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"content": "\u003cp>As U.S. immigration enforcement becomes stricter under the Trump administration, more immigrant families are cutting ties with health care services and other critical government programs, according to child advocates who work with these families.\u003c/p>\n\u003cp>In Texas, researchers studying the issue say it's a major reason why more children are going without health insurance.\u003c/p>\n\u003cp>Ana, who lives in Central Texas with her husband and two children, has been increasingly hesitant to seek help from the government. In particular, she's worried about getting help for her 9-year-old daughter, Sara, who was diagnosed with autism a few years ago.\u003c/p>\n\u003cp>Ana entered the country without documentation about 10 years ago, which is why NPR has agreed not to use her last name. Both her children were born in the U.S. and have been covered by Medicaid for years. But ever since President Trump took office, Ana has only been using the program for basics — such as checkups and vaccinations for the kids.\u003c/p>\n\u003cp>This decision to forgo care comes at a cost. Managing Sara's behavior has been challenging, even after the diagnosis brought some clarity about what was going on. Sara acts out and has tantrums, sometimes in public places. Ana finds it difficult to soothe her daughter, and it's become more awkward as Sara grows.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>\"To other people, Sara just seems spoiled or a brat,\" Ana says.\u003c/p>\n\u003cp>After the diagnosis, Ana felt unsure about her next steps. She eventually went to a nonprofit in Austin that guides and supports parents whose children have disabilities. It's called \u003ca href=\"http://velafamilies.org/\" rel=\"noopener\" target=\"_blank\">Vela\u003c/a> (\"candle\" in Spanish).\u003c/p>\n\u003cp>At Vela, Ana learned about a range of services Sara could get access to via her Medicaid plan — including therapy to help the child communicate better.\u003c/p>\n\u003cp>However, the thought of asking for more government services for her daughter increased Ana's anxiety. \"I am looking for groups who are \u003cem>not\u003c/em> associated with the government,\" Ana explains.\u003c/p>\n\u003cp>Ana is in the middle of the long, expensive legal process of applying for permanent resident status, known informally as a \"green card.\" Recently, the Trump administration announced that it may tighten part of this process – the \u003ca href=\"https://www.npr.org/2018/09/22/650808003/trump-administration-will-seek-to-limit-green-cards-for-immigrants-needing-publi\" rel=\"noopener\" target=\"_blank\">\"public charge\"\u003c/a> assessment. The assessment scrutinizes how many government services a green card applicant currently uses — or \u003cem>might \u003c/em>use later in life. If a person uses many government services, they could pose a net financial burden on the federal budget — or so goes the rationale. The government's algorithms are complex, but \"public charge\" is part of the determination for who gets a green card and who doesn't.\u003c/p>\n\u003cp>The rule change proposed by the Trump administration — which may not come to pass — has already led many applicants, or would-be applicants, to be wary of \u003cem>all\u003c/em> government services, even those that wouldn't affect their applications.\u003c/p>\n\u003cp>\"I am afraid they will not give me a legal resident status,\" Ana says.\u003c/p>\n\u003cp>Her husband already has a green card, and the couple is determined to not jeopardize Ana's ongoing application. So they have decided — just to be safe — to avoid seeking any more help from the government. That's even though their daughter, who is a citizen, needs more therapy than she's getting right now.\u003c/p>\n\u003cp>\"I feel bad that I have to do that,\" Ana says.\u003c/p>\n\u003cp>She says she would love to treat her daughter's autism, but has decided that there is nothing more important than getting that green card, in order to keep the family together in the U.S.\u003c/p>\n\u003cp>\"I'm running into families that, when it's time for re-enrollment or reapplication, they are pausing and they are questioning if they should,\" says Nadine Rueb, a clinical social worker dealing with Ana's case at Vela.\u003c/p>\n\u003cp>Reub says a range of fears are behind immigrants avoidance of government services. Some are staying under the radar to avoid immediate deportation. Others are more like Ana — they just want to be in the best position possible to finally get permanent legal status and move on with their lives.\u003c/p>\n\u003cp>\"The climate of fear is so pervasive at this point, and there is so much misinformation out there,\" says \u003ca href=\"https://www.childrensdefense.org/staff/cheasty-anderson/\" rel=\"noopener\" target=\"_blank\">Cheasty Anderson\u003c/a>, a Senior Policy Associate with the Children's Defense Fund in Texas.\u003c/p>\n\u003cp>Anderson thinks the parents' fears have led to an uptick in children going without health coverage in Texas.\u003c/p>\n\u003cp>\u003ca href=\"https://ccf.georgetown.edu/2018/11/21/nations-progress-on-childrens-health-coverage-reverses-course/\" rel=\"noopener\" target=\"_blank\">A recent study\u003c/a> from Georgetown University's\u003ca href=\"https://ccf.georgetown.edu/\"> Center for Children and Families\u003c/a> found that one out of every five uninsured kids in the U.S. lives in Texas. And a big percentage of those uninsured children are Latino.\u003c/p>\n\u003cp>The \u003ca href=\"https://ccf.georgetown.edu/wp-content/uploads/2018/11/UninsuredKids2018_Final_asof1128743pm.pdf\" rel=\"noopener\" target=\"_blank\">report\u003c/a> shows that after years of steady decline, the number (and percentage) of uninsured children in the U.S. increased in 2017, the first year of Trump's presidency. Nationally, 5 percent of all kids are uninsured — and in Texas the rate rose to 10.7 percent, up from 9.8 percent in 2016.\u003c/p>\n\u003cp>\u003ca href=\"https://ccf.georgetown.edu/author/joan-alker/\" rel=\"noopener\" target=\"_blank\">Joan Alker\u003c/a>, the author of the Georgetown report, says the Trump administration's effort to crack down on both legal and illegal immigration is one of many factors driving up the uninsured rates. And it's especially perceptible in Texas, where a quarter of children have a parent who is either undocumented, or who is trying to become a legal resident.\u003c/p>\n\u003cp>\"For these mixed-status families, there is likely a heightened fear of interacting with the government, and this may be deterring them from signing up their eligible children up for government-sponsored health care,\" Alker said in a phone call with reporters in November, when the report was released.\u003c/p>\n\u003cp>Anderson says the repercussions fall hardest on kids with disabilities — kids who need services.\u003c/p>\n\u003cp>\"Texas is proud to be Texas in so many ways, but this is one way in which we are failing ourselves,\" she says.\u003c/p>\n\u003cp>From the perspective of Reub, a disability rights specialist, timing is an essential issue for these children.\u003c/p>\n\u003cp>\"The sooner you catch [the diagnosis or condition], the sooner you support the child [and] the sooner you support the family,\" Reub says. \"I think it's just a win-win for everybody. You are supporting the emotions of the family, and then that supports the child.\"\u003c/p>\n\u003cp>For now, Ana says she's relying on the services offered by her daughter's public school — which aren't counted in the federal government's \"public charge\" assessment. And she'll keep doing that until she gets that green card.\u003c/p>\n\u003cp>[ad floatright]\u003c/p>\n\u003cp>\u003cem>This story is part of NPR's reporting partnership with KUT and \u003c/em>\u003ca href=\"http://www.kaiserhealthnews.org/\" rel=\"noopener\" target=\"_blank\">Kaiser Health News\u003c/a>. \u003c/p>\n\u003cdiv class=\"fullattribution\">Copyright 2019 KUT 90.5. To see more, visit \u003ca href=\"http://kut.org\">KUT 90.5\u003c/a>.\u003cimg src=\"https://www.google-analytics.com/__utm.gif?utmac=UA-5828686-4&utmdt=Fear+Of+Deportation+Or+Green+Card+Denial+Deters+Some+Parents+From+Getting+Kids+Care&utme=8(APIKey)9(MDAxOTAwOTE4MDEyMTkxMDAzNjczZDljZA004)\">\u003c/div>\n\n",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003cp>As U.S. immigration enforcement becomes stricter under the Trump administration, more immigrant families are cutting ties with health care services and other critical government programs, according to child advocates who work with these families.\u003c/p>\n\u003cp>In Texas, researchers studying the issue say it's a major reason why more children are going without health insurance.\u003c/p>\n\u003cp>Ana, who lives in Central Texas with her husband and two children, has been increasingly hesitant to seek help from the government. In particular, she's worried about getting help for her 9-year-old daughter, Sara, who was diagnosed with autism a few years ago.\u003c/p>\n\u003cp>Ana entered the country without documentation about 10 years ago, which is why NPR has agreed not to use her last name. Both her children were born in the U.S. and have been covered by Medicaid for years. But ever since President Trump took office, Ana has only been using the program for basics — such as checkups and vaccinations for the kids.\u003c/p>\n\u003cp>This decision to forgo care comes at a cost. Managing Sara's behavior has been challenging, even after the diagnosis brought some clarity about what was going on. Sara acts out and has tantrums, sometimes in public places. Ana finds it difficult to soothe her daughter, and it's become more awkward as Sara grows.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>\"To other people, Sara just seems spoiled or a brat,\" Ana says.\u003c/p>\n\u003cp>After the diagnosis, Ana felt unsure about her next steps. She eventually went to a nonprofit in Austin that guides and supports parents whose children have disabilities. It's called \u003ca href=\"http://velafamilies.org/\" rel=\"noopener\" target=\"_blank\">Vela\u003c/a> (\"candle\" in Spanish).\u003c/p>\n\u003cp>At Vela, Ana learned about a range of services Sara could get access to via her Medicaid plan — including therapy to help the child communicate better.\u003c/p>\n\u003cp>However, the thought of asking for more government services for her daughter increased Ana's anxiety. \"I am looking for groups who are \u003cem>not\u003c/em> associated with the government,\" Ana explains.\u003c/p>\n\u003cp>Ana is in the middle of the long, expensive legal process of applying for permanent resident status, known informally as a \"green card.\" Recently, the Trump administration announced that it may tighten part of this process – the \u003ca href=\"https://www.npr.org/2018/09/22/650808003/trump-administration-will-seek-to-limit-green-cards-for-immigrants-needing-publi\" rel=\"noopener\" target=\"_blank\">\"public charge\"\u003c/a> assessment. The assessment scrutinizes how many government services a green card applicant currently uses — or \u003cem>might \u003c/em>use later in life. If a person uses many government services, they could pose a net financial burden on the federal budget — or so goes the rationale. The government's algorithms are complex, but \"public charge\" is part of the determination for who gets a green card and who doesn't.\u003c/p>\n\u003cp>The rule change proposed by the Trump administration — which may not come to pass — has already led many applicants, or would-be applicants, to be wary of \u003cem>all\u003c/em> government services, even those that wouldn't affect their applications.\u003c/p>\n\u003cp>\"I am afraid they will not give me a legal resident status,\" Ana says.\u003c/p>\n\u003cp>Her husband already has a green card, and the couple is determined to not jeopardize Ana's ongoing application. So they have decided — just to be safe — to avoid seeking any more help from the government. That's even though their daughter, who is a citizen, needs more therapy than she's getting right now.\u003c/p>\n\u003cp>\"I feel bad that I have to do that,\" Ana says.\u003c/p>\n\u003cp>She says she would love to treat her daughter's autism, but has decided that there is nothing more important than getting that green card, in order to keep the family together in the U.S.\u003c/p>\n\u003cp>\"I'm running into families that, when it's time for re-enrollment or reapplication, they are pausing and they are questioning if they should,\" says Nadine Rueb, a clinical social worker dealing with Ana's case at Vela.\u003c/p>\n\u003cp>Reub says a range of fears are behind immigrants avoidance of government services. Some are staying under the radar to avoid immediate deportation. Others are more like Ana — they just want to be in the best position possible to finally get permanent legal status and move on with their lives.\u003c/p>\n\u003cp>\"The climate of fear is so pervasive at this point, and there is so much misinformation out there,\" says \u003ca href=\"https://www.childrensdefense.org/staff/cheasty-anderson/\" rel=\"noopener\" target=\"_blank\">Cheasty Anderson\u003c/a>, a Senior Policy Associate with the Children's Defense Fund in Texas.\u003c/p>\n\u003cp>Anderson thinks the parents' fears have led to an uptick in children going without health coverage in Texas.\u003c/p>\n\u003cp>\u003ca href=\"https://ccf.georgetown.edu/2018/11/21/nations-progress-on-childrens-health-coverage-reverses-course/\" rel=\"noopener\" target=\"_blank\">A recent study\u003c/a> from Georgetown University's\u003ca href=\"https://ccf.georgetown.edu/\"> Center for Children and Families\u003c/a> found that one out of every five uninsured kids in the U.S. lives in Texas. And a big percentage of those uninsured children are Latino.\u003c/p>\n\u003cp>The \u003ca href=\"https://ccf.georgetown.edu/wp-content/uploads/2018/11/UninsuredKids2018_Final_asof1128743pm.pdf\" rel=\"noopener\" target=\"_blank\">report\u003c/a> shows that after years of steady decline, the number (and percentage) of uninsured children in the U.S. increased in 2017, the first year of Trump's presidency. Nationally, 5 percent of all kids are uninsured — and in Texas the rate rose to 10.7 percent, up from 9.8 percent in 2016.\u003c/p>\n\u003cp>\u003ca href=\"https://ccf.georgetown.edu/author/joan-alker/\" rel=\"noopener\" target=\"_blank\">Joan Alker\u003c/a>, the author of the Georgetown report, says the Trump administration's effort to crack down on both legal and illegal immigration is one of many factors driving up the uninsured rates. And it's especially perceptible in Texas, where a quarter of children have a parent who is either undocumented, or who is trying to become a legal resident.\u003c/p>\n\u003cp>\"For these mixed-status families, there is likely a heightened fear of interacting with the government, and this may be deterring them from signing up their eligible children up for government-sponsored health care,\" Alker said in a phone call with reporters in November, when the report was released.\u003c/p>\n\u003cp>Anderson says the repercussions fall hardest on kids with disabilities — kids who need services.\u003c/p>\n\u003cp>\"Texas is proud to be Texas in so many ways, but this is one way in which we are failing ourselves,\" she says.\u003c/p>\n\u003cp>From the perspective of Reub, a disability rights specialist, timing is an essential issue for these children.\u003c/p>\n\u003cp>\"The sooner you catch [the diagnosis or condition], the sooner you support the child [and] the sooner you support the family,\" Reub says. \"I think it's just a win-win for everybody. You are supporting the emotions of the family, and then that supports the child.\"\u003c/p>\n\u003cp>For now, Ana says she's relying on the services offered by her daughter's public school — which aren't counted in the federal government's \"public charge\" assessment. And she'll keep doing that until she gets that green card.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>\u003cem>This story is part of NPR's reporting partnership with KUT and \u003c/em>\u003ca href=\"http://www.kaiserhealthnews.org/\" rel=\"noopener\" target=\"_blank\">Kaiser Health News\u003c/a>. \u003c/p>\n\u003cdiv class=\"fullattribution\">Copyright 2019 KUT 90.5. To see more, visit \u003ca href=\"http://kut.org\">KUT 90.5\u003c/a>.\u003cimg src=\"https://www.google-analytics.com/__utm.gif?utmac=UA-5828686-4&utmdt=Fear+Of+Deportation+Or+Green+Card+Denial+Deters+Some+Parents+From+Getting+Kids+Care&utme=8(APIKey)9(MDAxOTAwOTE4MDEyMTkxMDAzNjczZDljZA004)\">\u003c/div>\n\n\u003c/div>\u003c/p>",
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"title": "A Scaled-Back Bid to Care for Undocumented Californians",
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"content": "\u003cp>After shelving a plan to provide full government health benefits to all undocumented, low-income adults in the state, California lawmakers are trying to extend coverage to seniors and the disabled in that population.\u003c/p>\n\u003cp>An estimated 1.8 million adult immigrants live in California without authorization, and roughly 1.2 million of them are poor enough to qualify for Medi-Cal, the state’s version of Medicaid. They can get care in emergency rooms, but a proposed new law would have provided them with full Medi-Cal benefits, including preventive care. \u003c/p>\n\u003cp>That idea, contained in bills by Democratic Sens. Ricardo \u003ca href=\"https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180SB974\" rel=\"noopener\" target=\"_blank\">Lara\u003c/a> of Bell Gardens and Joaquin \u003ca href=\"https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201720180AB2965\" rel=\"noopener\" target=\"_blank\">Arambula\u003c/a> of Fresno, took a major hit this week when the measures were placed in the dreaded “suspense file,” where bills sit in limbo and often die. Instead, Democratic lawmakers have included a vastly scaled-back version in the ongoing budget negotiations, which will conclude in mid-June.\u003c/p>\n\u003cp>The original plan was estimated to cost California $3 billion a year, and Gov. Jerry Brown has signaled extreme reluctance to spend such a large portion of the state’s nearly $9 billion surplus. And billions in taxpayer funds for undocumented residents may be an especially hard sell in this election year, when state Republicans are using illegal immigration as a wedge issue, hoping to drive GOP voters to the polls to support their candidates and causes.\u003c/p>\n\u003cp>Democratic lawmakers are now pushing for $250 million in the next budget to cover roughly 114,000 low-income seniors and disabled residents who are undocumented. \u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>In 2016, the state extended Medi-Cal benefits to undocumented children, and nearly 250,000 have enrolled since then, at a cost to the state of about $280 million. Adults’ health care is more expensive overall than children’s. \u003c/p>\n\u003cp>Opponents have said it’s a mistake for the state to pay for full-scope health care benefits to any portion of the undocumented population—whether it’s adults, children or seniors—not just because of the cost but also on principle, because many people without documentation are here illegally.\u003c/p>\n\u003cp>John Baackes is CEO of LA Care Health Plan, the largest publicly operated health plan in the nation. Baackes said the undocumented adult population is the largest segment of people in the state without health insurance, and getting them coverage is a huge cost-saver in the long run. \u003c/p>\n\u003cp>“Their care right now is episodic and inefficient—and expensive,” he said. California is already paying to care for them in emergency rooms and other urgent-care facilities, so the choice is whether or not to do that in a low-cost way, he said. \u003c/p>\n\u003cp>Including the low-income undocumented population in Medi-Cal potentially could save federal dollars, because it would ease the financial burden of free care received at federally qualified health centers. \u003c/p>\n\u003cp>Lara has argued that providing full care would save the state money, both in the expense of care and in increased worker productivity, because working adults wouldn’t wait till they’re really sick and rush to get expensive emergency room care. \u003c/p>\n\u003cp>He and others said the Trump administration’s crackdown on illegal immigration is deterring some residents from seeking needed care. Immigration and health care advocates have speculated that’s why enrollment of undocumented children in California’s public health services has been slower than expected. Many immigrants fear that using those services could lead immigration officials to deport them or family members. \u003c/p>\n\u003cp>“The fear-mongering is higher now,” Lara said. But he said California needs to blaze its own path, to look at its long-term future: “Fear in the immigrant community was there before Trump, and it will be there after Trump.”\u003c/p>\n\u003cp>In the end,Sacramento policy shifts almost always come down to cost, said Micah Weinberg, president of the Bay Area Council Economic Institute, a nonprofit think tank based in San Francisco.\u003c/p>\n\u003cp>Multiple studies have shown, he said, that immigrants are a benefit to communities where they live. The real problem, Weinberg said, is that health care costs too much, so adding undocumented adults becomes a pricier proposition than it should be. \u003c/p>\n\u003cp>“More health care for more people costs more money,” Weinberg said. “There’s no way around that.”\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>\u003ca href=\"https://calmatters.org\" rel=\"noopener\" target=\"_blank\">CALmatters.org\u003c/a> is a nonprofit, nonpartisan media venture explaining California policies and politics.\u003c/p>\n\n",
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"excerpt": "A Democratic bid to extend government health coverage to all undocumented, low-income adults in California has been put on hold. Lawmakers now hope to cover at least the seniors and the disabled.",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003cp>After shelving a plan to provide full government health benefits to all undocumented, low-income adults in the state, California lawmakers are trying to extend coverage to seniors and the disabled in that population.\u003c/p>\n\u003cp>An estimated 1.8 million adult immigrants live in California without authorization, and roughly 1.2 million of them are poor enough to qualify for Medi-Cal, the state’s version of Medicaid. They can get care in emergency rooms, but a proposed new law would have provided them with full Medi-Cal benefits, including preventive care. \u003c/p>\n\u003cp>That idea, contained in bills by Democratic Sens. Ricardo \u003ca href=\"https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180SB974\" rel=\"noopener\" target=\"_blank\">Lara\u003c/a> of Bell Gardens and Joaquin \u003ca href=\"https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201720180AB2965\" rel=\"noopener\" target=\"_blank\">Arambula\u003c/a> of Fresno, took a major hit this week when the measures were placed in the dreaded “suspense file,” where bills sit in limbo and often die. Instead, Democratic lawmakers have included a vastly scaled-back version in the ongoing budget negotiations, which will conclude in mid-June.\u003c/p>\n\u003cp>The original plan was estimated to cost California $3 billion a year, and Gov. Jerry Brown has signaled extreme reluctance to spend such a large portion of the state’s nearly $9 billion surplus. And billions in taxpayer funds for undocumented residents may be an especially hard sell in this election year, when state Republicans are using illegal immigration as a wedge issue, hoping to drive GOP voters to the polls to support their candidates and causes.\u003c/p>\n\u003cp>Democratic lawmakers are now pushing for $250 million in the next budget to cover roughly 114,000 low-income seniors and disabled residents who are undocumented. \u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>In 2016, the state extended Medi-Cal benefits to undocumented children, and nearly 250,000 have enrolled since then, at a cost to the state of about $280 million. Adults’ health care is more expensive overall than children’s. \u003c/p>\n\u003cp>Opponents have said it’s a mistake for the state to pay for full-scope health care benefits to any portion of the undocumented population—whether it’s adults, children or seniors—not just because of the cost but also on principle, because many people without documentation are here illegally.\u003c/p>\n\u003cp>John Baackes is CEO of LA Care Health Plan, the largest publicly operated health plan in the nation. Baackes said the undocumented adult population is the largest segment of people in the state without health insurance, and getting them coverage is a huge cost-saver in the long run. \u003c/p>\n\u003cp>“Their care right now is episodic and inefficient—and expensive,” he said. California is already paying to care for them in emergency rooms and other urgent-care facilities, so the choice is whether or not to do that in a low-cost way, he said. \u003c/p>\n\u003cp>Including the low-income undocumented population in Medi-Cal potentially could save federal dollars, because it would ease the financial burden of free care received at federally qualified health centers. \u003c/p>\n\u003cp>Lara has argued that providing full care would save the state money, both in the expense of care and in increased worker productivity, because working adults wouldn’t wait till they’re really sick and rush to get expensive emergency room care. \u003c/p>\n\u003cp>He and others said the Trump administration’s crackdown on illegal immigration is deterring some residents from seeking needed care. Immigration and health care advocates have speculated that’s why enrollment of undocumented children in California’s public health services has been slower than expected. Many immigrants fear that using those services could lead immigration officials to deport them or family members. \u003c/p>\n\u003cp>“The fear-mongering is higher now,” Lara said. But he said California needs to blaze its own path, to look at its long-term future: “Fear in the immigrant community was there before Trump, and it will be there after Trump.”\u003c/p>\n\u003cp>In the end,Sacramento policy shifts almost always come down to cost, said Micah Weinberg, president of the Bay Area Council Economic Institute, a nonprofit think tank based in San Francisco.\u003c/p>\n\u003cp>Multiple studies have shown, he said, that immigrants are a benefit to communities where they live. The real problem, Weinberg said, is that health care costs too much, so adding undocumented adults becomes a pricier proposition than it should be. \u003c/p>\n\u003cp>“More health care for more people costs more money,” Weinberg said. “There’s no way around that.”\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>\u003ca href=\"https://calmatters.org\" rel=\"noopener\" target=\"_blank\">CALmatters.org\u003c/a> is a nonprofit, nonpartisan media venture explaining California policies and politics.\u003c/p>\n\n\u003c/div>\u003c/p>",
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"disqusTitle": "Too Late To Operate? Surgery Near End Of Life Is Common, Costly",
"title": "Too Late To Operate? Surgery Near End Of Life Is Common, Costly",
"headTitle": "The California Report | KQED News",
"content": "\u003cp>At 87, Maxine Stanich cared more about improving the quality of her life than prolonging it.\u003c/p>\n\u003cp>She suffered from a long list of health problems, including heart failure and chronic lung disease that could leave her gasping for breath.\u003c/p>\n\u003cp>When her time came she wanted to die a natural death, Stanich told her daughter, and she signed a \"do not resuscitate\" directive, or DNR, ordering doctors not to revive her should her heart stop.\u003c/p>\n\u003cp>Yet a trip to a San Francisco emergency room for shortness of breath in 2008 led Stanich to get a defibrillator implanted in her chest — a medical device to keep her alive by delivering a powerful shock to her heart if it started beating irregularly.\u003c/p>\n\u003cp>At the time, Stanich didn't fully grasp what she had agreed to, even though she signed a document granting permission for the procedure, said her daughter, Susan Giaquinto.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>That clarity came only during a subsequent visit to a different hospital, when a surprised ER doctor saw the defibrillator protruding from Stanich's thin chest. It was the first time a doctor clearly explained what the defibrillator would mean for Stanich, said Giaquinto, who accompanied her mother on both hospital trips.\u003c/p>\n\u003cp>To Stanich's horror, the ER doctor explained that the device wouldn't allow Stanich to slip away painlessly. Instead, the defibrillator would give her a jolt \"so strong that it will knock her across the room,\" Giaquinto said.\u003c/p>\n\u003cp>Surgery like Stanich's defibrillator implantation has become all too common among those near the end of life, experts say. Nearly \u003ca href=\"http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61268-3/fulltext\" target=\"_blank\" rel=\"noopener\">1 in 3 Medicare patients\u003c/a> undergoes an operation in the year before death, even though the evidence shows that many are more likely to be harmed than to benefit from it.\u003c/p>\n\u003cfigure id=\"attachment_11652868\" class=\"wp-caption aligncenter\" style=\"max-width: 1920px\">\u003cimg class=\"size-full wp-image-11652868\" src=\"https://ww2.kqed.org/news/wp-content/uploads/sites/10/2018/02/rita-redberg-toned-41-f9f41542571d59b90321a2c978b286c7de516c4d-e1519866638109.jpg\" alt=\"Dr. Rita Redberg, director of women's cardiovascular services at the University of California, San Francisco's cardiology division, tends to her mother, Mae Redberg, in Mae's apartment in New York City.\" width=\"1920\" height=\"1440\">\u003cfigcaption class=\"wp-caption-text\">Dr. Rita Redberg, director of women's cardiovascular services at the University of California, San Francisco's cardiology division, tends to her mother, Mae Redberg, in Mae's apartment in New York City. \u003ccite>(Yana Paskova/Kaiser Health News)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>The practice is driven by financial incentives that reward doctors for doing procedures, as well as a medical culture in which patients and doctors are reluctant to talk about how surgical interventions should be prescribed more judiciously, said \u003ca href=\"http://profiles.ucsf.edu/rita.redberg\" target=\"_blank\" rel=\"noopener\">Dr. Rita Redberg\u003c/a>, a cardiologist who treated Stanich when she sought care at the second hospital a week after her defibrillator was implanted.\u003c/p>\n\u003cp>\"We have a culture that believes in very aggressive care,\" said Redberg, who specializes in heart disease in women at the University of California, San Francisco. \"We are often not considering the chance of benefit and chance of harm, and how that changes when you get older. We also fail to have conversations about what patients value most.\"\u003c/p>\n\u003cp>While surgery can be lifesaving for younger people, operating on frail, older patients rarely helps them live longer or returns the quality of life they once enjoyed, according to \u003ca href=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4492901/pdf/nihms647215.pdf\" target=\"_blank\" rel=\"noopener\">a 2016 paper\u003c/a> in \u003cem>Annals of Surgery.\u003c/em>\u003c/p>\n\u003cp>The cost of these surgeries — typically paid for by Medicare, the government health insurance program for people over 65 — involve more than money, said Dr. Amber Barnato, a professor at the Dartmouth Institute for Health Policy and Clinical Practice. Older patients who undergo surgery within a year of death spent 50 percent more time in the hospital than others, and nearly twice as many days in intensive care.\u003c/p>\n\u003cp>And while some robust octogenarians have many years ahead of them, studies show that surgery is also common among those who are far more frail.\u003c/p>\n\u003cp>Eighteen percent of Medicare patients have surgery in their final month of life and 8 percent in their final week, according to a \u003ca href=\"http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61268-3/fulltext\" target=\"_blank\" rel=\"noopener\">2011 study \u003c/a>in \u003cem>The Lancet.\u003c/em>\u003c/p>\n\u003cp>More than 12 percent of defibrillators were implanted in people older than 80, \u003ca href=\"https://academic.oup.com/europace/article/17/2/174/569259\" target=\"_blank\" rel=\"noopener\">according to a 2015 study.\u003c/a> Doctors implant about 158,000 of the devices each year, according to the American College of Cardiology. The total \u003ca href=\"https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Inpatient2015.html\" target=\"_blank\" rel=\"noopener\">cost\u003c/a> of the procedure runs about $60,000.\u003c/p>\n\u003cp>Procedures performed in the elderly range from major operations require lengthy recoveries compared to relatively minor surgery performed in a doctor's office, such as the removal of nonfatal skin cancers that would likely never cause any problems.\u003c/p>\n\u003cp>Research led by Dr. Eleni Linos has shown that people with limited life expectancies \u003ca href=\"http://onlinelibrary.wiley.com/doi/10.1111/jgs.14202/abstract\" target=\"_blank\" rel=\"noopener\">are treated for nonfatal skin cancers as aggressively as younger patients\u003c/a>. Among patients with a nonfatal skin cancer and a limited time to live, 70 percent underwent surgery, \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/23699934\" target=\"_blank\" rel=\"noopener\">according to\u003c/a> her 2013 study in \u003cem>JAMA Internal Medicine\u003c/em>.\u003c/p>\n\u003cp>\u003cstrong>When less is more\u003c/strong>\u003c/p>\n\u003cp>Surgery poses serious risks for older people, who weather anesthesia poorly and whose skin takes longer to heal. Among seniors who undergo urgent or emergency abdominal surgery, 20 percent die within 30 days, \u003ca href=\"https://jamanetwork.com/journals/jamasurgery/article-abstract/2599170\" target=\"_blank\" rel=\"noopener\">studies show.\u003c/a>\u003c/p>\n\u003cp>With diminished mental acuity and an old-fashioned respect for the medical profession, some aging patients are vulnerable to unwanted interventions. Stanich agreed to a pacemaker defibrillator simply because her doctor suggested it, Giaquinto said. Many people of Stanich's generation \"thought doctors were God ... They never questioned doctors — ever.\"\u003c/p>\n\u003cp>According to the University of Michigan's National Poll on Healthy Aging, published Wednesday, more than half of adults ages 50 to 80 said doctors often recommend unnecessary tests, medications or procedures. Yet half of those who'd been told they needed an X-ray or other test – but weren't sure they needed it – went on to have the procedure anyway.\u003c/p>\n\u003cp>Dr. Margaret Schwarze, a surgeon and associate professor at the University of Wisconsin School of Medicine and Public Health, said that older patients often don't feel the financial pain of surgery because insurance pays most of the cost.\u003c/p>\n\u003cp>When a surgeon offers to \"fix\" the heart valve in a person with multiple diseases, for example, the patient may assume that surgery will \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/25749396\" target=\"_blank\" rel=\"noopener\">fix all of her medical problems,\u003c/a> Schwarze said. \"With older patients with lots of chronic illnesses, we're not really fixing anything.\"\u003c/p>\n\u003cp>Even as a doctor, Redberg said, she struggles to prevent other doctors from performing too many procedures on her 92-year-old mother, Mae, who lives in New York City.\u003c/p>\n\u003cp>Redberg said doctors recently treated her mother for melanoma — the most serious type of skin cancer. After the cancer was removed from her leg, Redberg's mother was urged by a doctor to undergo an additional surgery to cut away more tissue and nearby lymph nodes, which can harbor cancerous cells.\u003c/p>\n\u003cp>\"Every time she went in, the dermatologist wanted to refer her to a surgeon,\" Redberg said. \"Medicare would have been happy to pay for it.\"\u003c/p>\n\u003cp>But her mother often has problems with wound healing, she said, and recovery would likely have taken three months. When Redberg pressed a surgeon about the benefits, he said the procedure could reduce the chances of cancer coming back within three to five years.\u003c/p>\n\u003cp>Redberg said her mother laughed and said, \"I'm not interested in doing something that will help me in three to five years. I doubt I'll be here.\"\u003c/p>\n\u003cp>\u003cstrong>Finding solutions\u003c/strong>\u003c/p>\n\u003cp>The momentum of hospital care can make people feel as if they're on a moving train and can't jump off.\u003c/p>\n\u003cp>The rush of medical decisions \"doesn't allow time to deliberate or consider the patients' overall health or what their goals and values might be,\" said Dr. Jacqueline Kruser, an instructor in pulmonary and critical care medicine and medical social sciences at the Northwestern University Feinberg School of Medicine.\u003c/p>\n\u003cp>Many hospitals and health systems are developing \"decision aids,\" easy-to-understand written \u003ca href=\"http://centerforinnovation.mayo.edu/decision-aids/\" target=\"_blank\" rel=\"noopener\">materials and videos\u003c/a> to help patients make more informed medical choices, giving them time to develop more realistic expectations.\u003c/p>\n\u003cp>After Kaiser Permanente Washington introduced the tools relating to joint replacement, the number of patients choosing to have hip replacement surgery fell 26 percent, while knee replacements declined 38 percent, \u003ca href=\"https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2011.0686\" target=\"_blank\" rel=\"noopener\">according to a 2012 study\u003c/a> in the journal \u003cem>Health Affairs.\u003c/em> (Kaiser Permanente isn't affiliated with Kaiser Health News, which is an editorially independent program of the Kaiser Family Foundation.)\u003c/p>\n\u003cp>In research findings \u003ca href=\"https://jamanetwork.com/journals/jamasurgery/article-abstract/2599170\" target=\"_blank\" rel=\"noopener\">published last year\u003c/a> in \u003cem>JAMA Surgery\u003c/em> and the \u003ca href=\"http://www.jpsmjournal.com/article/S0885-3924(16)31228-3/pdf\" target=\"_blank\" rel=\"noopener\">Journal of Pain and Symptom Management,\u003c/a> Schwarze, Kruser and colleagues suggested creating narratives to illustrate surgical risks, rather than relying on statistics.\u003c/p>\n\u003cp>Instead of telling patients that surgery carries a 20 percent risk of stroke, for example, doctors should lay out the best, worst and most likely outcomes.\u003c/p>\n\u003cp>In the best-case scenario, a patient might spend weeks in the hospital after surgery, living the rest of her life in a nursing home. In the worst case, the same patient dies after several weeks in intensive care. In the most likely scenario, the patient survives just two to three months after surgery.\u003c/p>\n\u003cp>\"If someone says they can't tolerate the best-case scenario — which involves them being in a nursing home — then maybe we shouldn't be doing this,\" Schwarze said.\u003c/p>\n\u003cp>Maxine Stanich died in 2010, just after her 90th birthday. Although Redberg had deactivated the defibrillator at Stanich's request, it remained in her chest.\u003c/p>\n\u003chr>\n\u003cp>[ad floatright]\u003c/p>\n\u003cp>\u003ca href=\"https://khn.org/about-us\" target=\"_blank\" rel=\"noopener\">\u003cem>Kaiser Health News\u003c/em>\u003c/a>\u003cem> is a nonprofit news service covering health issues. You can follow Liz Szabo on Twitter: \u003c/em>\u003ca href=\"https://twitter.com/LizSzabo\" target=\"_blank\" rel=\"noopener\">\u003cem>@LizSzabo\u003c/em>\u003c/a>.\u003c/p>\n\u003cdiv class=\"fullattribution\">Copyright 2018 Kaiser Health News. To see more, visit \u003ca href=\"http://www.kaiserhealthnews.org/\" target=\"_blank\" rel=\"noopener\">Kaiser Health News\u003c/a>.\u003cimg src=\"https://www.google-analytics.com/__utm.gif?utmac=UA-5828686-4&utmdt=Too+Late+To+Operate%3F+Surgery+Near+End+Of+Life+Is+Common%2C+Costly&utme=8(APIKey)9(MDAxOTAwOTE4MDEyMTkxMDAzNjczZDljZA004)\">\u003c/div>\n\n",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003cp>At 87, Maxine Stanich cared more about improving the quality of her life than prolonging it.\u003c/p>\n\u003cp>She suffered from a long list of health problems, including heart failure and chronic lung disease that could leave her gasping for breath.\u003c/p>\n\u003cp>When her time came she wanted to die a natural death, Stanich told her daughter, and she signed a \"do not resuscitate\" directive, or DNR, ordering doctors not to revive her should her heart stop.\u003c/p>\n\u003cp>Yet a trip to a San Francisco emergency room for shortness of breath in 2008 led Stanich to get a defibrillator implanted in her chest — a medical device to keep her alive by delivering a powerful shock to her heart if it started beating irregularly.\u003c/p>\n\u003cp>At the time, Stanich didn't fully grasp what she had agreed to, even though she signed a document granting permission for the procedure, said her daughter, Susan Giaquinto.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>That clarity came only during a subsequent visit to a different hospital, when a surprised ER doctor saw the defibrillator protruding from Stanich's thin chest. It was the first time a doctor clearly explained what the defibrillator would mean for Stanich, said Giaquinto, who accompanied her mother on both hospital trips.\u003c/p>\n\u003cp>To Stanich's horror, the ER doctor explained that the device wouldn't allow Stanich to slip away painlessly. Instead, the defibrillator would give her a jolt \"so strong that it will knock her across the room,\" Giaquinto said.\u003c/p>\n\u003cp>Surgery like Stanich's defibrillator implantation has become all too common among those near the end of life, experts say. Nearly \u003ca href=\"http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61268-3/fulltext\" target=\"_blank\" rel=\"noopener\">1 in 3 Medicare patients\u003c/a> undergoes an operation in the year before death, even though the evidence shows that many are more likely to be harmed than to benefit from it.\u003c/p>\n\u003cfigure id=\"attachment_11652868\" class=\"wp-caption aligncenter\" style=\"max-width: 1920px\">\u003cimg class=\"size-full wp-image-11652868\" src=\"https://ww2.kqed.org/news/wp-content/uploads/sites/10/2018/02/rita-redberg-toned-41-f9f41542571d59b90321a2c978b286c7de516c4d-e1519866638109.jpg\" alt=\"Dr. Rita Redberg, director of women's cardiovascular services at the University of California, San Francisco's cardiology division, tends to her mother, Mae Redberg, in Mae's apartment in New York City.\" width=\"1920\" height=\"1440\">\u003cfigcaption class=\"wp-caption-text\">Dr. Rita Redberg, director of women's cardiovascular services at the University of California, San Francisco's cardiology division, tends to her mother, Mae Redberg, in Mae's apartment in New York City. \u003ccite>(Yana Paskova/Kaiser Health News)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>The practice is driven by financial incentives that reward doctors for doing procedures, as well as a medical culture in which patients and doctors are reluctant to talk about how surgical interventions should be prescribed more judiciously, said \u003ca href=\"http://profiles.ucsf.edu/rita.redberg\" target=\"_blank\" rel=\"noopener\">Dr. Rita Redberg\u003c/a>, a cardiologist who treated Stanich when she sought care at the second hospital a week after her defibrillator was implanted.\u003c/p>\n\u003cp>\"We have a culture that believes in very aggressive care,\" said Redberg, who specializes in heart disease in women at the University of California, San Francisco. \"We are often not considering the chance of benefit and chance of harm, and how that changes when you get older. We also fail to have conversations about what patients value most.\"\u003c/p>\n\u003cp>While surgery can be lifesaving for younger people, operating on frail, older patients rarely helps them live longer or returns the quality of life they once enjoyed, according to \u003ca href=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4492901/pdf/nihms647215.pdf\" target=\"_blank\" rel=\"noopener\">a 2016 paper\u003c/a> in \u003cem>Annals of Surgery.\u003c/em>\u003c/p>\n\u003cp>The cost of these surgeries — typically paid for by Medicare, the government health insurance program for people over 65 — involve more than money, said Dr. Amber Barnato, a professor at the Dartmouth Institute for Health Policy and Clinical Practice. Older patients who undergo surgery within a year of death spent 50 percent more time in the hospital than others, and nearly twice as many days in intensive care.\u003c/p>\n\u003cp>And while some robust octogenarians have many years ahead of them, studies show that surgery is also common among those who are far more frail.\u003c/p>\n\u003cp>Eighteen percent of Medicare patients have surgery in their final month of life and 8 percent in their final week, according to a \u003ca href=\"http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61268-3/fulltext\" target=\"_blank\" rel=\"noopener\">2011 study \u003c/a>in \u003cem>The Lancet.\u003c/em>\u003c/p>\n\u003cp>More than 12 percent of defibrillators were implanted in people older than 80, \u003ca href=\"https://academic.oup.com/europace/article/17/2/174/569259\" target=\"_blank\" rel=\"noopener\">according to a 2015 study.\u003c/a> Doctors implant about 158,000 of the devices each year, according to the American College of Cardiology. The total \u003ca href=\"https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Inpatient2015.html\" target=\"_blank\" rel=\"noopener\">cost\u003c/a> of the procedure runs about $60,000.\u003c/p>\n\u003cp>Procedures performed in the elderly range from major operations require lengthy recoveries compared to relatively minor surgery performed in a doctor's office, such as the removal of nonfatal skin cancers that would likely never cause any problems.\u003c/p>\n\u003cp>Research led by Dr. Eleni Linos has shown that people with limited life expectancies \u003ca href=\"http://onlinelibrary.wiley.com/doi/10.1111/jgs.14202/abstract\" target=\"_blank\" rel=\"noopener\">are treated for nonfatal skin cancers as aggressively as younger patients\u003c/a>. Among patients with a nonfatal skin cancer and a limited time to live, 70 percent underwent surgery, \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/23699934\" target=\"_blank\" rel=\"noopener\">according to\u003c/a> her 2013 study in \u003cem>JAMA Internal Medicine\u003c/em>.\u003c/p>\n\u003cp>\u003cstrong>When less is more\u003c/strong>\u003c/p>\n\u003cp>Surgery poses serious risks for older people, who weather anesthesia poorly and whose skin takes longer to heal. Among seniors who undergo urgent or emergency abdominal surgery, 20 percent die within 30 days, \u003ca href=\"https://jamanetwork.com/journals/jamasurgery/article-abstract/2599170\" target=\"_blank\" rel=\"noopener\">studies show.\u003c/a>\u003c/p>\n\u003cp>With diminished mental acuity and an old-fashioned respect for the medical profession, some aging patients are vulnerable to unwanted interventions. Stanich agreed to a pacemaker defibrillator simply because her doctor suggested it, Giaquinto said. Many people of Stanich's generation \"thought doctors were God ... They never questioned doctors — ever.\"\u003c/p>\n\u003cp>According to the University of Michigan's National Poll on Healthy Aging, published Wednesday, more than half of adults ages 50 to 80 said doctors often recommend unnecessary tests, medications or procedures. Yet half of those who'd been told they needed an X-ray or other test – but weren't sure they needed it – went on to have the procedure anyway.\u003c/p>\n\u003cp>Dr. Margaret Schwarze, a surgeon and associate professor at the University of Wisconsin School of Medicine and Public Health, said that older patients often don't feel the financial pain of surgery because insurance pays most of the cost.\u003c/p>\n\u003cp>When a surgeon offers to \"fix\" the heart valve in a person with multiple diseases, for example, the patient may assume that surgery will \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/25749396\" target=\"_blank\" rel=\"noopener\">fix all of her medical problems,\u003c/a> Schwarze said. \"With older patients with lots of chronic illnesses, we're not really fixing anything.\"\u003c/p>\n\u003cp>Even as a doctor, Redberg said, she struggles to prevent other doctors from performing too many procedures on her 92-year-old mother, Mae, who lives in New York City.\u003c/p>\n\u003cp>Redberg said doctors recently treated her mother for melanoma — the most serious type of skin cancer. After the cancer was removed from her leg, Redberg's mother was urged by a doctor to undergo an additional surgery to cut away more tissue and nearby lymph nodes, which can harbor cancerous cells.\u003c/p>\n\u003cp>\"Every time she went in, the dermatologist wanted to refer her to a surgeon,\" Redberg said. \"Medicare would have been happy to pay for it.\"\u003c/p>\n\u003cp>But her mother often has problems with wound healing, she said, and recovery would likely have taken three months. When Redberg pressed a surgeon about the benefits, he said the procedure could reduce the chances of cancer coming back within three to five years.\u003c/p>\n\u003cp>Redberg said her mother laughed and said, \"I'm not interested in doing something that will help me in three to five years. I doubt I'll be here.\"\u003c/p>\n\u003cp>\u003cstrong>Finding solutions\u003c/strong>\u003c/p>\n\u003cp>The momentum of hospital care can make people feel as if they're on a moving train and can't jump off.\u003c/p>\n\u003cp>The rush of medical decisions \"doesn't allow time to deliberate or consider the patients' overall health or what their goals and values might be,\" said Dr. Jacqueline Kruser, an instructor in pulmonary and critical care medicine and medical social sciences at the Northwestern University Feinberg School of Medicine.\u003c/p>\n\u003cp>Many hospitals and health systems are developing \"decision aids,\" easy-to-understand written \u003ca href=\"http://centerforinnovation.mayo.edu/decision-aids/\" target=\"_blank\" rel=\"noopener\">materials and videos\u003c/a> to help patients make more informed medical choices, giving them time to develop more realistic expectations.\u003c/p>\n\u003cp>After Kaiser Permanente Washington introduced the tools relating to joint replacement, the number of patients choosing to have hip replacement surgery fell 26 percent, while knee replacements declined 38 percent, \u003ca href=\"https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2011.0686\" target=\"_blank\" rel=\"noopener\">according to a 2012 study\u003c/a> in the journal \u003cem>Health Affairs.\u003c/em> (Kaiser Permanente isn't affiliated with Kaiser Health News, which is an editorially independent program of the Kaiser Family Foundation.)\u003c/p>\n\u003cp>In research findings \u003ca href=\"https://jamanetwork.com/journals/jamasurgery/article-abstract/2599170\" target=\"_blank\" rel=\"noopener\">published last year\u003c/a> in \u003cem>JAMA Surgery\u003c/em> and the \u003ca href=\"http://www.jpsmjournal.com/article/S0885-3924(16)31228-3/pdf\" target=\"_blank\" rel=\"noopener\">Journal of Pain and Symptom Management,\u003c/a> Schwarze, Kruser and colleagues suggested creating narratives to illustrate surgical risks, rather than relying on statistics.\u003c/p>\n\u003cp>Instead of telling patients that surgery carries a 20 percent risk of stroke, for example, doctors should lay out the best, worst and most likely outcomes.\u003c/p>\n\u003cp>In the best-case scenario, a patient might spend weeks in the hospital after surgery, living the rest of her life in a nursing home. In the worst case, the same patient dies after several weeks in intensive care. In the most likely scenario, the patient survives just two to three months after surgery.\u003c/p>\n\u003cp>\"If someone says they can't tolerate the best-case scenario — which involves them being in a nursing home — then maybe we shouldn't be doing this,\" Schwarze said.\u003c/p>\n\u003cp>Maxine Stanich died in 2010, just after her 90th birthday. Although Redberg had deactivated the defibrillator at Stanich's request, it remained in her chest.\u003c/p>\n\u003chr>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cp>\u003cstrong>Updated at 11:29 a.m. ET\u003c/strong>\u003c/p>\n\u003cp>The Trump administration is encouraging states to require “able-bodied” Medicaid recipients to work or volunteer in order to keep their health insurance coverage.\u003c/p>\n\u003cp>On Thursday, the Centers for Medicare and Medicaid Services, which is part of the Department of Health and Human Services, issued new \u003ca href=\"https://www.medicaid.gov/federal-policy-guidance/downloads/smd18002.pdf\">guidelines\u003c/a> for states that want some adults to work in exchange for the health insurance coverage.\u003c/p>\n\u003cp>Under the rules, states can require Medicaid beneficiaries to work, volunteer or participate in job training. People who are elderly or disabled, and pregnant women and children, would be excluded.\u003c/p>\n\u003cp>CMS Administrator Seema Verma said on \u003ca href=\"https://twitter.com/SeemaCMS/status/951401879740846080\">Twitter\u003c/a> that the new efforts will “improve Medicaid enrollee health outcomes by incentivizing community engagement.”\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>“This is about helping people rise out of poverty,” Verma said on a call with reporters.\u003c/p>\n\u003cp>She cited studies that show a correlation between good health and having a job.\u003c/p>\n\u003cp>But opponents to tying Medicaid to work argue that good health leads to the ability to hold down a job.\u003c/p>\n\u003cp>“Access to Medicaid makes it easier for people to look for work and obtain employment,” says Suzanne Wikle of the Center for Law and Social Policy. “A so-called ‘work requirement’ does not support work, but instead puts a critical support for work at risk.”\u003c/p>\n\u003cp>Ten states — Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah and Wisconsin — have already filed applications with CMS to add work requirements to their Medicaid programs.\u003c/p>\n\u003cp>But it’s not clear how many people would be affected by the new rules. A \u003ca href=\"https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2664514\">study\u003c/a> in December in \u003cem>JAMA Internal Medicine\u003c/em> found that about half of the Medicaid recipients in Michigan were already working.\u003c/p>\n\u003cp>In addition, people who are disabled under the Americans with Disabilities Act but have Medicaid benefits for another reason could be exempted or the state would be required to make “reasonable modifications,” such as a reduced hourly requirement to ensure that the requirements don’t disproportionately hurt people with disabilities.\u003c/p>\n\u003cp>And states are also required to make such accommodations for people with addiction to opioids and other substances. That could mean counting time spent in drug treatment as a form of “community engagement.”\u003c/p>\n\u003cp>The range of “community engagement” requirements can be quite broad, according to the CMS guidelines sent to states on Thursday. In addition to traditional work and job training, engagement could include caring for a child or elderly parent, seeking treatment for drug addiction or going to school.\u003c/p>\n\u003cp>Verma said the agency wants to give states as much latitude as possible to try out their own ideas.\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>“There are a lot of different ideas, and a lot of ways to go about this,” she said. “We want to give states as much flexibility as possible because that’s where we’ll be able to evaluate what actually works best.”\u003c/p>\n\n",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003cp>\u003cstrong>Updated at 11:29 a.m. ET\u003c/strong>\u003c/p>\n\u003cp>The Trump administration is encouraging states to require “able-bodied” Medicaid recipients to work or volunteer in order to keep their health insurance coverage.\u003c/p>\n\u003cp>On Thursday, the Centers for Medicare and Medicaid Services, which is part of the Department of Health and Human Services, issued new \u003ca href=\"https://www.medicaid.gov/federal-policy-guidance/downloads/smd18002.pdf\">guidelines\u003c/a> for states that want some adults to work in exchange for the health insurance coverage.\u003c/p>\n\u003cp>Under the rules, states can require Medicaid beneficiaries to work, volunteer or participate in job training. People who are elderly or disabled, and pregnant women and children, would be excluded.\u003c/p>\n\u003cp>CMS Administrator Seema Verma said on \u003ca href=\"https://twitter.com/SeemaCMS/status/951401879740846080\">Twitter\u003c/a> that the new efforts will “improve Medicaid enrollee health outcomes by incentivizing community engagement.”\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>“This is about helping people rise out of poverty,” Verma said on a call with reporters.\u003c/p>\n\u003cp>She cited studies that show a correlation between good health and having a job.\u003c/p>\n\u003cp>But opponents to tying Medicaid to work argue that good health leads to the ability to hold down a job.\u003c/p>\n\u003cp>“Access to Medicaid makes it easier for people to look for work and obtain employment,” says Suzanne Wikle of the Center for Law and Social Policy. “A so-called ‘work requirement’ does not support work, but instead puts a critical support for work at risk.”\u003c/p>\n\u003cp>Ten states — Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah and Wisconsin — have already filed applications with CMS to add work requirements to their Medicaid programs.\u003c/p>\n\u003cp>But it’s not clear how many people would be affected by the new rules. A \u003ca href=\"https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2664514\">study\u003c/a> in December in \u003cem>JAMA Internal Medicine\u003c/em> found that about half of the Medicaid recipients in Michigan were already working.\u003c/p>\n\u003cp>In addition, people who are disabled under the Americans with Disabilities Act but have Medicaid benefits for another reason could be exempted or the state would be required to make “reasonable modifications,” such as a reduced hourly requirement to ensure that the requirements don’t disproportionately hurt people with disabilities.\u003c/p>\n\u003cp>And states are also required to make such accommodations for people with addiction to opioids and other substances. That could mean counting time spent in drug treatment as a form of “community engagement.”\u003c/p>\n\u003cp>The range of “community engagement” requirements can be quite broad, according to the CMS guidelines sent to states on Thursday. In addition to traditional work and job training, engagement could include caring for a child or elderly parent, seeking treatment for drug addiction or going to school.\u003c/p>\n\u003cp>Verma said the agency wants to give states as much latitude as possible to try out their own ideas.\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>“There are a lot of different ideas, and a lot of ways to go about this,” she said. “We want to give states as much flexibility as possible because that’s where we’ll be able to evaluate what actually works best.”\u003c/p>\n\n\u003c/div>\u003c/p>",
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"disqusTitle": "Nursing Homes Worry Proposed Medicaid Cuts Will Force Cuts, Closures",
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"content": "\u003cp>The Senate vote on the health care bill has been pushed back, but it still has a lot of people in the nursing home industry worried. About two-thirds of nursing home residents are paid for by Medicaid. And the Congressional Budget Office \u003ca href=\"https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/52849-hr1628senate.pdf\">found\u003c/a> that the Senate health care bill would cut Medicaid by more than $770 billion over the next decade.\u003c/p>\n\u003cp>That could mean trouble for people like 88-year-old Betty Redlin. She's lived at the \u003ca href=\"http://victoriacarecenter.com/\">Victoria Care Center\u003c/a> in Ventura, Calif. for about 2 1/2 years.\u003c/p>\n\u003cp>She explains that she fell and broke her hip and never regained her ability to walk. \"I was living with my granddaughter,\" she says, \"and my doctor won't [allow] going back to her place.\"\u003c/p>\n\u003cp>Betty had a career as a bookkeeper. She also raised three children. Now she's spent everything she had. There's no way she could afford the roughly $80,000 a year this nursing home costs. (That fee is pretty standard for nursing homes.) So it's Medicaid that enables her to stay here.\u003c/p>\n\u003cp>\"There's nothing I can do about it,\" she says. \"It's gotta be [Medicaid] or [I'm] out on the street. One or the other.\"\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>\u003c!-- iframe plugin v.4.3 wordpress.org/plugins/iframe/ -->\u003cbr>\n\u003ciframe src=\"https://www.npr.org/player/embed/534764940/534764941\" width=\"100%\" height=\"290\" frameborder=\"0\" scrolling=\"no\" title=\"NPR embedded audio player\" class=\"iframe-class\">\u003c/iframe>\u003c/p>\n\u003cp>John Gardner, executive director of the Victoria Care Center, says that most of the long-term care residents like Redlin are on Medicaid or, as it's called in California, Medi-Cal.\u003c/p>\n\u003cp>\"If you look at what it costs to provide that service and what we get from Medi-Cal, we're actually losing a little bit of money every day on that.\" He says they make up the difference with short-term residents who have Medicare, which pays more than Medicaid does. Private pay patients also pay more than Medicaid.\u003c/p>\n\u003cp>Gardner says he's an optimist. Whatever Congress does, he doesn't think that Victoria Care Center would close down, though there might have to be cuts in staff and in the costs of food and supplies. Also, Gardner says that Victoria Care Center is part of a chain of 200 facilities, which could cushion the blow.\u003c/p>\n\u003cp>But not everyone is as optimistic as he is. According to the \u003ca href=\"https://www.ahcancal.org/Pages/Default.aspx\">American Health Care Association\u003c/a> (AHCA), a national trade group for nursing homes, the current Senate bill's cuts to Medicaid could mean that a typical nursing home would eventually run deficits of hundreds of thousands of dollars a year. James Gomez is the CEO of The \u003ca href=\"http://www.cahf.org/\">California Association of Health Facilities\u003c/a>, the AHCA's California chapter.\u003c/p>\n\u003cp>[contextly_sidebar id=\"mrVakER0R6f0AToNbkAK83dprja2VTaO\"]\u003c/p>\n\u003cp>\"If you can't break even or make a few dollars, you're not going to keep running your business,\" says Gomez. And that could lead to closures. \"So access [to nursing home beds] will become a huge issue.\"\u003c/p>\n\u003cp>The repercussions of cuts and closures would be felt across the nation's health care system, says Katie Smith Sloan, the president of \u003ca href=\"http://www.leadingage.org/\">Leading Age\u003c/a>, which represents non-profit nursing homes and other services for older adults.\u003c/p>\n\u003cp>\"People who are in nursing homes are there because they need the kind of services that a nursing home provides\" says Sloan. \"Without those services, they'll be forced to get that kind of care in a hospital, which will simply increase costs to Medicare.\"\u003c/p>\n\u003cp>Reining in Medicaid has been on conservatives' to-do list for a long time. House Speaker Paul Ryan has said he's \u003ca href=\"http://www.cnbc.com/2017/03/20/paul-ryan-has-wanted-to-reform-medicaid-since-his-frat-days.html\">dreamed of it\u003c/a> since his college days. Robert Moffit, a senior fellow in health policy studies at the conservative \u003ca href=\"http://www.heritage.org/\">Heritage Foundation\u003c/a>, argues that the program isn't being used as intended.\u003c/p>\n\u003cp>\"Do we want Medicaid, which was a program designed for the poor and the indigent, to become a kind of backdoor mechanism to establish a middle class entitlement for long-term care? Medicaid was never really intended to do that,\" says Moffit.\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>The Senate bill is likely to change. But leader Mitch McConnell has indicated that Medicaid cuts will still be part of it.\u003c/p>\n\u003cdiv class=\"fullattribution\">Copyright 2017 NPR. To see more, visit http://www.npr.org/.\u003cimg src=\"https://www.google-analytics.com/__utm.gif?utmac=UA-5828686-4&utmdt=Nursing+Homes+Worry+Proposed+Medicaid+Cuts+Will+Force+Cuts%2C+Closures&utme=8(APIKey)9(MDAxOTAwOTE4MDEyMTkxMDAzNjczZDljZA004)\">\u003c/div>\n\n",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003cp>The Senate vote on the health care bill has been pushed back, but it still has a lot of people in the nursing home industry worried. About two-thirds of nursing home residents are paid for by Medicaid. And the Congressional Budget Office \u003ca href=\"https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/52849-hr1628senate.pdf\">found\u003c/a> that the Senate health care bill would cut Medicaid by more than $770 billion over the next decade.\u003c/p>\n\u003cp>That could mean trouble for people like 88-year-old Betty Redlin. She's lived at the \u003ca href=\"http://victoriacarecenter.com/\">Victoria Care Center\u003c/a> in Ventura, Calif. for about 2 1/2 years.\u003c/p>\n\u003cp>She explains that she fell and broke her hip and never regained her ability to walk. \"I was living with my granddaughter,\" she says, \"and my doctor won't [allow] going back to her place.\"\u003c/p>\n\u003cp>Betty had a career as a bookkeeper. She also raised three children. Now she's spent everything she had. There's no way she could afford the roughly $80,000 a year this nursing home costs. (That fee is pretty standard for nursing homes.) So it's Medicaid that enables her to stay here.\u003c/p>\n\u003cp>\"There's nothing I can do about it,\" she says. \"It's gotta be [Medicaid] or [I'm] out on the street. One or the other.\"\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>\u003c!-- iframe plugin v.4.3 wordpress.org/plugins/iframe/ -->\u003cbr>\n\u003ciframe src=\"https://www.npr.org/player/embed/534764940/534764941\" width=\"100%\" height=\"290\" frameborder=\"0\" scrolling=\"no\" title=\"NPR embedded audio player\" class=\"iframe-class\">\u003c/iframe>\u003c/p>\n\u003cp>John Gardner, executive director of the Victoria Care Center, says that most of the long-term care residents like Redlin are on Medicaid or, as it's called in California, Medi-Cal.\u003c/p>\n\u003cp>\"If you look at what it costs to provide that service and what we get from Medi-Cal, we're actually losing a little bit of money every day on that.\" He says they make up the difference with short-term residents who have Medicare, which pays more than Medicaid does. Private pay patients also pay more than Medicaid.\u003c/p>\n\u003cp>Gardner says he's an optimist. Whatever Congress does, he doesn't think that Victoria Care Center would close down, though there might have to be cuts in staff and in the costs of food and supplies. Also, Gardner says that Victoria Care Center is part of a chain of 200 facilities, which could cushion the blow.\u003c/p>\n\u003cp>But not everyone is as optimistic as he is. According to the \u003ca href=\"https://www.ahcancal.org/Pages/Default.aspx\">American Health Care Association\u003c/a> (AHCA), a national trade group for nursing homes, the current Senate bill's cuts to Medicaid could mean that a typical nursing home would eventually run deficits of hundreds of thousands of dollars a year. James Gomez is the CEO of The \u003ca href=\"http://www.cahf.org/\">California Association of Health Facilities\u003c/a>, the AHCA's California chapter.\u003c/p>\n\u003cp>\u003c/p>\u003cp>\u003c/p>\u003cp>\u003c/p>\n\u003cp>\"If you can't break even or make a few dollars, you're not going to keep running your business,\" says Gomez. And that could lead to closures. \"So access [to nursing home beds] will become a huge issue.\"\u003c/p>\n\u003cp>The repercussions of cuts and closures would be felt across the nation's health care system, says Katie Smith Sloan, the president of \u003ca href=\"http://www.leadingage.org/\">Leading Age\u003c/a>, which represents non-profit nursing homes and other services for older adults.\u003c/p>\n\u003cp>\"People who are in nursing homes are there because they need the kind of services that a nursing home provides\" says Sloan. \"Without those services, they'll be forced to get that kind of care in a hospital, which will simply increase costs to Medicare.\"\u003c/p>\n\u003cp>Reining in Medicaid has been on conservatives' to-do list for a long time. House Speaker Paul Ryan has said he's \u003ca href=\"http://www.cnbc.com/2017/03/20/paul-ryan-has-wanted-to-reform-medicaid-since-his-frat-days.html\">dreamed of it\u003c/a> since his college days. Robert Moffit, a senior fellow in health policy studies at the conservative \u003ca href=\"http://www.heritage.org/\">Heritage Foundation\u003c/a>, argues that the program isn't being used as intended.\u003c/p>\n\u003cp>\"Do we want Medicaid, which was a program designed for the poor and the indigent, to become a kind of backdoor mechanism to establish a middle class entitlement for long-term care? Medicaid was never really intended to do that,\" says Moffit.\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>The Senate bill is likely to change. But leader Mitch McConnell has indicated that Medicaid cuts will still be part of it.\u003c/p>\n\u003cdiv class=\"fullattribution\">Copyright 2017 NPR. To see more, visit http://www.npr.org/.\u003cimg src=\"https://www.google-analytics.com/__utm.gif?utmac=UA-5828686-4&utmdt=Nursing+Homes+Worry+Proposed+Medicaid+Cuts+Will+Force+Cuts%2C+Closures&utme=8(APIKey)9(MDAxOTAwOTE4MDEyMTkxMDAzNjczZDljZA004)\">\u003c/div>\n\n\u003c/div>\u003c/p>",
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"disqusTitle": "Senate Republicans Reveal Long-Awaited Affordable Care Act Repeal Bill",
"title": "Senate Republicans Reveal Long-Awaited Affordable Care Act Repeal Bill",
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"content": "\u003cp>\u003cem>Updated at 2:32 p.m. ET Thursday\u003c/em>\u003c/p>\n\u003cp>Senate Republicans unveiled \u003ca href=\"https://www.documentcloud.org/documents/3872487-SenateHCBill.html\" target=\"_blank\" rel=\"noopener noreferrer\">their long-awaited health care overhaul proposal\u003c/a> on Thursday. The Senate bill, called the \"Better Care Reconciliation Act,\" would repeal major parts of the Affordable Care Act, also known as Obamacare. The broad outlines of it look a lot like the House bill, the American Health Care Act, which was passed in May.\u003c/p>\n\u003cp>In a lot of ways, the Senate's bill looks like the House bill: It rolls back the ACA's Medicaid expansion — making for deep spending cuts to that program, compared to current law. The Senate bill also proposes eliminating many ACA taxes, and the employer penalties associated with the employer and individual mandates would be repealed retroactively, dating back to the start of 2016. And like the House bill, young adults up to the age of 26 could stay on their parents' health care plans.\u003c/p>\n\u003cp>Larry Levitt, a health policy expert at the Kaiser Family Foundation, \u003ca href=\"https://twitter.com/larry_levitt/status/877910700315729920\" target=\"_blank\" rel=\"noopener noreferrer\">summed up his thoughts on the bill\u003c/a> on Twitter on Thursday: \"In broad strokes, the Senate bill is just like the House: Big tax cuts, big cut in federal heath spending, big increase in the uninsured.\"\u003c/p>\n\u003cp>As with the House bill, the Senate proposal also allows insurance companies to charge older people five times more than younger people — under the ACA, that ratio is 3 to 1. That's just one provision that could hit older Americans hard.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>A small group of Republican senators has written the bill in secret in recent weeks, with many Americans and even some fellow Republicans eagerly awaiting details about what's in the bill. After the bill was released on Thursday, protesters gathered outside Senate Majority Leader Mitch McConnell's office. \u003ca href=\"https://twitter.com/NBCNightlyNews/status/877915310526939136\" target=\"_blank\" rel=\"noopener noreferrer\">Video from NBC\u003c/a> showed police removing some of those protesters from the hallway.\u003c/p>\n\u003cp>https://twitter.com/NBCNightlyNews/status/877915310526939136\u003c/p>\n\u003ch3>Big Changes to Medicaid\u003c/h3>\n\u003cp>Some of the biggest changes this bill makes are to Medicaid, the entitlement program that provides health care to low-income Americans. In that sense, it looks like the House bill, which the CBO said would cut Medicaid by $834 billion over a decade (relative to current law), with a loss of 14 million beneficiaries.\u003c/p>\n\u003cp>Both bills roll back a Medicaid expansion undertaken under the Affordable Care Act. That law extended the program to some low-income Americans above the poverty level. The Senate proposal would roll back that expansion, though it would do so more slowly than the House bill proposes.\u003c/p>\n\u003cp>As with the House, the Senate also proposes giving states either a per capita cap on Medicaid spending or a block grant of funds. That's a fundamental change; currently the program is \"\u003ca href=\"http://www.commonwealthfund.org/publications/newsletters/headlines-in-health-policy/2017/jan/january-23-2017/medicaid\" target=\"_blank\" rel=\"noopener noreferrer\">open-ended\u003c/a>,\" meaning funding increases as need increases.\u003c/p>\n\u003cp>But there's another change on top of that. Those caps would vary based on the rate of inflation, and the inflation rate the Senate would attach to those caps is one that is lower than the inflation rate the House attached.\u003c/p>\n\u003cp>That might sound like a minor wonky change, but it's not, says one former Medicaid administrator.\u003c/p>\n\u003cp>\"That's a big deal. It's a big shift,\" said John Corlett, president of the Center for Community Solutions who also served as a director of Ohio's Medicaid program. \"It means billions of dollars less in federal aid to states for their Medicaid programs.\"\u003c/p>\n\u003ch3>Tax Cuts for Richer Americans\u003c/h3>\n\u003cp>The Senate bill is also much like the House bill in that it would repeal most of the taxes associated with Obamacare. (It would bump out the implementation of the so-called \"Cadillac Tax\" on expensive, employer-sponsored health care plans, from 2025 to 2026.)\u003c/p>\n\u003cp>Repealing those taxes, as the \u003ca href=\"http://www.taxpolicycenter.org/taxvox/new-cbo-ahca-score-confirms-what-we-already-knew\" target=\"_blank\" rel=\"noopener noreferrer\">Tax Policy Center reported\u003c/a> in May (regarding the AHCA), would overwhelmingly benefit higher-income Americans. The taxes in Obamacare were largely progressive, as Kyle Pomerleau of the right-leaning Tax Foundation told NPR.\u003c/p>\n\u003cp>To one health policy expert, those tax cuts, combined with the cuts to Medicaid, mean the bill isn't a health care overhaul.\u003c/p>\n\u003cp>\"It is a tax cut bill, and they had to find a way to finance it, and Medicaid beneficiaries are going to be the ones who hurt,\" said Nicholas Bagley, a University of Michigan Law School professor who specializes in health law.\u003c/p>\n\u003cp>There are a few other ways the Senate bill mirrors the House bill. It bans the use of any federal funds for any health care plan that covers abortion, except in the cases of rape, incest or where the pregnancy puts the mother's life in danger.\u003c/p>\n\u003cp>As of 2020, the bill also eliminates cost-sharing subsidies that help low-income Americans pay for their insurance.\u003c/p>\n\u003cp>But it also has some key differences from the House bill. For example, it cuts the upper-income limit that determines who gets premium tax credits. Currently, that upper limit is at 400 percent of the poverty level. This bill would limit that to 350 percent.\u003c/p>\n\u003cp>The Senate's proposal allows states substantial freedom in determining their own health care programs — even more freedom than the House bill allows for. Under the Affordable Care Act, states can apply for \"innovation waivers\" exempting them from parts of the law and allowing them to determine their own health care systems, to an extent.\u003c/p>\n\u003cp>However, there are strict rules in place stating that states getting those waivers must provide coverage that is \"at least as comprehensive\" as they would be otherwise, as the \u003ca href=\"https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-Innovation-Waivers/Section_1332_State_Innovation_Waivers-.html\" target=\"_blank\" rel=\"noopener noreferrer\">Centers for Medicare and Medicaid Services\u003c/a> explains.\u003c/p>\n\u003cp>The Senate proposal greatly widens that loophole, saying that states can get those waivers, provided their alternate plans simply don't grow the deficit.\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>[documentcloud url=\"https://www.documentcloud.org/documents/3872487-SenateHCBill\" notes=\"true\" text=\"true\" search=\"true\" sidebar=\"true\" pdf=\"true\" responsive=\"true\" page=\"1\"]\u003c/p>\n\u003cdiv class=\"fullattribution\">Copyright 2017 NPR. To see more, visit http://www.npr.org/.\u003cimg src=\"https://www.google-analytics.com/__utm.gif?utmac=UA-5828686-4&utmdt=Senate+Republicans+Reveal+Long-Awaited+Affordable+Care+Act+Repeal+Bill&utme=8(APIKey)9(MDAxOTAwOTE4MDEyMTkxMDAzNjczZDljZA004)\">\u003c/div>\n\n",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003cp>\u003cem>Updated at 2:32 p.m. ET Thursday\u003c/em>\u003c/p>\n\u003cp>Senate Republicans unveiled \u003ca href=\"https://www.documentcloud.org/documents/3872487-SenateHCBill.html\" target=\"_blank\" rel=\"noopener noreferrer\">their long-awaited health care overhaul proposal\u003c/a> on Thursday. The Senate bill, called the \"Better Care Reconciliation Act,\" would repeal major parts of the Affordable Care Act, also known as Obamacare. The broad outlines of it look a lot like the House bill, the American Health Care Act, which was passed in May.\u003c/p>\n\u003cp>In a lot of ways, the Senate's bill looks like the House bill: It rolls back the ACA's Medicaid expansion — making for deep spending cuts to that program, compared to current law. The Senate bill also proposes eliminating many ACA taxes, and the employer penalties associated with the employer and individual mandates would be repealed retroactively, dating back to the start of 2016. And like the House bill, young adults up to the age of 26 could stay on their parents' health care plans.\u003c/p>\n\u003cp>Larry Levitt, a health policy expert at the Kaiser Family Foundation, \u003ca href=\"https://twitter.com/larry_levitt/status/877910700315729920\" target=\"_blank\" rel=\"noopener noreferrer\">summed up his thoughts on the bill\u003c/a> on Twitter on Thursday: \"In broad strokes, the Senate bill is just like the House: Big tax cuts, big cut in federal heath spending, big increase in the uninsured.\"\u003c/p>\n\u003cp>As with the House bill, the Senate proposal also allows insurance companies to charge older people five times more than younger people — under the ACA, that ratio is 3 to 1. That's just one provision that could hit older Americans hard.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>A small group of Republican senators has written the bill in secret in recent weeks, with many Americans and even some fellow Republicans eagerly awaiting details about what's in the bill. After the bill was released on Thursday, protesters gathered outside Senate Majority Leader Mitch McConnell's office. \u003ca href=\"https://twitter.com/NBCNightlyNews/status/877915310526939136\" target=\"_blank\" rel=\"noopener noreferrer\">Video from NBC\u003c/a> showed police removing some of those protesters from the hallway.\u003c/p>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\n\u003ch3>Big Changes to Medicaid\u003c/h3>\n\u003cp>Some of the biggest changes this bill makes are to Medicaid, the entitlement program that provides health care to low-income Americans. In that sense, it looks like the House bill, which the CBO said would cut Medicaid by $834 billion over a decade (relative to current law), with a loss of 14 million beneficiaries.\u003c/p>\n\u003cp>Both bills roll back a Medicaid expansion undertaken under the Affordable Care Act. That law extended the program to some low-income Americans above the poverty level. The Senate proposal would roll back that expansion, though it would do so more slowly than the House bill proposes.\u003c/p>\n\u003cp>As with the House, the Senate also proposes giving states either a per capita cap on Medicaid spending or a block grant of funds. That's a fundamental change; currently the program is \"\u003ca href=\"http://www.commonwealthfund.org/publications/newsletters/headlines-in-health-policy/2017/jan/january-23-2017/medicaid\" target=\"_blank\" rel=\"noopener noreferrer\">open-ended\u003c/a>,\" meaning funding increases as need increases.\u003c/p>\n\u003cp>But there's another change on top of that. Those caps would vary based on the rate of inflation, and the inflation rate the Senate would attach to those caps is one that is lower than the inflation rate the House attached.\u003c/p>\n\u003cp>That might sound like a minor wonky change, but it's not, says one former Medicaid administrator.\u003c/p>\n\u003cp>\"That's a big deal. It's a big shift,\" said John Corlett, president of the Center for Community Solutions who also served as a director of Ohio's Medicaid program. \"It means billions of dollars less in federal aid to states for their Medicaid programs.\"\u003c/p>\n\u003ch3>Tax Cuts for Richer Americans\u003c/h3>\n\u003cp>The Senate bill is also much like the House bill in that it would repeal most of the taxes associated with Obamacare. (It would bump out the implementation of the so-called \"Cadillac Tax\" on expensive, employer-sponsored health care plans, from 2025 to 2026.)\u003c/p>\n\u003cp>Repealing those taxes, as the \u003ca href=\"http://www.taxpolicycenter.org/taxvox/new-cbo-ahca-score-confirms-what-we-already-knew\" target=\"_blank\" rel=\"noopener noreferrer\">Tax Policy Center reported\u003c/a> in May (regarding the AHCA), would overwhelmingly benefit higher-income Americans. The taxes in Obamacare were largely progressive, as Kyle Pomerleau of the right-leaning Tax Foundation told NPR.\u003c/p>\n\u003cp>To one health policy expert, those tax cuts, combined with the cuts to Medicaid, mean the bill isn't a health care overhaul.\u003c/p>\n\u003cp>\"It is a tax cut bill, and they had to find a way to finance it, and Medicaid beneficiaries are going to be the ones who hurt,\" said Nicholas Bagley, a University of Michigan Law School professor who specializes in health law.\u003c/p>\n\u003cp>There are a few other ways the Senate bill mirrors the House bill. It bans the use of any federal funds for any health care plan that covers abortion, except in the cases of rape, incest or where the pregnancy puts the mother's life in danger.\u003c/p>\n\u003cp>As of 2020, the bill also eliminates cost-sharing subsidies that help low-income Americans pay for their insurance.\u003c/p>\n\u003cp>But it also has some key differences from the House bill. For example, it cuts the upper-income limit that determines who gets premium tax credits. Currently, that upper limit is at 400 percent of the poverty level. This bill would limit that to 350 percent.\u003c/p>\n\u003cp>The Senate's proposal allows states substantial freedom in determining their own health care programs — even more freedom than the House bill allows for. Under the Affordable Care Act, states can apply for \"innovation waivers\" exempting them from parts of the law and allowing them to determine their own health care systems, to an extent.\u003c/p>\n\u003cp>However, there are strict rules in place stating that states getting those waivers must provide coverage that is \"at least as comprehensive\" as they would be otherwise, as the \u003ca href=\"https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-Innovation-Waivers/Section_1332_State_Innovation_Waivers-.html\" target=\"_blank\" rel=\"noopener noreferrer\">Centers for Medicare and Medicaid Services\u003c/a> explains.\u003c/p>\n\u003cp>The Senate proposal greatly widens that loophole, saying that states can get those waivers, provided their alternate plans simply don't grow the deficit.\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"disqusTitle": "Secret Hospital Inspection Reports Could Be Made Public",
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"content": "\u003cp>The public could soon get a look at confidential reports about errors, mishaps and mix-ups in the nation's hospitals that put patients' health and safety at risk, under a groundbreaking proposal from federal health officials.\u003c/p>\n\u003cp>The Centers for Medicare and Medicaid Services wants to require that private health care accreditors publicly detail problems they find during inspections of hospitals and other medical facilities, as well as the steps being taken to fix them. Nearly nine in 10 hospitals are directly overseen by those accreditors, not the government.\u003c/p>\n\u003cp>There's increasing concern among regulators that private accreditors aren't picking up on serious problems at health facilities. Every year, CMS takes a sample of hospitals and other health care facilities accredited by private organizations and does its own inspections to validate the work of the groups. In a 2016 report, CMS noted that its review found that accrediting organizations often missed serious deficiencies found soon after by state inspectors.\u003c/p>\n\u003cp>In 2014, for instance, state officials examined 103 acute-care hospitals that had been reviewed by an accreditor in the past 60 days. The state officials found 41 serious deficiencies. Of those, 39 were missed by the accrediting organizations. This disparity \"raises serious concerns regarding the [accrediting organizations'] ability to appropriately identify and cite health and safety deficiencies\" during inspections, CMS officials wrote when they released draft regulations including the proposed change on Friday.\u003c/p>\n\u003cp>The move follows steps CMS took several years ago to post government inspection reports online for nursing homes and some hospitals. ProPublica has created a tool, Nursing Home Inspect, to allow people to more easily search through the nursing home deficiency reports; the Association of Health Care Journalists has done the same for hospital violations.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>Those government inspection reports do not identify patients or medical staff, but they do offer a description—often detailed—of what went wrong. This includes medication errors, operations on the wrong patient or the wrong body part, and patient abuse.\u003c/p>\n\u003cp>But private accrediting organizations, the largest of which is The Joint Commission, have not followed suit, creating a patchwork of disclosure in which some inspections are public and others are not. CMS' proposed rules are designed to fix this.\u003c/p>\n\u003cp>\"We believe it is important to continue to lead the effort to make information regarding a health care facility's compliance with health and safety requirements\" publicly available, CMS officials wrote.\u003c/p>\n\u003cp>\"It's huge, absolutely,\" says Rosemary Gibson, a patient safety expert who wrote a book, Wall of Silence, about medical errors. \"Right now the public has very little information about the places where they're putting their life on the line, and that's just not acceptable. If you're a good place, what are they afraid of?\"\u003c/p>\n\u003cp>Medical errors are a leading cause of death and injuries in U.S. hospitals. A 1999 report by the Institute of Medicine estimated that up to 98,000 people a year die because of mistakes in hospitals; subsequent reports have said the number is much higher.\u003c/p>\n\u003cp>To qualify for federal funding, health facilities have to meet minimum requirements, known as Medicare conditions of participation. If a health facility has problems and doesn't fix them, it stands to lose its Medicare funding. Though this rarely happens, it can be crippling for an institution and could force it to close.\u003c/p>\n\u003cp>State health departments get funding from CMS to inspect facilities to ensure they comply with these requirements. But the law also allows hospitals, ambulatory surgery centers, home health agencies and hospices to pay private, national accrediting organizations for such oversight. The Joint Commission conducts unannounced inspections at hospitals at least once every 39 months, and more often if complaints arise.\u003c/p>\n\u003cp>Though accreditors have to be approved by the secretary of Health and Human Services, they rarely take punitive action against the organizations they oversee. Of the 4,018 hospitals listed on the The Joint Commission's website, more than 99 percent have full accreditation and only seven are on track to lose their \"gold seal of approval.\"\u003c/p>\n\u003cp>The Joint Commission said it is reviewing the CMS proposal and couldn't comment further. A smaller competitor, the Healthcare Facilities Accreditation Program, said it supports the goal of transparency but is studying what the change would mean in practice, both in terms of staffing and costs. \"We haven't talked to our hospital partners,\" says Gary Ley, its executive director. \"It would be a major change for them also. It's hard not to support the goals but we have to look at the execution.\"\u003c/p>\n\u003cp>For its part, the American Hospital Association said it supports providing the public \"useful information\" about hospital quality, but has doubts that detailed inspection reports fit that description.\u003c/p>\n\u003cp>\"It's important that the information shared with consumers has a clear purpose, is transparent and is readily understood by folks from all walks of life, not just those with deep expertise in health care,\" says Nancy Foster, AHA's vice president of quality and patient safety, in a statement. \"We are concerned that sharing a detailed report may not be the most useful or effective strategy for informing the public.\"\u003c/p>\n\u003cp>Foster says it might be more useful to provide a one- or two-page \"accurate summary\" of inspection findings, with \"key takeaways\" and why they are important. \"This summary could also draw from the plan of correction the hospital creates and summarize how the hospital plans to address the findings,\" Foster says.\u003c/p>\n\u003cp>For years, accreditors have been accused of putting the interests of the facilities that pay them ahead of patient safety. In 2002, the Chicago Tribune reported how The Joint Commission gave its seal of approval to \"medical centers riddled by life-threatening problems and underreporting of patient deaths due to infections and hospital errors.\"\u003c/p>\n\u003cp>Last week, BuzzFeed News reported how an Oklahoma psychiatric hospital was named a \"Top Performer in Key Quality Measures\" by The Joint Commission even though police records, state inspection reports and lawsuit records showed that it \"is a profoundly troubled facility where frequent violence endangers patients and staff alike, where children as young as 5 are separated from their parents and held in dangerous situations, and where wards lack adequate staffing and staff lack adequate training.\"\u003c/p>\n\u003cp>In a response to BuzzFeed, the company that runs the hospital, Universal Health Services, said it \"is proud of the care it provides patients at Shadow Mountain Behavioral Health.\"\u003c/p>\n\u003cp>On its website, The Joint Commission allows users to check the accreditation status of hospitals but provides scant information of what went wrong, even when hospitals are described as receiving a \"preliminary denial of accreditation.\" For one hospital, the explanation is: \"Existence at time of survey of a condition, which in The Joint Commission's view, poses a threat to patients or other individuals served.\" The threat itself is not disclosed.\u003c/p>\n\u003cp>Consumers Union's Safe Patient Project and other patient safety organizations have been pushing for years for more information about hospital inspections. Lisa McGiffert, who directs the Safe Patient Project, hopes this may be the opportunity for change. \"The information that's available now is so minimal and would not really inform anyone about real quality of a hospital,\" she says.\u003c/p>\n\u003cp>Comments on the proposal may be submitted from April 28 to June 13 through the CMS website.\u003c/p>\n\u003cp>[ad floatright]\u003c/p>\n\u003cp>\u003cem>Disclosure: Ornstein was previously president of the Association of Health Care Journalists. While he served in that position, AHCJ called for The Joint Commission to make its inspection reports public. The Joint Commission declined to do so. Have you complained about a hospital to The Joint Commission or another accrediting body? We'd like to hear from you. Email Charles.ornstein@propublica.org. ProPublica is an independent nonprofit newsroom based in New York.\u003cbr>\n\u003c/em>\u003c/p>\n\n",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003cp>The public could soon get a look at confidential reports about errors, mishaps and mix-ups in the nation's hospitals that put patients' health and safety at risk, under a groundbreaking proposal from federal health officials.\u003c/p>\n\u003cp>The Centers for Medicare and Medicaid Services wants to require that private health care accreditors publicly detail problems they find during inspections of hospitals and other medical facilities, as well as the steps being taken to fix them. Nearly nine in 10 hospitals are directly overseen by those accreditors, not the government.\u003c/p>\n\u003cp>There's increasing concern among regulators that private accreditors aren't picking up on serious problems at health facilities. Every year, CMS takes a sample of hospitals and other health care facilities accredited by private organizations and does its own inspections to validate the work of the groups. In a 2016 report, CMS noted that its review found that accrediting organizations often missed serious deficiencies found soon after by state inspectors.\u003c/p>\n\u003cp>In 2014, for instance, state officials examined 103 acute-care hospitals that had been reviewed by an accreditor in the past 60 days. The state officials found 41 serious deficiencies. Of those, 39 were missed by the accrediting organizations. This disparity \"raises serious concerns regarding the [accrediting organizations'] ability to appropriately identify and cite health and safety deficiencies\" during inspections, CMS officials wrote when they released draft regulations including the proposed change on Friday.\u003c/p>\n\u003cp>The move follows steps CMS took several years ago to post government inspection reports online for nursing homes and some hospitals. ProPublica has created a tool, Nursing Home Inspect, to allow people to more easily search through the nursing home deficiency reports; the Association of Health Care Journalists has done the same for hospital violations.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>Those government inspection reports do not identify patients or medical staff, but they do offer a description—often detailed—of what went wrong. This includes medication errors, operations on the wrong patient or the wrong body part, and patient abuse.\u003c/p>\n\u003cp>But private accrediting organizations, the largest of which is The Joint Commission, have not followed suit, creating a patchwork of disclosure in which some inspections are public and others are not. CMS' proposed rules are designed to fix this.\u003c/p>\n\u003cp>\"We believe it is important to continue to lead the effort to make information regarding a health care facility's compliance with health and safety requirements\" publicly available, CMS officials wrote.\u003c/p>\n\u003cp>\"It's huge, absolutely,\" says Rosemary Gibson, a patient safety expert who wrote a book, Wall of Silence, about medical errors. \"Right now the public has very little information about the places where they're putting their life on the line, and that's just not acceptable. If you're a good place, what are they afraid of?\"\u003c/p>\n\u003cp>Medical errors are a leading cause of death and injuries in U.S. hospitals. A 1999 report by the Institute of Medicine estimated that up to 98,000 people a year die because of mistakes in hospitals; subsequent reports have said the number is much higher.\u003c/p>\n\u003cp>To qualify for federal funding, health facilities have to meet minimum requirements, known as Medicare conditions of participation. If a health facility has problems and doesn't fix them, it stands to lose its Medicare funding. Though this rarely happens, it can be crippling for an institution and could force it to close.\u003c/p>\n\u003cp>State health departments get funding from CMS to inspect facilities to ensure they comply with these requirements. But the law also allows hospitals, ambulatory surgery centers, home health agencies and hospices to pay private, national accrediting organizations for such oversight. The Joint Commission conducts unannounced inspections at hospitals at least once every 39 months, and more often if complaints arise.\u003c/p>\n\u003cp>Though accreditors have to be approved by the secretary of Health and Human Services, they rarely take punitive action against the organizations they oversee. Of the 4,018 hospitals listed on the The Joint Commission's website, more than 99 percent have full accreditation and only seven are on track to lose their \"gold seal of approval.\"\u003c/p>\n\u003cp>The Joint Commission said it is reviewing the CMS proposal and couldn't comment further. A smaller competitor, the Healthcare Facilities Accreditation Program, said it supports the goal of transparency but is studying what the change would mean in practice, both in terms of staffing and costs. \"We haven't talked to our hospital partners,\" says Gary Ley, its executive director. \"It would be a major change for them also. It's hard not to support the goals but we have to look at the execution.\"\u003c/p>\n\u003cp>For its part, the American Hospital Association said it supports providing the public \"useful information\" about hospital quality, but has doubts that detailed inspection reports fit that description.\u003c/p>\n\u003cp>\"It's important that the information shared with consumers has a clear purpose, is transparent and is readily understood by folks from all walks of life, not just those with deep expertise in health care,\" says Nancy Foster, AHA's vice president of quality and patient safety, in a statement. \"We are concerned that sharing a detailed report may not be the most useful or effective strategy for informing the public.\"\u003c/p>\n\u003cp>Foster says it might be more useful to provide a one- or two-page \"accurate summary\" of inspection findings, with \"key takeaways\" and why they are important. \"This summary could also draw from the plan of correction the hospital creates and summarize how the hospital plans to address the findings,\" Foster says.\u003c/p>\n\u003cp>For years, accreditors have been accused of putting the interests of the facilities that pay them ahead of patient safety. In 2002, the Chicago Tribune reported how The Joint Commission gave its seal of approval to \"medical centers riddled by life-threatening problems and underreporting of patient deaths due to infections and hospital errors.\"\u003c/p>\n\u003cp>Last week, BuzzFeed News reported how an Oklahoma psychiatric hospital was named a \"Top Performer in Key Quality Measures\" by The Joint Commission even though police records, state inspection reports and lawsuit records showed that it \"is a profoundly troubled facility where frequent violence endangers patients and staff alike, where children as young as 5 are separated from their parents and held in dangerous situations, and where wards lack adequate staffing and staff lack adequate training.\"\u003c/p>\n\u003cp>In a response to BuzzFeed, the company that runs the hospital, Universal Health Services, said it \"is proud of the care it provides patients at Shadow Mountain Behavioral Health.\"\u003c/p>\n\u003cp>On its website, The Joint Commission allows users to check the accreditation status of hospitals but provides scant information of what went wrong, even when hospitals are described as receiving a \"preliminary denial of accreditation.\" For one hospital, the explanation is: \"Existence at time of survey of a condition, which in The Joint Commission's view, poses a threat to patients or other individuals served.\" The threat itself is not disclosed.\u003c/p>\n\u003cp>Consumers Union's Safe Patient Project and other patient safety organizations have been pushing for years for more information about hospital inspections. Lisa McGiffert, who directs the Safe Patient Project, hopes this may be the opportunity for change. \"The information that's available now is so minimal and would not really inform anyone about real quality of a hospital,\" she says.\u003c/p>\n\u003cp>Comments on the proposal may be submitted from April 28 to June 13 through the CMS website.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>\u003cem>Disclosure: Ornstein was previously president of the Association of Health Care Journalists. While he served in that position, AHCJ called for The Joint Commission to make its inspection reports public. The Joint Commission declined to do so. Have you complained about a hospital to The Joint Commission or another accrediting body? We'd like to hear from you. Email Charles.ornstein@propublica.org. ProPublica is an independent nonprofit newsroom based in New York.\u003cbr>\n\u003c/em>\u003c/p>\n\n\u003c/div>\u003c/p>",
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"disqusTitle": "What Happens to Elder Care With Proposed Caps to Medi-Cal?",
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"content": "\u003cp>It’s a Sunday evening at the home of Marc and Charlotte Altieri of Long Beach, and that means bath time for the couple’s children -- 2-year-old Gino and 5-month-old Jessie.\u003c/p>\n\u003cp>And for this moment at least, Charlotte, 39, is able to focus on her children rather than worrying about her mother, 71-year-old Carmencita Misa. Three years ago, a debilitating stroke stole Misa’s short-term memory, her sight and her mobility.\u003c/p>\n\u003cp>“Before my mom had a stroke, she always made sure that she danced,” Charlotte says. “She would work regularly, like 60 hours or so a week, but no matter what, she would make (sure) that (there was) at least one night a week where she could go dancing. That was her thing.”\u003c/p>\n\u003cp>[audio src=\"http://www.kqed.org/.stream/anon/radio/tcr/2017/03/20170314gtcr.mp3\" program=\"The California Report\" image=\"https://ww2.kqed.org/news/wp-content/uploads/sites/10/2017/03/RS24616_Brian-McGee-Carmencita-Misa-and-Charlotte-Altieri.jpeg\"]\u003c/p>\n\u003cp>But since the spring of 2014, Misa has required 24-hour care, which she now gets at a nearby nursing home. Charlotte says she wishes she could provide it herself -- but she can’t.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>“It’s not just physically having the logistics of two kids and their energies, and if they're hungry and if they’re sleepy,” Charlotte says. “It’s me trying to get my brain and heart together to go visit my mom, who’s not my mom. She’s just laying there.”\u003c/p>\n\u003cp>Initially, it was \u003ca href=\"https://www.medicare.gov/\" target=\"_blank\">Medicare\u003c/a>, the federal insurance program for those 65 and older, that paid for Misa’s nursing home care. But unbeknown to many, that program limits care to only 100 days. When Charlotte learned of the Medicare cutoff, she scrambled to figure out how to pay her mom’s monthly nursing home bill.\u003c/p>\n\u003cp>“The $5,000 -- we were wondering where it was going to come from,” she says.\u003c/p>\n\u003cp>For Misa, and for the tens of thousands of low-income Californians who need ongoing long-term services and support, there is one source of aid: the joint federal-state Medicaid program, known here in the Golden State as \u003ca href=\"https://www.medi-cal.ca.gov/\" target=\"_blank\">Medi-Cal\u003c/a>. Medicaid covers nursing home care if seniors can't pay for it themselves.\u003c/p>\n\u003cp>“Most people, when they think about Medicaid, they think of it as sort of a low-income, working population welfare health care program,” says Matt Salo, executive director of the National Association of Medicaid Directors. “But what really comes as a big surprise to almost everybody is that that’s not where Medicaid spends most of its dollars.”\u003c/p>\n\u003cp>Salo says Medicaid spends about two-thirds of its annual budget on the elderly and those with disabilities. And that’s why patient advocates say they’re worried about the Medicaid provision contained in the newly released \u003ca href=\"https://www.cbo.gov/publication/52486\" target=\"_blank\">GOP plan \u003c/a>to replace and repeal Obamacare.\u003c/p>\n\u003cp>That \u003ca href=\"http://www.foxnews.com/politics/interactive/2017/03/06/text-american-health-care-act/\" target=\"_blank\">legislation\u003c/a> would impose per-person limits on federal Medicaid spending, known as \"per capita caps.\" Those fixed spending limits would replace the existing funding approach in which the federal government provides matching funds of $1 to $3 for every $1 the state spends.\u003c/p>\n\u003cp>Eric Carlson is an attorney for the nonprofit advocacy group \u003ca href=\"http://www.justiceinaging.org/\" target=\"_blank\">Justice in Aging\u003c/a>. He’s also co-author of a new \u003ca href=\"http://www.justiceinaging.org/wp-content/uploads/2017/02/Medicaid-Funding-Caps-Would-Harm-Older-Americans.pdf\" target=\"_blank\">report\u003c/a> by the group , which says the proposed spending caps are certain to hurt older Americans who rely on Medicaid.\u003c/p>\n\u003cp>“It’s really a form of rationing where you have the care based on the money that’s budgeted rather than on the needs of the people,” Carlson says. “And that’s entirely backwards.”\u003c/p>\n\u003cp>But Oren Cass, a senior fellow with the \u003ca href=\"https://www.manhattan-institute.org/\" target=\"_blank\">Manhattan Institute, \u003c/a>disagrees.\u003c/p>\n\u003cp>“It just forces states to work within the budget constraints of a fixed amount of federal money, which, by the way, is how every other part of our federal government already works,” Cass says.\u003c/p>\n\u003cp>He says the GOP plan would also remove some federal rules now imposed on states and give them more flexibility in how they spend their Medicaid dollars. He and other supporters of that approach say it will allow states to better serve their Medicaid enrollees — while patient advocates argue it would harm them.\u003c/p>\n\u003cp>“Every time I see the words ‘program flexibility’ or ‘state flexibility,’ it makes us cringe,” says Pat McGinnis, executive director of \u003ca href=\"http://www.canhr.org/\" target=\"_blank\">California Advocates for Nursing Home Reform\u003c/a>. “Because there are so many federal protections under the current Medicaid system, and I think most of those would be gone.”\u003c/p>\n\u003cp>As Congress continues hammering out the details of the GOP plan to revamp Obamacare and Medicaid, Charlotte Altieri hopes her mother's long-term care coverage will be spared any cuts.\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>“My mom is getting the most basic of basic [care],” she says. “If they cut it, I don’t know what I’d do.”\u003c/p>\n\n",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>“It’s not just physically having the logistics of two kids and their energies, and if they're hungry and if they’re sleepy,” Charlotte says. “It’s me trying to get my brain and heart together to go visit my mom, who’s not my mom. She’s just laying there.”\u003c/p>\n\u003cp>Initially, it was \u003ca href=\"https://www.medicare.gov/\" target=\"_blank\">Medicare\u003c/a>, the federal insurance program for those 65 and older, that paid for Misa’s nursing home care. But unbeknown to many, that program limits care to only 100 days. When Charlotte learned of the Medicare cutoff, she scrambled to figure out how to pay her mom’s monthly nursing home bill.\u003c/p>\n\u003cp>“The $5,000 -- we were wondering where it was going to come from,” she says.\u003c/p>\n\u003cp>For Misa, and for the tens of thousands of low-income Californians who need ongoing long-term services and support, there is one source of aid: the joint federal-state Medicaid program, known here in the Golden State as \u003ca href=\"https://www.medi-cal.ca.gov/\" target=\"_blank\">Medi-Cal\u003c/a>. Medicaid covers nursing home care if seniors can't pay for it themselves.\u003c/p>\n\u003cp>“Most people, when they think about Medicaid, they think of it as sort of a low-income, working population welfare health care program,” says Matt Salo, executive director of the National Association of Medicaid Directors. “But what really comes as a big surprise to almost everybody is that that’s not where Medicaid spends most of its dollars.”\u003c/p>\n\u003cp>Salo says Medicaid spends about two-thirds of its annual budget on the elderly and those with disabilities. And that’s why patient advocates say they’re worried about the Medicaid provision contained in the newly released \u003ca href=\"https://www.cbo.gov/publication/52486\" target=\"_blank\">GOP plan \u003c/a>to replace and repeal Obamacare.\u003c/p>\n\u003cp>That \u003ca href=\"http://www.foxnews.com/politics/interactive/2017/03/06/text-american-health-care-act/\" target=\"_blank\">legislation\u003c/a> would impose per-person limits on federal Medicaid spending, known as \"per capita caps.\" Those fixed spending limits would replace the existing funding approach in which the federal government provides matching funds of $1 to $3 for every $1 the state spends.\u003c/p>\n\u003cp>Eric Carlson is an attorney for the nonprofit advocacy group \u003ca href=\"http://www.justiceinaging.org/\" target=\"_blank\">Justice in Aging\u003c/a>. He’s also co-author of a new \u003ca href=\"http://www.justiceinaging.org/wp-content/uploads/2017/02/Medicaid-Funding-Caps-Would-Harm-Older-Americans.pdf\" target=\"_blank\">report\u003c/a> by the group , which says the proposed spending caps are certain to hurt older Americans who rely on Medicaid.\u003c/p>\n\u003cp>“It’s really a form of rationing where you have the care based on the money that’s budgeted rather than on the needs of the people,” Carlson says. “And that’s entirely backwards.”\u003c/p>\n\u003cp>But Oren Cass, a senior fellow with the \u003ca href=\"https://www.manhattan-institute.org/\" target=\"_blank\">Manhattan Institute, \u003c/a>disagrees.\u003c/p>\n\u003cp>“It just forces states to work within the budget constraints of a fixed amount of federal money, which, by the way, is how every other part of our federal government already works,” Cass says.\u003c/p>\n\u003cp>He says the GOP plan would also remove some federal rules now imposed on states and give them more flexibility in how they spend their Medicaid dollars. He and other supporters of that approach say it will allow states to better serve their Medicaid enrollees — while patient advocates argue it would harm them.\u003c/p>\n\u003cp>“Every time I see the words ‘program flexibility’ or ‘state flexibility,’ it makes us cringe,” says Pat McGinnis, executive director of \u003ca href=\"http://www.canhr.org/\" target=\"_blank\">California Advocates for Nursing Home Reform\u003c/a>. “Because there are so many federal protections under the current Medicaid system, and I think most of those would be gone.”\u003c/p>\n\u003cp>As Congress continues hammering out the details of the GOP plan to revamp Obamacare and Medicaid, Charlotte Altieri hopes her mother's long-term care coverage will be spared any cuts.\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>“My mom is getting the most basic of basic [care],” she says. “If they cut it, I don’t know what I’d do.”\u003c/p>\n\n\u003c/div>\u003c/p>",
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"info": "Possible is hosted by entrepreneur Reid Hoffman and writer Aria Finger. Together in Possible, Hoffman and Finger lead enlightening discussions about building a brighter collective future. The show features interviews with visionary guests like Trevor Noah, Sam Altman and Janette Sadik-Khan. Possible paints an optimistic portrait of the world we can create through science, policy, business, art and our shared humanity. It asks: What if everything goes right for once? How can we get there? Each episode also includes a short fiction story generated by advanced AI GPT-4, serving as a thought-provoking springboard to speculate how humanity could leverage technology for good.",
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"soldout": {
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"title": "SOLD OUT: Rethinking Housing in America",
"tagline": "A new future for housing",
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