A Rush To Reconcile Health Enrollment Data, By Hand

More From All Tech Considered Digital LifeWireless Companies, FCC Reach Deal On 'Unlocking' CellphonesDigital LifeTake A Look At The Top Tweeted Moments Of The YearTechnologyA Rush To Reconcile Health Enrollment Data, By HandBusinessAmid Cuts And Tax Hikes, Tech Companies Get Love in Ireland

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A Rush To Reconcile Health Enrollment Data, By Hand

More From All Tech Considered Digital LifeWireless Companies, FCC Reach Deal On 'Unlocking' CellphonesDigital LifeTake A Look At The Top Tweeted Moments Of The YearTechnologyA Rush To Reconcile Health Enrollment Data, By HandBusinessAmid Cuts And Tax Hikes, Tech Companies Get Love in Ireland

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Bernie Sanders introduces The American Health Security Act

Introduced in the Senate, December 9, 2013

Download S. 1782, The American Health Security Act of 2013 (189 pages).

Summary of S. 1782, The American Health Security Act of 2013

The American Health Security Act of 2013 (S. 1782) provides every American with affordable and comprehensive health care services through the establishment of a national American Health Security Program (the Program) that requires each participating state to set up and administer a state single payer health program. The Program provides universal health care coverage for the comprehensive services required under S. 1782 and incorporates Medicare, Medicaid, the Children’s Health Insurance Program, the Federal Employees Health Benefits Program and TRICARE (the Department of Defense health care program), but maintains health care programs under the Veterans Affairs Administration. Private health insurance sold by for-profit companies could only exist to provide supplemental coverage.

The cornerstones of the Program will be fixed, annual, and global budgets, public accountability, measures of quality based on outcomes data designed by providers and patients, a national data-collection system with uniform reporting by all providers, and a progressive financing system. It will provide universal coverage, benefits emphasizing primary and preventive care, and free choice of providers. Inpatient services, long term care, a broad range of services for mental illness and substance abuse, and care coordination services will also be covered.

A seven-member national board (the Board) appointed by the President will establish a national health budget specifying the total federal and state expenditures to be made for covered health care services. The Board will work together with similar boards in each of the fifty states and the District of Columbia to administer the Program.

A Quality Council will develop and disseminate practice guidelines based on outcomes research and will profile health care professionals� patterns of practice to identify outliers. It will also develop standards of quality, performance measures, and medical review criteria and develop minimum competence criteria. A new Office of Primary Care and Prevention Research will be created within the Office of the Director of the National Institutes of Health (NIH).

The Program is designed to provide patient-centered care supported through adequate reimbursement for professionals, a wealth of evidence-based information, peer support, and financial incentives for better patient outcomes. The Program seeks to ensure medical decisions are made by patients and their health care providers.

The Program amends the tax code to create the American Health Security Trust Fund and appropriates to the Fund specified tax revenues, current health program receipts, and tax credits and subsidies under the Affordable Care Act. While the final structure of the financing component is still under consideration and is subject to change, the tax revenues in the draft include a new health care income tax, an employer payroll tax, a surcharge on high income individuals, and a tax on securities transactions.

The federal government would collect and distribute all funds to the states for the operation of the state programs to pay for the covered services. Budget increases would be limited to the rate of growth of the gross domestic product. Each state�s budget for administrative expenses would be capped at three percent.

Each state would have the choice to administer its own program or have the federal Board administer it. The state program could negotiate with providers and consult with its advisory boards to allocate funds. The state program could also contract with private companies to provide administrative functions, as Medicare currently does through its administrative regions. State programs could negotiate with providers to pay outpatient facilities and individual practitioners on a capitated, salaried, or other prospective basis or on a fee-for service basis according to a rate schedule. Rates would be designed to incentivize primary and preventive care while maintaining a global budget, bringing provider, patients, and all stakeholders to the table to best determine value and reimbursement.

Finally, the Program also relieves businesses from the heavy administrative burdens of providing health care coverage, puts all businesses on an even playing field in terms of healthcare coverage, and increases the competitiveness of American companies in the global marketplace. Every other industrialized nation has been able to use the power of a public authority to provide universal health care. The American Health Security Act of 2013 seeks to do just that for all Americans and their businesses.

Despite Big Market In Florida, Obamacare Is A Hard Sell

More From Shots - Health News HealthPopular Antacids Increase The Risk Of B-12 DeficiencyHealthTo Fight Meningitis Outbreak, Princeton Tries European VaccineHealthDespite Big Market In Florida, Obamacare Is A Hard SellHealthDon't Count On Insurance To Pay For Genetic Tests

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To Fight Meningitis Outbreak, Princeton Tries European Vaccine

More From Shots - Health News HealthPopular Antacids Increase The Risk Of B-12 DeficiencyHealthTo Fight Meningitis Outbreak, Princeton Tries European VaccineHealthDespite Big Market In Florida, Obamacare Is A Hard SellHealthDon't Count On Insurance To Pay For Genetic Tests

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To Curb Costs, New California Health Plans Trim Care Choices

More From Shots - Health News HealthTo Curb Costs, New California Health Plans Trim Care ChoicesHealthViolence In PG-13 Movies Comes With Plenty Of Sex And BoozeHealthNew York's Insurance Exchange Readies For Holiday RushHealthEpilepsy Patients Help Decode The Brain's Hidden Signals

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How to Revive the Fight for Single-Payer

Rep. Jim McDermott of Washington is optimistic that it will come�if we give states the tools to adopt it at their own pace.

When the media frenzy subsides and Republicans run out of scare stories, the country will be faced with the most important question about Obamacare: Can it deliver what it promised? Thanks to the Affordable Care Act, a new business model is rapidly emerging in the medical-industrial complex that, in theory, can dramatically reduce the inflated costs of healthcare while serving everyone�rich and poor, healthy and sick. But the reformed system will also still rely on the market competition of profit-making enterprises, including insurance companies. A lot of liberal Democrats, though they voted for Obama�s bill, remain skeptical.

�In the long arc of healthcare reform, I think [the ACA] will ultimately fail, because we are trying to put business-model methods into the healthcare system,� said Washington Representative Jim McDermott. �We�re not making refrigerators. We�re dealing with human beings, who are way more complicated than refrigerators on an assembly line.� I turned to the Seattle congressman for a candid assessment because he�s the third-ranking Democrat on the House Ways and Means Committee and has been an advocate of single-payer healthcare for decades. Plus, he�s a doctor.

The business transformation under way in healthcare involves the consolidation of hospitals, doctors and insurance companies in freestanding �integrated delivery systems��nonprofit and profit-seeking�that will have the operating scope and power to eliminate duplications and waste and hold down costs, especially the incomes of primary-care doctors. Major hospitals are buying up other hospitals and private practices, and they�re hiring younger doctors as salaried employees. An American Medical Association survey in 2012 found that a majority of doctors under 40 are employees, no longer independent practitioners.

�The medical-industrial complex is putting itself together so that the docs will be the least of our problem,� McDermott said. �They will simply be serfs working for the system.� The AMA�s market research reports that �hospitals focus on employing primary-care physicians in order to maintain a strong referral base for high-margin specialty service lines.� Big hospitals need a feeder system of salaried doctors, McDermott explained, to keep sending them patients in need of surgery or other expensive procedures.

�It�s possible hospital groups can reduce costs,� the congressman said, �but I look at the consolidations going on and ask myself, �Are we going to wind up with hospitals that are too big to fail? Are we going to have hospitals so powerful that we cannot not give them what they want?� It�s going to be the government against the medical-industrial complex, which is developing very rapidly. If the Little Sisters of Providence [his fanciful example] become a conglomerate and the government says you should close some of your hospitals, they will say, Who says?�

Despite these doubts�not to mention the Republican-promoted hysterical attacks on the ACA on other grounds�McDermott is actually optimistic. He expects stronger healthcare systems roughly resembling single-payer �to spring up like dandelions� around the country�led by progressive states that really want to make it work. �That�s probably going to happen in Vermont, Washington and Oregon,� he said. �California has tried twice to have a single-payer system and was defeated by the forces of money. Jerry Brown in California, maybe Cuomo in New York, maybe Kentucky. The governor in Oregon, John Kitzhaber, and our governor in Washington, Jay Inslee, all want it to happen.�

Having introduced a single-payer bill in Congress every year since 1993, McDermott is developing a different approach this time: a strategy designed to get around the hard-core resistance in so many states. �I now have a bill I�m going to drop in soon as a patch to the ACA,� he said. �What I�m trying to do is let the states that want it to go ahead, whether it�s Tennessee or Illinois. �Medicare for All� sounds wonderful, but the country is so diverse, you have to allow the delivery system to evolve where it can. You have to do it state by state.�

McDermott tried to sell this concept to the Obama administration and to Senator Max Baucus of Montana, chair of the Senate Finance Committee and one of the key Capitol Hill brokers in 2009�10 for what would become the ACA. No sale in either case. Instead, the president rejected the �public option� and made �bad deals� with hospitals, drug companies, the insurance industry and other players, McDermott said. Those interests agreed not to fight new rules on their behavior toward consumers, and in return Obama provided them with millions of new paying customers, subsidized by the government.

Under the ACA, hospital groups must sign a non-discrimination agreement, but as a practical matter they can still find ways to pick and choose which patients they will treat. The rules for Medicaid are set by each state, and enforcement varies widely among them. Typically, many private practices severely limit impoverished patients on Medicaid or refuse to serve any at all because that threatens their rate of return. Less obviously, some of the leading health conglomerates celebrated for their high quality and cost controls do the same. �When you dig down in all these great places like Mayo and the Cleveland Clinic, you see the same sort of thing,� McDermott said. �The Mayo doesn�t go out looking for Medicaid patients, and they don�t take just anyone who walks in the door.�

McDermott�s new legislation would break from the longstanding liberal assumption that the government must enact universal social programs that apply rules and benefits uniformly to all states at once. He figures that would allow the resistance to block single-payer for many years. So he wants to create a special deal for the limited number of states willing to uphold higher standards. State legislatures and governors can win approval to design and operate their own single-payer system, deciding how and where to spend the healthcare money the federal government already pumps into their state. (The Vermont Legislature has already approved, with the governor�s support, a move toward single-payer but can�t implement it until 2017, when it will need a federal waiver to do so.)

The congressman offered his hometown example, known as WWAMI�a five-state cooperative arrangement that includes Washington, Wyoming, Alaska, Montana and Idaho. The University of Washington has the only medical school in the Northwest border region, so the other states send their med students to Seattle and finance their education, in return for the students� commitment to come home to serve rural communities. This mutual support has functioned for forty years, despite red-blue differences. McDermott believes those five states could do a better job than distant DC of deploying and operating a first-class healthcare system.

To liberals who cry heresy, McDermott invokes Robert La Follette�s famous dictum that the states should be our �laboratory for democracy,� the best place to experiment and develop new solutions to public problems. Conservatives ought to like McDermott�s proposal because it disperses power closer to local decision-making. Liberals can embrace his approach as a practical way to break the stalemate on healthcare and open the way for basic solutions.

The congressman from Seattle thinks it may take a few more years of chaotic conflict before people understand the opportunity. But state governments�even in the neo-Confederate Republican Party�may start clamoring for this new approach once they begin to see the results.

�There are places where this could work,� McDermott said, �and once people see it work in Oregon or Washington, or maybe Kentucky, the people in Tennessee are going to say, �Why the hell don�t we have that? Are we not as good as the people in Oregon?� Then you�re going to get the governor of Tennessee to do an about-face.�

How to Revive the Fight for Single-Payer

Rep. Jim McDermott of Washington is optimistic that it will come�if we give states the tools to adopt it at their own pace.

When the media frenzy subsides and Republicans run out of scare stories, the country will be faced with the most important question about Obamacare: Can it deliver what it promised? Thanks to the Affordable Care Act, a new business model is rapidly emerging in the medical-industrial complex that, in theory, can dramatically reduce the inflated costs of healthcare while serving everyone�rich and poor, healthy and sick. But the reformed system will also still rely on the market competition of profit-making enterprises, including insurance companies. A lot of liberal Democrats, though they voted for Obama�s bill, remain skeptical.

�In the long arc of healthcare reform, I think [the ACA] will ultimately fail, because we are trying to put business-model methods into the healthcare system,� said Washington Representative Jim McDermott. �We�re not making refrigerators. We�re dealing with human beings, who are way more complicated than refrigerators on an assembly line.� I turned to the Seattle congressman for a candid assessment because he�s the third-ranking Democrat on the House Ways and Means Committee and has been an advocate of single-payer healthcare for decades. Plus, he�s a doctor.

The business transformation under way in healthcare involves the consolidation of hospitals, doctors and insurance companies in freestanding �integrated delivery systems��nonprofit and profit-seeking�that will have the operating scope and power to eliminate duplications and waste and hold down costs, especially the incomes of primary-care doctors. Major hospitals are buying up other hospitals and private practices, and they�re hiring younger doctors as salaried employees. An American Medical Association survey in 2012 found that a majority of doctors under 40 are employees, no longer independent practitioners.

�The medical-industrial complex is putting itself together so that the docs will be the least of our problem,� McDermott said. �They will simply be serfs working for the system.� The AMA�s market research reports that �hospitals focus on employing primary-care physicians in order to maintain a strong referral base for high-margin specialty service lines.� Big hospitals need a feeder system of salaried doctors, McDermott explained, to keep sending them patients in need of surgery or other expensive procedures.

�It�s possible hospital groups can reduce costs,� the congressman said, �but I look at the consolidations going on and ask myself, �Are we going to wind up with hospitals that are too big to fail? Are we going to have hospitals so powerful that we cannot not give them what they want?� It�s going to be the government against the medical-industrial complex, which is developing very rapidly. If the Little Sisters of Providence [his fanciful example] become a conglomerate and the government says you should close some of your hospitals, they will say, Who says?�

Despite these doubts�not to mention the Republican-promoted hysterical attacks on the ACA on other grounds�McDermott is actually optimistic. He expects stronger healthcare systems roughly resembling single-payer �to spring up like dandelions� around the country�led by progressive states that really want to make it work. �That�s probably going to happen in Vermont, Washington and Oregon,� he said. �California has tried twice to have a single-payer system and was defeated by the forces of money. Jerry Brown in California, maybe Cuomo in New York, maybe Kentucky. The governor in Oregon, John Kitzhaber, and our governor in Washington, Jay Inslee, all want it to happen.�

Having introduced a single-payer bill in Congress every year since 1993, McDermott is developing a different approach this time: a strategy designed to get around the hard-core resistance in so many states. �I now have a bill I�m going to drop in soon as a patch to the ACA,� he said. �What I�m trying to do is let the states that want it to go ahead, whether it�s Tennessee or Illinois. �Medicare for All� sounds wonderful, but the country is so diverse, you have to allow the delivery system to evolve where it can. You have to do it state by state.�

McDermott tried to sell this concept to the Obama administration and to Senator Max Baucus of Montana, chair of the Senate Finance Committee and one of the key Capitol Hill brokers in 2009�10 for what would become the ACA. No sale in either case. Instead, the president rejected the �public option� and made �bad deals� with hospitals, drug companies, the insurance industry and other players, McDermott said. Those interests agreed not to fight new rules on their behavior toward consumers, and in return Obama provided them with millions of new paying customers, subsidized by the government.

Under the ACA, hospital groups must sign a non-discrimination agreement, but as a practical matter they can still find ways to pick and choose which patients they will treat. The rules for Medicaid are set by each state, and enforcement varies widely among them. Typically, many private practices severely limit impoverished patients on Medicaid or refuse to serve any at all because that threatens their rate of return. Less obviously, some of the leading health conglomerates celebrated for their high quality and cost controls do the same. �When you dig down in all these great places like Mayo and the Cleveland Clinic, you see the same sort of thing,� McDermott said. �The Mayo doesn�t go out looking for Medicaid patients, and they don�t take just anyone who walks in the door.�

McDermott�s new legislation would break from the longstanding liberal assumption that the government must enact universal social programs that apply rules and benefits uniformly to all states at once. He figures that would allow the resistance to block single-payer for many years. So he wants to create a special deal for the limited number of states willing to uphold higher standards. State legislatures and governors can win approval to design and operate their own single-payer system, deciding how and where to spend the healthcare money the federal government already pumps into their state. (The Vermont Legislature has already approved, with the governor�s support, a move toward single-payer but can�t implement it until 2017, when it will need a federal waiver to do so.)

The congressman offered his hometown example, known as WWAMI�a five-state cooperative arrangement that includes Washington, Wyoming, Alaska, Montana and Idaho. The University of Washington has the only medical school in the Northwest border region, so the other states send their med students to Seattle and finance their education, in return for the students� commitment to come home to serve rural communities. This mutual support has functioned for forty years, despite red-blue differences. McDermott believes those five states could do a better job than distant DC of deploying and operating a first-class healthcare system.

To liberals who cry heresy, McDermott invokes Robert La Follette�s famous dictum that the states should be our �laboratory for democracy,� the best place to experiment and develop new solutions to public problems. Conservatives ought to like McDermott�s proposal because it disperses power closer to local decision-making. Liberals can embrace his approach as a practical way to break the stalemate on healthcare and open the way for basic solutions.

The congressman from Seattle thinks it may take a few more years of chaotic conflict before people understand the opportunity. But state governments�even in the neo-Confederate Republican Party�may start clamoring for this new approach once they begin to see the results.

�There are places where this could work,� McDermott said, �and once people see it work in Oregon or Washington, or maybe Kentucky, the people in Tennessee are going to say, �Why the hell don�t we have that? Are we not as good as the people in Oregon?� Then you�re going to get the governor of Tennessee to do an about-face.�

A New Worry Looms Online For The Affordable Care Act

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Weekend Edition Saturday

3 min 16 sec Playlist Download Transcript   Enlarge image i

Insurance companies say they are finding numerous mistakes on a digital form that's essential for signing up through HealthCare.gov.

AP

Insurance companies say they are finding numerous mistakes on a digital form that's essential for signing up through HealthCare.gov.

AP

Saturday is the day the Obama administration promised it would have HealthCare.gov working smoothly for the majority of people who need to sign up for health insurance.

As the Obama administration scrambles to fix the glitch-plagued site, experts are beginning to worry about another problem that may further impair the rollout of the Affordable Care Act.

Health insurance companies say they're seeing numerous errors in a form that plays a vital part in the enrollment process. The problems are manageable so far, but many worry about what will happen if enrollment surges in the weeks to come.

The 834

It's safe to say that the vast majority of consumers have never heard of an 834 EDI transmission form, despite its crucial role in the process of signing up for health insurance. It's a kind of digital resume that tells an insurance company's computer everything it needs to know about an applicant, says Bob Laszewski, a health policy consultant.

"It contains all of the person's enrollment information, all the information that [an] insurance company needs to get this person entered as a policy holder," Laszewski says.

The 834 has been around for a long time. The architects of the Affordable Care Act intended for it to play a central role in the sign-up process, says Tim Jost, a professor of law at Washington and Lee University.

"The 834 information is information the insurers have to have to get people enrolled in coverage, which of course is the point of going through the marketplace," Jost says.

Multiple Mistakes Make Insurers' Jobs Harder

But health insurance companies say the 834s they are receiving from applicants on the federal and state exchanges have sometimes been riddled with errors, Laszewski says.

"Duplicate enrollments, people enrolling and unenrolling, inaccurate data about who's a child and who's a spouse, files just not being readable," he says.

Highmark Blue Cross Blue Shield of West Virginia has been steadily processing new customers ever since the launch of Obamacare this fall. But Highmark President Fred Earley says mistakes in the 834s are making the job harder.

"We've had some situations where the records don't track, or we've seen duplicates," Earley says. "We've had situations where we'll get a record to show that someone canceled coverage when we've never had a record to show they enrolled in the first place."

Earley says his firm has been dealing with the problems by calling up state and federal officials and correcting the mistakes. The exact cause of the problems is unclear. The Obama administration has been slowly making fixes, and officials say they're making progress. But Laszewski says the fixes are not fast enough.

"The error rates have been falling," he says. "HealthCare.gov has been making progress, but we're not to the point yet where people can trust that high-volume enrollment can occur and we won't have serious customer service problems."

Laszewski says the test will come over the next few weeks. People who want coverage to begin on Jan. 1 have until just before Christmas to sign up, and there's likely to be a surge of new applicants in the weeks to come.

"What happens if we start getting hundreds of thousands or millions of people signing up by the Dec. 23 deadline, and the insurance industry is receiving hundreds or thousands of these a day?" he says. "That's what everyone's worried about."

Share Facebook Twitter Google+ Email Comment More From Health Care Health CareWhite House Optimistic At Deadline To Fix ObamacareHealth Care3 Stories From HealthCare.gov UsersHealth CareHow Will We Know If HealthCare.gov Is Fixed?Health CareA New Worry Looms Online For The Affordable Care Act

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Part-Time Workers With Minimal Health Coverage Get New Options

More From Shots - Health News Health2009 Flu Pandemic Was 10 Times More Deadly Than Previously ThoughtHealthPart-Time Workers With Minimal Health Coverage Get New OptionsHealth CareThese Californians Greeted Canceled Health Plans With SmilesHealthEmergency Contraceptive Pill Might Be Ineffective For Obese

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These Californians Greeted Canceled Health Plans With Smiles

More From Shots - Health News Health2009 Flu Pandemic Was 10 Times More Deadly Than Previously ThoughtHealthPart-Time Workers With Minimal Health Coverage Get New OptionsHealth CareThese Californians Greeted Canceled Health Plans With SmilesHealthEmergency Contraceptive Pill Might Be Ineffective For Obese

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FDA Tells 23andMe To Stop Selling Popular Genetic Test

More From Shots - Health News HealthYes, Your Toddler Really Is Smarter Than A 5-Year-OldHealthFDA Tells 23andMe To Stop Selling Popular Genetic TestHealth CareHealth Exchanges Brace For A December DelugeHealthIn Pregnancy, What's Worse? Cigarettes Or The Nicotine Patch?

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Health Exchanges Brace For A December Deluge

More From Shots - Health News HealthYes, Your Toddler Really Is Smarter Than A 5-Year-OldHealthFDA Tells 23andMe To Stop Selling Popular Genetic TestHealth CareHealth Exchanges Brace For A December DelugeHealthIn Pregnancy, What's Worse? Cigarettes Or The Nicotine Patch?

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The U.S. Lags in Life Expectancy Gains

From Bloomberg Businessweek –

Life expectancy in the U.S. has been growing more slowly than in other developed countries and is now more than a year below the developed-country average, according to a new report (PDF) from the Organisation for Economic Co-operation and Development.

Even though Americans, on average, live to be almost 80, this is not good news. Life expectancy at birth is affected by trends in everything from infant mortality, accident rates, and violence to chronic diseases and care for the elderly, which makes it a highly sensitive indicator of a nation�s economic development.

U.S. life expectancy in 2011 was 78.7 years. That was an increase of a little less than eight years since 1970. Impressive, but not as big as the 10-year gain for the OECD as a whole. �Life expectancy [in the U.S.] is now more than a year below the OECD average of 80.1,� the OECD said in a press statement, �compared to one year above the average in 1970.�

Why has the U.S. fallen off pace? The OECD report sums up some American studies by the National Research Council and the Institute of Medicine that suggest some causes. None of the theories reflect well on the U.S.:

1. The highly fragmented nature of the U.S. health system, with relatively few resources devoted to public health and primary care, and a large share of the population uninsured;

2. Health-related behaviors, including higher calorie consumption per capita and obesity rates, higher consumption of prescription and illegal drugs, higher deaths from road traffic accidents and higher homicide rates;

3. Adverse socioeconomic conditions affecting a large segment of the U.S. population, with higher rates of poverty and income inequality than in most other OECD countries.

Ouch.

Making Moves In Food Delivery, Chess And Health Care

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All Things Considered

3 min 55 sec Playlist Download Transcript  

The online magazine Ozy covers people, places and trends on the horizon. Co-founder Carlos Watson joins All Things Considered regularly to tell us about the site's latest discoveries.

This week, Watson tells host Arun Rath about a delivery service that allows you to track your food in real time, a chess master who is making the board game sexy and his recent interview with President Bill Clinton.

The New And The Next Shaking Up The Food Delivery Model Enlarge image i Radius Images/Corbis Radius Images/Corbis

"A couple of young guys who were UC Berkeley grads � food obsessed � were finding that they couldn't get their favorite foods delivered. So, they starteda new service called Caviar, that for a flat fee is creating quite the Uber-like stir around San Francisco and now in Seattle and New York. ...

"They've got a lot of your basics, whether it's fish tacos or pulled pork sandwiches, but they also have some of the higher-end restaurants who in the past have been a little hesitant about delivery who have agreed to do it."

Read 'Caviar: Like Uber For Eaters' At Ozy.com

Sexy Moves In The World Of Chess Enlarge image i Courtesy of Ozy.com Courtesy of Ozy.com

"Chess is not always the sexiest sport. But the No. 1 chess player in the world is a young guy from Norway named Magnus Carlsen, who is becoming quite the sensation. He is not only a champion chess player but he is also a male model and that's a very different look from Bobby Fischer or Garry Kasparov, who were two other famous chess champions of the past. ... Guys like Kasparov and others are saying, 'I hope he does really well and puts chess back into the larger mainstream conversation.' "

Read 'Meet the New Ambassador of Chess' At Ozy.com

President Bill Clinton Talks Health Care With Ozy Youtube/YouTube

"He reminded us that when President George W. Bush rolled out the Medicare Part D plan that there also were a number of hiccups in the early days. So, that was his way of offering context to the current troubles with HealthCare.gov. And saying, be a little bit patient. While there may be a number of troubles in the first couple months with HealthCare.gov, they ultimately should be fixable and this won't have been the first time that we've had to smooth over some things in the early going."

Read 'Assessing the Healthcare Rollout' At Ozy.com

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New Medical Device Treats Epilepsy With A Well-Timed Zap

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Can You Keep Your Old Health Plan? It May Depend On Where You Live

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Can You Keep Your Old Health Plan? It May Depend On Where You Live

More From Shots - Health News HealthFor Many People, Lowering Blood Pressure Will Take A VillageHealthCan You Keep Your Old Health Plan? It May Depend On Where You Live HealthFederal Brain Science Project Aims To Restore Soldiers' MemoryHealthConsumer Guide To Obama's Plan For Canceled Health Policies

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Insurers Aren't Keen On Obama's Pledge To Extend Coverage

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'Holy Cow' And 'Kangaroo Court': Panel Grills HealthCare.gov Officials

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Despite Health Law, Uninsured Rely On Prevention Care Patchwork

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The First Estimate On Insurance Signups Is Pretty Darned Small

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When Caregivers Are Abusers: Calif. Complaints Go Unanswered

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Jim Fossum holds a photograph of his aunt, Elsie Fossum, who died from injuries her caregiver said were the result of a fall.

Mina Kim/KQED

Jim Fossum holds a photograph of his aunt, Elsie Fossum, who died from injuries her caregiver said were the result of a fall.

Mina Kim/KQED

Nurse assistants and home health aides provide intimate care, bathing, feeding and dressing the elderly, disabled or ill. So what happens when an abusive caregiver hurts a patient?

Public health regulators in California have been letting many complaints sit for years � even when they involve severe injuries or deaths.

'Beaten To A Pulp'

Elsie Fossum's nieces and nephews say she was the aunt you wanted to have.

"She gave us our first car," Janet Flynn remembers. Her brother, Jim Fossum, chimes in: "A '59 Ford Galaxie 500, with massive fins on it."

Flynn says their aunt, a librarian and teacher who never married or had kids, always looked chic.

Enlarge image i

Elsie Fossum's niece, Janet Flynn, and nephews Jim Fossum, left, and John Fossum, say they never heard from California's Department of Public Health following their aunt's death.

Mina Kim/KQED

Elsie Fossum's niece, Janet Flynn, and nephews Jim Fossum, left, and John Fossum, say they never heard from California's Department of Public Health following their aunt's death.

Mina Kim/KQED

"She would come for the summer with this tiny Samsonite suitcase," Flynn says. "And she would be impeccably dressed, mixing and matching, and her hair was always done. Always looked wonderful."

But on the morning of July 3, 2006, Elsie Fossum lay in a pool of blood on the floor of her bedroom at Claremont Place, a Los Angeles-area assisted living facility. The 95-year-old Fossum had lived there for two years.

Her eyes were bruising black, her lip was badly cut, and her right arm was broken. But she was alive.

The lone caregiver on Fossum's floor that night said Fossum fell, but Beverlee McPherson, a registered nurse who supervised nurse assistants at Claremont Place, suspected abuse.

"She looked like she went four or five rounds with Muhammad Ali," McPherson says.

Unable to take much food or water through her swollen mouth, Fossum died of dehydration less than three weeks later. A Los Angeles County coroner could not rule out assault and called the manner of death undetermined.

McPherson is resolute.

"Oh, I'm 100-percent convinced she didn't fall out of bed, 100 percent," she says. "If you saw this woman's face, I mean, her entire face was beaten to a pulp."

'Staying On Top Of Complaints'

Emergency room nurses who treated Fossum at a nearby hospital also suspected abuse. The hospital quickly notified the California Department of Public Health, the agency responsible for decertifying nurse assistants who violate standards of care.

Cases Closed With No Action Taken

The number and rate of license revocations against nursing assistants and in-home health aides suspected of abuse have plunged, while cases closed without action have increased.

Enlarge image i Center For Investigative Reporting/KQED Center For Investigative Reporting/KQED

But internal documents obtained by the Center for Investigative Reporting show department investigators shelved Fossum's case for six and a half years.

CDPH Director Ron Chapman blames the delays in handling complaints on a backlog of more than 900 cases that piled up between 2004 and 2008.

"There were a number of reasons for that backlog, including poor management decisions during that time," Chapman says.

The department implemented a plan in 2009 to address the backlog, says Chapman, who was sworn in to his position in 2011.

"In the two years that I've been in the job, there's now new management from top to bottom, and we're staying on top of all the complaints as they come in," he says.

Yet the number of nurse assistants facing disciplinary action following complaints has dropped, from 27 percent a few years ago to 9 percent last year.

Chapman says he sees no evidence that addressing the backlog has undermined the quality of the department's current work, but Marc Parker, who headed the investigations section for nine years, says he was forced to cut corners.

"Hundreds of cases were closed, hundreds, with nothing but a phone call," he says.

'A Failure To Protect'

Parker says without visits to facilities, investigators are unable to see the layout of a room, conduct impromptu interviews, or assess a person's body language. Parker retired in December of 2011, earlier than planned.

"I could not protect the public any longer," he says. "There was just a failure to protect the most vulnerable people in our state from abuse and neglect."

A Sudden Drop

The California Department of Public Health is required to notify the attorney general's office when its investigators find evidence of crimes, especially violent acts, at health care facilities. After 2009, the department all but stopped sending patient abuse deaths to state prosecutors.

Enlarge image i Center For Investigative Reporting/KQED Center For Investigative Reporting/KQED

Public health regulators are required to report all suspected crimes to the state attorney general. In the seven years before addressing the backlog, the department referred an average of 37 deaths a year. Last year, they referred three. The year before that, two.

"We don't understand that decline in numbers," Chapman says. "It's very concerning to me and we are looking into it." He says his staff is drafting agreements with the attorney general's office to improve communication.

As for Elsie Fossum's suspicious death, department investigators closed her case this year, and decided no action was warranted against her caregiver.

Also this year, however, the Los Angeles County Sheriff's Department opened a homicide investigation into Elsie Fossum's death. Her caregiver is the sole person of interest. Chapman now says he's willing to review the case.

Elsie Fossum's nephews and niece say they never heard from the Department of Public Health. Flynn says their calls and emails to state agencies and local police have turned up little information.

"I would think that this would be very chilling to anyone who has loved ones in a facility, especially if you think safeguards are in place and you think that staff are qualified and that this is being regulated, and this I find chilling," Flynn says.

This story was co-reported by Ryan Gabrielson at the Center for Investigative Reporting.

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How The Affordable Care Act Pays For Insurance Subsidies

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The President Wants You to Get Rich on Obamacare

From the New York Times –

Tom Scully bolted through the doors and up the stairs to a private dining room on the third floor of the �21� Club. Scully, 56, is slightly taller than average and has tousled graying hair, an athletic build and a lopsided smile. He typically projects a combination of confidence and bemusement, but on this rainy September afternoon, he was frenzied. Scully was scheduled to deliver the keynote address at an event hosted by the Potomac Research Group, a Beltway firm that advises large investors on government policy (tag line: �Washington to Wall Street�). Today�s discussion centered on the most significant change in decades to the nation�s health care policy, the Patient Protection and Affordable Care Act, a.k.a. Obamacare. As Scully walked to the front of the room, some 50 managers from hedge funds, mutual funds and private equity firms tucked into the round tables. Others gathered in the hallway. A hush of anticipation hung in the air.

During the past year, anxiety about the onset of Obamacare has created a chill in some parts of the economy. While large health care businesses � insurance companies, for instance, and hospital chains � have poured significant resources into preparing for millions of new customers, countless investors have appeared spooked by the perpetual threats to repeal, or at least revise, the law. According to Thomson Reuters, private equity investment, usually the lifeblood for entrepreneurialism, has dropped by an astonishing 65 percent in the health care sector this year.

Scully has been trying to assuage these worries, but the nervous questions keep coming at him. Before he even began his speech, one attendee said he feared that only three million new patients, far fewer than estimated, would be signing up for insurance. �No way,� Scully said. �Way more � way more. At least 15 million, maybe 20 million. The Democrats have a huge incentive to make this work.� Another asked if Scully was worried about Congressional repeal. �It�s just not going to happen,� he said. �Don�t pay attention to Rush Limbaugh.� When Scully finally began his speech, he noted that the prevailing narrative among Republicans � assuming that many in the room were, like him, Republican � was incorrect. �It�s not a government takeover of medicine,� he told the crowd. �It�s the privatization of health care.� In fact, Obamacare, he said, was largely based on past Republican initiatives. �If you took George H. W. Bush�s health plan and removed the label, you�d think it was Obamacare.�

Scully then segued to his main point, one he has been making in similarly handsome dining rooms across the country: No matter what investors thought about Obamacare politically � and surely many there did not think much of it � the law was going to make some people very rich. The Affordable Care Act, he said, wasn�t simply a law that mandated insurance for the uninsured. Instead, it would fundamentally transform the basic business model of medicine. With the right understanding of the industry, private-sector markets and bureaucratic rules, savvy investors could help underwrite innovative companies specifically designed to profit from the law. Billions could flow from Washington to Wall Street, indeed.

Scully, who has spent the last 30-some years oscillating between government and the private sector, is hoping to be his own best proof of the Obamacare gold mine. As a principal health policy adviser under President George H. W. Bush, he helped formulate many of those past Republican initiatives � like the shift to private-insurance programs � that Obamacare has put into law. Under George W. Bush, he ran the Centers for Medicare and Medicaid Services and oversaw a host of proto-Obamacare reforms, like Medicare Part D, which introduced competition into the government-supported health care market. After leaving C.M.S. in 2004, Scully began working simultaneously at Welsh, Carson, Anderson & Stowe, a leading health care private equity firm, and Alston & Bird, a law firm and health care lobbying organization. When the Affordable Care Act became law in 2010, he found himself in the rare position of being a lobbyist, private equity executive and former government health care official with access to a serious amount of capital. During the past three years, as other Republicans have tried to overturn Obamacare, Scully searched for a way to make a killing from it.

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'Loyal Soldier' Sebelius Vows To Stay Put, Fix HealthCare.gov

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Health and Human Services Secretary Kathleen Sebelius speaks Thursday in Phoenix.

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Health and Human Services Secretary Kathleen Sebelius speaks Thursday in Phoenix.

Laura Segall/Getty Images

This has not been an easy month for Health and Human Services Secretary Kathleen Sebelius.

Republican Sen. Pat Roberts of Kansas � who learned the political ropes working for Sebelius' father-in-law, then a Kansas congressman � called for her to step down over the debut of HealthCare.gov, the problem-plagued website where people are supposed to apply for coverage under the Affordable Care Act.

Invited on the usually friendly-to-Democrats The Daily Show, Sebelius was lampooned by host Jon Stewart, who challenged her to a race of sorts: "I'm going to try and download every movie ever made, and you're going to try to sign up for Obamacare, and we'll see which happens first."

And while she was able to laugh off Stewart's opening gag, Sebelius had trouble clearly explaining why, if businesses have been given an extra year to implement Obamacare, individuals shouldn't have the same delay.

Sebelius served six years as the Democratic governor of largely Republican Kansas. She is the daughter of the late Ohio Gov. John Gilligan. University of Kansas political science professor Burdett Loomis says she remains popular at home, despite the hits she's been taking in Washington:

"This hasn't been an easy time for her. The Obamacare rollout has clearly been problematic; she pretty much got roasted on Jon Stewart; but she's been a loyal soldier to Barack Obama and I think she truly believes that Obamacare is in the best interest of the country."

Seven years ago the Bush administration unveiled Medicare Part D, which provides seniors with prescription drug benefits. The website for that program had a similarly rocky debut. The HHS secretary then was former Utah Gov. Mike Leavitt, who notes Sebelius did not make many of the key decisions regarding the rollout of Obamacare. Leavitt says he empathizes with Sebelius:

"It's much like being the pilot of an airplane full of passengers sitting on the tarmac with a series of complications you don't entirely control. It's better to say to the passengers, 'This is where we are. This is how much time we expect it'll take. ... Here's what we're doing to remedy it and here's how it's going to affect you. We're doing our best.' "

Before being elected governor, Sebelius was Kansas insurance commissioner. The Republican occupant of the job now, Sandy Praeger, says the glitches in the rollout of Obamacare are not Sebelius' fault.

"The complexity of what she's having to deal with is massive and in an environment that's been pretty politically charged, to say the least. So I have a great deal of sympathy for what she's having to work through," says Praeger. "I know she's probably very frustrated."

Praeger says calls for Sebelius to resign are totally inappropriate. And in an appearance in Phoenix, Sebelius rejected Republican demands she step down.

'The majority of people calling for me to resign I would say are people who I don't work for and who do not want this program to work in the first place," Sebelius said Thursday. "I have had frequent conversations with the president and I have committed to him that my role is to get the program up and running, and we will do just that."

Sebelius is expected to testify before a House committee investigating the Affordable Care Act's implementation as soon as Wednesday.

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How Politics Set The Stage For The Obamacare Website Meltdown

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Obamacare Fight Leads Sen. Roberts To Turn Against Old Friend Sebelius

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Hitches On Health Exchanges Hinder Launch Of Insurance Co-op

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Why A Medical Device Tax Became Part Of The Fiscal Fight

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All Things Considered

3 min 33 sec Playlist Download Transcript  

Among the bargaining chips in the budget crisis on Capitol Hill, there's the small but persistent issue of taxing medical device manufacturers.

The 2.3 percent sales tax covers everything from MRI machines to replacement hips and maybe even surgical gloves. The tax was imposed to help pay for the Affordable Care Act. It didn't attract much attention at first � at least, not outside the world of medical device manufacturers.

But they have waged a persistent campaign to undo the tax, and right now is the closest they have come to succeeding.

House Republicans have made repeated efforts to kill the tax, but Democrats had opposed any changes to the health care law.

Senate Finance Committee Chairman Max Baucus, D-Mont., last month dismissed changes in the medical devices tax. He told Politico that the industry had agreed to it when the bill was being written and "a deal's a deal."

But even Democrats have started softening that hard line.

Illinois Sen. Richard Durbin, the Senate's second-ranking Democrat, told CNN recently: "We can work out something, I believe, on the medical device tax � that was one of the proposals from the Republicans � as long as we replace the revenue."

Last week, a bipartisan compromise in the Senate included the idea of delaying the tax for two years.

Maine Republican Sen. Susan Collins spearheaded the proposal. She cited the lobbying campaign's work when she said the tax "will cause the loss of as many as 43,000 domestic jobs, according to industry estimates."

Related NPR Stories Shots - Health News How A Tax On Medical Devices United Political Rivals It's All Politics A Hint Of Bipartisanship On This Obamacare Tax? Shots - Health News Veterinarians Say Health Law's Device Tax Is Unfair To Pets

Those estimates are crucial to the lobbying effort.

The CEO of one of the industry's giants, Medtronic, said last fall that the company likes to "focus on things we can control." Medtronic, which is based in Minnesota, did not respond to an interview request Tuesday.

But one of Minnesota's senators is a leader of the anti-tax campaign.

Democrat Amy Klobuchar gave industry advocates some advice this summer.

"I think that at the beginning of this battle, people didn't understand in Congress how many medical device manufacturers they had," she said. "I think just making the case at home and also back in Washington makes a difference."

And that is what the medical device industry has been doing, quietly but assiduously.

Cook Group, the largest privately owned maker of medical devices, boosted its lobbying outlays significantly in the past two years. It's also working with an industry consultant, Joe Hage, on a website called no2point3.com.

The website collects stories of anger and anguish from the small-business people who run a lot of the companies. It also has a petition to repeal with 11,000 signatures. It's all fueled by a LinkedIn group that Hage runs.

"The medical devices group is not in league with Washington lobbyists directly," Hage says, but he quickly adds: "We like to think that this effort complements their effort by giving them another bow in their quiver."

Still, it's hardly clear whether those efforts will move votes or whether the whole tax question will be just a pawn in the much larger debate over the budget and the debt limit.

Share Facebook Twitter Google+ Email Comment More From The Government Shutdown PoliticsShutdown Diary: Hope Turns Into Wall Street WarningPoliticsWhy A Medical Device Tax Became Part Of The Fiscal FightPoliticsOn Capitol Hill, A Flurry Of Activity But Still No Deal BusinessJPMorgan To Front Customers If Federal Shutdown Drags On

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Please keep your community civil. All comments must follow the NPR.org Community rules and terms of use, and will be moderated prior to posting. NPR reserves the right to use the comments we receive, in whole or in part, and to use the commenter's name and location, in any medium. See also the Terms of Use, Privacy Policy and Community FAQ.

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Why A Medical Device Tax Became Part Of The Fiscal Fight

Listen to the Story

All Things Considered

3 min 33 sec Playlist Download Transcript  

Among the bargaining chips in the budget crisis on Capitol Hill, there's the small but persistent issue of taxing medical device manufacturers.

The 2.3 percent sales tax covers everything from MRI machines to replacement hips and maybe even surgical gloves. The tax was imposed to help pay for the Affordable Care Act. It didn't attract much attention at first � at least, not outside the world of medical device manufacturers.

But they have waged a persistent campaign to undo the tax, and right now is the closest they have come to succeeding.

House Republicans have made repeated efforts to kill the tax, but Democrats had opposed any changes to the health care law.

Senate Finance Committee Chairman Max Baucus, D-Mont., last month dismissed changes in the medical devices tax. He told Politico that the industry had agreed to it when the bill was being written and "a deal's a deal."

But even Democrats have started softening that hard line.

Illinois Sen. Richard Durbin, the Senate's second-ranking Democrat, told CNN recently: "We can work out something, I believe, on the medical device tax � that was one of the proposals from the Republicans � as long as we replace the revenue."

Last week, a bipartisan compromise in the Senate included the idea of delaying the tax for two years.

Maine Republican Sen. Susan Collins spearheaded the proposal. She cited the lobbying campaign's work when she said the tax "will cause the loss of as many as 43,000 domestic jobs, according to industry estimates."

Related NPR Stories Shots - Health News How A Tax On Medical Devices United Political Rivals It's All Politics A Hint Of Bipartisanship On This Obamacare Tax? Shots - Health News Veterinarians Say Health Law's Device Tax Is Unfair To Pets

Those estimates are crucial to the lobbying effort.

The CEO of one of the industry's giants, Medtronic, said last fall that the company likes to "focus on things we can control." Medtronic, which is based in Minnesota, did not respond to an interview request Tuesday.

But one of Minnesota's senators is a leader of the anti-tax campaign.

Democrat Amy Klobuchar gave industry advocates some advice this summer.

"I think that at the beginning of this battle, people didn't understand in Congress how many medical device manufacturers they had," she said. "I think just making the case at home and also back in Washington makes a difference."

And that is what the medical device industry has been doing, quietly but assiduously.

Cook Group, the largest privately owned maker of medical devices, boosted its lobbying outlays significantly in the past two years. It's also working with an industry consultant, Joe Hage, on a website called no2point3.com.

The website collects stories of anger and anguish from the small-business people who run a lot of the companies. It also has a petition to repeal with 11,000 signatures. It's all fueled by a LinkedIn group that Hage runs.

"The medical devices group is not in league with Washington lobbyists directly," Hage says, but he quickly adds: "We like to think that this effort complements their effort by giving them another bow in their quiver."

Still, it's hardly clear whether those efforts will move votes or whether the whole tax question will be just a pawn in the much larger debate over the budget and the debt limit.

Share Facebook Twitter Google+ Email Comment More From The Government Shutdown PoliticsShutdown Diary: Hope Turns Into Wall Street WarningPoliticsWhy A Medical Device Tax Became Part Of The Fiscal FightPoliticsOn Capitol Hill, A Flurry Of Activity But Still No Deal BusinessJPMorgan To Front Customers If Federal Shutdown Drags On

More From The Government Shutdown

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Please keep your community civil. All comments must follow the NPR.org Community rules and terms of use, and will be moderated prior to posting. NPR reserves the right to use the comments we receive, in whole or in part, and to use the commenter's name and location, in any medium. See also the Terms of Use, Privacy Policy and Community FAQ.

Please enable Javascript to view the comments powered by Disqus.

FAQ: How Obamacare Affects Employers And How They're Responding

This is one of several explainers to help consumers navigate their health insurance choices under the Affordable Care Act, or as some call it, Obamacare. Click here for answers to other common questions. Have a question we missed? Send it to health@npr.org. We may use it in a future on-air or online segment.

Do employers have to do anything different under the Affordable Care Act?

Not right away. The only thing required of employers at the start is that they notify workers that the new health insurance exchanges have opened. You may have received a letter from your employer to this effect � you probably don't need to do anything.

Starting in 2015, large employers with 50 or more workers have a responsibility � but no mandate � to offer employees health coverage. If they don't, they may face fines, but only if their workers go to health insurance exchanges and have earnings low enough to qualify for federal subsidies. Stores and restaurants � less likely to offer health insurance in the past � may be most affected. The coverage rule doesn't affect workers who put in less than 30 hours a week.

There are no responsibilities for small employers with fewer than 50 workers. If they want to buy coverage for their employees, the insurance exchanges represent a new option for them in terms of where to shop. Certain employers with fewer than 25 workers are eligible for federal tax credits. To qualify, the company has to cover at least half of the premium for all of its employees, and also have average wages of less than $50,000. For details on these tax credits, see this answer sheet from the IRS.

Will my employer cut back on my insurance coverage?

A number of employers have been overhauling the health benefits they offer employees, citing rising costs.

There are two themes to what they are doing. In trying to control their own spending, employers often are shifting health costs to employees. So the average annual deductible for an individual � what consumers pay before insurance kicks in � nearly doubled in the past seven years, from $584 in 2006 to $1,135 this year, according to the Kaiser Family Foundation.

But employers aren't just making workers pay more. They're trying to make them think more about health-related expenses and behavior.

Companies such as grocer Kroger Co. pay only a fixed amount for particular drugs or procedures, giving patients incentive to shop around for the best price. IBM started giving rebates to workers who adopt healthy lifestyles. Penalizing smokers with surcharges is one of the few discriminatory measures the health act allows.

What about part-time workers?

Nothing in the Affordable Care Act says that employers have to cover part-time workers. The law defines part time as someone who works less than 30 hours a week.

Some employers that have offered part-time workers minimal coverage, such as Trader Joe's and Home Depot, have dropped it on the grounds that those workers can now find coverage through the insurance exchanges. Most workers in this situation will be pleased with the outcome. They'll likely find better coverage than what they had for less money. Although depending on the situation, some people may see their premiums go up.

Are employers reducing their workforce as a result of the Affordable Care Act?

There have been reports of employers holding back on hiring in order to stay under the 50-employee threshold that triggers health insurance responsibilities. There also have been reports of employers cutting workers' hours to below 30 per week so that they don't count as full-time. While there is anecdotal evidence of both things happening, there's no evidence that those cases have added up to a broader drag on the economy as a whole.

Will my company stop offering coverage to my spouse and dependents?

Some companies, including UPS, have decided to stop covering working spouses if they have access to coverage at their own jobs. The health law does not require employers to cover spouses, but surveys show that only a minority of companies have implemented a "spousal exclusion."

However, employers increasingly offer incentives to get spouses off their plans. They may charge workers extra if a covered spouse has access to other insurance, or they may pay bonuses when spouses are not on the company policy.

The health law requires employers who offer coverage to employees to also offer coverage to dependent children, or pay a penalty.

See other Frequently Asked Questions on the Affordable Care Act:

Understanding The Health Insurance Mandate And Penalties For Going Uninsured All About Health Insurance Exchanges And How To Shop At Them A Young Adult's Guide To New Health Insurance Choices What Retirees And Seniors Need To Know About The Affordable Care Act Where Medicaid's Reach Has Expanded � And Where It Hasn't

Additional coverage from NPR Member Stations:

California (KQED, San Francisco) California (KPCC) California (KXJZ Capital Public Radio, Sacramento) Colorado (Colorado Public Radio) Massachusetts (WBUR, Boston) Minnesota (Minnesota Public Radio) Georgia (WABE, Atlanta) New York (WNYC) Oregon (Oregon Public Broadcasting) Pennsylvania (WHYY newsworks.org) Texas (KUHF) Texas (KUT, San Antonio)

This FAQ was produced through a collaboration between NPR and Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonpartisan health-care policy research organization. The Kaiser Family Foundation is not affiliated with Kaiser Permanente.

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