy last
year. “On the issue of Medicaid expansion, we
should not jump into the deep end without knowing
what’s on the bottom,” Otter said in his annual
address to state lawmakers on Monday. Otter, who
last year lobbied hard for a state-run exchange, said
he’s carefully tracking the expansion experience in
conservative states.
Mississippi, too, appears
unlikely to move in the new year. The state’s
governor, Republican Phil Bryant, reiterated his
opposition to expansion last week. “We have a
group that will not step over the political,
Republican line to accept those funds,” said Bobby
Moak, the Democratic leader of the Mississippi
House.
It’s that entrenchment that has some
experts doubting whether the Medicaid expansion
map will change at all this year, in the shadow of
the midterm elections. “As more bad news emerges
about costs, coverage, access problems, etc.,
polarization will prevent movement,” emailed Dennis
Smith, a conservative health care consultant who
has worked on Medicaid for President George W.
Bush, Wisconsin Gov. Scott Walker and The
Heritage Foundation. Robert Blendon, a Harvard
University health policy professor, predicted states
would wait for the outcome of the 2014 elections
before committing to expansion because Republican
legislators are afraid of primary challenges from the
right. However, he added that expansion is more
likely where governors have unilateral authority to
expand. To others, though, the allure of billions of
dollars in federal funding and a sharply reduced
uninsured population — as well as the fear that
hospitals without enhanced Medicaid funding could
31
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
shut down or shed jobs — will keep expansion in
play in the unlikeliest of states. “In general I agree
that states like Texas, Louisiana, South Carolina,
Georgia, Mississippi will not change,” said Ray
Scheppach, former executive director of the National
Governors Association. “I do think it is possible for
some of the others as the numbers are
overwhelming in terms of the positive economic
impacts.” (Politico, 1/10/14)
the end of enrollment on March 31 to avoid paying
the law's penalty for not having health insurance.
A FACTOR OF PRICE
The Affordable Care Act, popularly known as
Obamacare, prevents insurers from charging people
more if they have a health problem. Age is one of
the few factors that can affect the price, with
insurers allowed to charge up to three times more
for a 64-year-old than someone in their early 20s.
But the healthcare costs for a 64-year-old on
average are nearly five times as much as a 21-yearold, according to a study of claims from three large
insurers Yamamoto conducted for the Society of
Actuaries. "The more that the marketplace is able
to attract a broad mix of enrollees including the
young and healthy ... the more that costs will be
sustainable and premiums will be more affordable,"
said Robert Zirkelbach, spokesman for America's
Health Insurance plans, a trade group for insurers.
Other factors may be as crucial, if not more, in
determining the stability of the new market,
including the health status of enrollees, regardless
of their age, and how that lines up with what
individual insurers had projected. But those details
will only become clearer later in the year based on
the medical claims filed by the newly insured,
making age the best early proxy about whether the
market is sustainable. The Centers for Medicare
and Medicaid Services, which oversees the
marketplace for 36 states, has yet to provide any
demographic data about enrollees. CMS is expected
to release an enrollment report later this month.
Data may come sooner from insurers as they
discuss their recent financial performance with
investors in the next few weeks. Humana, Inc. said
on Thursday that the mix of enrollment in its
marketplace plans were likely to be "more adverse
than previously expected. But healthcare experts
say insurers need a better mix of enrollees than
seen in the early data. "If a quarter or more of the
enrollees are young adults, I would think that's an
encouraging sign, particularly for the first half of the
open enrollment period," said Larry Levitt, senior
vice president at the Kaiser Family Foundation
healthcare think-tank. By the end of March, "if it's
lower than that, I think there would be some cause
for concern," Levitt said. Levitt and colleagues at
Kaiser analyzed a scenario that they deemed "worst
case" in which young adults represented 25 percent
of enrollees. They found that costs then would be
about 2.4 percent higher, but insurers would retain
a very slim profit margin. As a result, the Kaiser
authors projected the companies would raise
premiums by a commensurate amount, but not
enough to destabilize the market. Using the same
data as Kaiser but different assumptions, Seth
Chandler, a law professor at the University of
Houston who specializes in insurance, said costs
http://dyn.politico.com/printstory.cfm?uuid=B71BCD
21-013D-4466-A8B7-EEF94021A8B8
Obamacare May Get Sick If Young
Americans Don't Sign Up
Now that more than 2 million people have signed up
for private insurance plans created by President
Barack Obama’s healthcare law, a crucial next
check-up for the new marketplace will be to see
how old customers are. Early data from a handful
of state exchanges shows the administration needs
more young adults to sign up in the next three
months to help offset costs from older enrollees and
prevent insurers from raising their rates. Critics of
Obama's Affordable Care Act say the market won't
attract enough young people to keep it financially
viable, putting more pressure on government funds
to compensate for any insurer losses. Data from
seven states and the District of Columbia, which are
running their own marketplaces, show that of more
than 200,000 enrollees, nearly 22 percent are 18 to
34 years old, according to a Reuters analysis. The
administration had hoped that over 38 percent, or
2.7 million, of all enrollees in 2014 would be 18 to
35 years old, based on a Congressional Budget
Office estimate that 7 million people would sign up
by the end of March.
"The whole insurance
relationship is counting on them signing up," said
Dale Yamamoto, an independent healthcare
actuarial consultant. "Otherwise rates will have to
increase." The picture from the initial state data is
likely to change, since it mostly includes people who
enrolled only through November, before a year-end
surge of sign-ups for people wanting coverage
effective Jan 1. Many experts speculate the early
enrollees were more likely to be in urgent need of
coverage, and therefore more likely to be older or
sicker. A recent survey by The Commonwealth
Fund, a healthcare research foundation, found that
41 percent of those who had shopped at the various
state marketplaces by the end of December were
ages 19 to 34, up from 32 percent from an October
survey. One marketplace with current data, the
District of Columbia, said on Friday that of the 3,646
enrollees in private plans through Thursday, about
44 percent are young adults. Healthcare experts
say many young healthy people may sign up only at
32
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
would be 3.5 percent higher, should only 25 percent
of enrollees be young adults. "If we see fewer than
30 percent of the enrollees being in that 18-to-34
age bracket, that's a warning sign that there are
problems," Chandler said. "If the demographics
come in poorly, insurers are going to lose money."
Chandler is a skeptic of the healthcare law and
writes a blog called "ACA Death Spiral." Such a
spiral is thought to occur if insurers facing higher
costs raise premiums, so only very sick people buy
coverage, leading to even higher premiums with the
pattern continuing until the insurance market either
disappears or shrinks to the point that it is not
sustainable. The penalty for not buying insurance
increases significantly by 2016, which should bring
in more young and healthy holdouts over time. Not
everyone, however, is significantly concerned about
the age of Obamacare enrollees this year. Linda
Blumberg, senior fellow at the Urban Institute's
Health Policy Center, said that Obamacare's
protections for insurers in the first few years means
the program has time to get the demographics
sorted out. "That all combines to make me much
less worried about the mix for this year," Blumberg
said. "I don't think we have to get a certain
percentage of enrollees to be below age 35 or this
thing crumbles." (Reuters, 1/12/14)
it one way, the word canceled gets attached to it. If
they do it another way, they say they are amending
the policy. It sounds more gentle but it’s the same
thing,” said Gary Claxton, an expert in private
insurance at the Kaiser Family Foundation. “The
basic point is, for many people in the small-group
market at some point soon their coverage is going
to change.” The transformation of the small-group
market is just one of the many ripple effects of the
Affordable Care Act that will reshape the insurance
industry in coming years. With millions of previously
uninsured people getting coverage, the insurance
industry’s business model is being upended, and
that’s leading to changes involving all sorts of
products, not just those sold through the online
marketplaces to individuals.
The impact of
cancellations in the small-group market is expected
to be less dramatic than in the individual market,
partly because a higher percentage of smallbusiness policies provide more generous benefits.
Still, the changes being made by the insurance
industry are leaving some small-business owners
confused and disillusioned about the law — whether
it is directly to blame for the changes or not.
Stephen Lohman, owner of Allegheny Plant Services,
a trucking company in Pittsburgh, said the Aetna
PPO plan he offers his 38 employees will be
discontinued at the end of this year. He said he has
been offered a new Aetna policy with premiums that
are 40 percent higher, and that other insurers’ rates
are similar. “We were very surprised,” he said,
adding that it is “important to me personally” to
offer insurance to his employees, but he is not sure
he can afford the premium increase. Now that
insurers aren’t able to charge more to people with
preexisting conditions, companies with sicker
workers may see lower premiums, while those with
a healthier workforce may see higher premiums.
Many small businesses are also discovering that the
new plans have more restrictions on access to
specific doctors, hospitals and prescription drugs.
The reason, said Robert Zirkelbach, a spokesman for
America’s Health Insurance Plans, the industry’s
main trade group, is that the law requires small
businesses to purchase coverage that is more
comprehensive than what some buy today, and that
drives up costs. Some small businesses are eligible
for new tax credits to partially offset the cost of
insurance. Also, firms no longer have to worry
about the possibility of large premium increases if
too many of their workers fall ill.
http://www.reuters.com/article/2014/01/12/us-usahealthcare-enrollment-idUSBREA0B07Y20140112
Second Wave Of Health-Insurance
Disruption Affects Small Businesses
When millions of health-insurance plans were
canceled last fall, the Obama administration tried to
be reassuring, saying the terminations affected only
the small minority of Americans who bought
individual policies.
But according to industry
analysts, insurers and state regulators, the
disruption will be far greater, potentially affecting
millions of people who receive insurance through
small employers by the end of 2014. While some
cancellation notices already have gone out, insurers
say the bulk of the letters will be sent in October,
shortly before the next open-enrollment period
begins. The timing — right before the midterm
elections — could be difficult for Democrats who are
already fending off Republican attacks about the
Affordable Care Act and its troubled rollout. Some
of the small-business cancellations are occurring
because the policies don’t meet the law’s basic
coverage requirements. But many are related only
indirectly to the law; insurers are trying to move
customers to new plans designed to offset the
financial and administrative risks associated with the
health-care overhaul. As part of that, they are
consolidating their plan offerings to maximize profits
and streamline how they manage them. “If they do
‘Ending Discrimination’
An estimated 18 million to 24 million people in the
United States have insurance through employers
with fewer than 50 workers, and about 40 million
have coverage through firms with fewer than 100
workers. The Department of Health and Human
Services estimated in 2010 that up to 80 percent of
33
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
small-group plans, defined as having fewer than 100
workers, could be discontinued by the end of 2013.
But many small employers bought themselves extra
time by renewing policies early through the end of
2014. Jonathan Gruber, a key architect of the
health law and a professor of economics at the
Massachusetts Institute of Technology, said the
number of people covered by small-group policies
that will be discontinued is “not trivial.” “We’re
ending discrimination [against people who are sick,
and as a result] the people who were previously
benefiting may now suffer,” Gruber said. “That’s
sad for them, but it does not mean we should
continue discrimination.” He said the change for
most small businesses will simply be a “labeling
issue,” with companies able to switch to similar
plans at similar prices with the same carriers,
although the plans themselves may have different
names. A smaller group will have to pay more for a
more generous plan. Gruber said the number of
genuine “losers” under the health-care law — those
who will have to pay more for the same or inferior
coverage — is “very, very small.” In November,
President Obama, responding to criticism about
widespread cancellation of individual policies, said
insurers could extend policies that do not meet the
law’s requirements for an additional year, if state
regulators agreed. His announcement applied to
small-group plans as well. There is substantial
turnover in individual and small-group policies every
year, even without the health law. But insurers say
the change that’s starting to occur is significantly
larger than before. In New Jersey, the state’s
association of health plans says 650,000 people with
small-group coverage have had their plans
disrupted. In Colorado, regulators said small-group
plans covering 143,000 people are being
discontinued in 2014. In New Hampshire, the
state’s largest insurer, Anthem Blue Cross Blue
Shield, is moving all of those in its small-group plan
— 60,000 to 70, 000 people — to plans that are
similar to those sold on the marketplace created by
the health-care law. These plans have drawn fire
from consumers because they include only 16 of the
state’s 26 acute-care hospitals. In Pennsylvania,
Delaware and West Virginia, Highmark Blue Cross
Blue Shield is discontinuing all its small-group plans
for those who did not renew early, and offering new
policies with different coverage and premiums. The
company says 99.5 percent of the 5.3 million people
it covers through its individual and small-group
plans will be affected, but it declined to break out
the number under small-group plans for competitive
reasons.
fewer than 50 employees to purchase new policies
through the government-run online marketplaces.
The rules go into effect in 2014 in Vermont and
2015 in the District. About 39,300 people in
Vermont are being affected, according to state
regulators.
The District requirement will be
extended to employers with up to 100 employees in
2016; it could affect as many as 125,000 people.
Regulators took the step to try to ensure that the
exchanges — the smallest in the country, by
population served — would have enough young,
healthy enrollees to offset the cost of older, sicker
participants.
Judith Kennedy, president of the
National Association of Affordable Housing Lenders,
based in the District, recently received a notice
informing her that the group’s small-group plan was
being discontinued. She said she worries about the
consequences as both an employer and as a parent.
“The notion that the plans on the exchanges may or
may not limit providers scares a mom who has lived
through chronic illness with her child,” she said.
Also facing disruption are people who purchase
insurance through professional or trade associations
and don’t have any employees. This includes some
doctors, lawyers and accountants in solo practice.
Under the health law, that type of association plan
is not allowed; sole proprietors must purchase
coverage on the individual market. Cynthia Rutzick,
49, who has her own law practice in Oak Hill, Va.,
said that the policy she had been buying for years
through the state bar association was already
offering the benefits mandated by the health law.
But the policy, which cost $1,500 a month for
herself, her husband and their two children and
included 94 percent of the physicians in her area,
was canceled. The new one, which costs $1,600 a
month for her and her two children (her husband is
going on Medicare next year) includes 82 percent of
area physicians. Her broker said plans like her old
one don’t exist anymore. “So I had a blue car, but
could not go out and buy another blue car,” she
said. “I have to buy a red car, and it’s not as good
and way more expensive.” (Washington Post,
1/11/14)
http://www.washingtonpost.com/national/healthscience/second-wave-of-health-insurancedisruption-affects-smallbusinesses/2014/01/11/dc2f7404-6ffe-11e3-a523fe73f0ff6b8d_story.html
After Waging War On Poverty
For 50 Years, Let's Not Surrender
Fifty years ago Wednesday, President Lyndon B.
Johnson delivered what may have been the last
genuinely uplifting State of the Union speech we've
had. "This administration, here and now, declares
unconditional war on poverty in America," he said.
Business for Marketplaces
In Vermont and the District, regulators are making
other changes in the small-group market. They are
requiring small businesses and associations with
34
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
"We shall not rest until that war is won. The richest
nation on Earth can afford to win it. We cannot
afford to lose it." Since LBJ's launch of the War on
Poverty, the effort has become a whipping boy on
the right and even the left. President Reagan's
judgment from 1986 seems to have won the battle
for the most repeated crack: "In 1964 the famous
War on Poverty was declared and a funny thing
happened … I guess you could say, poverty won the
war."
Reagan's quote remains part of the
conservative rap on the War on Poverty today,
during its 50th anniversary. Here's Robert Rector of
the Heritage Foundation, writing in the Wall Street
Journal: "The country has invested $20.7 trillion in
2011 dollars over the past 50 years. What does
America have to show for its investment?
Apparently, almost nothing: The official poverty rate
persists with little improvement." But like so many
of Reagan's apercus, his remark about the War on
Poverty was beside the point in its implications, and
wrong on the facts. The truth is that the nation's
anti-poverty programs, which include LBJ-era
initiatives as well as earlier programs like Social
Security, have brought the poverty rate down
sharply. The measure cited by Rector doesn't show
a significant fall in the overall rate because it doesn't
count income from anti-poverty programs as real
income. There's some sleight-of-hand here: Rector
isn't shy about listing all the things that Americans
living near or below the poverty line have today that
they wouldn't have had in 1964: "a house or
apartment that is in good repair," a car and TV,
freedom from hunger and malnutrition. But much
of that is bought with the help of food stamps,
earned income tax credits, and other benefits that
he doesn't cite as income. The truth is that the
nation's investment in the War on Poverty has
yielded huge and lasting gains. That's partially
because LBJ's program was not just a plan for
financial handouts. It also encompassed a broad
approach encompassing "better schools, and better
health, and better homes, and better training, and
better job opportunities," as he put it in his address
on Jan. 8, 1964. LBJ's campaign brought us Head
Start (in 1965) as well as Medicare and Medicaid.
He
understood
that
political
and
social
empowerment were indispensable factors in
economic betterment, so he pushed for the Civil
Rights Act of 1964 and the Voting Rights Act of
1965. The successful results can be seen from a
poverty statistic called the Supplemental Poverty
Measure, which the Census Bureau introduced in
2010, and which researchers at Columbia University
used to recalculate the poverty rate going back to
the 1960s. The measure incorporates expenses that
aren't included in the standard poverty stat, as well
as income and benefits from government programs.
Instead of showing a poverty rate mired within a
range of about 12% to 15% of all households over
the last 50 years, the supplemental measure shows
that the poverty rate has actually fallen from more
than 25% in 1967 to about 16% today. Without
poverty-fighting tax breaks and other transfers, the
poverty rate would be close to 30% today. The
effect of the War on Poverty is especially
pronounced on children and the elderly. The child
poverty rate has fallen from nearly 30% to less than
20%, the Columbia researchers found. For the
elderly, it has come down from more than 45% to
15%. The biggest factor in the latter figure, of
course, is Social Security; the degree to which Social
Security keeps millions of seniors out of poverty
should be a reproach to legislators on both sides of
the aisle who think these crucial benefits should be
cut to preserve tax breaks for the rich. One
disquieting trend does emerge from these figures,
however: after falling fairly consistently for some
four decades, the poverty rate began to creep up
after 2008. It's not surprising that the crash and
recession that year drove poverty up, but what's
disturbing is that it has kept going up. The reason
plainly is that the nation's anti-poverty and antirecession programs haven't been fully up to the task
of
combating
the
effects
of
long-term
unemployment or the systematic redirection of
income from the working class to the shareholding
class — income inequality. That's what's overlooked
by Republicans like Sen. Marco Rubio of Florida,
who last week tried to seize the anti-poverty high
ground for his party with a speech proposing a host
of new measures. "Our modern-day economy has
wiped out many of the low-skill jobs that once
provided millions with a middle-class living," Rubio
said. "Those that have not been outsourced or
replaced by technology pay wages that fail to keep
pace with the cost of living." Rubio's diagnosis is
incomplete. He left out all the still-existing jobs that
once paid a middle-class wage and offered middleclass benefits, but don't do so any longer. He left
out the effect of corporate policies like that of
Boeing, which just squeezed its unionized rank-andfile manufacturing workers with big cuts in pension
and healthcare benefits — and came this close to
hammering them on wages too — while showering
its shareholders with an enormous increase in
dividends and some $17 billion in stock buybacks,
and awarding its chief executive a 20% raise. While
talking up the economic virtues of marriage, Rubio
forgot to mention the role of a fair distribution of
the profits of productivity in fostering economic
mobility. What's dangerous about the claim that
anti-poverty spending has been a waste is that it
morphs easily into an excuse for doing less of it, or
refashioning successful programs so they're cheaper
and less effective. Among Rubio's big ideas is to
turn federal anti-poverty programs over to the
states "so they can design and fund creative
initiatives that address the factors behind inequality
35
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
of opportunity."
This idea of the states as
laboratories of innovative government is one of the
most treasured notions of politicians, but the few
states where the reputation is deserved (including
California) are outnumbered by those where state
control of federal dollars will perpetuate inequality,
inefficiency and stupidity. One need look no further
than the failure of 25 states to take up the
government's offer of free Medicaid expansion to
give their citizens access to health insurance. This
dereliction has left some 5 million Americans
uncovered — and it's hardly a coincidence that
several of those states already rank at the bottom of
the heap in public health programs. If they're
laboratories, they're being run by mad scientists.
These are some of the same states, by the way,
that are systematically cutting back on voting rights.
Rubio proposes making these block grants to the
states "revenue neutral," which sounds like
delivering assistance to some recipients means
taking it away from others.
Economist Jared
Bernstein also warns that it means those programs
couldn't expand in times of need, like recessions. He
points out that of three major safety net programs
— food stamps, unemployment insurance and
Temporary Assistance for Needy Families (TANF) —
the only one that didn't grow to meet the challenge
of the recession was the last, which is the only one
block-granted to the states. People trying to be fairminded about Rubio's platform have given him
credit for at least taking a stab at showing empathy
for the poor. But he's outgunned by members of his
own party who think the answer to grinding poverty
is for the poor to notch in their belts in the name of
government austerity. They include people like our
favorite hypocrite, Rep. Doug LaMalfa (R-Richvale),
who instructed people on food stamps that they
should accept a "modest" retraction of $20 billion in
the program, though his own family collected more
than $5 million in crop subsidies since 1995. The
worst flaw in any diagnosis of anti-poverty policy
that focuses on the amount of money spent is that it
treats poverty as a phase rather than as a condition.
Enhancements to income are essential parts of any
relief program, but as LBJ perceived, social mobility
is the key. Poverty may yet win the war, proving
Reagan right; but if that happens it's because
American society has handed over victory by
default. Programs addressing that factor have really
taken it in the gut during this last recession. The
sequester, which still remains in effect, has hollowed
out Head Start programs across the country and
deprived thousands of families of adequate public
housing. Turning control of anti-poverty programs
to the states may satisfy some fantasy of grassroots political resourcefulness, but when the states
face budget crunches they invariably hack away at
public education, public housing, public health. (LA
Times. 1/12/14)
http://www.latimes.com/business/la-fi-hiltzik20140112,0,1032268.column#ixzz2qIyeNYEJ
Va. Doesn’t Need Another
Mental Health Task
By Pete Earley
Virginians should be embarrassed and angry that a
newly appointed state mental health task force
convened Tuesday in Richmond. It is the 16th task
force asked to investigate the state’s mental health
system. Are Virginia legislators so dense that they
need yet another expert panel to tell them what’s
wrong? Four major studies, from 1997 through
2000, in Virginia each identified the same problems
and made similar recommendations. Yet the system
remains a mess. Why? Outgoing governor Robert
F. McDonnell (R) appointed the newest panel after
the November stabbing of state Sen. Creigh Deeds
(D-Bath) by his son, Austin, who then killed himself.
A local mental health official said afterward that
Austin had not been treated because no psychiatric
hospital bed was available locally. That may have
shocked the governor, but it wasn’t a surprise to
those of us with family members who need mental
health care. Virginia’s inspector general warned in a
May 2011 report that 200 people were turned away
from hospitals during one 12-month period because
of a lack of beds, even though the patients were
considered a danger to themselves or others. The
practice had become so widespread hospital officials
coined a term for it: “streeting.” The mental health
task force that I served on issued its findings after
the Virginia Tech shootings in 2007 that left 33
people dead, including the shooter, who had been
deemed dangerous but hadn’t received treatment.
Our recommendations led to sweeping legal
changes and an additional $42 million in mental
health funding spread over a two-year period.
Problem solved. Or so we thought. Since 2006,
I’ve visited more than a hundred treatment
programs in 48 states and three countries, and I’ve
found that the problems in Virginia and nationally
are not the result of ignorance. Mental health
professionals know how to help most people with
serious disorders.
Four things are missing in
Virginia. Unfortunately, it’s unlikely the new task
force will focus on any of them.

36
Virginia is missing a leader powerful enough to
force state and local agencies to work as a
team. Bexar County, Tex., (which surrounds
San Antonio) went from needing to build a new
jail to having a 1,000-jail bed surplus and
saving an estimated $9 million annually in jail
costs and inappropriate emergency room
admissions. What happened? A local judge,
prompted by an innovative mental health
advocate, forced law enforcement and the
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
judiciary to stop jailing nonviolent mentally ill
individuals and arm-twisted housing officials
into providing decent housing.

Mental health services in Virginia are managed
by 40 Community Services Boards (CSBs), and
that patchwork is often blamed for problems
with the system.
While cumbersome, the
boards are not the problem. Regardless of how
a CSB is operated, it cannot require police
chiefs to implement specialized training for
their officers or demand that a judge create a
mental health court, even though both have
proved to reduce violent incidents, save tax
dollars and help the mentally ill get treatment.

Virginians must stop thinking that mental
health is solely a problem for the CSBs and
state Department of Behavioral Health and
Developmental Services. Mental health cuts a
wide swath. Housing, veterans’ assistance,
drug and alcohol services, transportation and
employment all play a role in helping someone
recover. Sadly, so does law enforcement and
the judiciary. It takes leadership to bring these
divergent agencies together.

legislator told me, “check that department’s
priorities and you’ll find its best-funded
programs are aimed at helping the intellectually
disabled. Not mental illness.” Why? Because
many parents of children with intellectual
disabilities are well organized and are used to
fighting for their children. They call their local
representative, show up at town meetings and
vote. Parents with mentally ill kids in jail,
homeless or in hospitals often are ashamed to
speak out and demand improvements. The
only time anyone cares about mental illness is
after a tragedy.
We don’t need another task force. We need a
leader with enough clout to bring everyone to the
table, get them the money they need to do their
jobs and direct them to create a true system, not a
fractured one being held together by Band-Aids that
we apply each time there’s a tragedy. Pete Earley is
the author of “Crazy: A Father’s Search Through
America’s Mental Health Madness.” (Washington
Post, 1/10/13)
http://www.washingtonpost.com/opinions/vadoesnt-need-another-mental-healthtask/2014/01/10/3fffaa14-78bd-11e3-8963b4b654bcc9b2_story.html
Good treatment requires adequate financing.
After the Virginia Tech shootings, the
legislature approved the $42 million in new
money, but within three years had instituted
across-the-board budget cuts that reduced
mental health spending to below what was
being spent before the shootings. Successful
mental health programs are often costly to
launch but ultimately save tax dollars, as much
as $22 saved for each $1 spent, according to a
Texas study carried out by the Perryman
Group.
Few politicians want to invest in
programs that offer far-off results, but that’s
where we should be putting our tax dollars, not
in quick, one-time fixes.

Virginians must look at the big picture. After
the Virginia Tech shootings, our task force
lowered the criteria for involuntarily committing
someone into a hospital. While a positive step,
this has proved ineffective because there are
not enough hospital beds.
Meanwhile, 80
people in state hospitals are ready to go home
but can’t leave because there is no affordable
housing in their communities. It costs $590 per
day to keep those patients in a hospital. It
would cost $120 per day for them to live in a
community setting. You can’t fix one tire and
expect a car to run if the other three are flat.

Mental health must be an ongoing priority.
While Virginia’s Department of Behavioral
Health and Development Services “may pay lip
service to serious mental illness,” a top
Health Care Signups:
More Older Americans So Far
Young adults from 18 to 34 are only 24 percent of
total enrollment, the administration said Monday in
its first signup figures broken down for age, gender
and other details. With the HealthCare.gov website
now working, the figures cover the more than 2
million Americans who had signed up for
government-subsidized private insurance through
the end of December in new federal and state
markets. Enrolling young and healthy people is
important because they generally pay more into the
system than they take out, subsidizing older adults.
While 24 percent is not a bad start, say independent
experts, it should be closer to 40 percent to help
keep premiums down. Adults ages 55-64 were the
most heavily represented in the signups, accounting
for 33 percent of the total. Overall, the premiums
paid by people in that demographic don’t fully cover
their medical expenses. Some are in the waiting
room for Medicare; that coverage starts at age 65.
The administration and its allies remain confident
they’ll be able to get young adults interested. Many
experts expected older, sicker people to be more
heavily represented in the early numbers. Younger
people might procrastinate, waiting until the March
31 enrollment deadline is near, weighing whether
they want to risk tax penalties for remaining
uninsured. “The dynamic of younger people is that
they are going to get educated, they are going to
37
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
get informed, and they are going to enroll as we get
closer to that deadline,” said Aaron Smith, founder
of Young Invincibles, an advocacy group for young
adults. Insurers, nonprofit groups and advocates
are moving ahead with marketing campaigns that
were put on hold when the federal website that
serves 36 states was struggling. Administration
officials said that in the coming weeks they plan to
increase outreach to young people in 25
communities located in states served by the federal
website. That effort includes a national youth
enrollment day on Feb. 15 and targeted outreach by
sororities and fraternities, as well as Voto Latino,
which focuses on Hispanic youth. But even if the
age mix remains tilted toward older adults, “it’s
nothing of the sort that would trigger instability in
the system,” said Larry Levitt, an insurance expert
with the nonpartisan Kaiser Family Foundation.
Premiums would go up next year for the overhaul,
along with taxpayer costs per enrollee, but not
enough to push the system into a “death spiral” in
which rising premiums discourage healthy people
from signing up. Still, he said, “it underscores a
need to heighten outreach efforts to young people.”
Considering that the federal health care website was
down most of the time in October, administration
officials said they were pleased that the percentage
of young adults was as high as it was. “We think
that more and more young people are going to sign
up as time goes by,” said Gary Cohen, head of the
Health and Human Services Department’s office in
charge of Obama’s push to cover the uninsured.
With Monday’s numbers, a fuller picture has started
to emerge of who’s signing up. Some of the
highlights:
—
available only to certain groups of people,
including those under 30.
—
A few states accounted for a huge share of the
enrollment. California alone had 23 percent of
the signups. California, New York, Florida,
Texas and North Carolina accounted for nearly
half the total.
Some questions remained unanswered. For
example, the administration is unable to say how of
many of those enrolling for coverage had been
previously uninsured.
Some might have been
among the more than 4.7 million insured people
whose previous policies were canceled because they
didn’t meet the law’s standards. In Miami, 19-yearold college student Stacy Sylvain was one of the
last-minute online signups as 2013 drew to a close.
In about an hour, the part-time waitress signed up
for a plan with a $158 monthly premium, with the
feds kicking in $48. She has a $2,500 deductible.
Sylvain said she had no trouble navigating the
website. “Many people have a preconceived notion
that young people are healthy and don’t need to go
to the doctor,” said Sylvain, who suffered a minor
injury when she fell and hit her head during an
indoor soccer class in 2012. “Not having to worry
about being uninsured and the what-ifs has made
an incredible impact on my life.” (Washington Post,
1/14/14)
http://www.washingtonpost.com/politics/healthcare-signups-more-older-americans-sofar/2014/01/14/38fa705e-7cf6-11e3-97d3b9925ce2c57b_story.html
Older Pool Of Health Care
Enrollees Stirs Fears On Costs
The administration continues to play catch-up.
Originally, officials hoped to sign up more than
3.3 million people through the end of 2013,
nearly halfway to the goal of 7 million
enrollments by the end of March. Instead,
enrollment as of Dec. 31 was not quite 2.2
million.
—
Fifty-four percent of those who signed up were
women, a slightly higher proportion of females
than in the population.
—
Nearly four out of five who signed up got
financial help with their premiums.
—
The most popular coverage option was a socalled silver plan, which covers about 70
percent of expected medical costs. Three out
of five people picked silver. One in five picked
a lower-cost bronze plan. Only 13 percent
picked gold, which most closely compares to
the typical employer plan. Another 7 percent
went for top-tier platinum plans, and about 1
percent picked skimpy “catastrophic” plans
People signing up for health insurance through the
Affordable Care Act’s federal and state marketplaces
tend to be older and potentially less healthy,
officials said Monday, a demographic mix that could
threaten the law’s economic underpinnings and
cause premiums to rise in the future if the pattern
persists. Questions about the law’s financial viability
are likely to become the next line of attack from its
critics, as lawmakers gear up for the midterm
elections this fall. Republicans quickly seized on the
government’s progress report on Monday as
evidence that the health insurance law would not
work.
But administration officials expressed
optimism that more young people would sign up in
the months ahead, calling the latest enrollment
numbers “solid, solid news” for the health care law.
They said that interest in obtaining insurance
through the marketplaces was increasing sharply
across all age groups and that youth outreach
efforts would become more aggressive as the March
31 open enrollment deadline approached.
38
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
selecting plans were previously uninsured or how
many have paid premiums. People are required to
pay their share before coverage takes effect.
Officials also did not know the race or ethnic origin
of those who signed up. The age breakdown was
the most highly anticipated data being released
because of what it could say about the health of
those who will be insured. Under the law, insurers
can no longer deny coverage or charge higher
premiums because of a person’s medical history or
pre-existing conditions. As a result, White House
and health policy experts have repeatedly said that
insurers need to sign up large numbers of younger
people to balance the financial risks of covering
older Americans who require more medical care.
Larry Levitt, a senior vice president of the Kaiser
Family Foundation, has said that “the mix of
enrollment is much more important than the total
number.” “If you assume that sicker individuals are
likely to come in first, then a smaller pool is likely to
be a sicker pool,” Mr. Levitt said.
“The best
guarantee of a diverse pool is a big pool, because
that means you are probably reaching younger and
healthier people.”
Mr. Levitt said that people
enrolling early included some with the greatest
needs: people who had been locked out of the
individual insurance market because of serious
illnesses and those coming from federal and state
programs for people with pre-existing conditions.
The report from the administration showed that
older Americans accounted for a large share of
those choosing health plans in a handful of states,
including West Virginia and Wisconsin, where 66
percent were age 45 to 64. In Maine, 64 percent
were in that age bracket, and in Arkansas their
share was 63 percent.
Robert Laszewski, a
consultant who works closely with insurers, said,
“You need healthy people of all ages,” and so far,
he said, “the program is not ramping up fast enough
to guarantee a good balance of healthy and sick
people, which you need to sustain the program.”
Robert E. Zirkelbach, a spokesman for America’s
Health Insurance Plans, a trade group, said “it’s too
early to know” if the enrollment of younger and
healthier people was adequate to keep premiums
stable in coming years. Insurers will need to see
enrollment numbers for the full six-month period, he
said. Many people who bought insurance on their
own have received notices saying their policies were
being canceled or discontinued because the policies
did not comply with coverage requirements of the
new health care law. Those expecting high medical
bills had the strongest motivation to overcome the
obstacles to buying insurance on the federal
exchange. Caroline F. Pearson, a vice president of
Avalere Health, a research and consulting company,
said that “early enrollment is skewed toward older
individuals.” She added: “Sicker, older folks tend to
sign up first because they are more motivated.
Graphic
Health Exchange Enrollment Picked Up in December
Nearly 2.2 million people picked a health insurance
plan through the exchanges established by the
Affordable Care Act through Dec. 28.
“We’re pleased to see such a strong response and
heavy demand,” said Kathleen Sebelius, the
secretary of health and human services. “Among
young adults, the momentum was particularly
strong.” Of those who signed up in the first three
months, administration officials said, 55 percent are
age 45 to 64. Only 24 percent of those choosing a
health insurance plan are 18 to 34, a group that is
usually healthier and needs fewer costly medical
services. People 55 to 64 — the range just below
the age at which people qualify for Medicare —
represented the largest group, at 33 percent. The
latest figures about enrollment add pressure on the
Obama administration after a disastrous rollout of
the HealthCare.gov website in October. Senior
officials said they understood the stakes and were
working to increase sign-ups. The White House
recently hired Marlon Marshall, the deputy national
field director for Mr. Obama’s 2012 presidential
campaign, to run a campaign-style effort aimed at
increasing sign-ups, especially among young people.
Brendan Buck, a spokesman for the House speaker,
John A. Boehner, Republican of Ohio, predicted that
the White House would fail to meet its goals and
said that insurance premiums would rise. “There’s
no way to spin it: youth enrollment has been a bust
so far,” Mr. Buck said.
“When they see that
Obamacare offers high costs for limited access to
doctors — if the enrollment goes through at all —
it’s no surprise that young people aren’t rushing to
sign up.” The demographic information, which had
not been broadly available until Monday, also offers
the first concrete evidence about whether the
national health care experiment will work the way it
has in Massachusetts, where a government
marketplace also offers insurance to people who do
not receive it through their employers. Officials said
they were optimistic because the pattern of sign-ups
among young people looked similar to the one they
had seen in that state, which had a surge in signups as the deadline approached. Overall, officials
said that 2.2 million people had signed up by Dec.
28 for health insurance through HealthCare.gov and
the state-based websites. Administration officials
have previously said they hope to see seven million
people enrolled in private health plans through the
federal and state exchanges by March 31. Of those
who signed up, about 54 percent are female and 46
percent are male. Nearly 80 percent of those who
selected a plan qualified for federal subsidies to
reduce their premiums, officials said.
Federal
officials said they did not know how many people
39
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
They are likely to have health care costs early in the
year.” Anne Filipic, the president of Enroll America,
a nonprofit group trying to expand coverage, said,
“We know from our research that when uninsured
consumers learn about the financial help that is
available to them, they are eager to enroll.” Health
plans in the marketplace are separated into four
categories — bronze, silver, gold and platinum —
indicating the generosity of coverage, or the share
of costs paid by insurance for an average enrollee.
Of people choosing plans so far, 60 percent selected
silver plans and 20 percent signed up for bronze
plans. Thirteen percent chose gold plans, and 7
percent platinum coverage. In December, for the
first time since the marketplaces opened, the
number of people selecting plans in the federal
exchange exceeded the number signing up through
state exchanges. For the first half of the enrollment
period, through December, the federal exchange,
which serves 36 states with about two-thirds of the
nation’s population, accounted for 56 percent of
those selecting plans. The other 44 percent were in
state exchanges. (New York Times, 1/13/14)
policymakers see three-year programs as a way to
produce physicians, particularly primary-care
doctors, faster as the new health-care law funnels
millions of previously uninsured patients into the
medical system. Enormous student loans are cited
as one reason some newly minted doctors choose
lucrative specialties such as radiology or
dermatology, which pay twice as much as pediatrics
or family medicine. But debt and the shortage of
primary-care doctors are not the only factors fueling
interest in accelerated programs. Some influential
experts are raising questions about the length of
medical school in part because much of the fourth
year is devoted to electives and applying for a
residency, a process that typically takes months.
(Similar questions are being raised about the third
year of law school.) In a piece published in the
Journal of the American Medical Association in 2012,
University of Pennsylvania Vice Provost Ezekiel
Emanuel and Stanford economist Victor Fuchs
proposed that a year of medical school could be
eliminated “without adversely affecting academic
performance.” The overall time it takes to train
physicians, they wrote, is an example of waste in
medical education and could be shortened without
affecting patient care or eroding clinical skills;
students could be assessed on “core competencies
rather than on time served.” A 2010 report by the
Carnegie Foundation recommended that fasttracking be considered. So far, fewer than a dozen
of the nation’s 124 medical schools are offering or
actively considering three-year programs, which
typically involve the elimination of electives,
attendance at summer classes and the provisional
guarantee of a residency — offered because threeyear graduates might be at a disadvantage
compared with other applicants. NYU launched its
program in September with Hill and 15 other
students chosen from a pool of 50 applicants —
nearly a third of the medical school’s 160-member
class. Texas Tech University Health Sciences Center
in Lubbock graduated its first three-year class in
2013; its nine students are training in family
medicine. Fifteen more students started this fall. In
September, Columbia University’s College of
Physicians and Surgeons launched a “fast track MD”
for candidates who already hold doctorates in
biology; there were 40 applicants for four slots.
Despite the growing popularity of such programs,
critics question the wisdom of jettisoning the fourth
year of medical school, which they say plays a
crucial role in preparing doctors for residency and
subsequent practice. Some note that the three-year
track was offered by a few dozen medical schools in
the late 1970s but subsequently abandoned, largely
because of student burnout from trying to cram too
much into three years. Supporters of the three-year
option say that contemporary medical school
programs are different from 1970s curricula, which
http://www.nytimes.com/2014/01/14/us/healthcare-plans-attracting-more-older-less-healthypeople.html?partner=rss&emc=rss&_r=0
Should Medical School Be
Shortened To Three Years? Some
Programs Try Fast Tracking.
For Travis Hill, it was an offer too good to refuse.
Last year when the 30-year-old neuroscientist was
admitted to a new program at New York University
that would allow him to complete medical school in
only three years and guarantee him a spot in its
neurosurgery residency, he seized it. Not only would
Hill save about $70,000 — the cost of tuition and
living expenses for the fourth year of medical school
— he would also shave a year off the training that
will consume the next decade of his life. “I’m not
interested in being in school forever,” said Hill, who
earned a PhD from the University of California at
Davis in June 2013 and started med school in
Manhattan a few weeks later. “Just knowing where
you’re going to be for residency is huge.” So is Hill’s
student loan debt: about $200,000, dating back to
his undergraduate days at the University of
Massachusetts. And he won’t begin practicing until
he is 40. The chance to finish medical school early
is attracting increased attention from students
burdened with six-figure education loans: The
median debt for medical school graduates in 2013
was $175,000, according to the Association of
American Medical Colleges. This year, the combined
cost of tuition and fees for a first-year medical
student ranges from just over $12,000 to more than
$82,000. Some medical school administrators and
40
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
relied more heavily on rote memorization, and that
the new programs have been designed to minimize
burnout. “This has been tried before, and it was a
miserable failure,” said Stanley Goldfarb, associate
dean for curriculum at the University of
Pennsylvania’s Perelman School of Medicine, who
co-authored an essay opposing three-year programs
in a recent New England Journal of Medicine.
“Since the 1970s things have gotten so much more
complex in medicine,” he said. The more relaxed
fourth year, he said, gives students the chance to
pick the field that best suits them and to carefully
evaluate residencies. More than three-fourths of
students, he said, enter medical school uncertain
about their eventual specialty. Goldfarb said he
favors enhancing the fourth year, not eliminating it.
Medical students have mixed feelings about threeyear programs, said Nida Degesys, president of the
Reston-based American Medical Student Association.
While many are eager to reduce their debt, they are
also concerned about missing opportunities; fourthyear electives can include ophthalmology, critical
care and emergency medicine.
“I personally
changed my mind” during med school, Degesys
said. “In the first year I thought I was going to do
OB-GYN, but I later found that emergency medicine
is truly the right fit for me.” For more than a
century, medical schools have largely designed their
programs around a template: two years of
preclinical or classroom work in basic medical
science, followed by two years of clinical rotations,
mostly in hospitals. After med school, students
continue their training in residencies lasting from
three to seven years, which increasingly is followed
by a fellowship of one year or more. “There have
always been some individuals who wondered about
the length of medical school,” said John Prescott,
former dean of the medical school at West Virginia
University and chief academic officer at the
Association of American Medical Colleges. To speed
the production of doctors, medical training during
World War II was shortened to three years with no
ill effect, he said. Prescott calls the current threeyear programs “well-designed experiments” that
may provide models about how to prepare students
“in the most cost-effective way.” But he doubts
they will supplant the conventional four-year track
for most students. Steven B. Abramson, vice dean
of NYU’s medical school, agrees, but he said he
expects three-year programs to multiply over the
next five years. NYU’s accelerated program, he
said, is best suited for highly qualified students who
are typically older, more mature and certain of their
choice of specialty. Because three-year students
take the same core courses as their classmates,
they will be equally well prepared, he said. And
Abramson noted the proliferation of dual-degree
programs: students who earn an MD along with a
graduate degree in science, business administration
or public health. “The core content we deliver is
rigorous, comprehensive and very well monitored,”
he said. To stay in the three-year program, students
must remain in the upper half of the class; they
retain the option of switching to the four-year track
if they find it too taxing. First-year students are
also assigned mentors in their intended residency.
While students at NYU can designate a variety of
specialties, the three-year Family Medicine
Accelerated Track at Texas Tech is limited to those
who intend to pursue that specialty. “There weren’t
enough primary-care doctors before the Affordable
Care Act,” said Texas Tech medical school dean
Steven Berk, who trained as a family physician.
“There are lots of towns in Texas with 25,000
people and no doctor. And it’s the primary-care
physicians who find the small breast mass or control
patients’ blood pressure. They are essential to the
functioning of the health-care system.”
Many
students who chose the three-year course have
committed to primary care based on their previous
work experience. “We have students who have
been PAs, EMTs and RNs,” he said, referring to
physician assistants, emergency medical technicians
and registered nurses. Texas Tech students are
awarded a $15,000 full tuition scholarship to cover
the first year. When they graduate, their average
debt for tuition and living expenses totals about
$60,000, Berk said. Like the NYU program, students
have the option of switching to the four-year track
— none has so far — and are granted a residency
spot when they enter med school. Fears that they
will not perform as well as their four-year
counterparts have not been validated, Berk said.
Scores on licensing exams are equivalent, and
burnout has not been a problem. Charles Willnauer,
30, a graduate of Texas Tech’s first three-year class,
said the accelerated program worked well for him.
The promise of a residency in family medicine, a
specialty that “fits with my values and goals,” was
enticing, as was the lower price tag. “A lot of
people have to apply to 30 or more residency
programs,” said Willnauer, now a first-year resident.
“That’s a very large cost and a lot of time.” It was
also a bonus in other ways. Married and the father
of two toddlers born while he was in medical school,
Willnauer, age 30, said, “I bought a house and knew
I wouldn’t have to uproot my family.” (Washington
Post, 1/13/14)
http://www.washingtonpost.com/national/healthscience/medical-school-donefaster/2014/01/13/4b6d9e54-5c40-11e3-be07006c776266ed_story.html
A Solution That Now
Looks Crazy ‘American Psychosis’
Attacks Mental Health Care
41
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
“How the Federal Government Destroyed the
Mental Illness Treatment System”: That subtitle is
the opening shot across the bow in this jeremiad of
a book by the psychiatrist Dr. E. Fuller Torrey. It
could just as well have read: “How a group of wellintentioned, starry-eyed idealists made a hash of
mental health care.” You could hardly blame them
for trying, though. The care of people with serious
mental illness was long a national disgrace. By the
1950s, slightly more than half a million psychiatric
patients resided in overcrowded and underfunded
state mental hospitals, often under appalling
conditions.
Enter a group of high-minded
psychiatrists with a vision to “create a brave new
world, a mentally healthy America,” in Dr. Torrey’s
words. Armed with little more than optimism, they
helped start the National Institute of Mental Health
and set in motion an ambitious agenda for the next
half-century: closing the state mental hospitals,
initiating a federal takeover of the mental health
system, and creating a nationwide network of
community mental health centers.
well with outpatient treatment. How wrong they
proved to be. The sorry tale of what happened to
the
half-million
Americans
who
were
deinstitutionalized over the past 50 years is the
subject of this unsparing and lively takedown of
American psychiatry by Dr. Torrey, a longtime critic
of national mental health policy and the founder of
the
Treatment
Advocacy
Center.
Deinstitutionalization itself was not the problem. The
discharge of hundreds of thousands of mental
patients from state hospitals was a broadly humane
measure, made possible by the effectiveness of new
antipsychotic medicines like Thorazine.
The
egregious error was the failure to provide treatment
to patients after they left the hospital. The idea that
community mental health centers could supplant
state mental hospitals was little more than a
fantasy. The N.I.M.H.’s own data showed that
these centers were largely treating not people with
severe mental illness, but those with “social
maladjustment or no mental disorder” — better
known as the worried well. Tragically, vast numbers
of deinstitutionalized patients ended up in jails and
prisons, in nursing homes or homeless on our
streets.
Some law-enforcement agencies have
become de facto mental health systems, and at
least one-third of homeless people have serious
mental illness. The capacity of some of these
individuals for violence, of course, has received lurid
and sensational focus in the media, and Dr. Torrey
does not shy away from recounting one horror story
after another. It’s true that effective treatment for
mental illness would probably decrease violence in
the community. But because only 4 percent of
violence in the United States can be attributed to
people with mental illness, even giving all of them
the best psychiatric treatment would have a very
small effect on violence over all. Late in the book,
Dr. Torrey finally gets around to putting the risk in
perspective, but by then the force of all his
anecdotes has only served to exaggerate it.
Curiously, he does not explore the possibility that
better psychiatric treatment might well reduce the
risk of suicide: A vast majority of people who
commit suicide, in contrast to homicide, do have a
diagnosable and treatable psychiatric illness. Dr.
Torrey’s solutions for our broken mental health care
system are mostly thoughtful, though not everyone
will like them. Aside from increasing the number of
public psychiatric hospitals, he would lower the bar
for involuntary treatment. “The freedom to be
insane is a cruel hoax,” he writes, “perpetrated on
those who cannot think clearly by those who will not
think clearly.” After the mass shootings of the past
decade or so, the public may well agree with him.
But the risk of lowering the threshold to involuntary
treatment could be to discourage people with
mental illness from seeking help in the first place.
Few will disagree with his advice that we should
AMERICAN
PSYCHOSIS
How
the
Federal
Government Destroyed the Mental Illness Treatment
System.
By
E.
FullerTorrey,
M.D.
Oxford University Press. 224 pages. $27.95.
Reform was well underway when President John F.
Kennedy endorsed this new era in mental health in
a 1963 speech, calling for a “bold new approach” in
which “reliance on the cold mercy of custodial
isolation will be supplanted by the open warmth of
community concern and capability.” Those were
heady days in American psychiatry, when
psychoanalysis and the mental hygiene movement
held sway and promised to cure all manner of ills by
early intervention and improving the social
environment. In hindsight, the therapeutic zeal of
these professionals was impressively naïve: They
were certain that severely mentally ill patients in
state hospitals — many living there for decades —
would magically adjust to the community and do
42
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
focus our resources on the most problematic
patients — the estimated 10 percent who are
repeatedly hospitalized, imprisoned, or made
homeless. This wise and unflinching book is an
object lesson in good intentions gone awry on a
grand scale. It should be widely read. (New York
Times, 1/13/14)
none at all. "No state is providing high-end services
in all of their schools," said Sharon Stephan, codirector of the Center for School Mental Health, a
national organization based at the University of
Maryland that provides training for schools and
mental health providers. Baltimore and Chicago
have robust screening and treatment programs.
Teachers in one South Florida school district screen
children as young as kindergarten by filling out a
short questionnaire, while students in Minnesota
answer anonymous surveys about drug use and
depression. In Olympia, Wash., 21,000 students
were screened for substance abuse and mental
health issues in 2010, but that dropped to only
7,500 in 2012 due to lack of funding. Mental health
issues typically start during adolescence. If left
untreated, they can lead to substance abuse, school
drop outs and difficulty maintaining steady jobs and
relationships. Yet many people are not diagnosed
until later in life when they don't have access to
services because they don't have health insurance
or their insurance doesn't cover it.
The U.S.
Surgeon General reports that 10 percent of children
and adolescents suffer from serious emotional and
mental disorders that significantly affect their daily
lives. However, offering mental health screening in
schools can raise other complex issues. Some warn
that mass screenings will over-diagnose students
and stigmatize them with a life-long label. "People
have to be very cautious when they are talking
cavalierly about screening these kids. How do
people feel if they are over-identify or underidentify? ... The consequences to that are big," said
Linda Juszczak, president of the School-Based
Health Alliance, a group that advocates for school
clinics.
Some also say mass screenings could
uncover mental health problems that schools lack
resources to treat. "Once we screen and assess and
discover the need, I think it's our responsibility to
have the resources in place to service every one of
those needs that are uncovered," said Denise
Wheatley-Rowe, of Behavioral Health System
Baltimore. The organization developed a system
that has gained national recognition using a team of
school officials and community mental health
experts to target students most in need. The
program has grown from four schools to more than
100 in the past 25 years. The team identifies
children who may need help based on factors like
whether they have a parent in prison or who
struggles with substance abuse. Before children
enter middle and high school, the team scans data
for those struggling academically and behaviorally,
including those with high truancy or suspension
rates, and then offers individual counseling or family
therapy based on the student's need. Matthew
Palma, 10, attended play sessions as a
kindergartener as part of Primary Project, which
screens 3,000 kindergarten and first-graders in Palm
http://www.nytimes.com/2014/01/14/health/americ
an-psychosis-attacks-mental-healthcare.html?ref=views
Controversy Plagues Mental Health
Screenings At Schools
After his father was diagnosed with cancer, a 15year-old Champaign, Ill., teen started skipping
school, erupting in angry outbursts, yelling at
teachers and punching holes in walls or retreating to
his room paralyzed by an overwhelming sadness.
When the teen's assistant principal approached him
a few months ago about seeking help for mental
illness, the student initially declined, saying he didn't
need it. However, eventually he did seek treatment.
Diagnosed with major depressive disorder, he joined
group therapy sessions at his school. As stories
about increasing school violence dominate
headlines, experts say many teens are struggling
with untreated mental illness.
However, even
though federal health officials recommended
universal mental health screenings for students
nearly a decade ago, they still aren't required. An
Associated Press review of policies around the
nation shows screenings vary widely not only from
state to state, but within each school district.
There's no consistency on whether the schools
screen, what age they screen and what they screen
for. "We have (schools) screening for all kinds of
rare infectious diseases and then we don't screen
for common behavioral disorders that are costly to
the individual, the family and society in terms of
health care utilization, crime cost and high risk of
death ... it doesn't make any sense from a public
health perspective," said Mike Dennis, of Chestnut
Health Systems in Normal, Ill. He teaches clinicians
in 49 states how to assess and treat patients with
mental illness and substance abuse. Although the
15-year-old Illinois student was not diagnosed
through a school program, in his school-based
group therapy he's learning practical tips to identify
his triggers and calm them before emotions spin out
of control. "I think it is a good idea because a lot of
people think they don't need help but they actually
do," said the teen, who is not being identified by
The Associated Press because he is a minor. The
federal government does not keep track of school
mental health screening, so it's all but impossible to
say how many schools do or don't offer it. The
offerings vary from intensive services to virtually
43
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
Beach County each year through a one-page
assessment completed by teachers. About 650 are
referred for play sessions. Children with less severe
issues, such as trouble expressing themselves or
making friends, attend play therapy weekly for three
months. Children with more serious issues are
referred for other services. The program, which
costs $560,000 a year, is in 12 schools — about 10
percent of schools in the district — but program
leaders say they get daily requests to expand.
Matthew's mother, Susan, says his confidence
improved dramatically and the now fifth grader isn't
afraid to talk to adults or raise his hand in class.
(Lakeland Ledger, 1/13/14)
know they would qualify for Medicaid. Martinez
estimates seven out of ten of the uninsured patients
she sees can now get coverage, if those patients
follow up and apply. Hospitals are motivated to sign
patients up. For those who qualify for subsidized,
private insurance, the reimbursement rates are
welcome revenue at a time when hospitals are
facing Medicare cuts. As for Medicaid, 26 states and
the District of Columbia have opened the program
up to most poor adults, and that means if an
uninsured patient, like Angela, is found eligible,
hospitals can get paid retroactively for medical
treatments going as far back as three months. “I
think the emergency department waiting room is
one of those places where you have low-hanging
fruit,” says Renee Hsai, an associate professor of
emergency medicine at the University of California,
San Francisco. “They’re not the sickest of the sick
because at least someone, the triage nurse, has
deemed them stable enough to wait. And if they’re
waiting, they might as well be filling out some
application form, or at least learning about the
process.” The president and CEO of O’Connor
Hospital, Jim Dover, doesn’t expect to get a whole
lot more money if more people are signed up for
Medicaid. California has one of the lowest
reimbursement rates in the nation. Even so, he
sees it as a worthy goal. Dover says he wants to
get patients insured so they don’t have to come to
the ER for common problems. “Let me use this
metaphor: A person is coming down the river, and
they’re drowning, and you jump in and pull them
out. And then they come down again, and you pull
them out. Next. Two. Three. Four. Five. At
some point, you have to go up the river and take
care of the spot where they’re all falling in.” But
few in the crowd staring blankly at the TVs in the
emergency department waiting room, and parents
corralling sick and grumpy children, seem in the
mood to sign up for health insurance. Angela Felan
emerged from seeing the doctor clutching a stack of
papers. The doctor told her she had a worrisome
ear infection and needed antibiotics. When she
came to the emergency department a few days ago,
the discharge nurse didn’t mention anything about
new insurance option. But at the end of this visit,
she says, “someone said they would give me a
financial packet, and I could call the number on that
and someone would go over financial options with
me.” Calling later sounded good to Felan. She had
spent enough time in the ER and was ready to rest.
“You just want to go home and just relax and not
deal with anything ‘cause your head is pounding and
you just don’t feel good.” (Kaiser Health News,
1/14/14)
http://www.theledger.com/article/20140113/NEWS/
140119673/-1/NEWS99?p=all&tc=pgall#gsc.tab=0
Emergency Rooms Are Front Line For
Enrolling New Obamacare Customers
Angela Felan is sitting in the emergency department
waiting room at O’Connor Hospital for the second
time in a week. A blue surgical mask covers her
nose and mouth, and her hoodie sweatshirt is pulled
snug over her head. She first came into the
emergency room a few days ago with what she
thought was bronchitis. The doctor prescribed an
inhaler that cost her $56. She works part-time in
retail and hasn’t had insurance for at least a decade
because she can't afford it. “And unfortunately,
even not having insurance is just as expensive,” she
says. Felan, 31, has heard of the state’s insurance
exchange – called Covered California – but she
worries coverage will still be pricey. She’s unsure if
she will qualify for subsidies for private insurance
because of her low income, or even Medicaid. “As
far as today goes, I’m expecting another large bill
from the hospital,” Felan says. “Previously, when I
would come in uninsured, I would get like a $200 or
$300 bill for just one visit.” Some 5,000 uninsured
people come into O’Connor Hospital’s emergency
department each year, and now it is Araceli
Martinez’s job to help them find coverage. In an
office just down the hall from the ER, Martinez runs
the Health Benefits Resource Center which has
beefed up staffing and hours, with funding from
Covered California, in response to the Affordable
Care Act. Martinez says prior to 2014, uninsured
patients had few options to pay off hefty hospital
bills or enroll in health coverage. Now when they
come in through the emergency room and are faced
with a bill, “they’re saying at that time, ‘Well, maybe
I can afford [some coverage].’” Still, most patients
remain thoroughly befuddled about the law. Half of
uninsured adults who could get policies now
through the health insurance marketplaces have
never tried to buy insurance on their own, and, in
California, nearly one out of two poor adults don’t
http://www.kaiserhealthnews.org/Stories/2014/Janu
ary/14/Signing-Up-For-Obamacare-In-The-ER.aspx
44
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
the monthly premium but the lower the copays and
deductibles.
Nearly A Quarter Of Health Marketplace
Enrollees Are Young Adults
Nearly a quarter of the 2.2 million people who have
enrolled in health coverage in the health law's
insurance marketplaces are young adults — the
population that's hardest to reach and yet most vital
for the financial stability of the new exchanges, the
Obama administration announced Monday. While
federal officials say they are pleased with the early
turnout, they want to increase the proportion of
young adults buying plans before open enrollment
ends March 31. Almost 40 percent of the potential
market for the exchanges is people 18 to 34 years
old. Based on the Congressional Budget Office
estimate that 7 million people would enroll this year,
that would be 2.7 million young adults. According
to the government figures released Monday, 24
percent of those enrolling in the marketplaces
through Dec. 28 were adults ages 18 to 34. Though
no one expected young adults to be first in line
signing up for coverage this fall, trouble with
healthcare.gov during October and November has
increased the challenge of reaching them. "There's
no question because of the technological challenge,
that outreach to that population was put on hold
and folks coming to the website in October and
November were those who were super-motivated,"
said Sabrina Corlette, research professor at the
Health Policy Institute at Georgetown University.
Corlette noted that experts always expected most
young people to wait until late in the enrollment
period to enroll. "I do not see anything about the
age breakdown figures that strikes me to get super
excited about or super depressed about," she said.
Getting enough young adults to sign up for
coverage is critical to keeping the marketplaces
financially viable by subsidizing the older and sicker
people who are gaining coverage because insurers
can no longer turn people away for pre-existing
illnesses or charge them higher rates. If too many
sick people buy insurance, it could lead to higher
rates in future years that could eventually
compromise the market. The health law's individual
mandate was put in place largely to make sure
young adults signed up. The details about young
adults came in a briefing from top Health and
Human Services officials and from an HHS report
that for the first time provided details about
enrollees' age and plan choice on a state by state
basis. Some states individually had released data.
The officials announced:
-- About 60 percent of people buying policies on the
marketplaces chose a silver plan, 20 percent bought
bronze, 13 percent bought gold and 7 percent
bought platinum. Policies run from platinum as the
most expensive, followed by gold, silver and bronze,
the lowest tier. The higher the metal tier, the higher

Only about 1 percent of people chose a
catastrophic plan which requires enrollees to
pay much of their medical costs up to a certain
amount. Catastrophic plans are available for
people under age 30, those with a financial
hardship or those who have had their insurance
policy canceled.

About 80 percent of those buying a plan
qualified for a financial subsidy. Women were
more likely to purchase plans on the exchange
with only 46 percent of enrollees being male.
Administration officials say they hope to enroll
more men.

The top five states for enrollment are California
(498,794), Florida (158,030), New York
(156,902), Texas (118,532) and North Carolina
(107,778).
Young adults are the most likely group to lack
coverage — 19 million people between 18 and 34
are uninsured. Most say they do not buy policies
because they can’t afford it, says Aaron Smith,
founder and executive director of nonprofit group
Young Invincibles, a proponent of the health law.
"The 24 percent figure suggests we are on the right
track," he said. About 18 million of the 19 million
will qualify for subsidies to buy private coverage or
for Medicaid, he said. Because of concerns about
sicker consumers overwhelming the risk pool, much
attention has been centered on young adults. But
Cori Uccello, senior health policy fellow at American
Academy of Actuaries, cautioned that age
distribution is only important as a rough barometer
of health status of people signing up for coverage.
"It’s not just the distribution of age, but the health
status at every age and what is their experience (in
using insurance)," she said. She added that the age
distribution of those buying coverage only matters if
it's much different than what insurers based their
assumptions on in setting premiums.
"Among
young adults, momentum is particularly strong,"
Health and Human Services Secretary Kathleen
Sebelius said in the telephone briefing with
reporters. In addition to young adults buying health
plans, about 3 million have gained coverage
because of a provision in the law that allow them to
stay under their parents' policy until age 26, she
said.
The data about young people released
Monday mirror what some state marketplaces have
already reported. There had been concerns that
states relying on the federal exchange would have
less consumer outreach and would have a lower
proportion of younger people signing up. So far,
there’s not a big difference. Among the 14 state
exchanges, about 25 percent of enrollees are
between 18 and 34 compared to 23 percent for the
45
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
36 states in the federal exchange. The percentage
of young people enrolling ranges from 17 percent in
West Virginia and Arizona to 44 percent in the
District of Columbia.
The individual state
proportions matter because each state is a different
insurance market that has its own pricing. The low
level in Arizona is “a little surprising because we’ve
been doing enrollment at community colleges and
we have had a good response,” said David Aguirre,
health care marketplace coordinator for the Greater
Phoenix Urban League. But since so many of the
students live out of state, they may be reluctant to
enroll in Arizona’s exchange, which is administered
by the federal government, he said. Now that the
second semester of college has started for many
students, Aguirre said his staff is giving it another
try. He expects more younger people will enroll by
March 31. “We are pushing every day and we are
out there bugging them to make sure they
understand,” he said.
Smith of the Young
Invincibles said that the disparity of rates among
states shows those doing outreach will see a larger
share of young people sign up. No data was
released about people enrolling in individual plans
outside the marketplaces. Those numbers could, of
course, impact insurers’ risk pools. HHS officials
said that some of the differences reflect differences
in the average age of state populations. They noted
that West Virginia and Arizona have higher
percentages of older people than some other states.
California, which accounts for nearly 500,000 people
who have chosen a health plan, had 25 percent
enrollment
among
young
adults.
HHS
spokeswoman Julie Bataille said the administration
would widen its outreach efforts in the next few
months, which is expected to include television
advertising during the Olympic Games in February.
“There has been a lot of attention to the mix of
individuals signing up for coverage so at the end of
the day we have a balanced insurance pool,” said
Mike Hash, who directs the HHS’ Office of Health
Reform. “The trend is suggestive of an appropriate
mix in the marketplace. We are only halfway
through and we expect an increase in the proportion
of young adults as we go forward.” A recent survey
by The Commonwealth Fund, a nonpartisan
research group, found that 41 percent of those who
had shopped on state marketplaces were ages 19 to
34. A study in November by the Kaiser Family
Foundation (KHN is an editorially independent
program of the foundation), downplayed concerns
about so called "death spiral" if not enough young
people enrolled. Under a worst-case scenario in
which just 25 percent of enrollees are age 18 to 34,
then insurers would have to raise premiums by just
2.4 percent in 2015. (Kaiser Health News, 1/13/14)
Insurance Sign-Ups Skew Older,
Spurring Cost Concerns
Halfway through the six-month enrollment period
for private insurance under the health care law, just
one in four adult enrollees are between ages 18 and
34, the crucial demographic group whose
participation rates are key to keeping monthly
premiums affordable. Administration officials say
they are confident that a greater proportion of
young people will enroll by the end of March.
The New York Times: Older Pool of Health Care
Enrollees Stirs Fears on Costs,
People signing up for health insurance through the
Affordable Care Act’s federal and state marketplaces
tend to be older and potentially less healthy,
officials said Monday, a demographic mix that could
threaten the law’s economic underpinnings and
cause premiums to rise in the future if the pattern
persists (Shear and Pear, 1/13).
The Washington Post: Health-Insurance Sign-Ups By
Young Adults Are Off Pace Seen As Key To New
Law’s Success.
Young adults account for slightly less than onefourth of the Americans who signed up for health
plans during the initial three months of federal and
state insurance marketplaces — fewer so far than
the government has said will be needed to make the
economics of the new exchanges work. The figures,
part of a monthly progress report on the
marketplaces that was issued Monday, offer the first
glimpse into whether the health plans available
under the Affordable Care Act are becoming
provinces of the old and sick or are managing to
attract young, healthy people who have not
previously
considered
insurance
worthwhile
(Goldstein and Somashkehar, 1/13).
The Wall Street Journal: Health Sign-Ups Skew
Older, Raising Fears Over Costs.
One-third of health plan enrollees in new insurance
marketplaces are 55 or older, the Obama
administration said Monday, a figure that insurers
said makes the pool older than they would need to
sustain their coverage at current premiums.
Administration officials said they are pushing to
enroll more young people before a March 31
deadline for most people to get coverage for this
year, and some cushions built into the law mean it
won't necessarily face trouble right away even if the
2014 pool of enrollees skews older (Radnofsky and
Weaver, 1/13).
The Associated Press: Health Care Signups: More
Older Americans So Far.
http://www.kaiserhealthnews.org/Stories/2014/Janu
ary/13/HHS-marketplace-enrollment-data.aspx
46
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
Younger people went for President Barack Obama at
election time, but will they buy his health insurance?
New government figures show it's an older, costlier
crowd that's signing up so far for health insurance
under Obama's health care law. Enrollments are
lower for the healthy, younger Americans who will
be needed to keep premiums from rising (AlonsoZaldivar, 1/14).
Halfway through the six-month enrollment period
for private marketplace health insurance, just one in
four new adult enrollees are between ages 18 and
34, the crucial demographic group whose
participation rates are key to keeping monthly
premiums affordable under Obamacare. In the first
release of extensive demographic data about the
new enrollee population, the Obama administration
said Monday that 55 percent, or roughly 1.2 million
of the nearly 2.2 million people who’ve selected a
federal or state marketplace plan, are generally
older adults, ranging in age from 45 to 64. About
517,000, or 24 percent, of the new enrollees were
young adults ages 18 to 34 (Pugh and Kumar,
1/13).
USA Today: Most Insurance Enrollees Older Than
45, Records Show.
More than half of the almost 2.2 million people who
bought health insurance on federal and state
exchanges in the past three months are older than
45, records released Monday show. If that trend
holds, it could skew the health insurance market as
older policyholders that use more health care are
not balanced by younger policyholders who tend to
use less health care. In effect, the younger
policyholders subsidize older ones (Kennedy, 1/13).
Marketplace: Obamacare Stats Show Young Folks
Are Signing Up.
Just under a quarter of Obamacare sign-ups so far
have been in the critical 18-to-35-year-old age
range, the Obama administration revealed Monday,
the first time officials have given demographic data
about health plan enrollees. The administration had
set a goal of around 38 percent to 40 percent of the
enrollees in that age bracket by the time the sign-up
season ends March 31 (Cheney and Millman, 1/14).
Today, the Department of Health and Human
Services announced that nearly 2 million people
enrolled for health insurance through the federal
and state exchanges in December. That includes a
dramatic increase in the number of young people
signing up.
That number of so-called 'young
invincibles' is higher than some had predicted. And
in a conference call today, HHS officials said that
about one in four of all the consumers on the
exchanges are between the ages of 18-34. Ideally,
you want to see a higher rate, about 40 percent, of
exchange customers in that age range. The data
raises a bunch of questions (Gorenstein, 1/13).
CBS News: Obamacare Sign-Ups Among Young
Adults Off To Slow Start.
The Fiscal Times: Four New Mysteries in the
Obamacare Enrollment Numbers.
About one-quarter of those who signed up for
Obamacare by the end of 2013 were between the
ages of 18 and 34, the Obama administration
reported Monday, falling below what experts have
called the ideal proportion of young adults in the
new health insurance marketplace.
However,
administration officials said they are comfortable
with the proportion of young enrollees so far, and
they expect Obamacare enrollment in the key
demographic group to accelerate in the second half
of the six-month open enrollment period (Condon,
1/13).
The White House is still lagging to meet selfimposed enrollment targets. And young people are
not signing up at the pace the White House needs,
no matter how CMS claims that they’re on track to
meet their goals. Now that we know the December
data, here are four mysteries in the Obamacare
numbers (Francis, 1/14).
Politico: Young Adults Make Up One-Fourth Of
Obamacare Enrollees.
The Fiscal Times: White House Claims It Will Reach
Obamacare
Goal
Nearly a quarter of the 2.2 million Americans who
have signed up for Obamacare so far are young
people, ages 18-34, the demographic most
important to the success of the president’s
healthcare law. It’s not clear yet, however, how
many have actually paid their premiums. A new
White House report released Monday shows some
489,460 Americans ages 18-34 have signed up for
health insurance through the state and federal
exchanges since Obamacare's launch on Oct 1.
Though White House officials say they are
encouraged by the new numbers, they are well
below the administration’s goal of enrolling 2.7
million young Americans which are needed to
Fox News: Insurers Raise Cost Concerns After
ObamaCare Demographic Data Released.
Insurers have raised concerns that too few young
people are signing up for health insurance through
the ObamaCare exchanges after newly released
statistics showed that less than a quarter of people
who have enrolled are between the ages of 18 and
34 (1/14).
McClatchy: Young Adult Enrollment In Health Care
Marketplaces Lags.
47
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
subsidize the cost of older, sicker Americans (Ehley,
1/13).
a plan, the federal government will give the
subsidies directly to the states, instead of to
individuals and families. The states are supposed to
pool the money and then use the financial leverage
to push insurers to offer less expensive coverage. A
number of states, including New York and
Washington, are eager to create such programs, but
they can’t until the Obama administration issues the
regulations that will govern them. “We all thought
we were going to be able to start in 2014 and then
we waited for the rules, and we waited and waited
and waited,” said Varon, who sits on a state board
that will develop Washington’s Basic Health Program
when the rules are finally written. Some now fear
states won’t be able to launch the programs before
2016.
CQ HealthBeat: HHS Optimistic About Exchange
Sign-Ups Among Young, But Enrollment Still Key
Federal officials reported Monday that nearly 2.2
million Americans through Dec. 28 selected health
plans from federal and state insurance exchanges.
The officials said they are pleased with the sign-up
rate by the key demographic group of young
Americans, even though so far the percentage of
young adults is lower than what the Obama
administration has said will be needed by the time
that open enrollment ends on March 31 (Reichard,
1/13). (Kaiser Health News, 1/14/13)
http://www.kaiserhealthnews.org/DailyReport.aspx?reportdate=1-14-2014
A Computational Labyrinth
For now, low-income Americans who aren’t eligible
for Medicaid must rely on the financial help that is
available to them on the health insurance
exchanges. Determining how much that amounts to
is a computational labyrinth. According to the ACA,
a family of three whose annual income is at 133
percent of the federal poverty level (an annual
income of $24,352), should have to pay no more
than 3 percent of their household income in annual
premiums, or $731. In that case, the federal
government would pay the insurance company the
difference between $731 and the actual premium.
The percentage an individual or family is expected
to pay rises at higher income levels, up to 400
percent of poverty. At that income level, paying up
to 9.5 percent of household income on health
insurance is considered affordable. So, a family of
three making $73,240 would receive a subsidy to
cover premium amounts above $6,958. People
making between 133 and 250 percent of the poverty
level also can get help with their out-of-pocket
medical expenses, such as co-payments for visits to
the doctor, providing they purchase at least a
“Silver” plan on the exchange. The exchanges offer
up to four different tiers of health insurance plans:
“Bronze,” “Silver,” “Gold” and “Platinum.” Bronze
plans have the cheapest premiums, but leave
policyholders with the highest co-payments and
deductibles.
Platinum plans have the highest
premiums but the lowest co-pays and deductibles.
Under the Silver plans, people making more than
250 percent of the poverty level can expect to
contribute an average of 30 percent for their
medical costs, with their insurance company paying
the rest. But those with incomes below 250 percent
of the poverty level can get federal assistance with
their out-of-pocket expenses. At 133 percent of the
poverty level, an individual or family could
contribute as little as 6 percent to the cost of their
medical bills with the insurance company and the
federal government picking up the rest. Those cost-
Affording the Affordable Care Act
The promise of the Affordable Care Act is right there
in its title: Affordable. Yet, anti-poverty agencies
across the country fear that even with the federal
financial assistance available under the law, health
insurance will remain unaffordable for significant
numbers of low-income Americans. “For those with
very low wages trying to raise kids, after paying for
housing, electricity, food, transportation, and child
care, asking people to pay another $50 or $100 a
month, that’s just out of reach,” said Sireesha
Manne, a staff attorney at the New Mexico Center
on Law and Poverty. The Affordable Care Act
(ACA) is designed to make insurance affordable for
Americans with low and moderate incomes—
particularly since it requires all Americans to have
health insurance starting this year, or face financial
penalties. The law expands Medicaid eligibility (in
the states that have agreed to do so) to the poorest
Americans—those making up to 133 percent of the
federal poverty line. But it also provides financial
assistance for those making up to 400 percent of
the poverty level to help them buy private insurance
on the new state health exchanges. Still, the
financial help isn’t enough for some. “Even with the
subsidies, some people simply won’t be able to
manage to pay their health insurance premiums
consistently with all the other costs facing them,”
said Janet Varon, executive director of the
Northwest Health Law Advocates in Seattle which
works on health access issues.
Financial Leverage
The authors of the ACA anticipated this problem.
To address it, the law allows states to create a
separate insurance program, called the Basic Health
Program, for people who earn too much to qualify
for Medicaid and too little to afford insurance on the
state exchanges, even with federal aid. Under such
48
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
saving breaks, however, are only available for those
selecting Silver plans, apparently to entice people
away from Bronze plans with their high deductibles
and co-pays.
seems months away, if not longer.
In the
meantime, she predicts that policymakers will be
hearing about legions of Americans who still can’t
afford health care—no matter the title of the
Affordable Care Act. (Stateline, 1/14/14)
Defining “Affordable”
Obamacare’s Narrow Networks Are
Going To Make People Furious — But
They Might Control Costs
Despite all of this assistance, health insurance still
may not be “affordable” for some. Affordability, like
beauty, is a matter of opinion. “What it means for
something to be affordable or not affordable is
totally debatable,” said Sherry Glied, dean of New
York University’s Robert F. Wagner Graduate School
of Public Service. “It isn’t like there’s a fixed
definition of affordability.” That’s particularly true in
the U.S., where the cost of living varies so strikingly.
“What’s poor in Mississippi is different from what’s
poor in New York state,” said Elisabeth Benjamin, an
executive with the Community Service Society of
New York. “People have so little disposable income
in New York City and other urban areas, but the law
doesn’t do geographic indexing.” Using cost of
living data on the Albuquerque area from the
Economic Policy Institute, Kelsey Heilman, a former
staff attorney with the New Mexico Center on Law
and Poverty, showed that a single mother of two
making 200 percent of the poverty level would have
virtually no money left for health care premiums or
health care expenses after paying for housing, food,
transportation and other necessities. That mother,
Heilman said, might decide to go with the cheaper
Bronze plan, but then she would forgo the costsharing help the federal government makes
available for Silver plan policyholders. As a result,
she might pay as much as 40 percent of her medical
expenses out of pocket, instead of the 13 percent
she would have to pay with a Silver plan. That
difference could amount to more than $3,000 a
year. Those who decide to forgo insurance can ask
for hardship exemptions from the financial penalty.
But getting medical care is likely to become
increasingly difficult for them because the federal
government is cutting its payments to hospitals that
provide charitable care to the poor. Other possible
solutions to the affordability problem have also
surfaced. Massachusetts, which enacted its own
health care reforms in 2006, won federal permission
to use Medicaid dollars to provide premium and
cost-sharing assistance for those with incomes
below 300 percent of the poverty level who
purchased private insurance on the Massachusetts
exchange. Other states could apply for permission
to do the same, but it is a months-long process.
States also might seek to raise eligibility for
Medicaid above the 133 percent threshold. Manne,
with the New Mexico Center on Law and Poverty,
said some businesses and hospitals have talked
about voluntarily undertaking sponsorships to help
those unable to pay premiums or meet out-ofpocket obligations. But, Manne said, broad relief
Welcome to Health Reform Watch, Sarah Kliff’s
regular look at how the Affordable Care Act is
changing the American health-care system — and
being changed by it. You can reach Sarah with
questions, comments and suggestions here. Check
back every Monday, Wednesday and Friday
afternoon for the latest edition or sign up here to
receive it straight from your inbox. Read previous
columns here.
"Surprise!
Kentucky health
exchange networks may exclude your hospital,"
reads one recent headline in the Louisville Courier
Journal. Or, as Time magazine puts it, "Keeping
your doctor under Obamacare is no easy feat."
Behind these stories lurks a policy idea that's central
to Obamacare's approach to controlling costs, but
anathema to many health-care consumers: "Narrow
networks." Just the name itself, a narrow network,
sounds like a miserable, restrictive health plan that
you would just as well avoid. But health-care
experts love narrow networks, pointing out that they
underpin some of the country's most successful
health plans. So what's a narrow network? It's best
to start with some definitions: Narrow networks are
health insurance plans that place limits on the
doctors and hospitals available to their subscribers.
They tend to do this in two ways, the first -- and
most obvious -- by simply not paying for trips to
doctors that aren't in their restricted network. The
second version, a bit more nuanced, typically has
health insurance plans charging higher co-payments
to go see a doctor who isn't in the "top tier." In this
case, you can go out-of-network -- but will have to
pay a higher price in order to do so. Why shouldn't
I be able to see any doctor I want? Less choice in a
health plan typically means lower premiums. First,
the insurance plan can decide to only sign contracts
with the hospitals that charge lower prices. There is
huge, huge variation in health-care prices; an
appendectomy, for example, can cost anywhere
between $1,529 and $186,955. By only signing
contracts with providers who are more in the
$1,529-range -- and, ideally, who also have pretty
good outcomes on their appendectomies -insurance plans can lower the price of providing
health care without compromising quality. Second,
insurance plans that work with a smaller handful of
providers would have more leverage to demand
even lower prices from these hospitals and doctors.
They're essentially promising to buy in bulk from a
49
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
small set of physicians, and can therefore reduce
the cost they pay for each visit. That, then, allows
them to offer lower premiums to the people buying
health insurance. Did Obamacare invent narrow
networks?
No, Obamacare is accelerating a
preexisting trend. Narrow network plans have
become increasingly popular in recent years,
growing from 15 percent of the insurance plans that
employers offered in 2007 to 23 percent in 2012.
Many exchange carriers are offering limited provider
networks," Timothy Jost, a supporter of the health
law, writes in a recent edition of Health Affairs.
"Consumers will like the low premiums but will be
unhappy to learn that their doctors are not available
and shocked to discover charges from out-ofnetwork specialists when they go to in-network
hospitals." Are narrow network plans worse for
patients? The growth of narrow network plans, as
Jost points out, isn't one that tends to be favorably
viewed by patients. When they're told certain
doctors are off limits, subscribers are predictably
frustrated. But whether narrow networks are
actually bad for patients' health -- whether losing
access to the most expensive hospital also means
losing access to the best hospital -- is a totally
different question, and one that's difficult to answer.
The patients' worry tends to be losing access to the
best doctors, especially when the networks getting
cut out are the most expensive. It makes sense,
intuitively, that the most expensive hospitals are
probably the best -- if not, why would they charge
so much money? Alas, the health-care system is
anything but intuitive and, most research suggests,
there is very little connection between how much
we pay for health care and the quality of the
provider. "Evidence of the direction of association
between health care cost and quality is
inconsistent," Peter Hussey, Samuel Wertheimer and
Ateev Mehrotra wrote in a recent RAND literature
review.
"Most studies have found that the
association between cost and quality is small to
moderate, regardless of whether the direction is
positive or negative."
In other words: It's
completely possible that cutting out an expensive
hospital cuts out a top-notch provider. And, it's
equally possible that cutting out an expensive
hospital eliminates a provider who charges
excessive fees without delivering really great
As you can see in this graph from the Kaiser Family
Foundation, narrow networks were taking hold well
before the Affordable Care Act, as employers looked
to tamp down on premiums growth. But most
observers also agree that the health-care law helped
accelerate the growth of these plans. So what's
Obamacare doing here, exactly? The move toward
narrow networks in Obamacare is a function of the
way the law sets up competition between insurers
on the exchanges. Insurers can no longer compete
by trying to be the best at only covering healthy
people, or by endlessly lowering benefits and raising
deductibles. So limiting provider choice emerged as
one of the few levers that health plans had to hold
down premiums.
And a lot of them did:
approximately 70 percent of the exchange plans are
either narrow or ultra-narrow plans, according to a
study by McKinsey and Co. The consulting firm
defined "narrow" as having at least 30 percent of
the 20 largest hospitals in the geographic region not
participating in the plan.
50
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
medical care. "Narrow networks are not some cruel
attempt to limit patient choice foisted upon us by
the insurance industry," David Dranove and Craig
Garthwaite, two professors at Northwestern
University's Kellogg School of Business, write.
"Instead, these plans may provide our best
opportunity for harnessing market forces to lower
prices. Even high priced providers know they stand
a good chance of being in broad networks. But
insurers offering narrow networks can be picky
about which providers they select." And, in some
cases, the narrowness of a network can be a big
boon: Doctors get to know their smaller group of
patients very well. As Bill Eggbeer and Dudley
Morris point out in a recent BDC Advisors’ white
paper, Kaiser Permanente is arguably the country's
largest narrow network provider, although it rarely
gets described that way. Kaiser limits patients'
choices to the doctors it employs -- but also gives
each and every one of those doctors access to a
patient's medical record. In this narrow network
there's space for managing a patient's care across
different visits. The health plan has "approximately
9 million members and is achieving high marks for
cost efficiency and patient satisfaction," they write.
It also limits patients' choice severely, just to Kaiser
Permanente facilities, which all use the same
electronic medical records. When your choice of
hospitals gets limited to those with high quality
ratings then, all of a sudden, a limited network
doesn't seem so bad at all. That's not to say this is
the case with all exchange plans; it most likely is
not. Rather, a narrow network isn't inherently a bad
health insurance policy. It all depends on the
quality of providers that end up in the narrow
network, and how well they work together to deliver
health care. (Washington Post, 1/13/14)
2010 Affordable Care Act seeks to get health
insurance to the 15 percent of Americans who don’t
have it in several ways: with online health
marketplaces called exchanges, by expanding
Medicaid and by changing insurance laws so that
companies cannot refuse to cover certain people or
stop their coverage once it gets expensive. To sign
people up, the Obama administration recruited and
trained so-called navigators, assistants to help
people choose which plans would be best for them
among the dozens of choices in some states. And
community health centers launched their own
efforts, because many of their clients fall into the
groups most in need of health insurance. But after
the Supreme Court gave them the option, many
states decided not to expand Medicaid — even
though the federal government will pay for the
entire cost until 2017. Around 20 have decided
against it. In addition, states such as Missouri,
Montana, Texas and Florida have passed law
restricting what navigators and others can ask and
say in helping people enroll in health care. They're
all states that have refused to expand Medicaid or to
operate exchanges, forcing the federal government
to step in and do it. The Missouri law requires the
navigators to pass an exam and pay a fee before
they can be licensed by the state.
Texas is
requiring extra training and testing for navigators,
while Florida forbids navigators from working in
state offices.
Supporters of the laws say it's
important to ensure that people working with
private information — names, addresses, Social
Security numbers and income details — be properly
trained and vetted. The Obama administration calls
it "bullying." "This is a blatant attempt to add
cumbersome requirements to the navigator program
and deter groups from working to inform Americans
about their new health insurance options and help
them enroll in coverage,” U.S. Health and Human
Services department spokesman Fabien Levy said in
September after Texas passed its law. Some of the
laws were passed to address issues raised by
licensed insurance agents and brokers, Rosenbaum
says. But it has affected efforts to help people sign
up. “The big smoking gun as far as I am concerned
is assisting in selecting a health plan,” Rosenbaum
told NBC News. “There is a highly significant
difference between the restrictive states and the
non-restrictive states in community enrollment
assisters who are actually helping people figure out
the health plans.” Don McBride of ACCESS Family
Care in Neosho, Mo., says he’s seen it. “We have
been handicapped,” McBride told NBC News. “But
with everything that is going on, I think we are
making the best of it.” “We haven’t been able to
reach as many people,” agreed Kally Taul, outreach
coordinator and a navigator at the clinic system.
But McBride, Taul and others say they are not
simply being hobbled by state laws. It’s more
http://www.washingtonpost.com/blogs/wonkblog/w
p/2014/01/13/obamacares-narrow-networks-aregoing-to-make-people-furious-but-they-mightcontrol-costs/
State Efforts To Block Obamacare Are
Working, Study Finds
States whose governments are hostile to
Obamacare are hindering efforts to get people
signed up for health insurance, according to a study
released Tuesday. Laws restricting outreach and
enrollment efforts have handicapped community
health centers that are a key component of plans to
get health insurance to millions of Americans who
lack it, researchers at George Washington University
found.
“This is the first study to attempt to
measure the impact of restrictive state policies,”
said Sara Rosenbaum, who led the team at GW’s
Department of Health Policy that did the study.
“The navigator laws are having a real effect.” The
51
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
complex than that, they say. “It’s not the funding.
The main thing is the negative publicity,” Taul said.
Bad publicity had made people mistrustful, McBride
agreed. “They call it ‘Obamacare’ and it’s like the
atom bomb,” he said. “It is definitely going to take
some time to build trust.” Rosenbaum’s team
surveyed 606 out of the nation’s 1,198 federally
qualified community health centers. They compared
the answers from health centers in states that have
embraced health reform to those that have been
less welcoming and found that community health
centers in restrictive states had smaller enrollment
staffs and workers there expected more of the
patients they assisted to remain uninsured. At least
19 states have passed laws that limit what
navigators or other assisters may say and do, or
that add hours of training and licensing
requirements on top of what the federal
governments asks. “Health centers in restrictive
states reported approximately half the staffing
capacity maintained by health centers in full
implementation states,” the report reads.
“Of
particular significance in measuring the impact of
navigator restrictions is the fact that health centers
in restrictive states were significantly less likely to
assist with plan enrollment,” it adds. This can hurt
because the people signing up at health centers are
those who are the least likely to understand health
insurance in the first place, Rosenbaum says. “The
significantly lower rate of plan enrollment assistance
suggests that the regulatory burdens created by
navigator laws are affecting not only the work of
certified navigators but community outreach and
enrollment efforts more generally,” the report
concludes.
“When you change the policy
environment and put the brakes on things, it really
trickles down to the community,” Rosenbaum said.
The survey was done last year and it's too soon to
say whether actual enrollments were affected. The
Obama administration said Monday that 2.2 million
people have signed up for private health insurance
on the exchanges, and more than 3 million more
have newly qualified for Medicaid, the state-federal
health insurance plan for the low-income. (NBC
News, 1/14/14)
http://www.nbcnews.com/health/state-effortsblock-obamacare-are-working-study-finds2D11922402
Monday night, neutralized almost all of the 134
policy provisions that House Republicans had hoped
to include, with negotiators opting for cooperation
over confrontation after the 16-day government
shutdown in October. Measures to eliminate the
Environmental Protection Agency’s ability to regulate
greenhouse gases and reverse clean water
regulations did not survive the final negotiations.
Republicans also relented on their efforts to strip
financing to carry out the Affordable Care Act.
“Obamacare lives another day,” said Senator
Barbara A. Mikulski, Democrat of Maryland, the
chairwoman
of
the
Senate
Appropriations
Committee. The compromises may be difficult to
accept for conservative Republicans, many of whom
campaigned in 2010 vowing never to vote on a
phone-book-size bill they have not had time to read.
And because many of them will balk, the bill will
have to have bipartisan support to pass. Republican
and Democratic leaders said they believed they
would easily get majorities in the House and Senate,
but not without loud protests from both the right
and the left. Republicans do get to point to some
conservative victories. The bill would cut $1 billion
from the Affordable Care Act’s Prevention and Public
Health Fund, which Republicans have long targeted,
fearing the administration would use it to bolster the
law’s online insurance exchanges. The legislation
also would impose new requirements for the
Internal Revenue Service in reporting its activities to
the public and Congress after the agency’s scrutiny
of Tea Party groups’ applications for nonprofit
status. The $11.3 billion appropriated for the I.R.S.
is down $503 million from the level enacted in 2013.
No money would be given to Vice President Joseph
R. Biden Jr.’s high-speed rail projects, or to Mr.
Obama’s preschool development grants program.
And some new regulations supported by liberals
would be blocked, including a standard for energyefficient light bulbs and livestock and poultry
controls.
Conservatives also succeeded in
prohibiting the Obama administration from
transferring inmates to the United States from the
military prison in Guantánamo Bay, Cuba.
Otherwise, the bill’s winners and losers seem to
follow no patterns.
The National Institutes of
Health, long a congressional favorite, would get
$29.9 billion, down $714 million from the level
approved by Congress for 2013. Still, the N.I.H.
would end up with $1 billion more than it did last
year after the across-the-board spending cuts,
known as sequestration, severely curtailed its
research grants. In contrast, Head Start, which also
suffered last year, would see a $612 million
increase, enough to restore the sequestration cuts.
The military budget would total $572.6 billion, $20
billion less than House Republicans wanted. The bill
also explicitly prohibits the Postal Service from
cutting Saturday mail delivery or closing rural post
House And Senate Negotiators
Agree On Spending Bill
House and Senate negotiators reached accord on a
trillion-dollar spending plan that will finance the
government through September, reversing some
cuts to military veterans’ pensions that were
included in a broader budget agreement last month
and defeating efforts to rein in President Obama’s
health care law. The hefty bill, filed in the House on
52
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
offices. Despite the concern over security after the
2012 attack on the United States Mission in
Benghazi, Libya, the spending bill earmarks less to
embassy security, construction and maintenance
than it allotted for fiscal 2013 — $2.67 billion, down
by $224 million. Specific areas of the country would
benefit from provisions. They include $128 million
for an expanded border crossing station at San
Ysidro, Calif., between San Diego and Tijuana,
Mexico. But the final bill allocates less than the
$226 million for the project that had been requested
by the Obama administration. The spending bill’s
costs were set in a deal last month by
Representative Paul D. Ryan of Wisconsin and
Senator Patty Murray of Washington, leaders of the
Budget Committees. But the final bill restores part
of that accord’s most controversial spending cut — a
one-percentage-point reduction in cost-of-living
adjustments to the pensions of working-age military
veterans. Under the bill, that cut will not apply to
disabled veterans. Lawmakers in both parties have
pledged to eliminate the reduction. The final plan
would raise spending on programs at Congress’s
annual discretion by $25 billion over the limit
originally set by the House, but it cuts spending by
$25 billion from the limit approved by the Senate.
(New York Times, 1/13/14)
But in a blow to the District, it provides only partial
funding to continue constructing buildings for the
Department of Homeland Security’s campus in
Anacostia. The White House and leaders of both
parties praised the measure, which would fund
federal agencies for the remainder of the fiscal year
and end the lingering threat of a government
shutdown when the current funding bill expires at
midnight
Wednesday.
“The
bipartisan
appropriations bill represents a positive step forward
for the nation and our economy,” White House
budget director Sylvia Mathews Burwell said in a
statement. The spending bill puts flesh on the
bones of a bipartisan budget deal struck in
December, when Republicans and Democrats
agreed to partially repeal the sequester, heading off
a roughly $20 billion cut set to hit the Pentagon on
Wednesday and restoring funding to domestic
agencies, which had already absorbed sequester
reductions. Despite the increases, the bill would
leave agency budgets tens of billions of dollars
lower than Obama had requested and congressional
Democrats had sought. That represents a victory
for congressional Republicans, who, after three
years of fevered battles over the budget, have
succeeded in rolling back agency appropriations to a
level on par with the final years of the George W.
Bush administration, before spending skyrocketed in
an effort to combat the recession. Rep. Tom Cole
(R-Okla.), a senior member of the House
Appropriations Committee, said he expects a
majority of lawmakers in both parties to support the
measure.
“Everybody can find something to
complain about — legitimately so,” Cole said. “But
from the Republican standpoint, gosh, this is $164
billion less than Bush’s last discretionary budget, so
that’s pretty good progress in cutting spending.”
http://www.nytimes.com/2014/01/14/us/politics/ho
use-and-senate-negotiators-agree-on-spendingbill.html?emc=edit_tnt_20140113&tntemail0=y&_r=
0
Lawmakers Unveil Massive $1.1 Trillion
Spending Bill In Bipartisan Compromise
Congressional negotiators unveiled a $1.1 trillion
funding bill late Monday that would ease sharp
spending cuts known as the sequester while
providing fresh cash for new priorities, including
President Obama’s push to expand early-childhood
education. The 1,582-page bill would fully restore
cuts to Head Start, partially restore cuts to medical
research and job training programs, and finance
new programs to combat sexual assault in the
military. It would also give all federal workers a 1
percent raise.
53
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
Many Democrats agreed.
“Compared to the
sequester, this is obviously a big improvement. But
compared to investments we should be making, it
falls far short,” said Rep. Chris Van Hollen (Md.), the
senior Democrat on the House Budget Committee.
The measure proves, he said, that “this notion that
the federal government is on a spending binge is
just nonsense.” With the deadline for a government
shutdown fast approaching Wednesday night, House
and Senate leaders were preparing a temporary bill
to keep the government open through Saturday.
That would give lawmakers the rest of the week to
review the massive new measure, which proposes
funding and policy changes that would reach into
every corner of the federal government. House
Appropriations Committee Chairman Harold Rogers
(R-Ky.) and Senate Appropriations Committee
Chairman Barbara A. Mikulski (D-Md.) met through
the weekend to put the finishing touches on the
package. The pair released a joint statement late
Monday, along with a photo showing them smiling
happily and shaking hands.
“As with any
compromise, not everyone will like everything in this
bill,” the statement said.
“But in this divided
government a critical bill such as this simply cannot
reflect the wants of only one party.” Given barely a
month to complete work on the package, Mikulski
and Rogers were able to overcome early partisan
disputes over funding for the Affordable Care Act,
Obama’s signature legislative achievement, and
payments due to the International Monetary Fund, a
frequent target of conservatives. To sweeten the
package, they agreed to include a provision that
would exempt disabled veterans from a modest
pension reduction for military retireesenacted last
month to help cover the cost of the sequester
repeal. All told, the bill would provide $1.012 trillion
to the Pentagon and other federal agencies. An
additional $92 billion would be set aside for
overseas operations, including military activity in
Afghanistan and assistance for the growing flow of
refugees fleeing the war in Syria. The bill also
authorizes $6.55 billion for domestic disaster relief.
The measure authorizes a 1 percent pay increase for
civilian federal workers and U.S. military personnel.
But in response to several examples of excess
spending by federal agencies, the bill would put in
place new limits on certain conferences, official
travel and employee awards.
The National
Institutes of Health would receive $29.9 billion, $1
billion more than under the sequester but $714
million less than the agency was due to receive last
year before the sequester hit last March. Carrie
Wolinetz, president of United for Medical Research,
a consortium of patient, provider and research
organizations, said the proposal “won’t adequately
reverse the damage done by last year’s budget
sequester and ensure the nation’s biomedical
research enterprise makes continued progress in
lifesaving research and development.”
The
Department of Education would get $70.6 billion,
including full restoration of Head Start funding. And
while Republicans refused to finance Obama’s push
for universal pre-kindergarten classes, they granted
his request to expand Head Start partnerships that
benefit toddlers and infants. The Department of
Homeland Security would face a reduction in
funding of about $336 million, with most of the cuts
at the scandal-ridden Transportation Security
Administration. In a victory for Republicans who
have sought for years to boost the use of private
security contractors, the agreement increases
funding for private security screeners and caps the
TSA’s overall screening personnel at 46,000. The
agreement is riddled with dozens of controversial
policy riders. One would bar funding to enforce a
law that requires incandescent light bulbs to meet
new efficiency standards.
The measure would
continue a ban on transferring terrorism detainees
at the detention facility at Guantanamo Bay, Cuba,
to sites in the United States. It would also withhold
additional funding for the government of
Afghanistan until the country agrees to a new
bilateral security agreement. And the measure
would ban foreign aid for Libya until Secretary of
State John F. Kerry “confirms Libyan cooperation”
with ongoing investigations into the Sept. 11, 2012,
attack at the U.S. diplomatic outpost in Benghazi.
The measure would also provide new congressional
backing for Obama’s strategy of continuing aid to
Egypt, despite a law that forbids U.S. military aid to
governments that have taken power by military
coup, as Egypt’s interim military-backed government
did in July. Several issues regarding gun control are
also included in the bill. The legislation restricts the
Justice and Homeland Security departments from
establishing programs similar to the “Fast and
Furious” gun-tracking effort.
In response to
allegations that the administration has been
stockpiling ammunition for use by federal agents,
the measure also requires Homeland Security to
provide detailed reports on its purchase and use of
ammunition. The measure also continues a ban on
the use of federal funding to perform most
abortions, including abortions in the District and for
federal prisoners.
But Republicans agreed to
jettison other contentious proposals, including a ban
on new federal regulations for greenhouse gases
and the “global gag rule,” which sought to prohibit
U.S. funding for organizations that give women
information about abortion. (Washington Post,
1/14/14)
http://www.washingtonpost.com/business/economy
/members-of-congress-to-unveil-massive-spendingbill-in-bipartisancompromise/2014/01/13/71db3a8c-7c9e-11e39556-4a4bf7bcbd84_stor
54
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
the estimated seven million who would sign up
overall for 2014. The accompanying chart shows
the exchanges aren't hitting that goal. Just 24
percent of those who have chosen a plan were
between 18 and 34. By contrast, the largest share
of enrollees -- one third -- are between 55 and 64.
(There's a caveat here: The administration could
claim that its definition of young and healthy
covered everyone under 35, including the 6 percent
of exchange enrollees who are under 18. That
would still leave it short of its stated goal, as well as
looking a touch eager to persuade the naysayers.)
Everyone Can Celebrate
New Obamacare Numbers
Today the federal government released the most
comprehensive data yet about who signed up for
Obamacare through Dec. 28. There's reason to
cheer for both the law's supporters and its
detractors. Let's start with the good news for
Obamacare fans.
President Barack Obama's
administration predicted -- or, well, prayed -- that
enrollment in the law's state insurance exchanges,
which was initially anemic, would accelerate toward
the end of 2013, as the deadline approached for
getting coverage by this month. As you can see
from the accompanying charts, that prediction came
true: More than 2 million people had chosen
exchange plans by Dec. 28, almost a five-fold
increase over the number enrolled a month earlier.
The number of people who were deemed eligible for
Medicaid also increased, but not at the same rate as
private coverage.
As you can see from the right-hand side of the
chart, that's significantly different from the age
breakdown of the uninsured population, which
skews much more heavily toward the young. So
one of two things is happening here. Either the old
and sick are self-selecting into Obamacare, which
spells trouble for insurers (and, by extension, the
government, which backstops insurers against
higher-than-expected risks).
Or young people
without insurance are taking their sweet time
signing up but will do so before the March 31
deadline. The administration is obviously hoping for
the latter.
Today's numbers don't settle the
question of whether the administration will hit its
goals for enrollment in the exchanges, measured
either in raw numbers or demographic breakdown.
But they show that those goals are within reach.
(Bloomberg, 1/13/14)
The accompanying chart also shows that federally
run exchanges, which initially performed worse than
those operated by the states, are now enrolling
people at a quicker rate than state exchanges.
That's a validation of sorts for the Department of
Health and Human Services, as it supports the
notion that it's learning from its early mistakes.
There's still plenty of work to do. For starters, in
some states the number of women enrolling in
Obamacare coverage exceeds the number of men,
out of all proportion with demographics. But that
doesn't mean the law isn't working; it means the
administration needs to find better ways to
persuade men to sign up for coverage. Now, the
good news for detractors. The government said last
year that to get the right balance between healthy
and sick people on the exchanges -- and, by
extension, to produce affordable premiums -- it
needed 2.7 million people between 18 and 34 to
sign up for coverage. That's about 40 percent of
http://www.bloomberg.com/news/2014-0113/everyone-can-celebrate-new-obamacarenumbers.html
R&D Funding Is the Best Medicine
American innovation, badly damaged last year by
federal budget tightening and the across-the-board
cuts known as sequestration, appears to be getting
partial relief with the bipartisan budget deals struck
55
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
last month and Monday night. The progress is
praiseworthy, but it will not counteract the decadeslong decline in federal funding for research and
development that is so essential to our economic
future and critical to accelerating treatments for
today’s major health care challenges, including
Alzheimer’s, diabetes, heart disease and cancer.
Federal R&D expenditures plummeted by 16.3
percent, in constant dollars, between fiscal years
2010 and 2013, and the nation’s federal investment
in science as a share of the economy currently
stands at roughly 0.82 percent — the lowest point in
50 years. This recent decline comes at a time when
other countries are ramping up their own
investments in science and innovation.
For
instance, Chinese investment in R&D from all
sources has increased by more than 400 percent
over the past decade, while South Korea’s has more
than doubled.
America still outpaces those
countries in total dollars invested in R&D: In 2011
(the most recent year for which there are reliable
numbers), the United States invested $414 billion,
compared with China’s $208.2 billion and South
Korea’s $59.9 billion. But U.S. growth has been
much slower than many of its peers’, and as a share
of the economy we invest only slightly more in R&D
than we did in the year 2000. Private companies
contributed $249 billion toward the nation’s total
2011 R&D investment, but industry cannot do it
alone.
Governments worldwide must provide
adequate support — especially for basic science,
which promises big payoffs but requires the longerterm, sustainable funding that can be impractical for
the private sector. Basic science aims to expand our
knowledge broadly — opening doors to innovation,
jobs and economic prosperity — but breakthroughs
are often unpredictable and come from unlikely
sources. Investigations of coral’s microstructure, for
instance, eventually yielded special ceramics now
commonly used in bone grafts and prosthetic eyes.
Studies of jellyfish gave rise to better methods for
diagnosing and treating cancer.
In the global
marketplace, rapidly turning ideas into products
requires an open approach to innovation:
Increasingly, corporate scientists must collaborate
with university researchers and even competitors.
This is why 13 pharmaceutical companies last year
teamed up with the U.S., British and United Arab
Emirates governments, as well as the Bill & Melinda
Gates Foundation, to help eradicate 10 neglected
tropical
diseases.
U.S.-based
public-private
partnerships are pursuing new treatments for
conditions ranging from cancer and diabetes to
Crohn’s disease. Such efforts are critical in the
biomedical field, as 67 million Americans deal with
high blood pressure, 13 million live with cancer, 5
million suffer from Alzheimer’s disease and the
number diagnosed with diabetes more than tripled
between 1980
1/13/14)
and
2011.
(Politico
Magazine,
http://www.politico.com/magazine/story/2014/01/re
search-and-development-funding-is-the-bestmedicine-102122.html#ixzz2qOnKVvg5
Dealing With It
A year ago the nation was caught up in a deeply
emotional and contentious debate about gun control
in the wake of a mass shooting of first-graders in
Newtown, Conn. Although that debate withered
away without expanded background checks or other
significant - and sensible - measures at the national
level, a related discussion continues and, we're
happy to say, seems to be getting results. That
discussion has to do with fixing a mental health
system that, in theory, could have headed off such
tragedies as Newtown, the 2011 attack on then-U.S.
Rep. Gabrielle Giffords and last year's Washington
Navy Yard rampage. Thirty-six states and the
District of Columbia increased funding for mental
health after the Newtown shootings, according to a
report released last month by the National Alliance
on Mental Illness. The NAMI report noted that
Texas boosted mental health funding by $259
million, the largest increase in state history. In a
state that ranked 49th in the nation for mental
health funding, that's a significant development.
Texas also passed a law requiring teachers and
students to undergo training in how to recognize
and respond to symptoms of suicide or mental
illness. Meanwhile, the White House last month
promised $100 million to improve mental health
facilities and community centers. And last week the
White House proposed a new regulation clarifying
the circumstances that would bar a person with
mental problems from purchasing or possessing a
firearm. Last week's new regulation, issued by the
Department of Justice, would expand the criteria for
barring firearms sales and possessions to people
ordered by a judge to undergo outpatient mental
health care.
Under current law, only people
deemed mentally "defective" or involuntarily
committed to an inpatient mental health facility can
be denied a firearm. According to mental health
experts, the gap between inpatient and outpatient
care has been a significant loophole allowing
dangerous persons to gain access to guns. It's not
always easy to determine who should not have
guns, although it's easy to see how the system has
at times broken down. In 2007, for example,
Virginia Tech shooter Seung-Hui Cho was able to
buy two handguns he used to kill 32 people, even
though a judge had ordered him into outpatient
care. Under Virginia law at the time, outpatient care
wasn't a sufficient reason to submit a person's name
to the FBI's National Instant Criminal Background
56
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
Check System, or NICS. It's important to note that
the vast majority of people dealing with mental
health issues are not prone to violence, and efforts
to identify those who might be a danger should not
add to the stigma of mental illness. Fortunately,
professionals have more tools than ever to make
that determination. "This nation has moved forward
in knowledge of what it takes to help, but has
moved backwards in getting that help done. And
where there is no help there is no hope," said U.S.
Rep. Tim Murphy, R-Pa., in a recent CNN interview.
Murphy, who spent three decades as a psychologist
before being elected to Congress, has introduced
legislation to increase funding for mental health
initiatives. Fortunately, he's not the only elected
official who has arrived at the same conclusion
about the importance of dealing with mental health
issues. (Houston Chronicle, 1/14/14)
Seated handshakes: The photo of Mikulski and
House Appropriations Committee chairman Hal
Rogers, R-Kentucky, sealing the deal is a double
win: a more natural-looking, lawmakers-at-work
shot than the traditional standing handshake. And it
masks the significant height difference between the
two powerful lawmakers.
Obamacare: (And see below.) No gain in funds, but
no loss of funds, either. Given the razor-sharp
opposition to the health care law, a spending bill
that doesn't get snagged in the Obamacare debate
(and vice versa) could be considered a win.
Appropriations committees: Think of it as a reality
game show that no one would enjoy. The chairmen
and staffs of the House and Senate appropriations
committees had less than a month to agree on 12
detailed spending bills and fold them into one
1,582-page document that both parties could sign.
http://www.chron.com/opinion/editorials/article/Dea
ling-with-it-5143343.php
Losers
EPA: The deal restores some of the funds cut by
sequester to the Environmental Protection Agency,
but not all. In a summary of the measure,
Republicans boasted that with this bill, they have
cut the EPA's funding by 20% since 2010.
Winners And Losers In Congress'
$1 Trillion Spending Deal
You could read the entire 1,582-page, $1 trillion
omnibus spending plan announced in Congress
Monday night. Or you can check out our handy
cheat sheet of some of the key winners and losers
in the plan.
IRS: The tax agency's funding has been cut to 2009
levels, according to the Republican House
Appropriations Committee. And just to send a more
direct message, this appropriations bill states that
the agency cannot use its funds to target citizens or
groups based on their ideology.
Winners
Little kids: Big winners. Funding for the Head Start
and early Head Start programs would jump by $1
billion. That's $1 billion more than last year's low
point after budget cuts.
TSA: You have millions of passengers to screen
everyday and now Congress has capped the number
of employees you can hire. If passed, the deal
would set a limit of 46,000 TSA screeners and
require the TSA to find a way to make half of the
traveling public eligible for "expedited" screening by
the end of this year.
The mentally ill: Social-worker-turned-SenateAppropriations-Chairwoman Barbara Mikulski, DMaryland, has long pushed for mental health
programs. This year she got them an additional
$173 million dollars more than their funding level
with last year's budget cuts.
Russia: Two reasons. 1. Sen. Mark Kirk, R-Illinois,
told CNN the deal fully funds a U.S. missile defense
system in Romania, which the Russians do not like.
2. The measure makes it harder for the United
States to buy weapons from Russia, including some
controversial helicopters. To get around the ban,
the omnibus requires the Pentagon to reveal the
number of anti-aircraft missiles the Russian
weapons agency has sold to Syria's Bashar al-Assad.
Disabled veterans and surviving families: No longer
would a planned cut in pensions hit "medically"
discharged military retirees or military spouses or
children who depend on military pensions.
Federal workers and active military: A 1% pay raise
would come to both groups of furlough- and
sequester survivors.
Obamacare: (And see above.) If the Obama
administration needs more funds to implement the
health care law, it isn't going to get them from
Congress. The bill doesn't add any funding and also
blocks the administration from dipping into a
prevention fund as a backup pool of money.
G-men: The FBI stands to gain $700 million+ over
the funding it got following last year's budget cuts.
Social Security Administration: The agency gets a
hefty $651 million increase to help it make up for
budget cuts in the past.
57
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
Generals and admirals: Flag and general officers in
the military would see a cut in their staff expense
budgets under this plan.
states going full-bore for the law and the states that
want no part of it,” said Jonathan Oberlander, a
health policy expert and professor at the University
of North Carolina. The report, which reflects the
sign-up rush in December, shows that Medicaid
expansion is the most obvious dividing line under
the health law. But the trend doesn’t always break
cleanly between red and blue states. Although
nearly all Democrat-led states extended the
program, several large states headed by Republican
governors also did, including Ohio, Michigan and
New Jersey. About half the states, including most
across the South, declined any expansion in 2014.
Obamacare provides private-plan subsidies to those
who earn between 100 percent and 400 percent of
the federal poverty level, but not for the lowestincome Americans, whom the law assumed would all
be eligible for Medicaid. In states that didn’t expand
the program to include that population, there is a
yawning “coverage gap,” and those who earn less
than the poverty level have no new options.
Someone in North Carolina making $25,000 can
qualify for a subsidy, for instance, while a person
there who earns $7,000 gets no assistance.
“There’s a huge gap in the Obamacare safety net
because of the Supreme Court decision,” Oberlander
said. Nationwide, about 4.8 million people fall into
the gap, according to the Kaiser Family Foundation.
In Texas alone, which currently has one of the least
generous Medicaid programs, it includes more than
1 million people, and in Florida, more than 750,000
people, Kaiser estimates.
“Community health
centers are beside themselves in places like Florida
and Texas where people are coming in and they
can’t offer them anything,” said Dan Hawkins, policy
director at the National Association of Community
Health Centers, which represents providers of health
care to low-income people. The government has
bolstered the centers’ funding in the last year,
distributing about $156 million to double the
number of staff positions — to more than 7,500 —
to help with enrollment.
In December, HHS
distributed another $58 million, this time favoring
centers in states with only federal-run exchanges
“because it was understood that they were not
getting much help from state agencies to find and
enroll people,” Hawkins said. The new, concrete
numbers could provide an opportunity for
Democrats. The unpopular federal health law has
been a terrible political headache, one that turned
into a full-blown migraine with the unmitigated
disaster of the enrollment website’s rollout in
October.
But in states where leaders, usually
Republican, have refused to go along, the hundreds
of thousands of people who remain uninsured
because of that decision could become a rallying
point for Obamacare supporters.
Evidence of
ongoing consumer interest in coverage through the
Affordable Care Act could bolster arguments that
The president of Afghanistan: The bill specifically
prohibits any of its funds from going to "the direct
personal benefit of the president of Afghanistan."
Portrait artists: The bill bans government officials
from spending money to have a portrait made.
Jerry Brown: No funds for you. The California
governor hoped to get some federal funds for his
dream of a $60 billion high-speed rail line between
L.A. and San Francisco.
But Republicans
successfully blocked the idea in this deal. (CNN,
1/14/14)
http://www.cnn.com/2014/01/14/politics/budgetwinners-losers/index.html?hpt=po_c2
State Fights Creating 2 Obamacares
Determining who has health insurance under
Obamacare is almost as simple as figuring out which
political party runs a state. Republican-led states
like Texas that have refused Obamacare every step
of the way have left hundreds of thousands of
people without health care, while Democrat-led
states like Kentucky that have embraced key
portions of the law have seen a dramatic expansion
in people signed up for private health plans and
expanded Medicaid coverage. A report released
Monday by the Obama administration painted the
starkest picture yet about the state-by-state politics
of the Affordable Care Act. With some notable
exceptions, the enrollment numbers reveal what
could become two health care systems driven and
divided by politics — one that offers low- and
moderate-income people greater access and
another that doesn’t.
Kentucky, which has
embraced Obamacare, and Louisiana, which has
not, are telling examples of these two scenarios.
Although a larger percentage of Louisiana residents
are uninsured, only about half as many people
signed up for private plans — 17,500, compared to
33,000 in the Bluegrass State. Both states have
about 4.5 million residents. And the figures are
even more skewed when it comes to expanding the
Medicaid program, which the Supreme Court made
voluntary in its landmark 2012 ruling that otherwise
upheld the law. Kentucky accepted federal funding
to extend the insurance program for the poor to
everyone up to 138 percent of the federal poverty
level, and more than 100,000 of its residents have
qualified for Medicaid since Obamacare launched
Oct. 1. Louisiana turned down the expansion offer,
and its Medicaid-eligible population has increased
since then by fewer than 5,000 — a twentyfold
difference. “In the short run, you’re likely to see
some fairly significant differences between the
58
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
Republicans should get out of the way. “That is
why it has been especially appalling to see Texas
elected officials promote misinformation about what
the ACA does — from shutting down the
government to placing regulatory burdens on the
state’s navigators,” Rep. Joaquin Castro (D-Texas)
wrote in an email. His state has the second largest
number of signups on the federal exchange,
showing, he said, that Texans are “hungry” for the
coverage. “I am hopeful that the reality of the
benefits of the Affordable Care Act for Americans
will soon overtake the right-wing propaganda
machine that has been set up to disparage” the law.
The differences between Obamacare cooperation
and opposition states go beyond Medicaid, however.
About 20 states either built their own exchanges or
are running exchanges in partnership with the
federal government, giving them access to hundreds
of millions of dollars in outreach money that dwarfs
what is being spent in states that rejected such
help. That also appears to be making a difference
in some states. “We have run TV, print, billboards,
bus ads, social media and digital, advertising on
Hulu and Pandora, on ESPN, BET, all those that the
young kids watch,” said Carrie Banahan, executive
director for Kynect, Kentucky’s exchange. “That has
complemented the direct outreach that the
exchange has done as well — going to community
events, sporting events, and the state fair.”
Nonprofit organizations, led by Enroll America, have
banded together to try to fill the outreach void in
states without a federally financed marketing
campaign, and Obama administration officials,
especially Health and Human Services Secretary
Kathleen Sebelius, have been stumping in those
states’ major media markets. But it’s a far cry from
a well-funded centralized marketing campaign,
experts say. Some exceptions are evident in the
data released Monday. While the Medicaid numbers
tend to be reliably larger in states that expanded
that program, there are surprises in how many
people have signed up for private plans in certain
places.
North Carolina and Georgia, both
nonexpansion states, provide another interesting
illustration. Despite North Carolina’s lack of funding
or state buy-in for outreach or advertising, nearly
108,000 people there enrolled in private plans
through December. Georgia, which has about the
same population of just under 10 million and a
higher uninsured rate, enrolled only 58,000. And
even though Florida Gov. Rick Scott’s administration
forbade state health facilities from hosting the
health law’s navigators to help people sign up, more
than 158,000 Floridians enrolled for plans, slightly
more than the number who signed up in New York
— an original Obamacare enthusiast. The states
have roughly the same population, although Florida
has about 1 million more uninsured people than
New York. Some of the most pro-Obamacare states
have turned in disappointing numbers so far,
especially in their own exchange signups. Oregon,
an early adopter that was expected to be a national
leader, debuted an exchange that performed worse
than even HealthCare.gov in its first two months.
Enrollment in Maryland and Minnesota has been
lackluster as well, due in part to troubled exchange
technology. Meanwhile, California leads the pack,
with 500,000 private plan sign-ups — nearly a
quarter of the 2.2 million people who have enrolled
nationwide. (Politico, 1/14/14)
http://dyn.politico.com/printstory.cfm?uuid=84DE7F
75-2D4C-45FD-AA0A-FDBC356537A1
Medical Debt Will Persist
Despite Health Law
Millions of Americans will get health insurance
through the Affordable Care Act that will protect
them from potentially ruinous medical expenses, but
a new USA TODAY analysis shows the health plans
they can choose still leave them vulnerable to
thousands in deductibles and other out-of-pocket
costs each year. Medical insurance deductibles for
plans on the federal exchange covering 34 states
average $3,000, and those for the least expensive,
bronze-level plans average $5,082, according to the
USA TODAY analysis of deductible data for
HealthCare.gov. Those costs, according to a recent
study, may still be more than many people can
afford. The USA TODAY analysis also found the
lowest out-of-pocket limits on HealthCare.gov plans
were $4,350 for individuals on bronze plans and
$8,700 for families, although these were not the
norm and are likely paired with high premiums.
Even relatively modest cost sharing can prove
unaffordable
because
expenses
are
often
unexpected, and most Americans have less than
$3,000 to cover such costs, according to a new
Kaiser Family Foundation report on medical debt
among the insured concludes. The new health care
law requires consumers' portions of health care
expenses — known as cost sharing — to be capped
at $6,350 for individuals and $12,700 for families.
Many plans have lower limits on out-of-pocket costs
than the federal limit, but the plans increasingly also
have separate deductibles for prescription drugs.
And expenses for drugs that aren't covered by plans
or for out-of-network physicians aren't applied
against limits. That makes it more likely consumers,
especially those with chronic health conditions such
as asthma or high blood pressure, will be hitting
these out-of-pocket maximums, says Matt Eyles,
executive vice president at consulting firm Avalere
Health. "The ACA is an important safety net, but it
doesn't necessarily solve the problem of high upfront medical expenses for those who don't have
ability to pay for them," Eyles says. Kaiser analyzed
59
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
Centers for Disease Control and Prevention survey
data and did case studies of 23 people with medical
debt, which is the leading cause of bankruptcy in
the U.S. It found cost sharing for covered services
that were in-network providers and facilities was the
leading contributor to debt for those interviewed.
CDC's 2012 National Health Interview Survey
showed 34% of people in higher-deductible health
plans had difficulty paying medical bills compared
with 24% of people in lower-deductible health
plans. "It starts with the cost sharing that they're
not really prepared to pay and are not in a position
to budget for," says Karen Pollitz, a Kaiser Family
Foundation senior fellow who co-authored the study
with the Georgetown Health Policy Institute. "Then
there are the multiplying factors where it's the mom
and the infant and it's crossing plan years and
people start doing drastic things" to pay the debt.
Department of Health and Human Services
spokesman Joanne Peters said the situation is still
far better than it was before the ACA. "The new
marketplace is night and day from what consumers
faced in the individual market before the health care
law, where they could see unlimited out-of-pocket
expenses for plans with limited benefits and high
deductibles, if they (could) even get coverage
without being denied for a pre-existing condition,"
Peters said in an e-mail. The 40% portion of
medical bills borne by those with bronze plans may
also shock many consumers when the bills start
rolling in. Consumers with incomes below 250% of
the federal poverty level ($28,725 for an individual)
have lower cost-sharing limits if they buy silver
plans on the exchanges. But families of four with
incomes above 400% of poverty ($94,200) are
ineligible for financial assistance and unlikely to
have enough cash on hand to pay even the
deductible for many plans, the Kaiser study showed.
These families tend to have about $12,000 in liquid
assets, Kaiser says, but when other consumer debt
is taken into consideration, most have net liquid
assets of $5,200 or less.
Premiums can add
significantly to health care costs: An earlier USA
TODAY analysis of premiums on the HealthCare.gov
site found more than half of counties lacked a plan
that would meet the federal affordability test for a
couple making about $62,000 a year, or just over
the amount eligible for subsidies. A third didn't
have a plan deemed affordable for an individual
above 400% of the poverty level or about $47,000,
meaning the premium cost more than about 8% of
annual income. John Roll, a former transportation
consultant from Southern California, has an
outstanding medical bill of $88,000 from
neurological tests that followed brain surgery in
2009. That bill went to a collections agency. Making
matters worse, Roll has an urgent operation coming
up this year to remove a hematoma near his liver.
He can't work and his wife is unemployed, but at
least having that bill capped at under $6,500 makes
it possible that they could pay it out of retirement
savings, he says. "I'm hugely relieved," Roll says of
the ACA caps. "In 2011, we were talking about a
strategic divorce so we wouldn't have to get sucked
under by the medical bills." Cathy and Scott Carson
of Truckee, near Reno, say medical debt will be
unavoidable for them. They are waiting to hear
whether they can get a hardship exemption so they
don't have to buy a new plan to replace the one
that got canceled last year because it didn't meet
the ACA requirements. The cheapest one they can
find includes a $5,000 deductible for each of them
and costs $729 a month, Cathy Scott says that's
more than they can afford on their combined
$80,000 annual income, which is patched together
through seasonal and contract work. But she hardly
likes the option of going without insurance either.
Either way, "Debt is only an accident or serious
illness away," she says. Any unexpected health cost
at a doctor's office — where upfront payment is
generally required — would have to be paid for by
credit card, she says, and it could take years to pay
if off. While deductibles are increasing in amount,
they are increasingly applied even before copayments start. So while preventive care is covered
in full under ACA, many plans will charge the full
cost of visits for injuries or ailments until the
deductible is met. This is going to create some
sticker shock for consumers used to paying small
co-pays for these, says Nancy Thompson, senior
vice president at CBIZ Benefits and Insurance
Services. Deductibles for employer-provided plans
have increased in the last five years, but are far
below the averages on HealthCare.gov.
The
average deductible was $1,135 a year in 2013,
according to a study Kaiser released in August.
While that was largely unchanged from 2012, it was
up considerably from the average of $735 in 2008.
For at least another year, employers can basically
double workers' out-of-pocket costs by having a
separate drug deductible if an outside company
manages the company's drug benefits. Cathy Scott
is relieved that ACA has taken effect, but hopes
"over time changes will be made to make it
affordable and equitable to all." (USA Today,
1/15/14)
http://www.usatoday.com/story/news/nation/2014/
01/14/affordable-care-act-medical-debt/4362603/
3 Predictions On How Docs Will
Treat You Under Obamacare
The Obamacare rollout has reached its third month,
with some 2.2 million people signing up for plans,
marking the continued reinvention of the American
health care system.
Barring a radical change,
Obamacare is here to stay, at least until 2016. But
60
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
the end product of this reinvention has yet to be
determined, and is a matter of fierce debate. The
White House contends that Obamacare will reduce
the number of uninsured, reign in health care costs,
cut the deficit and improve the quality of health
care. Opponents of the law argue that it’s simply
another costly entitlement program that won’t
control costs and will lower quality of care all while
incurring hundreds of billions in new costs. To get
an idea of what the act of receiving health care will
be like in the next five to 10 years with Obamacare
as the law of the land, we reached out to experts
who fell into one of three camps. One predicts
disaster, another predicts success, and another
doesn’t believe the Affordable Health Care Act will
change much of anything.
treat Medicare patient will accelerate the trend
towards concierge medicine, where they fire 80
percent of their patients and charge the remaining
20 percent - roughly 300 to 500 patients - retainer
fees,” he said. Herrick added that this would
increase the number of ER visits, making that
experience more burdensome.
“Medicare and
Medicaid patients already make up nearly two-thirds
of ER visits,” he said. “This will get worse as seniors
and Medicaid enrollees experience increased
obstacles to care.”
The Pragmatist: Tom Miller, a resident fellow at the
American Enterprise Institute, said that he doesn’t
expect Obamacare to be the driver of changes to
health care delivery. “The doom and gloom folks
say this is a slow march toward single payer,” he
said. “The flip side is that we have the magic
formula.
It’s neither one of those extreme
scenarios.” Miller added that he does not believe
that Obamacare will grow as quickly as many of its
backers claim. “Will it be more pervasive and
expansive than originally envisioned? It’s not going
to happen. It’s not going to expand more broadly
and dominate the health care system,” he said.
Instead, Miller said he believes demand driven by
patients for alterations to the way health care is
delivered will be the true driver of change. “Care
evolves. It is going to less mass produced, just like
we’ve seen in the pharma sector,” he said.
“Blockbuster drugs are rarely occurring anymore.
We’re matching treatments to an individual.” He
said the real barometer for Obamacare’s success is
how the program is administered and evolved. That
human factor will ultimately decide its success.
“There are smart people who can do things better,”
Miller said, “but there are a lot of dumb ones who
can screw things up.” (Fiscal Times, 1/15/14)
The Optimist. Shana Alex Lavarreda, director of
Health Insurance Studies at the UCLA Center for
Health Policy Research, said that the act of visiting a
doctor or the emergency room wouldn’t
fundamentally change. However, the way medicine
is managed will fundamentally change. “People will
need to do so much less because under the
Accountable Care Organizations that will be in much
wider existence, the dispersion of best practices for
preventive care, and increased care management
for those with chronic conditions,” Lavarreda said in
an email. Lavarreda also said that Obamacare
would help people to better manage their health,
improving management of more serious conditions.
“More appropriate care outside of the hospital or
doctor's office will lead to more efficient care when
one is needed.” Finally, she said she believed that
remote medicine would become more common.
“Telemedicine will increase, allowing the health
system to both increase productivity and to reach
patients in remote areas,” Lavarreda said.
The Pessimist: Devon M. Herrick, a senior fellow at
the National Center for Policy Analysis in Dallas in
less optimistic about the benefits from Obamacare.
He predicts a patient experience much more
unpleasant than the one we have today. “You’re
right to question whether the Affordable Care Act
will indeed be affordable over the long run. The
ACA does nothing to reduce spending. It will have
the opposite effect,” he said. “There aren’t enough
doctors to treat all the new enrollees. The ones
most likely to suffer are those whose insurers pay
the lowest reimbursements. Medicaid pays, on
average, only about half what private insurers pay
for the same service. Medicare pays only about 80
percent of what private insurers pay,” Herrick
added. “Keep in mind the ACA calls for Medicare
physician fees to be cut below Medicaid fees. If
that happens, seniors and Medicaid enrollees will
have even a harder time finding doctors who will
treat them.” This would fundamentally alter how
people receive treatment, he said. “Doctors who
http://www.thefiscaltimes.com/Articles/2014/01/15/
3-Predictions-How-Docs-Will-Treat-You-UnderObamacare
New Report from Bipartisan
Commission Suggests Sweeping, StateDriven Health Care Reforms
A group of former governors, policy leaders,
advocates, and insurance company executives
released a lengthy set of recommendations to curb
future health care spending, with a particular focus
on the role of states in driving reform. The State
Health Care Cost Containment Commission was
convened by the University of Virginia’s Miller Center
and co-chaired by former governors Mike Leavitt (RUT) and Bill Ritter (D-CO). The report cites higher
costs; uncoordinated care systems that provide little
incentive for consumers to seek lower-cost, highquality care; market concentration among providers,
61
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
and the expensive nature of end-of-life care as
principal drivers of runaway costs. Given states' role
in funding and operating Medicaid, oversight of the
private insurance market, and ability to implement
policies that promote healthy lifestyles and market
transparency, the commission argued that states are
uniquely positioned to implement these systemic
reforms.
Accordingly,
many
of
the
recommendations involve state-level actions,
including:






Define and Collect Data to Create a Profile of
Health Care in the State
Establish Statewide Baselines and Goals for
Health Care Spending, Quality, and Other
Measures as Appropriate
Use Existing Health Care Spending Programs to
Accelerate the Trend Toward Coordinated,
Risk-Based Care
Encourage Consumer Selection of High-Value
Care Based on Cost and Quality Data, and
Promote Market Competition
Reform Health Care Regulations to Promote
System Efficiency
Help Promote Better Population Health and
Personal Responsibility in Health Care
(Lexology, 1/10/14)
http://www.lexology.com/library/detail.aspx?g=4b9
ab68c-6600-4937-96141f7faa6afb3c&utm_source=Lexology+Daily+Newsfe
ed&utm_medium=HTML+email+-+Body++Federal+secti

Plans. Healthy Michigan provides coverage
through the state’s existing network of
Medicaid managed care plans. Michigan did
not seek to use premium assistance to
purchase qualified health plan coverage
through the Marketplace.

Benefits. Under the ACA, covered benefits for
newly-eligible
adults
in
Medicaid
(the
Alternative Benefit Plan), are based on ACAdefined Essential Health Benefits with certain
additional requirements, including early periodic
screening, diagnosis and treatment (EPSDT) for
19- and 20-year-olds and non-emergency
transportation. Healthy Michigan will provide
the full scope of benefits covered under the
Alternative Benefit Plan.

Premiums. Healthy Michigan enrollees with
incomes from 100% to 133% of the FPL will be
required to pay a monthly premium of 2% of
income—the same amount they would have
been required to pay had they purchased
coverage through the Marketplace with
premium tax credits.
However, Medicaid
coverage cannot be denied if an enrollee fails
to pay premiums.

Cost Sharing. All Healthy Michigan enrollees will
be required to make cost-sharing payments in
amounts consistent with federal Medicaid law.
Healthy
Michigan
enrollees
will
make
contributions to an account maintained by their
health plans based on their prior six months of
utilization. Providers will notify enrollees of
copayment amounts when delivering the
service, but enrollees will be billed for such
copayments on a quarterly basis, rather than at
the point of service.
Enrollees cannot be
denied coverage or services if they fail to make
cost-sharing contributions.

Healthy Behavior Incentives. Healthy Michigan
enrollees may have their cost-sharing and
premium obligations reduced if they adopt
specified healthy behaviors. Michigan must
submit for CMS approval a draft protocol
outlining the healthy behavior incentives. The
state must demonstrate that the healthy
behaviors are data driven and that it engaged
stakeholders when developing the healthy
behaviors.
CMS Approves Michigan’s Amendment To
Its Waiver Implementing ACA Medicaid
Expansion Through “Healthy Michigan”
On December 30, 2013, the Centers for Medicare
and Medicaid Services (CMS) approved Michigan’s
request to amend an existing waiver to implement
the Affordable Care Act (ACA) Medicaid expansion
effective April 1, 2014 through the “Healthy
Michigan” program.
Under Healthy Michigan,
coverage for the expansion adults will be provided
through Medicaid managed care plans already under
contract with the state. Michigan will provide the
full range of services required for expansion adults,
unlike Iowa where the recently approved waiver
authorized a one-year waiver of non-emergency
medical transportation. Adults in Michigan with
incomes between 100% and 133% of the federal
poverty level (FPL) will have a premium obligation
equal to 2% of income. All expansion adults will
have-cost sharing obligations and be eligible for
healthy behavior incentives. The key features of the
Healthy Michigan program include:

Commonalities and Differences
Michigan and Iowa Programs
between
the
The Healthy Michigan program shares several
common features with Iowa’s expansion waiver,
approved by CMS on December 10, 2013. Under
both states’ waivers, enrollees with incomes from
100% to 133% of the FPL are required to make
premium contributions of up to 2% of income, but
Eligibility. All individuals in the new adult group
are eligible for Healthy Michigan.
62
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
coverage may not be denied based on failure to
pay.
Additionally, both waivers use financial
rewards to encourage enrollees to engage in healthy
behaviors. In Michigan, individuals engaging in
healthy behaviors can have their premium and costsharing reduced, while in Iowa, healthy behaviors
can reduce premium requirements.
There are,
however, some important differences between the
two programs. Iowa uses premium assistance to
purchase qualified health plans for Medicaid
enrollees, while Michigan provides coverage through
its traditional network of Medicaid managed care
plans. Also, Iowa uses premiums but no significant
cost-sharing, while Michigan uses both premiums
and cost-sharing. Notably, because the Michigan
expansion will not go into effect before April 2014,
Michigan must establish protocols to transition to
Medicaid individuals with incomes between 100%
and 133% of the FPL who enroll in QHPs during
Marketplace open enrollment. Michigan also must
submit for approval protocols detailing the
operations of the cost-sharing accounts and healthy
behavior incentives, including: (i) standards and
evidence-based rules to ensure that accounts are
debited and credited accurately and (ii) a strategy
for noticing and educating providers and enrollees
on program rules. Michigan must submit these
protocols at least 90 days prior to implementation of
the cost-sharing accounts or healthy behavior
incentives. In addition, the implementation plan
must include a phased approach, beginning with
beneficiaries with incomes above 100% of the FPL.
To view a chart comparing key features of current
state waivers applicable to expansion adults, click
here. (Lexology, 1/6/14)
that it was the insurance company of New York
City’s public hospital system; to a typical shopper on
New York’s health exchange, it looks no different
from big-name companies, like Empire or United.
But to the Health and Hospitals Corporation, the
city’s public hospital agency, it is not merely another
insurance plan. The corporation created MetroPlus,
and sees it as a powerful opportunity to attract a
different class of patients — somewhat higherincome, more educated and more stable — to a
system whose historic mission has been to serve the
poor, and whose finances have been straining.
Robyn Chapman, an artist, signed up with MetroPlus
as well. The hospital system is hoping to attract
more affluent patients. “It’s a potential significant
source of additional revenue,” said Alan Aviles, the
corporation’s president. While “we won’t necessarily
have concierge services; there won’t be a piano in
the atrium,” he said he hoped the new customers
would find that his hospitals were underrated.
Around the country, a number of public health
systems and charity hospitals serving large numbers
of poor patients see the health exchanges, created
by the states under the act, as a way to widen their
customer base. In Los Angeles, L.A. Care, a publicly
run health plan, has enrolled about 8,000 people so
far via the California exchange. The Henry Ford
Health System in Detroit, which has roots in
organized labor and the auto industry, has signed
up about 4,000 people in its exchange plans. The
University of Arizona Health Plans have attracted
only 250 people, said James Stover, their chief
executive. But he said they were still trying to sign
up young people who were part of the university
system, as well as uninsured people on the cusp of
Medicaid eligibility, who are partly responsible for
the system’s $100 million a year in uncompensated
care. “It makes a lot of sense from a mission
standpoint to go into the marketplace and try to find
coverage for these individuals,” Mr. Stover said. By
Dec. 24, the deadline for receiving coverage on Jan.
1, MetroPlus, one of 10 companies selling exchange
plans in New York City, had enrolled 18,397
members, about 32 percent of all those who signed
up citywide. Enrollment hit 22,000 last week, the
corporation said, and it hopes to reach 40,000 by
the end of 2014. Currently, only 7 percent of the
1.4 million people treated by the city’s public
hospitals each year have private insurance,
according to the Greater New York Hospital
Association. Another 58 percent are on Medicaid or
Medicare, and 35 percent are uninsured; half of
those are illegal immigrants, who cannot get
coverage under the new law. That patient mix
fosters a common belief that the public hospitals are
a last resort, or as one Yelp reviewer described
Woodhull Medical and Mental Health Center in
Brooklyn: “If you were writing for a TV drama about
the downtrodden castoffs of society, you could not
http://www.lexology.com/library/detail.aspx?g=d72
b6d43-1923-47bd-9e2e41d25dee5d8e&utm_source=Lexology+Daily+Newsf
eed&utm_medium=HTML+email+-+Body++Other+states+section&utm_campaign=Lexology+
subscriber+daily+feed&utm_content=Lexology+Dail
y+Newsfeed+2014-01-15&utm_term=
Public Hospitals Hope To Attract More
Upscale Patients Under Affordable Care Act
Todd Obolsky lives in a studio apartment in
Manhattan, drives a leased Toyota Corolla and
occasionally splurges on experimental cuisine in the
East Village. When the Affordable Care Act allowed
him to buy insurance for the first time in years, he
was so price-sensitive that $30 a month made a
difference in which plan he picked. So the obvious
choice was MetroPlus. It offered the best deal at
the coverage level he was looking for — about $400
a month for a gold plan, the second-highest of the
four levels. “That’s like as high as I can possibly go
without living on rice,” he said. He never noticed
63
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
have conceived of a more appropriate place.” In
the Medicare system’s Hospital Compare ratings, the
city’s public hospitals typically score lower in patient
satisfaction than private ones. But they compare
well on medical measures, like whether they follow
protocols for heart attack, pneumonia and surgery
patients. For years, the hospitals corporation has
tried to polish its image by contracting with private
hospitals and medical schools to staff the public
hospitals; for example, many Bellevue doctors come
from NYU Langone Medical Center next door. And
by attracting more affluent and choosy customers,
the corporation hopes, it can also attract doctors
into the MetroPlus networks who would not normally
associate with public hospitals.
MetroPlus was
created in 1985 as a managed-care plan for
Medicaid recipients. While there is no guarantee
that offering MetroPlus on the health exchange will
be profitable, the corporation projects that the
exchange plans will bring $120 million a year in
revenue to a system now running a $250 million
annual deficit. By this week, 66 percent of its
customers were enrolled in the silver plan,
suggesting that they had low to moderate incomes
and expected to qualify for subsidies. But 10
percent enrolled in gold and 18 percent in platinum,
suggesting higher incomes, which surprised
MetroPlus officials. As Mr. Obolsky discovered,
MetroPlus offers the lowest premiums on the New
York exchange for the top three standardized plans:
$359 a month for silver, $396 a month for gold and
$443 a month for platinum. One major reason for
the low prices is that MetroPlus will cover patients
only at the city’s 11 public hospitals and four private
ones — Beth Israel’s two campuses in Manhattan
and Brooklyn, St. Luke’s-Roosevelt in Manhattan,
and Lutheran in Brooklyn. Except in an emergency,
plan members will not be covered at some of the
more prestigious hospitals like Mount Sinai and NYU
Langone. Mr. Aviles said that to keep its premiums
down, MetroPlus had to offer relatively low
reimbursement rates for hospitals. Several hospitals
said they were still negotiating with MetroPlus and
might join the network.
Mr. Obolsky, 48, a
consultant, said he was happy to hear that St.
Luke’s-Roosevelt was on the plan, because its
campuses were near him on the Upper West Side.
Robyn Chapman, an artist who pieces together a
living making and selling comic books, working as a
legal assistant and cat sitting, signed up for a silver
MetroPlus plan. Her first bill was for $119.42 a
month after tax credits. She had not realized that
MetroPlus was run by the city hospital system. But
that would not have stopped her, she said, because
she was looking mainly for price. She was familiar
with one city hospital — Woodhull in Brooklyn —
because she had used its clinics for routine medical
care at $20 a visit. She said the waiting times there
were very long, many patients seemed desperate
and some nurses and doctors were “a bit cold,
maybe even a little rude.” She might try a different
hospital, but otherwise she said: “I can’t complain.
I’m honestly very grateful.” Mark P. Scherzer, a
consumer lawyer and counsel to New Yorkers for
Accessible Health Coverage, said he expected
MetroPlus would “still be sort of a poorer person’s
plan,” with lower prices and lower quality. Mr.
Aviles conceded that for some people, public
hospitals would never be acceptable, regardless of
how well they delivered care. “There’s always a
headwind in terms of how many hospitals there are
in New York City and how many have designer
labels,” he said. “In the same way that if you’re
affluent and buying a pair of jeans, you may be
willing to spend $200 for those jeans because they
have a designer label.” (New York Times, 1/15/14)
http://www.nytimes.com/2014/01/16/nyregion/publi
c-hospitals-hope-to-attract-more-upscale-patientsunder-affordable-careact.html?hpw&rref=nyregion&_r=0
What A Shocker! Young People
Like Obamacare: New HHS Numbers
Show Those Under The Age Of 35
Care About Getting Coverage.
First it was, we think we are invincible. Then it was
that the penalty was too low, or that we would be
turned off by website glitches.
After the
Department of Health and Human Services released
its initial age breakdown enrollment data Monday, it
is time to finally put the pessimism to rest. Young
people are enrolling in health care coverage under
the Affordable Care Act, and for good reason —
being covered is essential to their economic
security. On Monday, the Department of Health &
Human Services announced that 30% of
Obamacare's 2.2 million private insurance enrollees
are under the age of 35. More specifically 24% of
enrollees are between the ages of 18- and 34-yearsold.
In other words, the exchanges have a
percentage of young adult enrollees that is
comparable to their proportion of the overall
population. All the evidence suggests that youth
enrollment will only go up as we get closer to the
deadline. We are ecstatic to see young people
enrolling at such a fast clip this early on in the
enrollment process — but we're not surprised. Polls
have consistently shown that this generation wants
coverage. To give some context, the average
income for an uninsured 25-year-old is about
$17,800.
In the post-ACA world, that same
individual can get a silver plan for about $63 a
month, with a reduced deductible, thanks to new
tax credits and cost sharing subsidies. In fact, the
vast majority of young adults will have plans
available for under $100 a month. Those making
64
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
below about $16,000 a year could even qualify for
free coverage under Medicaid. These new options
create a new day in health care for young people.
We are confident that young adult enrollment rates
will continue to surge — as was the case in
December — in the months ahead. A recent survey
by the Commonwealth Fund found that 41% of
federal and state health insurance marketplace
visitors were between the ages of 19 and 34,
suggesting that many young adults might still be
checking out their options. Moreover, we saw a
similar enrollment pattern in Massachusetts with
their health care reform law. According to the New
England Journal of Medicine, enrollments among the
non-chronically ill population — a younger
population — increased over 175% before the
Massachusetts mandate kicked in.
This makes
sense — those who have been discriminated against
due to a medical condition were always expected to
be first to gain coverage once the Marketplaces
open. We anticipate seeing a similar surge in the
rate of young adult enrollments ahead of March 31st
deadline to get covered and avoid the penalty.
Outreach campaigns will also ramp up over the next
couple of months, accelerating enrollment rates
among the younger population. In addition, many
young people are learning what a premium is or
what a deductible is for the first time, which is why
it will take them more time to select the plan that
best suits their needs, and why educations
campaigns are critical. This education process can
take time but it works over the long run. In
Massachusetts, for example, youth uninsurance
rates dropped from 27% to 8% over several years
as the word continued to spread. The Affordable
Care Act's opponents will undoubtedly scrutinize the
enrollment numbers of this population. Some have
speculated that approximately 35% to 38% of
Obamacare enrollees should be young for premiums
to remain low in the insurance market. However,
recent analysis by the Kaiser Family Foundation
demonstrates that rates will remain stable even with
far fewer young people enrolling. Moreover, this
view does not take into account rate stabilizers built
into the law if the enrolled population is slightly
older. To find such strong interest after having
essentially only one month of enrollments to
consider—given the website malfunctions in October
and November—is a big deal. So don't buy the
narrative that young people are not enrolling. The
young uninsured know a good deal when they see
one. Aaron Smith is co-founder of Young Invincibles.
(USA Today, 1/15/14)
Drinking Linked To Faster
Mental Decline In Men
Middle-aged men risk a faster mental decline as
they age if they've been drinking heavily for years,
new research suggests. The study of about 5,000
British civil servants found that over a decade, the
added decline was the equivalent of about two extra
years of aging for a combined measure of mental
abilities like reasoning, and about six years for
memory.
The heavy drinkers' abilities were
compared to those of men who drank moderately or
abstained.
It's no surprise that heavy alcohol
consumption can affect the brain, but the study
focuses on an age range that has received much
less attention from alcohol researchers than the
elderly and college students.
The work was
published online Wednesday by the journal
Neurology. Researchers found no such effect in
women, but the study included too few female
heavy drinkers to test the effect of drinking the
same amount as in men, said Severine Sabia, a
study author from University College London. In an
email, she said it was not possible to identify a
specific minimum level of consumption at which the
risk begins in men. Her study used data from over
20 years. Using questionnaires, researchers
calculated the men's average daily intake of alcohol
for the decade up to when they were an average of
56 years old. Then, they tracked decline in mental
abilities over the following decade from tests
administered every five years. Accelerated decline
was seen for the heaviest-drinking group, which
included 469 men with a wide range of alcohol
intake. The minimum amount was the equivalent of
about 13 ounces of wine a day or about 30 ounces
of beer. The maximum was about three times that.
Men drinking that minimum amount are not
necessarily at risk for accelerated mental decline,
since the results pertain to the category overall, said
Sara Jo Nixon, a substance abuse researcher at the
University of Florida in Gainesville, who did not
participate in the work. She also said that the study
shows a link between drinking and faster mental
decline but not proof that alcohol intake was
responsible. And she said that because of the
sensitive mental tests used in the study, the extra
declines in performance may be too subtle to make
a difference in daily life. Sabia said she believed the
difference would eventually be noticeable. Still,
Nixon said, the study "does suggest that middleaged to young-old individuals do need to pay
attention to what their drinking habits have been,
and are." (Miami Herald, 1/15/14)
http://www.usatoday.com/story/opinion/2014/01/14
/obamacare-website-enrollment-young-peoplecolumn/4475161/
http://www.miamiherald.com/2014/01/15/3872617/
drinking-linked-to-faster-mental.html#storylink=cpy
65
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
Program to End Homelessness Among Veterans
Reaches a Milestone in Arizona
federal response to homelessness, said in an
interview. “And if we do this for veterans, it’s
something that as a nation, if we set our mind to,
we can achieve for other populations as well.”
Arizona has more homeless veterans than most
other states — roughly one in five homeless adults,
according to statistics from the state’s Department
of Veterans’ Services.
In an interview, Greg
Stanton, the mayor of Phoenix and a longtime
proponent
of
increasing
investment
and
partnerships on homeless outreach, characterized
the recent achievement as “important because we’re
helping people in need, but also important because
it helps our economy.” According to local and
national surveys, it is more expensive to cover the
costs of emergency room visits or nights in jail for
homeless people than it is to give them homes. A
2009 analysis commissioned by the Los Angeles
Homeless Services Authority, which handles the
largest population of homeless veterans in the
country, found that the monthly cost of housing and
supportive services for one person was $605, while
the public costs of a person living on the streets
were roughly $2,900 a month. Across the country,
the strategy is centered on an approach called
Housing First, through which a home is not treated
as a reward for good behavior. As Ms. Zeilinger put
it, it is instead “the platform of stability that lets
previously homeless people work on the other
issues they’re facing,” like mental illness and
addiction, which are particularly common among the
chronically homeless. The term is defined as those
who have continuously lived on the streets for a
year or have done so at least four times over three
years. Some advocates say the concept works more
easily in places like Phoenix, where there is room to
build. Victory Place, the 104-apartment complex
where Mr. Mackenstadt and Mr. Hankins live,
opened last year on the city’s south side. (An
additional 96 units are under construction on the
same campus.) Meanwhile, in cities like Los Angeles,
building is expensive and competition is stiff for
existing affordable-housing units, which are already
scarce, said Steve Peck, president and chief
executive of U.S. Vets, the nation’s largest nonprofit
service provider for veterans. There is also the
challenge of sustaining the investment, given the
steady stream of soldiers back from Iraq and
Afghanistan who have been ending up on the
streets. “The question,” said Mr. Peck, who served
in the Marine Corps in Vietnam, “is how we create
enough housing units to house those who are
homeless and where we find the money to provide
all the services that are essential to keep them in
those units.” Through a joint program that is the
backbone of the federal effort, the Departments of
Housing and Urban Development and Veterans
Affairs have given $913 million since 2010 in
vouchers, as well as clinical and social services, to
Launch Media Viewer
Their descent into homelessness began almost as
soon as they had closed a dignified chapter in their
lives: their military service. Dexter Mackenstadt, 63,
a sailor who spent the Vietnam War tracking
submarines along the East Coast, slipped into
alcoholism. Robert Stone, 56, who spent three
years stationed at naval bases in California, fell to
that, too, and to a failing heart. John Hankins, 52,
who repaired intercontinental ballistic missiles at an
Air Force base in Wyoming, spent years as a drifter,
living in a methamphetamine lab in the Arizona
desert. Today they are neighbors and participants
in a program that White House officials have said
has led Phoenix to become the first community in
the country to end homelessness among veterans
with long or recurrent histories of living on the
streets. In 2011, by a city count, there were 222
chronically homeless veterans here, a vulnerable,
hard-to-reach population of mostly middle-age men,
virtually all battling some type of physical or mental
ailment along with substance abuse. Federal and
city officials acknowledged that was not an exact
number, but it is widely regarded as the best
measure of the veteran population. Last month, the
last 41 members of that group were placed in
temporary housing. Shane Groen, a director at the
Arizona Coalition to End Homelessness, one of the
city’s partners in the program, said the goal was to
have them all in permanent housing by Feb. 14. Mr.
Stone said, “I’m coming up on nine months sober,
and a big part of it is because I have a roof over my
head.” He lived on the streets off and on for 15
years until he moved into an apartment here in
March. This month, Salt Lake City placed the last of
its chronically homeless veterans in housing, its
mayor, Ralph Becker, announced. These milestones
are the first significant achievements by individual
communities in the federal government’s plan to
end homelessness among veterans by 2015, part of
its ambitious and complex push to eliminate
homelessness over all by 2020. Although officials
have conceded that the plan is behind schedule,
they point to the significant decline in the number of
homeless veterans — to roughly 58,000, or 9
percent of the homeless population, last January
from 76,000, or 12 percent of the nation’s
homeless, in 2010 — as a hopeful sign, given that it
happened in spite of difficult economic times. (The
number of homeless people over all fell by 5 percent
during the same period.) “We do think we can get
to the point where we can say there are no more
homeless veterans in the country,” Laura Zeilinger,
deputy director of the United States Interagency
Council on Homelessness, which coordinates the
66
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
chronically homeless veterans in or near the
communities where they live. (The veterans
contribute 30 percent of their gross income toward
housing.) In cities like Philadelphia and Salt Lake
City, private donors and religious groups have
helped pay for the types of expenses not covered by
the vouchers, like furniture and security deposits.
Here the United Way is funding 14 workers known
as navigators, who have been deployed to walk the
veterans through the confusing process of applying
for benefits and housing. One of them, James
Roberson, 57, who served in the Navy in the Persian
Gulf, said the job also involved more mundane
tasks, like making sure the veterans had food at
home, that they were clean and that their
apartments were in order. Patience is crucial, he
said. “You can’t force things on people who have
been on the streets so long,” he said. “They won’t
take it.” While the retention rate for homeless
veterans placed in permanent housing stood at 85
percent nationally after one year, a survey by the
Arizona Coalition to End Homelessness put it at 94
percent in Phoenix, a success attributed largely to
the navigator program. Mr. Hankins, the former
airman, was homeless for six years when a Veterans
Affairs social worker stationed at the agency where
he had gone to recharge his food stamps card
pulled him aside and offered to help. He is one of
eight clients of Mr. Roberson’s at Victory Place. “If I
had to do this on my own,” Mr. Hankins said one
recent morning as he strolled in Victory Place, “I’d
never have made it here.” (New York Times,
1/16/14)
http://www.nytimes.com/2014/01/16/us/programto-end-homelessness-among-veterans-hitsmilestone-in-arizona.html?ref=economy
http://www.miamiherald.com/2014/01/16/3874143/
legislators-to-consider-private.html#storylink=cpy
Obama Data Analysts Study Health-Care
Habits Under Obamacare
A group of data analysts who helped President
Barack Obama win two terms in the White House
are now partnering with a coalition of health-care
providers in Camden, N.J., to study how people’s
consumption habits change under the new health
law. BlueLabs, a company formed last year by
members of the Obama data team, is partnering
with the Camden Coalition of Healthcare Providers
to compile information tracking the treatment
patterns of people who enroll in Medicaid or the
new insurance marketplaces under the Affordable
Care Act. For example, the team will gather data on
how frequently the newly insured go emergency
rooms or outpatient health centers and compare
that with their previous behavior. The goal is to
help health-care providers and policymakers in other
parts of the country understand what is driving
health-care costs and better serve patients’ needs.
The work is being funded by a $450,000 grant
awarded to the Camden Coalition by the John S.
and James L. Knight Foundation. The project will
give the BlueLabs team a chance to employ some of
the same methods they honed studying voters’
behavior
during
back-to-back
presidential
campaigns. Mr. Obama’s re-election effort is widely
considered the most sophisticated campaign in
modern politics thanks in large measure to a data
team that collected large amounts of information
about which voters were perusable, what messages
moved them and the best method for delivering
those messages. “On the 2012 Obama campaign,
our analytics team consolidated critical data from
across the organization into a single database and
used that resource to run one of the most
successful and efficient campaigns in U.S. history,”
said Erek Dyskant, a co-founder of BlueLabs. “Now,
we’re using the same techniques to make
community health programs more effective.” The
collaboration will build on work the Camden
Coalition has been doing in New Jersey for years.
The Coalition, which is comprised of doctors, nurses
and other health-care administrators, started
gathering patient data years ago from the three
major health-care systems in Camden. The coalition
eventually compiled that information in a central
database that helped local health-care providers
improve outcomes and bring costs down. The
group discovered, for example, that in one year just
13% of the patients in Camden accounted for 80%
of the health-care costs there, according to its
website. Often these were people who were going
to emergency rooms for common ailments, like a
head cold or sore throat, or others who waited until
Legislators To Consider
Private Option Change
A legislative committee is to hear a budget
presentation from the Arkansas Department of
Human Services and questions about the state's
Medicaid expansion plan are likely to come up. The
Joint Public Health Committee meets at 3 p.m.
Thursday. The meeting comes days after a special
election expanded the Republican majority to 22-13
in the Senate, which could signal trouble for
Democratic Gov. Mike Beebe's plan to continue the
state's Medicaid expansion. Last year, legislators
narrowly approved a plan to subsidize private
insurance for low-income people who qualify for
coverage through a federally funded Medicaid
expansion.
Legislators begin a fiscal session on
Feb. 10, and Beebe says he is hopeful that the votes
will be there to continue the program. (Miami
Herald, 1/16/14)
67
E-Newsletter – National and Industry News
Florida Council
January 20, 2013
their illness advanced because they did not seek
preventative care.
The Camden Coalition and
BlueLabs will now apply those methods to see how
people change their health-care consumption
patterns under the Affordable Care Act. The goal is
to help hospitals, outpatient centers and community
health organizations spend money efficiently and
address patients’ needs. BlueLabs and the Camden
Coalition will anonymously aggregate medical claims
and other patient information and break it down by
geography and demographic groups. The new tool
has been dubbed the Camden Health Explorer. The
Camden Coalition will then work with health-care
providers and policymakers in other communities to
help them interpret the information in an effort to
trim costs and improve treatment. “By creating an
open source of anonymous data, the Explorer will
inform broader, important discussion about the
health of entire communities,” said Aaron Truchil,
manager of research for the Camden Coalition.
“This tool will leverage the data generated during
patient care to improve the efficiency of communitylevel health programs, enabling organizations to
make smarter decisions, ranging from deciding
where to locate a new clinic or what language
should be used to run a diabetes class.” (Wall Street
Journal, 1/15/14)
http://blogs.wsj.com/washwire/2014/01/15/obamadata-analysts-study-health-care-habits-underobamacare/
68