City Life = Brain Damage?

posted by John Buntin

The evidence is surprisingly strong, some neuroscientists say.

Attention and self-control are particularly harmed by urban life. The best antidote seems to be a big dose of nature. In particular, humans respond well to the the rich variety of places like New York's Central Park.

In contrast, researchers say, the denuded savanna of, say, the national Mall in downtown Washington does little to soothe the mind or promote sanity.

Could this explain the occasional madness of Congress? If the incoming Obama administration wants to bring sanity to Washington, DC perhaps it should plant some trees as part of that stimulus package...

Tobacco Turns Into Porn

posted by Alan Greenblatt

The British government plans to force merchants to keep cigarettes and other tobacco products under the counter and ban their public display.

If this policy goes forward, I would be surprised not to see some U.S. jurisdiction try it out.

From the Independent:

The Health Secretary today unveiled plans to force cigarette sales "under the counter" in an attempt to cut smoking by children.

Alan Johnson also announced that the Government was taking on powers to make it more difficult for under-18s to use cigarette vending machines - and may ban them if that does not work.

The move to ban prominent displays of tobacco products and advertising at the point of sale provoked storms of protest from shopkeepers, who argue it will cost them much-needed business during the economic crisis.

Candidates Get Ideas From States

posted by Alan Greenblatt

The Washington Post devotes a sizable chunk of its front page today to comparisons of health coverage plans put out by John McCain and Barack Obama. It notes in both cases that their plans seem to be based on ideas that have been tried in "M" states.

As has been widely noted in Obama commercials, McCain's plan relies heavily on a health insurance tax credit. Recognizing that the free market approach won't work for everyone, McCain's plan relies on a dramatic expansion of state-sponsored high-risk pools.

So he is calling for a guaranteed access plan, a federal effort to share the cost of high-risk pools and dramatically expand their reach -- from fewer than 200,000 Americans in state plans today to perhaps 5 million.

...

Among the high-risk pools in 34 states, Minnesota's is the oldest, largest and, many believe, the most successful. "It just seems to work," said Doug Holtz-Eakin, senior policy adviser to McCain.

Created in a wave of health-care changes here in the late 1970s, the Minnesota Comprehensive Health Association (MCHA) had a membership of 28,000 last year, equaling nearly 7 percent of the state's uninsured population. Small as that share was, it far exceeded any other state's, according to the National Association of State Comprehensive Insurance Plans.

...

McCain has said that, under his guaranteed access plan, the federal government would cover half the cost of such pools, with the rest paid by states and the insurance industry. In the spring, Holtz-Eakin estimated that the federal share might be $7 billion or $8 billion a year. "It's going to be twice that, realistically," he said in a recent interview.

Obama's plan, of course, follows a different model -- that pursued by Massachusetts.

Lynn is one of 439,000 people here who have gained insurance since Massachusetts embarked two years ago on a path to near-universal coverage. More than half of them are paying toward it; the rest, like Lynn, get it free. How close Massachusetts can come to its goal -- and what obstacles it encounters -- is significant, because its strategies resemble much of the approach to health care that Obama has said he would pursue if elected president next week.

Obama says he would keep the familiar arrangement in which most Americans get health insurance through their jobs, as Massachusetts is doing. Yet he also favors profound -- and controversial -- changes that Massachusetts also is putting in place: Expanding government insurance programs and subsidies. Requiring employers to offer their workers coverage or face penalties if they do not. Forbidding insurance companies to reject anyone or charging more if they are sick. Creating a national health insurance exchange to help people to find and compare private insurance policies on their own.

In the most significant departure from the Democratic nominee's thinking, Massachusetts has imposed a mandate that requires most adults to carry health insurance -- and fines them if they refuse.

In the 31 months since the experiment here began, the share of working-age people without health insurance has plunged -- from 13 percent to 7 percent by one estimate -- more sharply and quickly than anyone expected, leaving Massachusetts with the lowest uninsured rate in the country. But the unexpected number of people also has translated into higher-than-expected costs. Massachusetts has been forced twice to scrounge for extra money, totaling more than $250 million this year and last, from state funds and other places.

Another Sign of Hard Times

posted by Penelope Lemov

As California goes, so goes the nation?

This time it's not leadership in some cutting-edge trend that other states are following. Rather, it's the failure to pass health care reform that would have an impact on the number of uninsured.

This week, Pennsylvania joined California (as well as Illinois and New Mexico) in debating an ambitious reform package and then blinking.

According to news stories, a Republican-led Pennsylvania Senate was put off by a weakening economy and a fear of having to raise taxes to pay the bill. Given the current economic crisis, it's an argument that even health-reform advocates understand. "Health reform at the state level," says Diana Rowland, executive director of the Kaiser Commission on Medicaid and the Uninsured, "is a very heavy lift for any state." When the economy turns down, she adds, it becomes "more difficult to accomplish and more difficult to sustain."

So far, Massachusetts -- which passed its bill in healthier economic times -- stands alone in having a health reform effort that is significantly reducing the numbered of uninsured residents in the state.

When Your Former Employer Is On Life-Support...

posted by Penelope Lemov

Talk about rocking the health care world -- at least as it pertains to retirees. General Motors, which has 100,000 salaried retirees and their dependents on its health care rolls, is dumping them and the $3.3 billion a year it costs the company to provide them with insurance.

In lieu of covering them under the GM health plan, the retirees will get an additional $300 a month tacked onto their pension payments to use toward buying health care -- $3,600 a year to buy insurance that costs a whole lot more than that. They can, however, sign up for Medicare plans starting this week, which is a month earlier than Medicare's enrollment for everyone else.

As a story in the Detroit Free Press noted, "Given costs of the Medicare drug plans, many retirees will wind up paying much more than $300 a month."

(Here's a Q&A on the changes from GM and a letter the company sent its employees.)

With other major companies -- to say nothing of states and localities -- feeling a whole lot of fiscal pressure over retiree health care coverage, it brings up the old saw about GM: Is what's good for General Motors good for the country?

A Short Reminder from the Reality Police

posted by Penelope Lemov

In case anyone needed a Medicaid reality check, there was this from Barbara Edwards, the former head of Medicaid for Ohio: States that plan to tackle the problem of the uninsured by expanding Medicaid and SCHIP programs in their states -- and there are at least a dozen of them -- should jog their short term memory.

The Bush administration, Edwards noted, has been downright hostile to such increases. States are eying Medicaid, in part because low-income adults who do not qualify for Medicaid account for more than half of U.S. residents without health insurance. (That's according to a report recently released by the AARP Public Policy Institute.)

Edwards, who is currently currently a principle with Health Management Associates,  was one of the panel members at a recent Alliance for Health Reform session on Low-Income Adults: Can Medicaid Fill the Coverage Gap? Although panel members came up with various statistics and scenarios to support a tapping into Medicaid for low-income adults, the outlook of the session was pretty negative.

A webcast of the forum is available online at kaisernetwork.org. 

Wholesome Lunches in Charm City

posted by Zach Patton

What do the following have in common: a peach straight from the orchard, a fresh tomato salad with basil and mozzarella, raw cauliflower with a dipping sauce, super-sweet corn on the cob shaved into crab soup and a vegetarian loaf with lentils, garlic, and onions?

Well, for one thing, they all sound delicious.

But there's something esle: they're all items that might be showing up on the menus this year in Baltimore's public school cafeterias.

Tony Geraci, the new top chef for Baltimore city schools (profiled in this great online Gourmet piece), hopes to rescue Baltimore's school lunches from their unhealthy past.

Lunchtime for Baltimore’s 82,000 students may never be the same. Long a place where the typical diet centered on snack foods, soda, and fried chicken in a box from the corner store, Baltimore is going Berkeley.

“Anything is possible,” says Geraci, a 51-year-old New Orleans native who came to Baltimore from New Hampshire, where he gave school lunchroom menus a major makeover and then ran a program to prepare low-income and developmentally disabled adults for careers in the culinary field. Geraci has vowed that within his first year in Charm City he will wipe out most of the frozen lunches that one teacher describes as “breaded bread with bread sauce,” and replace them with Maryland-grown farm specialties at least three days a week.

Gone are the days of rubbery chicken nuggets and fries. In their place the chef plans to offer roasted poultry and baked herbed potatoes. Pizza will now be made with whole-grain crust, and each slice will come with a garden salad and fresh fruit.

As the profile suggests, incorporating whole grains and farm-fresh vegetables will likely be more of a challenge in Baltimore than in a locavore-friendly place like Berkeley. But by the same token, healthier fare could make much more of a difference in a place where children are so unaccustomed to real food. (At lunch last week, on the first day of the new school year, two first-graders told Geraci that it was the first time they'd ever tasted a fresh peach.)

And who knows?  If Geraci is as successful as he hopes, maybe one day we'll all be trucking down to the local elementary school to grab lunch.

A Measure of Success in Massachusetts

posted by Penelope Lemov

No one thought it would be cheap. The question was, would it be effective?

And now the latest report from Massachusetts on its universal health care plan is this: two-thirds of the 600,000 or so Bay Staters who were uninsured two years ago now have coverage. Just under half of them bought their insurance through the private sector; the rest are in subsidized plans -- hence the increase in costs.

While the state is locked in a fierce battle to figure out how to pay for its success--it's bigger and sooner than expected--there is some payback. With emergency room visits down, the state reports it spent 41 percent less for uncompensated care in the first quarter of fiscal 2008 than it did in the same period in the prior year. That came to $68 million less in cash the state had to lay out.   

Just to put these numbers into some kind of perspective, a recent Web report from Health Affairs found that government programs pay for about three-quarters -- or roughly $43 billion -- of the uncompensated care bill. A chunk of that bill -- $15 billion -- is paid by state and local governments.

The Dis Side of Incentives

posted by Penelope Lemov

A few days ago, I blogged about the link between education and health, and the ideas propounded by James Heckman of the University of Chicago and Robert Kaestner of the University of Illinois at Chicago -- the need for early childhood intervention and a good education to, as Kaestner put it, "make it easier for people to obtain and process information about the causes and consequences of health.”

I'm writing more about that in my health column in the September issue of Governing.

But today I saw a report on West Virginia's Medicaid "redesign." This is the one where the state rewards those who sign a "personal responsibility" agreement ("I will do my best to stay healthy.") and punishes those who do not by restricting their access to certain health services.

For children, it means the parents have to sign. Turns out, a lot of parents did not. One year into the plan, nine out of ten West Virginia children with Medicaid have had benefits restricted.

I can't help but think about the Heckman and Kaestner theories as some sort of explanation for why parents failed to sign the agreement. (It didn't help that the state did not do a good job in  explaining the program and advising parents about what was at stake.)

Not only have West Virginia's changes resulted in limiting benefits primarily for children, they have also, according to a study by Georgetown University's Center for Children and Families, had "no discernible impact on the stated goals of improving beneficiaries' health and increasing healthy behavior."

As the report also notes, "Programs designed to change personal behaviors based on positive or negative incentives can be valuable but they are complex and are dependent on beneficiary understanding and active participation."

Getting Real in Massachusetts

posted by Penelope Lemov

The knock on Massachusetts' universal health reform  package is that it does nothing to address the root cause of unaffordable health insurance: the high price of health care.

Last week, the state stepped up to the plate.

Legislators didn't go back to the usual pitch: shrink payments to providers; cut back on health services available to beneficiaries. They wrote into law some measures that could actually help tame costs in the Bay State.

One piece of the bill goes after inefficiencies. It calls for a commission to develop uniform billing and coding standards for health care providers and insurers and it sets a statewide goal of adopting electronic health records by 2015 .

The bill also takes on the problem of primary care--fewer physicians go into the field and that pushes patients into higher-care settings for basic health care. What the Massachusetts law calls for is expanding enrollment at the UMass medical school and providing incentives for students to go into primary care specialties.

It's a start.