Without much fanfare — or time for opponents to respond — they abandoned the state’s relatively loose rules for getting an exemption and issued a regulation requiring families to consult personally with local public health departments before obtaining an immunization waiver.

The new rule sidestepped potential ideological firefights in the state Legislature, which have plagued lawmakers in other states trying to crack down on vaccination waivers. The regulation had a dramatic effect. In the first year, the Michigan Department of Health and Human Services reported that the number of statewide waivers issued had plunged 35 percent. Today, Michigan is in the middle of the pack among vaccination rates.

“The idea was to make the process more burdensome,” said Michigan State University health policy specialist Mark Largent, who has written extensively about vaccines. “Research has shown that if you make it more inconvenient to apply for a waiver, fewer people get them.”

Michigan’s experience demonstrates a way for governments to increase immunization rates without having to address religious or philosophical opposition to vaccines.

For many years, opposition to mandatory childhood vaccines has served as a frequent rallying point for those who see immunizations as interference with nature’s intentions, rebel against them as government meddling in family affairs or raise concerns about their safety.

Vaccine advocates and health professionals regard these views as dangerous, noting that the drugs have dramatically lowered the number of serious childhood illnesses and that studies suggesting they are not safe have been debunked. They also note that vaccines’ proven effectiveness lies in “herd immunity”— the higher the participation rate, the greater the community’s protection against outbreaks of infectious disease.

Many states adopt strategies to curb exemptions “by making applications complicated to fill out or complete,” according to University of Georgia public policy expert W. David Bradford, who studies immunization. Some states require parents to notarize applications or have them certified by a physician before sending them in, and “generally speaking, anything that raises the opportunity cost [of exemptions] works to some degree,” Bradford said. “Michigan took it a step further.”

Increasing the number of vaccinated kids in Michigan, which has a Republican governor and Republican majorities in both legislative houses, took a degree of political finesse.

“Health and Human Services wanted to do something, but the legislative option wasn’t there,” Largent said. Instead, Michigan decided to use a strategy he calls “inconvenience.”

Since 1978, Michigan had required schoolchildren entering kindergarten and middle school to obtain vaccination waiver certificates from county officials. “Some counties allowed you to do it over the phone; in others you mailed in a form and some even let you do it online,” Largent said. But in studying vaccine policy across the country, he noted, “one thing is really clear — health departments that have much lower rates.”

Michigan offered the perfect vehicle for introducing inconvenience into the process. The Joint Committee on Administrative Rules reviews state agency regulations and, if it takes no action, allows them to go into effect after 15 legislative days. The committee is composed of lawmakers, giving it a legislative imprimatur, but it is not the Legislature itself, thus avoiding the political rancor that can accompany debate on controversial issues.

During the 2013-14 school year, the federal Centers for Disease Control and Prevention found, Michigan had of children entering kindergarten who had been exempted from vaccinations.ÌýThe state Health and Human Services officials proposed a simple requirement: Parents seeking vaccine waivers must be briefed in person by a county health educator before a waiver would be granted. The joint committee approved the rule Dec. 11, 2014. It tookÌýeffect Jan. 1, 2015.Ìý

“We were not aware of the rule until the day it happened,” said Suzanne Waltman, president of Michigan for Vaccine Choice, an anti-vaccine organization. “We thought it was a stealth move.”

The office of Gov. Rick Snyder did not respond directly to requests for comment on the political hazards of vaccine policy. Retired Republican state Sen. John Pappageorge, co-chair of the administrative rules committee in 2014, voted to adopt the rule and described the procedure as a simple one designed to ensure “that implementation is in concurrence with the law.” Republican Rep. Tom McMillin, who was co-chair of the committee at the time and voted against the rule, did not respond to requests for an interview.

In a look at ,Ìýbefore 2015, about Ìýdid not get the fourth round of immunizations for diphtheria, tetanus and pertussis that is required by the state. That had fallen to ,Ìýslightly better than the national average.

The Traverse City outbreaks were overshadowed in the national media by a more dramatic measles outbreak in Southern California’s Disneyland, which also occurred over the 2014-15 holidays and ultimately led to 150 cases of the disease. But the states’ responses were quite different.

California’s solution was what Largent calls “eliminationism.” The state Legislature, with Democratic supermajorities, passed a measure doing away with religious and philosophical vaccine exemptions. Passage of the law triggered among opponents of vaccines.ÌýBesides California, only West Virginia and Mississippi .

Largent said a small number of children need waivers for medical reasons, usually because of allergies or immune deficiencies. Much larger numbers seek waivers for religious or philosophical reasons.

“The idea was to bring the waiver rate down,” Michigan Health and Human Services spokeswoman Angela Minicuci said. “From the perspective of the general population, vaccinations are recommended. This doesn’t take away choice. It simply ensures that people have education.”

But Largent said most vaccine opponents are not necessarily swayed by arguments in favor of immunization. Instead, “by heightening the burden, you change some of the incentives” for obtaining waivers. “Moral claims and ideology don’t matter as much when it’s inconvenient.”

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Three years later California thumbed its nose at the ban by starting its own multi-billion dollar stem cell program, and several states followed suit. Even though the restrictions were lifted in 2009, the insurgent movement survived and grew. Today at least seven states offer stem cell researchÌý funding or other incentives to local scientists and industry.

These initiatives have not yet produced the eagerly anticipated “cures” for conditions such as melanoma or Parkinson’s disease. But early public disappointment has yielded to the realization that years of research lie ahead before treatments can routinely enter the marketplace.

Still, as an engine for generating economic development and jobs, and as a mechanism for enhancing local scientific prestige, stem cell research for many states appears to be worth the investment.

“We want to show what we have,” said Dan Gincel, executive director of the Maryland Stem Cell Research Fund. He pointed to a sophisticated science community and easy access to the National Institutes of Health and the Food and Drug Administration.

Controversy arose early in the century over the use of embryonic stem cells, which can differentiate into any cells in the body, but which are obtained by destroying unneeded human embryos created through in vitro fertilization. Anti-abortion groups and religious conservatives opposed embryonic stem cell research, and Bush in 2001 created after his order because of concerns over the sanctity of life.

Three years later California voters approved ballot Proposition 71, creating the (CIRM)Ìýto make grants and loans for stem cell research, funding it with a $3 billion bond issue—which is generating a total of $6 billion with interest and is expected to last until 2020.

“Without George Bush, this agency would not exist,” said David Jensen, publisher of California Stem Cell Report, a blog focused on the California institute. “The campaign raised expectations that therapies were right around the corner. The federal government wasn’t funding it, and the voters said that since we want to save lives, we’ll fund it.”

The institute in the past decade has become one of the most important and perhaps the biggest nonfederal dedicated stem cell research center in the world, spending about $180 million per year. Different parts of the National Institutes of Health spent a combined $1.4 billion on stem cell research in 2014.

Over the years the California institute has endured sharp criticism for failing to deliver cures and spending around 90 percent of its funds on basic research while ignoring drug development.

An Institute of Medicine study in 2012 also warned of cronyism, noting that the vast majority of CIRM grants were going to academic institutions whose members sat on the board of directors. Early critics also questioned whether usurping a federal research agenda was the best use of California’s tax dollars.

Much of this was dictated by Proposition 71 itself. The law mandates who sits on the board. It also provides the money, and the institute must spend it. In a California-centric program, supporters say, conflicts of interest are endemic, and board members frequently recuse themselves during the grant process.

C. Randal Mills, chosen in 2014 as the institute’s new president and chief executive officer, said the organization is adjusting to “a world that has changed significantly” since 2004 by moving away from simply funding good ideas in isolation to what he describes as a “system-based agency.”

Last year the institute had 10 programs in clinical trials, but expects to have 20 by the end of this year.

“We’re setting up continuous paths to move basic research to clinical trials,” he added. “It’s like a train moving down a track, where each grant is the link to the next step down the line.” Ìý

In 2009, President Barack Obama on embryonic stem cell research,Ìýbut by that time researchers were already using adult stem cells extensively and had learned to cells into embryonic-like induced pluripotent stem cells.

Despite the improved national climate, states, both for economic and scientific reasons, have continued to fund their own programs. NIH lists initiatives in six states, not counting Minnesota, and other reports have suggested that as many as 15 states either have dedicated programs or fund stem cell research or did so in the past.

Yet in a discipline that is just beginning to enter a translational phase, it is hard to evaluate the effectiveness of individual programs: “It’s a huge field, and it’s still early,” said Heather Rooke, scientific director for the International Society for Stem Cell Research. “States will continue to do basic research, and California has certainly already had important influence driving the research to the clinic.”

Results will take time, agreed Minnesota’s Tolar, but it is worth the trouble: “We started on drugs a hundred years ago. Then we went to monoclonal antibodies—biologicals,” he said. “We are now getting ready to use cells as a third way of doing medicine. We are at a historical sweet spot.”

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The (PCORI)Ìýalready has funded 468 studies, and last month opened the second phase of a program to create research networks covering specific diseases and involving millions of patients across the country.

The institute’s work, known as “comparative effectiveness research,” poses deceptively simple questions to find out vital information about which therapy or medication works best in the real world. Institute research goes beyond clinical trials and so-called “best practices” and extracts evidence from the individual experiences of massive numbers of patients.

Early results are encouraging. For example, many older patients fear the side effects of blood thinners, even though they decrease the incidence of stroke by 50 percent, but an of 12,500 stroke patients with atrial fibrillation found that the use of the blood thinning drug warfarin worked just as well without causing undue bleeding for patients over 80 as it did for younger patients. Another Ìýof children suffering from osteomyelitis, a bacterial bone inflammation, found that kids could take antibiotics orally instead of through an IV, a complicated and unpleasant procedure with risk of infection. The study reached that assessment after reviewing data from more than 2,000 children and adolescents treated at 36 children’s hospitals that have various protocols for handling the disease.

“We like studies embedded in real world settings, with big samples,” said Joe Selby, the institute’s executive director who is also a family practitioner, “in part because you want to be sure of the answer.”

Yet, some experts caution that it is too soon to proclaim the institute a success: “The jury is still out,” said Emory University Health economist Victoria Phillips. “We’ll need to look at what they deliver. Does the focus on patients disseminate the evidence more quickly and lead to faster implementation?” she asked. Other questions she raised: Is the integration between patients and researchers a success? Could another party do it more cheaply?

The institute, established in 2011as part of the Affordable Care Act, ,Ìýwith Republican opponents charging that it would be used to ration health care or even to serve as a “death panel” to determine who gets treatment and who does not.Ìý But the work has gone forward and raised few, if any, complaints.

The institute is a nonprofit financed from a trust fund set up by the Affordable Care Act that is expected to provide around $3 billion that must be spent by the end of 2020.

“Our job is to provide evidence,” Selby said. “We do not make policy or write guidelines. What patients and clinicians do with the evidence will be done by them, not us.”

In 2014 the institute launched the Patient-Centered Outcomes Research Networks, a program creating formal organizations overseen by medical professionals with patient participation and capable of conducting research surveys and studies into many diseases and conditions. These include both Clinical Data Research Networks, usually based at large university medical centers with access to repositories of millions of electronic health records, and Patient-Powered Research Networks that link thousands of patient volunteers with academic partners. The institute funded the first phase of the program for $93.5 million. Phase Two began Oct. 1 and will cost $142.5 million for three years.

Instead of merely funding individual studies, the networks give the institute additional tools for researchers to conduct multiple studies with resources already in place. Clinical Data Networks could enable medical professionals to query the records of millions of patients to learn the results of past or current medical care. One set for this network is to determine the optimal daily dose of aspirin to help prevent heart attack or stroke in people with coronary artery disease.

Patient Powered Research Networks partner academic researchers with patients, who help set the research agenda. The networks, working with patient-focused groups, recruit participants and identify concerns for potential studies.

In both types of networks, leaders vet research proposals, query their groups and send the resulting data to the research teams. The teams do not see patients’ individual medical records. Institute-funded studies must be peer-reviewed, and researchers must also prepare separate 500-word summaries of their results for clinicians and patients and post them on the institute’s website.

Each clinical network is required to research one common condition and one rare condition, but over time they are expected to be able to address practically any disease. So far, there are 13 clinical networks examining conditions that include breast cancer, anemia and atrial fibrillation, muscular dystrophy, cystic fibrosis and congenital heart defects.

“We’re trying to build a model that’s cheaper to use and more efficient” than conventional research trials, said Russell L. Rothman, a primary care physician and leader of the Mid-South Clinical Data Research Network, which is based at Vanderbilt University in Nashville but can draw on a sample base of 9 million patients in its region. The network’s early work has focused on coronary heart disease, especially on disparities in care, and sickle cell anemia.

Rothman said the network has spent its first 18 months making record systems compatible and appointing committees of physicians, patients and other health care providers to vet research requests. “We can use electronic health record data, to identify patients with a particular condition and follow them over time,” he added.

Health economist Rachael Fleurence, in charge of supervising the networks and developing reliable methodologies for them, said her program has worked at “getting everybody organized” but the networks have now begun to do research.

One of the more unusual new networks is focused on care for mental health problems, especially depression, in underserved communities in Los Angeles and New Orleans.

Called the ,Ìýthe initiative grew from a collaboration begun by University of California at Los Angeles psychiatrist Kenneth Wells and Loretta Jones, the founder of the Los Angeles-based community organization Healthy African-American Families.

“It was very difficult to get the community to talk about depression,” Jones said, but in 2003 she and Wells sponsored a conference where they asked community members what was needed. The conference helped spur efforts to improve mental health care opportunities in the community. The network they built, now one of the institute’s Phase 2 Patient Participatory networks, expanded its model to New Orleans after Hurricane Katrina, and today involves as many as 250,000 people in Louisiana and California.

The key feature of comparative effectiveness research, no matter how it is conducted, is to “improve patient care,” the Mid-South’s Rothman said. “Clinical trials typically test the effects of drugs against a placebo, while comparative effectiveness research compares one standard treatment to another in a real world situation to see what works better. We’re taking the next step.”

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For the high percentages of elderly and uninsured patients who live in rural areas, closures mean longer trips for treatment and uncertainty during times of crisis. “I came to the emergency room when I had panic attacks,” said George Taylor, 60, a retired federal government employee. “It was very soothing and the staff was great. I can’t imagine Mount Vernon without a hospital.”

The Kansas-based National Rural Health Association, which represents around 2,000 small hospitals throughout the country and other rural care providers, says that 48 rural hospitals have closed since 2010, the majority in Southern states, and 283 others are in trouble. In Texas along, 10 have changed.Ìý

“If there was one particular policy causing the trouble, it would be easy to understand,” said health economist Mark Holmes, from the University of North Carolina, whose rural health research program studies national trends in rural health care. “But there are a lot of things going on.”

Experts and practitioners cite declining federal reimbursements for hospitals under the Affordable Care Act as the principal reason for the recent closures. Besides cutting back on Medicare, the law reduced payments to hospitals for the uninsured, a decision based on the assumption that states would expand their Medicaid programs. However, almost two dozen states have refused to do so. In addition, other Medicare cuts caused by a budget disagreement in Congress have also hurt hospitals’ bottom lines.

But rural hospitals also suffer from multiple endemic disadvantages that drive down profit margins and make it virtually impossible to achieve economies of scale.

These include declining populations; disproportionate numbers of elderly and uninsured patients; the frequent need to pay doctors better than top dollar to get them to work in the hinterlands; the cost of expensive equipment that is necessary but frequently underused; the inability to provide lucrative specialty services and treatments; and an emphasis on emergency and urgent care, chronic money-losers.

‘Another Disaster’Ìý

Rural health care experts caution that national and state officials need to address the problems for rural hospitals or they could face a repeat of the catastrophic closings that followed changes in the Medicare payment system 30 years ago. That 1983 change, called the “prospective payment system,” established fixed reimbursements for care instead of payments based on a hospital’s reported costs. That change rewarded large, efficient providers, but 440 small hospitals closed before the system was adjusted in 1997 to help them. Those adjustments created the for some small, isolated facilities, which are exempted from the fixed payment system.

“And now, beginning in 2010, we’ve had another series of cuts that are all combining to create another expansion of closures just like we saw in the ‘90s,” said Brock Slabach, senior vice president of the Rural Health Association. “We don’t want to wake up with another disaster.”

The current surge in closures means federal officials need to come up with new legislation to halt the recent cuts to small hospitals in order to “buy time” to figure out how rural hospitals should effectively operate in the future, said the association’s chief lobbyist, Maggie Elehwany. “It is important to stop the bleeding right now.”

“The community went into panic mode,” he said. “I figured I had to step up.”

The non-profit ETMC Regional Healthcare System, based in Tyler, Texas, closed the Mount Vernon hospital and two others of its then-12 rural hospital affiliates because it could no longer sustain operating losses that had persisted for five years.

“There was no ill will,” Franklin County Judge Scott Lee said in an interview from his Mount Vernon office. “They were losing money. We had a good working relationship for years, and they had a business decision to make.”

Mount Vernon’s IssuesÌý

Perry Henderson, senior vice president of affiliate hospitals for ETMC, a major health care provider in East Texas, noted that rural hospitals have many uninsured patients, and Medicare accounts for “60 to 70 percent of the business,” while in “Dallas or Houston it’s a fraction of that.”

Mount Vernon, with lakefront properties that are attractive to retirees, has its share of elderly patients. Henderson also noted that many rural hospitals also have to deal with large numbers of agricultural accidents. Farming, another Mount Vernon staple, is one of the country’s most dangerous occupations. Finally, he added, country roads bring large numbers of traffic accidents. When there’s no hospital, emergencies mean longer trips to get help.

Henderson and other experts cite three reasons for the rash of closures nationally. Sequestration, the across-the-board federal budget cut that arose out of the legislative impasse between the Obama administration and congressional Republicans, has resulted in a 2 percent reduction in Medicare reimbursements since 2013.

“If Medicare is 50 percent of your revenue and you lose two points,” North Carolina’s Holmes said, “it can be a killer.”

Rural hospitals took a second hit from the federal health law’s reductions in “disproportionate share hospital” payments to hospitals with large numbers of indigent and uninsured patients. Federal officials made the cuts assuming that the law would assure that more patients had insurance.

It hasn’t worked well in rural areas, the Rural Health Association’s Elehwany said, because annual deductibles for the new insurance plans, which come out of consumers’ pockets, “are running between $2,500 and $5,000,” and people can’t pay them.

And in communities such as Mount Vernon, this problem is exacerbated because Texas, along with 22 other states, has refused to expand Medicaid, a key provision of the Affordable Care Act.

“That’s a big deal,” ETMC’s Henderson said. “That’s when we had the hurt.”

Latortue, who came to Mount Vernon as an ETMC hospital doctor in 2008, appears undaunted by the challenges of reinventing the hospital, which was treating an average of eight inpatients a week when it closed. Still, he said, “I’m very busy, and patients need to be seen—we’ll be all right.”

He intends to provide both outpatient services, including lab work, at the new clinic, and emergency care, stabilizing patients until they can be transferred to the Titus Regional Medical Center in Mt. Pleasant, 16 miles away, or to a smaller facility in Winfield, eight miles away. He also plans a wellness clinic to treat obesity and will offer Botox and laser cosmetic services. A cardiologist and a gastroenterologist will make weekly visits, and he is also looking for an ob-gyn.

Latortue got a favorable lease from the town of Mount Vernon and inherited an X-ray machine and other equipment from ETMC, but he still took out $150,000 in loans for remodeling and needs another $60,000 to $70,000 for equipment.

Still, none of this will replace the hospital, and his patients know it. “I live right behind the building,” said Mary Hunter, a very fit grandmother of 73. “I’ve had very good health until my blood pressure spiked last week,” she said. “We retired in 2006 and moved here, partly because of the hospital. And now it’s gone.”

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The Department of Justice estimates former inmates and detainees will comprise about 35 percent of the people who will qualify for Medicaid coverage in the states expanding their programs to anyone earning less than 138 percent of the federal poverty level, or about $15,000 for an individual in 2013. The Congressional Budget Office estimated earlier this year Ìýthat 9 million people will get that new coverage next year.

In addition, the expansion could help states cover the medical costs of some current inmates who need hospitalization or other expensive specialized care outside of prison.

Michigan, which has long been recognized as an innovator in inmate health care, is . ÌýOfficials here say that funding could help cover the needs of some seriously ill inmates as well as provide new coverage for released offenders, which could be a valuable tool in curbing recidivism.

“A significant number have never prepared their own meals. They don’t know how to shop, or how to budget,” said Tammy Meek, prisoner re-entry coordinator for the Gus Harrison Correctional Facility in this small city in southern Michigan. “Some can’t even write their name in cursive. Health care is critical in protecting the public and giving the client [former inmate] the tools he needs to succeed.”

GOP Lawmakers’ Concerns

But the Medicaid coverage for former offenders has stoked the interest of some powerful GOP members of Congress, including one from Michigan, House Energy and Commerce Committee Chairman Fred Upton. He and Health Subcommittee Chairman Joe Pitts of Pennsylvania last month of the health law’s Medicaid provisions on former offenders. “WeÌý must better understand the true costs of expanding the program to any new population and weigh such costs with the competing interests of our nation’s most vulnerable law-abiding citizens,” they wrote.

A Republican committee source said Upton and Pitts simply wanted “updated data” from GAO on “how Medicaid interacts with the criminal justice system” because they were “committed to understanding how every Medicaid dollar” will be spent under the new health law.

A Democratic committee source, however, dismissed the Upton initiative as “a complete red herring” prompted by Republicans’ search “for another way to come up with something that will ding the Affordable Care Act.”

The congressmen’s request notes that some researchers have suggested that large numbers of people added to the Medicaid rolls in an expansion could be prisoners. But ordinary, in-prison health care is not covered by Medicaid. The Medicaid law, passed in 1965, denies federal matching funds for convicted prisoners—about 1.5 million adults nationwide—and for 750,000 unconvicted detainees held for trial or petty crimes and misdemeanors in county and city jails on any given day. Each state, county or city must pay for the medical needs of all detainees from its general funds. The Affordable Care Act does not change this law.

However, since 1997, the federal government has allowed matching Medicaid funds to pay for specialized hospital care for 24 hours or more outside the prison system for inmates who were enrolled in or eligible for Medicaid before their incarcerations. Since most states narrowly draw the eligibility rules for adults, this funding generally covered people such as the frail elderly, patients suffering from serious disabilities and chronic diseases and pregnant women.

Michigan received $8 million in matching funds for that program during the year ending Sept. 30, state Department of Corrections spokesman Russ Marlan said. Next year, when about half the states have agreed to expand their Medicaid programs, the number of these patients should rise dramatically as will the federal matching funds. Marlan said Michigan could receive $20 million in Medicaid funding from the federal government in 2014 to help pay for such specialized treatment of prisoners, “but it’s probably too early to know for sure.”

Potentially far more important for the state’s bottom line, Medicaid expansion will also cover low-income inmates leaving prison.

“Having access to health care and mental health care contributes to their success in staying out of prison,” noted Heidi E. Washington, warden at the Charles E. Egeler correction facility in Jackson, Mich.

Lowering Recidivism

Helping former inmates adjust to the outside world has been shown in many studies to curb recidivism. Michigan, which has used state funds for reentry programs that include health care for nearly a decade, has seen its prison population drop in the past five years from 51,554 to 43,636. For released offenders with special needs—mostly mental disorders—recidivism rates plummeted from 50 percent in 1998 to 22.5 percent in 2012. Michigan spends $35,000 each year for every imprisoned inmate.

But curbing recidivism doesn’t just hinge on having funding from programs like Medicaid, noted Ira Burnim, legal director of the Bazelon Center for Mental Health Law. “These folks have to have services, and when they have access to housing and local support, they do very, very well.”

Michigan in 2005 hired a private company, Professional Consulting Services, to coordinate individual release plans for special needs inmates, serving as an intermediary between the Department of Corrections, state Medicaid officials and outside housing and service providers.

Chief Operating Officer Betsy Hardwick said PCS handles about 1,200 cases at any one time, preparing individual support plans and monitoring inmates for their first nine months on the outside. Hardwick said that 28 percent of the special needs inmates had Medicaid on release, but by the end of their first year in the community, “anecdotally we think between 60 percent and 70 percent are being approved.”

The effort appears to be a critical confidence builder for Martin Baker, 61, a repeat offender for breaking and entering who earlier this month was getting ready for parole at Adrian’s Gus Harrison prison and had been notified that he will have Medicaid upon release.

“I’ve got a bad liver from hepatitis C, and I couldn’t afford any medications on my own,” said Baker, a small but fit gray-haired man who also suffers from bipolar disorder and battled drug issues in the past. “My primary goal is to get my medical situation stabilized and get into a solid recovery program.”

Without insurance, he said, “you feel sick, and it causes you to get depressed and not care, so you say, ‘okay, I’m going out and get a pack of heroin.’ I don’t want that to happen.

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The VA told a Senate committee in late March that it had hired 1,089 additional staff with four months remaining until the deadline, and Michael Culpepper, the VA’s chief officer for workforce management, said in an interview the agency “feels optimistic about meeting our goals.”

But several experts expressed misgivings about the overall effect of the VA initiative on the delivery of mental health care, not only to veterans but also to the public at large. Mental health consultant Charles Curie, former administrator of the Substance Abuse and Mental Health Services Administration, suggested the VA was playing a “zero-sum game”—recruiting experienced caregivers from community-based organizations that will find it difficult to replace them.

“You might end up just shifting them around,” Curie said. “There could be unintended consequences—more staff for the VA but less for everyone else.”

M. David Rudd, scientific director at the National Center for Veterans Studies at the University of Utah, added the VA initiative will do little to address the nation’s endemic scarcity of mental health providers. “Being a clinician in the mental health field is not a very lucrative profession,” Rudd said. “Often the cost of education has driven people into other fields where they are better able to pay off their loans.”

The VA’s need for better mental health care is well-documented. Since 2005 the number of veterans receiving specialized treatment for depression, post-traumatic stress disorder, substance abuse and other behavioral conditions has risen steadily from 927,052 to 1.3 million in 2012. Twenty-two veterans commit suicide every day.

VA officials have been under intense pressure to improve services for veterans and the White House promised Friday to increase funding for veterans’ mental health services by 7.2 percent to $7 billion in the fiscal year starting in October. Funding for the increased mental health professionals, however, had already been approved. President Barack Obama on Aug. 31, 2012, signed an executive order to improve mental health services for veterans stressed by “long deployments and intense combat conditions” dating back to the middle of the 20th century and culminating in 10 years of war in Afghanistan and Iraq. The order endorsed the VA’s efforts to increase its staff by 1,600 mental health professionals by June 30, 2013. When the recruitment drive began one year ago the VA had a staff of more than 18,000 mental health professionals.

VA spokesman Josh Taylor said Friday that the department would consider hiring even more professionals if needed. “The secretary has said that if it is determined that more are needed, more will be added,” Taylor said.

Clinical psychologist Mary Schohn, the VA’s director of mental health operations, said the VA trains more than 6,400 providers every year in many occupations, including psychiatrists, psychologists, social workers, nurses, nurse practitioners and pharmacists. Still, she acknowledged, “we needed an aggressive campaign,” to expand the staff so significantly in such a short time.

Culpepper said the VA has organized publicity campaigns in each of the agency’s 21 geographic subdivisions, using posters, blast e-mails, public service announcements and television commercials to encourage recruits to visit the website vacareers.va.gov and fill out an application. Many professional associations are posting VA notices on their websites, he added.

It is not difficult for the VA to get the attention of potential mental health providers. According to Heather Kelly, senior legislative officer for veterans’ affairs at the American Psychological Association, the VA is the biggest employer of psychologists in the country. And for a mental health professional, the VA generally offers unmatched pay, benefits, working conditions and travel and research opportunities.

“We can’t compete,” said Jerry Mayo, executive director of Pine Belt Mental Healthcare Resources, a community mental health organization in Hattiesburg, Miss. “We’’e lost our last five licensed psychologists to the VA.” Mayo said Pine Belt also has a shortage of psychiatrists, but has compensated by hiring foreign doctors who work on special visas for a prescribed period of time. Whenever possible, he added, he tries to hire local staff who are likely to stay in the area.

The VA faces similar staffing difficulties in more rural areas of the country, and would like to correct this deficiency in its recruitment drive, but its competition with local mental health centers is usually “not helpful,” Mayo said, because “it seldom brings new people into the state.” It simply means that workers leave community mental health centers for a better economic deal at the VA.

One solution to the scarcity of available mental health care staff might be for the VA to partner with community mental health centers: “In rural areas particularly, the VA may only need a tenth of a person,” Schohn said. “Can somebody move there so we can share a health care professional?”

This is an idea “that would make perfect sense,” said Linda Rosenberg, the president and chief executive officer of the National Council for Community Behavioral Healthcare, representing 2,000 community mental health organizations. But “the VA seems unwilling or uninterested in doing that. They’re not very good collaborators.”

While this seems to be the case in Mississippi, some community mental health providers tell a different story. “I would find it hard to say anything bad about our local VA,” said Randy Tate, chief executive officer of NorthCare, in Oklahoma City. NorthCare partners with the VA on a veterans’ treatment program and hopes to join the agency on other projects.

Still, while veterans’ mental health care seems ripe for symbiosis between the VA and community organizations, John Van Camp, president of Southwest Solutions in Detroit, said Obama’s executive order, which will strip 1,600 licensed and near-licensed personnel from a scarce national talent pool, is not conducive to cooperation.

“We’re a half-mile from the VA and we have a phenomenal relationship,” Van Camp said. “But what I don’t understand is the single-mindedness that says all veterans have to be treated in the VA system.”

While some veterans want to be with other veterans, “others want to be treated in the neighborhood—there is no ‘one size-fits-all,'” he said. The executive order “could be a great opportunity for a public-private partnership, but it is not a collaborative approach.”

Washington Post staff writer Steve Vogel contributed to this article.

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Garcia has brought his niece and her infant child for a checkup at the Peñalver Clinic, a cool, airy stucco building in Little Havana where the underserved residents of Florida’s Miami-Dade County can receive primary health care at nominal fees. The niece and child are covered by Medicaid, but Garcia himself has no medical insurance, which does not particularly bother him. His boss doesn’t offer it, and, anyway, he says with a shrug, “there’s nothing wrong with me.”

According to the U.S. Census Bureau, there were an estimated 771,874 uninsured people living in Miami-Dade in 2011, which was 30.5 percent of the county’s total population and the fifth highest percentage of medically uninsured of any county in the country.

Miami-Dade is Florida’s biggest county, and Florida, with 29 electoral votes, is the largest of the critical swing states in the Nov. 6 general election. Health care routinely polls nationally as one of the nation’s top two or three concerns, and in Florida in August, a Quinnipiac/CBS/New York TimesÌýÌý of likely voters put it in second place, four points behind the economy, and well ahead of Medicare and the budget deficit.

With this high profile, the availability of health insurance should loom as a pivotal issue for Miami-Dade’s uninsured voters, especially with the stark choice facing them: the goal of Obama’s Affordable Care Act is health insurance for everyone; Romney has promised to repeal the law.

Yet most uninsured patients interviewed in mid-October visits to Peñalver and the Helen B. Bentley Health Center in Coconut Grove, did not routinely link their concerns about health care to their voting intentions. Instead, preferences tracked much more closely with how the candidates’ positions were expected to help the poor generally, or with their stances on Cuba (Miami’s anti-Castro exiles have been a reliable Republican constituency for most of the last 50 years).

“I don’t like Obama’s plan,” said Antero Blanco, 61, a Cuban-born U.S. citizen visiting Peñalver Clinic to seek help for his nephew, a construction worker with stomach cancer and no insurance. “It only benefits some people.”

Blanco did not describe his nephew’s immigration status. The health care law does not apply to undocumented aliens, but with rare exceptions virtually any Cuban immigrant can qualify for permanent residence—and coverage under the new law—after residing in the United States for a year. The nephew is 41 and needs $3,500 for tests at Jackson Memorial, Miami’s immense public hospital. “He hasn’t got the money,” Blanco said.

Blanco has employer-based health insurance, but his nephew’s plight has no influence on his own views. “I’m a Republican,” he said. “Always have been.”

For Miami’s uninsured, the health care rhetoric of battleground-state politics doesn’t appear to resonate. Instead, patients spend their time trying to gain access to medications and physicians and finding the money to pay for them.

Linda Quick, president of the South Florida Hospital & Healthcare Association, noted that while neighborhood hospitals cannot refuse emergency room treatment to the uninsured, patients get charged for follow-up procedures or specialty treatments. “If they don’t have the money, Jackson has to take them,” Quick said. “But that says nothing about when they take them. Historically they have had to wait weeks or months for an appointment.”

Three years ago, Yadiel Molina, then 25, was assaulted at a gas station and had his leg broken. He was treated at Jackson, but has never been able to get enough money to have the steel pins taken out of his leg. “He’s at the emergency room now, trying to get an appointment,” said his mother, Elizabeth Lopez, 52. Molina is a U.S. citizen and works construction when he can, but his leg periodically swells up, all but crippling him. He has never had medical insurance.

The Peñalver and Bentley centers were created to provide preventive and primary medical care to Miami’s underserved populations and neighborhoods. Bentley is a Federally Qualified Health Center, supervised by the federal Health Resources and Services Administration; it receives some federal funding. Peñalver follows the federal guidelines, but is not an FQHC and gets no federal funding.

“The general and overwhelming explanation” why Miami-Dade County has such a large number of uninsured, said Steven Marcus, president and CEO of the Health Foundation of South Florida, a nonprofit, grant-making public charity, is that a staggering 52 percent of the population is foreign-born, “both legal and undocumented.” The county has a large service economy “and we have a lot of migrant labor, seasonal labor and construction workers,” jobs that often don’t come with insurance. In this environment, illness can quickly become a catastrophe.

“My mother is a citizen and had never been sick until a year ago,” said Carmen Cabrera, who cleans houses in Miami. Her mother, Ofelia Romero, 64, has lost so much strength and weight from a mysterious undiagnosed disease that she can only navigate the hallways of the Bentley Health Center with the aid of a walker. Cabrera, 45, and her brother, a Guatemala-born construction worker, managed to scrape together $700 for an MRI and other tests, but her mother needs a specialist, “and we can’t pay for it.” Cabrera is at Bentley hoping to find help.

Boris Alvarez, executive director of Peñalver, and Caleb Davis, his counterpart at the Bentley Center, agree that despite treating some exotic ailments, the bulk of their business is the treatment of adult diabetes and hypertension, expectant mothers and children. “It has always been that way,” said Davis, in charge at Bentley since 1980.

“I ended up running out of insulin, and borrowed it from my fiancée’s mother,” said Miami native Joseph Exantus, 33, an unemployed and uninsured cook and plumber who has diabetes and is recovering from back surgery. “And then I ran out again and went to Baptist [Hospital] emergency. I had to pay $50 and the doctor ordered blood work, but that cost almost $300, and I didn’t have it.”

Exantus, who is homeless, acknowledges that health care is “very important” to him, but does not connect his concern directly to his support for Obama. Instead, he said, “I want to vote for him again just because he deserves a second chance, and my mother always raised me to give people a second chance.”

Alvarez says Penalver treats around 11,000 patients each year, and Bentley, according to Davis, treats 16,500 patients. Patients average about three visits annually. And while most appear to use the clinics because they are the only prompt medical care available to them, some prefer it. Both health centers are sunny and immaculately clean; same-day appointments are easy to get; and wait times seem reasonable.

“Personally, it’s about the comfort level,” said Bentley patient Natalie Santiyani, 21, a full-time scholarship student at Florida International University. “They have health insurance at school, but I’ve been coming here for a long time and paying out-of-pocket.” She plans to vote for Obama because “he’s better for the middle class and the lower class,” she said, but health care is only one piece of her agenda. Santiyani’s mother and grandmother have had a difficult life ever since they emigrated from Honduras 30 years ago, and, Santiani said, “I want to help them anyway I can.”

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In May, Missouri’s General Assembly (both houses are controlled by Republicans) passed a ballot measure for the November elections that would prohibit establishment of state health insurance exchanges, a cornerstone of the Affordable Care Act, without approval by the legislature or the voters. The reform law directs states by 2014 to set up the exchanges on the Internet, where consumers can comparison-shop for the health plan that best suits them.

GOP State Sen. Robert Schaaf, the bill’s author, said he wanted to block Jay Nixon, the Democratic governor who is running for re-election, from establishing an exchange by executive order. Nixon spokesman Scott Holste said the governor has no intention of issuing such an order.

What the ballot initiative all but ignores, however, is that if the state does not implement its own health care exchange by 2014, the health law requires the federal government to impose its own version.

Missouri Secretary of State Robin Carnahan, a Democrat who is not running for re-election and who is responsible for explaining difficult issues for the voters, clearly spotted this hole in the initiative language and in early July decided to make her own political statement. Her summary, to appear on the ballot on Election Day, did not use a light touch.

Shall Missouri law be amended to deny individuals, families, and small businesses the ability to access affordable health care plans through a state-based health benefit exchange unless authorized by statute, initiative or referendum or through an exchange operated by the federal government as required by the federal health care act?”

Republicans were outraged, none more so than Lt. Gov. Peter Kinder, who stepped in “within minutes of publication,” he said in an interview. This “biased, loaded language “is not fair, it’s not accurate, it’s not impartial—we have to get this into court.” So he filed suit to have Carnahan’s summary thrown out.

Since then, Kinder, locked in a tough re-election race against several opponents in Missouri’s TuesdayÌýprimary, has used the initiative and his opposition to the health law as a centerpiece of his campaign: “The whole entire law was founded in lies, passed with lies and is based in lies now, and the American people are not going to stand for it,” Kinder said. “Certainly the people of Missouri are not going to stand for it.”

Carnahan’s office said that as the defendant in the case Carnahan would not publicly comment on Kinder’s accusations, but she was clearly unmoved: “Obviously, some candidates see this as good political theater during an election year,” Carnahan spokesman Ryan Hobart said in a statement, “but we maintain that this is aÌýfair and sufficient summary of the ballot measure.”

Theater or not, the Missouri referendum has served as a reminder of the important role health care will play in this year’s elections. It also demonstrates how health care hyperbole can drown out reasonable discourse. The initiative’s language implies that approval means Missouri will have no insurance exchange unless the legislature or the voters sign off on it (not true); Carnahan’s ballot language implies that approval will deny consumers access to insurance (also not true).

Nationally, opinion on the health care law itself remains volatile and deeply divided. While no recent polls have tested the Affordable Care Act’s popularity in Missouri, another largely symbolic ballot initiative exempting Missourians from mandated health insurance won 71 per cent of the vote in 2010. A July 28 poll this year showed Obama trailing presumptive Republican challenger Mitt Romney by .

“President Obama and the health care law in general are not popular in Missouri,” said George Connor, head of the political science department at Missouri State University, in Springfield. “Any opposition to President Obama on health care by anybody gets you bonus points with the voter.”

And Democrats, Connor added, are trying to stay clear of Obama. The popular and politically savvy Nixon has been successful at it, and is a clear favorite for re-election. Incumbent Democratic Sen. Claire McCaskill, however, a supporter of the health care law who is closely identified with the president, is trailing against any of three possible GOP opponents competing in the primary.

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The state is focusing on seniors who officials say need assistance but not in a nursing home and not with an equivalent level of treatment in home or community-based services. The state TennCare Medicaid program will pay up to $15,000 a year to help these participants stay in their homes or receive meals and other services in adult day care facilities or other less restrictive community settings. Under its old program, all participants qualifying for long-term care under TennCare—whether they were in a nursing home or other care—were entitled to benefits equal to the cost of a nursing home.

The program, which has received federal approval and began this month, is the first of its kind in the nation because it creates this new category of patients who don’t qualify for nursing home care. Up to now, under federal law, everyone who receives long-term care under Medicaid first had to qualify to be admitted to a nursing home.

“Federal law requires that program eligibility be tied to eligibility for nursing homes,” said , executive director of the National Association of Medicaid Directors. “Tennessee is stepping ahead to create this new category of at-risk individuals whose benefits are not linked to nursing homes.”

But consumer advocates worry that the $15,000 annual limit will fall short of meeting the needs of some seniors, who could end up going without services or relying on funds from family or friends. , executive director of the Tennessee Justice Center, said he feared that “a lot of frail people are not going to make it on the reduced package.”

State officials say the money should be sufficient and that seniors whose need for care increases may qualify for more extensive TennCare benefits: nursing home or community-based care up to $55,000 a year.

TennCare hopes to save $47 million from the new program this year. In the longer run, the state expects by retooling the system it will be better prepared to accommodate an expected spike in enrollees as baby boomers grow older.

TennCare’s long-term care system serves 23,705 elderly. TennCare, like Medicaid in other states, is financed with federal and state funds. In addition to low-income seniors, it covers children, pregnant women and the disabled. Tennessee’s financial share for long-term elderly care is $1.1 billion per year.

Nationally, Medicaid plays a ,Ìýcovering more than two-thirds of all nursing home residents and footing more than 40 percent of the industry’s costs. The average cost per year for nursing home care nationally is about $80,000.

The new program is the second time in three years TennCare has moved to reduce use of nursing homes. In 2009, the state obtained permission from the federal government to offer nursing home patients—and new long-term care enrollees—the option of receiving care in a family- or community-based setting. Under that program, nursing home care would only be required if the alternative setting could not meet the patient’s needs or if the cost of those needs exceeded the $55,000 per year.

That change has been successful. In 2010, around 83 percent of Tennessee’s long-term Medicaid patients were in nursing homes, with 17 percent in home and community settings under a prior waiver. Today, 66 percent of patients are in nursing homes and 34 percent are receiving home- and community-based services.

Dr. Melinda Henderson, executive director at the UnitedHealthcare Community Plan, one of three managed care organizations that administer Tennessee’s Medicaid system, said patients overwhelmingly choose not to be in nursing homes.

“You kind of lose your independence at a nursing home,” said Sarah Stewart, who lives in Bolivar in rural southwest Tennessee. “I just prefer to be at home and be independent.”

Stewart, 78, had a heart attack in 2008 and is legally blind because of macular degeneration. She was hospitalized for breast cancer surgery in 2011 and put in a nursing home afterward, an experience she did not enjoy, in part, she acknowledged, because she was not allowed to have Molly, her Chihuahua, with her.

The change in the program in 2009 enabled her to leave nursing care last fall and go home, where a caregiver helps her with shopping, housework and personal needs for six hours a day, five days a week. She has five children, eight grandchildren and 13 great-grandchildren — virtually all of them living out of state.Ìý But home care “is making me comfortable,” she said. “I’m very pleased.”

The new program is an outgrowth of what officials learned from the 2009 change.Ìý They said they found that many people didn’t need more than $15,000 a year in assistance.

State officials decided they could raise the level of need for patients to qualify for full long-term care benefits, whether in a nursing home or elsewhere.Ìý The legislature approved the change in April, as did the federal Centers for Medicare & Medicaid Services.

Under the new regulations, the current requirementÌý – that someone need help with an “activity of daily living” such as dressing or using the bathroom – has been replaced by a complicated weighted point system that makes it considerably more difficult for patients to reach the standard to qualify for nursing home care.

The focus of this endeavor, said , is to make sure healthier patients who currently qualify for nursing facilities are served “more appropriately” in community-based settings. “We want nursing homes to target patients who truly need their services,” Killingsworth said. The system will spend less, she acknowledged, “but we will serve more people with home- and community-based care.”

Killingsworth said 40 percent of elderly Medicaid patients receiving community benefits before the change spent “less than $15,000 per year” and if they were entering the system now would receive “an appropriate level of benefits.”

Bonnyman, the consumer advocate, said TennCare has not done the analysis to warrant this assertion: “On paper what they’re talking about looks fine,” he said. But “all of this starts with a mandate designed to save $47 million.”

Jesse Samples, executive director of the Tennessee Health Care Association, representing the majority of Tennessee’s 330 nursing homes, agreed with Bonnyman that TennCare’s chief motivation is to save money and also agreed with Killingsworth that nursing homes were the target.

“In an ideal world we would increase funding for all categories of services,” Samples said. “But we’re playing a zero-sum game here. In order to get money for home and community-based services, you have to take it from somewhere else. That would be nursing homes.”

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The panel had theÌý of ,Ìýa former U.S. congressman who describes himself as the first House member to denounce the health law as unconstitutional. Georgia has joined 25 other states in aÌýlegal challenge to the law likely to be resolved by the Supreme Court.

But if the 2010 health law is not overturned by the court or repealed, states will have two choices—comply with the law, or wait for the federal government to force it on them.

This reality, and the opportunity to address the dysfunction in state health care systems, has tempered opposition to the Affordable Care Act, not only in Georgia but also in some other Republican-led states.

In Alabama, Gov. Robert Bentley, a physician, also opted toÌý to plan for an exchange and fought his legislature’s decision to scale back Medicaid after enhanced federal funding expired. In Virginia, a task force appointed by Republican Gov. Robert F. McDonnell hasÌýÌýa sweeping review of state health care policies and produced a set ofÌý designed to implement the law if it is not repealed.

Ìýof 29 Republican governors have accepted up to $1 million each in federal grants to designÌý state health insurance exchanges, marketplaces where individuals and businesses can shop for medical coverage. In addition, three of these states – Indiana, Mississippi and Nevada — have receivedÌý $31 million to implement the plans, according to theÌý of the grants. Arizona Gov. Jan Brewer hasÌý $29.8 million for one of these grants despite opposition from her own party.

The exchanges aim to encourage competition among insurers and give consumers access to a variety of insurance options. Under the health law, each state must have its exchange in place by Jan. 1, 2014. If not, the federal government will set one up for them.

The deadline has prompted states to “take a more practical approach,” said Tricia Brooks, of the Georgetown University Health Policy Institute, which tracks the progress of the health law. Conservatives in many states have been forced to take a sobering look at their health care delivery systems, “and when they can get away from the politics of all this,” Brooks continued, “they can see that maybe the (new law) isn’t all bad.”

In Georgia, this may well be the case. More than 20 percent of its population lacks health coverage of any kind,ÌýÌýout of 50 states in this dubious category. Only 29 percent of Georgia firms with fewer than 10 employees are offering health coverage. Many small businesses are so crippled by insurance costs that they say they either cannot hire new employees, are losing the ones they have or are unable to expand because they cannot afford it.

“We’ve got to do something,” said Republican State Rep. Richard H. Smith, the chairman of Georgia’s House Insurance Committee. “An insurance exchange can work whether (the health care law) survives or not. We still need to give people access to health insurance.”

DealÌý the Health Insurance Exchange Advisory Committee in June after being forced to pull an exchange bill when tea party conservatives launched a protest just as the General Assembly was getting ready to vote on it.

“We knew it was going to be controversial,” said Smith, lead sponsor of the House bill. “With this committee, we wanted to give more people a chance to buy in to the idea of an exchange and to understand it.”

The committee, established by a Deal executive order, includes members from Deal’s cabinet, both parties in the General Assembly, the insurance industry, health care providers, business and small business, consumer groups and the tea party.

On Oct. 27 the committee reached consensus on recommendations it would send to Deal. The Georgia exchange should be a quasi-governmental nonprofit that would operate like the state Lottery Corp. It would have a seven-member board of directors, with each director serving up to three, three-year terms. There would be separate pools within the exchange for small businesses and for individuals. “Small business” would be defined as 1 to 50 employees until 2016, when it could rise to 100 employees.

The committee mostly stayed out of the weeds, referring complicated details to the governor’s office for resolution. How and when would providers be reimbursed? How would the exchange pay for itself?

Insurance broker Russ Childers prompted an argument by suggesting that it was impossible for exchange directors to be both knowledgeable and “free of conflicts of interest.” Eventually the panel reworded the language: there should be “a formal process for addressing and resolving conflicts of interest.”

Cindy Zeldin, executive director of Georgians for a Healthy Future, a group that supports the new health law, described the recommendations as “more deferential to industry and less mindful of consumers than I would have liked,” but acknowledged that debate and discussion, both on Oct. 27 and at earlier meetings, was unfailingly “cordial and constructive.”

And “everybody listened,” added tea party representative Ed Painter, a photo shop owner from Dalton, Ga. “I like the free market, and the (new law) isn’t free market. On the other hand, I’d do anything to facilitate real health care reform. It’s a real conundrum for me, and that’s why they put me on the committee. This is hard.”

The lack of bombast was easily noticed at the October meeting. Not a single Republican in the committee room at Atlanta’s Department of Community Health referred to the health care law as “Obamacare,” a term repugnant to Democrats, and no advocate of the new law referred to the health care exchange as “compliance” with the law. “We’re doing what’s best for Georgia,” said independent health care consultant Gerry Purcell—a conservative.

Deal declined to be interviewed for this story, but Blake Fulenwider, Deal’s health policy adviser, said the governor would receive the committee’s formal report by Dec. 15. If the governor decides “to go forward,” Fulenwider said, “I’m confident we can craft an acceptable project for Georgia.” Fulenwider said Deal and the legislature have not yet decided whether to draft a health care exchange bill.

Several committee members credited the federal health law for serving as the “catalyst” for a needed debate, but whether Georgia would build a state health insurance exchange if the act were struck down was “a big unknown,” said Kyle Jackson, state director of the National Federation of Independent Businesses. “There are benefits to a health care exchange, especially for small business,” he said, but without the federal law, “I don’t know if the political will is there to make it happen.”

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