At the end of the summer, I had the chance to present at two town hall meetings in Washington State that were hosted by the Alzheimer’s Association of Western and Central Washington, a Voices for Better Health state partner. I was excited to explain how the dual eligible demonstration projects for integration of care for people with both Medicare and Medicaid were unfolding across the country and in Washington State. As I listened to the stories of caretakers and people living with Alzheimer’s, two phrases resonated with me and evoked powerful memories of my own family’s experience caring for a loved one with this disease.

“Take care of you,” was advice given by a man who was caring for his wife. He described things he was doing to make sure he could provide the best care to his spouse, which included attending a support group for caregivers, hiring more help at home and volunteering at the local high school to maintain a vibrant connection to his broader community. 

I thought about my father-in-law, who was one of his mother’s primary caregivers during the last few years of her life. By the time I met her, Patti’s* Alzheimer’s had progressed to the point that she could not be safe staying at home alone. While she knew some English, her primary language was Tamil. If Appa* wanted to attend an event or go to work, he needed to make sure he had someone to take care of Patti. It was impossible to find someone who both spoke Tamil and had the ability to take care of her complex health needs. He chose one or the other, depending on who was available on a given day, and how long he needed coverage.

Another speaker said that she “focused on the now” in taking care of her husband. She tried not to worry about or focus on what was going to happen down the road. She did things to enjoy the time she had now with her spouse.

Appa and his siblings spent many moments being present with Patti. In May 2011, my partner and I began planning for the arrival of our first child. Part of our preparation process was to schedule visits for grandparents to be with us and get to know their new grandchild. While my parents could fairly predictably arrange their work schedules to have time off, Appa coordinated with his siblings to have Patti’s care covered. Implicit in his planning was the understanding that the length of his visit might need to be adjusted on very short notice if Patti’s condition were to change.

A universal theme in the town halls was a message that living with and taking care of someone with Alzheimer’s is complicated and scary. So much is unknown about how and how quickly the disease will progress; so much is difficult in trying to create a safe space to function when Alzheimer’s is in your life. So much is challenging about building a bridge between the smaller world you try to create, in which your loved one is cared for and safe, and the wider community you strive to remain part of. So much is sad about asking for and accepting help without feeling like a failure.

When our daughter was three months old, we went to visit Appa and Patti at their home, out of state. While Patti had to be reminded of who we were, the unmistakable love apparent in her expression when she looked at her newest great-grandchild did not show any traces of Alzheimer’s disease. When we look at the picture of four generations of family members taken on that visit, we feel lucky to have had this time with her.

At the town meetings – and most every day – I am reminded that underneath the policy and logistical intricacies involved in designing and implementing the dual eligible demonstration projects, they are, at their heart, about improving people’s lives. And, in many instances, this includes giving people the ability to live lives that are not consumed with trying to navigate a complicated and frustrating health care system. Delivering health care that is coordinated and integrated makes it much more possible for involved family members to take care of an ailing loved one, “take care of themselves,” and feel well-supported enough to be “focused on the now.” 

* Patti is the word for grandmother, and Appa, the word for father in the Tamil language of southern India.

It’s no secret that medical device and pharmaceutical companies have had long-standing relationships with medical schools, teaching hospitals, and their faculty and clinical staff.  And although fruitful collaborations with these companies, primarily for research, should continue, some of these relationships have gone too far. 

While many schools have significantly strengthened their conflict-of-interest policies that govern these relationships, industry still brings biased information into our nation’s medical schools and teaching hospitals. These institutions are the training grounds for medical education—places that should be steeped in evidence-based clinical care and learning. One recent survey of medical schools, for example, found that up to half of medical students and residents reported receiving personal gifts from pharmaceutical companies, even in schools graded highly on the AMSA Scorecard.

Effective conflict-of-interest policies, guidelines for how industry can (or cannot) interact with an institution, are key to preventing this industry overreach. There is evidence demonstrating that COI policies at medical schools can, in fact, impact prescribing behavior. One study showed that graduates from schools with strong COI policies prescribed antidepressants more rationally than graduates with weaker or no COI policies.  

Yesterday the Pew Charitable Trusts, in partnership with an expert task force of leaders from academic medicine and other partners, including Community Catalyst, released a set of 15 best practices for medical schools and teaching hospitals to use in developing conflict-of-interest policies. These experts have set a high standard for schools and teaching hospitals, with recommendations that COI policies should include banning pharmaceutical representatives from any interaction with faculty, students or trainees to ensure affiliate hospitals and clinics are following the same policies. See a shorter version of these best practice recommendations in the December 2013 issue of the Journal of the American Medical Association. 

 Community Catalyst believes that though these recommendations are strong, they can be attained. To that end, we have created Toolkits to assist academic leaders, faculty and students in working for improvements in their institutions. Toolkits are now available on interactions with sales representatives, receipt of gifts from drug companies, samples, industry support of continuing medical education, promotional speaking, ghostwriting and COI curricula.   

Progress is being on many fronts, but setting a high bar for controlling conflicts of interest will help medical institutions play the critical leadership role that patients and students expect.

--Marcia Hams is a member of the Expert Task Force

There have been many stories in the news about plan cancellations and President Obama’s recent announcement that insurers will have the opportunity to continue selling plans they otherwise would have cancelled. While some have celebrated the President’s announcement, plan cancellations really mean that 7 million to 10 million people can now purchase better insurance plans. Plan cancellations are an indication that the weak standards of the individual health insurance market are finally getting fixed.

So did President Obama break his promise that “if you like your plan, you can keep it”? Not really. Back in 2010, insurers were allowed to keep plans that they wanted to have “grandfather status,” or carry over into the 2014 Marketplace. To keep their grandfathered status, insurers were not allowed to alter plans’ benefits or cost sharing greatly. Some plans are currently being cancelled because in 2010, insurers decided they wanted to raise premiums or reduce benefits on existing plans, or create new plans that did not meet the grandfathered rules. If the insurer changed a plan or if a consumer changed plans, this broke the grandfather status of the pre-2010 plan. When Obama said, “If you like your plan you can keep it,” this meant only if insurers choose to keep offering it.

Prior to the ACA, many consumers who signed up for coverage in the individual market thought they would be protected from high bills if they got sick or hurt. However, that was often not the case. Many of the people who were enrolled in these plans were underinsured and wouldn’t know it until something catastrophic happened and their insurance did not provide the safety net they expected. Insurers were allowed to discontinue plans, raise premiums, or cut benefits when they chose, and they could do so based on the health status of their enrollees.

Under the ACA, the individual market is finally seeing a new day. Plans are required to cover 10 areas of essential health benefits, which means they can’t skimp on coverage like maternity care or chronic disease management. Plans also cannot discriminate based on gender or pre-existing conditions, and prices prorated with age are greatly limited. People who have received plan cancellation notices can go to the Marketplace where many will find a lower-cost plan. Through the Marketplace many of those people will receive financial assistance through federal tax credits, and will get higher value for their premium dollars.

However, the issues with the Healthcare.gov portal have made it difficult for those who have had their policies cancelled to enroll in new and, usually, cheaper and better plans through the Marketplace. Because people had a hard time understanding the plan changes and accessing options, the plan cancellation issue gained traction. In response to this, President Obama recently announced consumers can renew these cancelled plans for 2014. President Obama’s ruling leaves it up to state departments of insurance to decide whether to allow insurers to keep offering non-ACA-compliant plans. Insurers can also decide whether they will continue to offer the old plans or not. President Obama’s rule gives consumers another option in the individual market—to keep their existing plan. Importantly, it also requires insurers to tell consumers the difference in benefits between their current plan and the ones offered on the Marketplace. This transparency shows consumers the risks of where their current plans fall short.

Despite this change, the best coverage option for most consumers is still to shop for a plan in the Marketplace, since these plans are higher value and may be more affordable. Importantly, consumers who stick with their existing plans will not be eligible for tax credits to lower the cost of premiums or for cost-sharing assistance.

The future of this issue is untold: If Healthcare.gov technology issues are not resolved soon, consumers whose plans have been cancelled face obstacles to enrollment in new plans on the Marketplace. If not, this issue may continue to see interest in Congress where there are currently a number of bills moving. A bill introduced by Congressman Upton (R-MI) allows insurers to keep selling plans that are not compliant with ACA regulations and allows any plan insurers sell to satisfy the individual mandate requirement. Senator Udall (D-CO) has introduced a bill that would allow people in the individual insurance market to keep their current plan for up to two more years.

People in the individual market now have more options: they can keep their current plan, if their insurer chooses to continue to offer it, or choose from better options on the Marketplace. Either way, information is a consumer’s strongest weapon. You wouldn’t buy auto insurance that doesn’t cover accidents, so why buy insurance that doesn’t cover all your medical needs?

-- Sarah Gordon, Private Insurance Intern

Recently, Community Catalyst’s Voices for Better Health program released a new video featuring the story of a mother and daughter – Sally and Edna – whose lives have been dramatically improved in the last few years. These improvements came about after Sally enrolled in an integrated care system – Commonwealth Care Alliance – which provided her with care designed especially for frail older adults.

These models of care emerged from the hard work of geriatrics researchers and practitioners, many of whom have been supported over the past two decades by the John A. Hartford Foundation. This dynamic group of Hartford Foundation grantees, with expertise in geriatric medicine, nursing and social work, has developed an expanding knowledge base that is critical to how our health care system treats the growing number of older patients. Now the Hartford Foundation is putting this knowledge to work at the practice, delivery and policy levels. Recognizing that we desperately need health care institutions and systems that deliver better outcomes and manage costs effectively, the foundation has just launched the Change AGEnts Initiative. This initiative is an interdisciplinary effort to leverage the Foundation’s powerful network, help its scholars and grantees learn from and support one another, and work directly on changes in practice and service delivery that improve the health of older Americans. The Hartford Foundation has awarded a multi-year $5 million grant to the Gerontological Society of America (GSA) to launch and develop the Change AGEnts Initiative.

The Initiative will have two main components. First, the Change AGEnts community will provide Hartford Foundation scholars, fellows, mentors, advisors and grantees with support and training to mobilize for action. Second, the Change AGEnts networks – small, interdisciplinary groups – will focus on specific areas of vital health care concerns. The first two such networks are focused on caregiving for people with dementia, and patient-centered medical homes.

Community Catalyst’s Voices for Better Health program fits closely with the aims of the Change AGEnts Initiative, as the program is working to improve the lives of older adults with both Medicare and Medicaid, sometimes referred to as “dual eligibles.” A recent grant from the Hartford Foundation to Voices for Better Health enables us to mobilize geriatrics health care leaders who will work closely with consumer advocates, shaping the development of new integrated care systems serving dual eligibles and infusing them with geriatrics know-how and best practices. The diverse and expert group of professionals joining the Change AGEnts Initiative is ready-made for this work, and we look forward to working with many of them in the months and years to come.

Congratulations to the good folks at the Hartford Foundation on the launch of this exciting new initiative. We are proud to be adding our “Voices” to the mission of the Change AGEnts!

Employment and income are among the social and economic factors that impact individual and community health. Studies have linked unemployment to shortened lifespans, increased mental health problems, and other health issues. But we don’t need studies to tell us what is obvious – having a steady job means having a steady income and perhaps benefits like health insurance, which mean better health for individuals and families. Finding solutions to chronic unemployment is one way to improve the health of communities.

A big contributor to chronic unemployment is a history of incarceration. Job applicants who have been imprisoned are usually screened out by questions about criminal history on the initial application, no matter how long ago their incarceration occurred, and whether or not the crime committed has any relevance to the available job. Because African Americans and Latinos are arrested, convicted and incarcerated at higher rates than white people, employment practices that discriminate against ex-offenders contribute to the nation’s racial jobs disparity – the disparity in employment between white people and people of color. In the United States, the unemployment rate for African Americans is double the unemployment rate for white people, and for Latinos the unemployment rate is about 50 percent higher than it is for whites. Disproportionate incarceration of African Americans and Latinos significantly contributes to these higher unemployment rates.

Nowhere is the racial jobs disparity starker than in Minnesota, which has the highest racial jobs gap in the United States. The Twin Cities has the biggest racial jobs gap of any metropolitan region in the nation, with African-Americans three times more likely to be unemployed than whites, regardless of income and education. The TakeAction Minnesota Education Fund, an organization committed to social, racial, and economic justice, is tackling this jobs disparity head on.

Through the Roadmaps to Health Community Grant Program, the TakeAction Minnesota Education Fund led a campaign for “Ban the Box” policies, which would prevent employers from asking job applicants about their criminal backgrounds on an initial employment application. Asking applicants about their criminal records, which is standard among employers in all but three states, significantly contributes to the high unemployment rate among people who have been in prison. TakeAction was successful in 2013 in passing statewide Ban the Box legislation, and since then they have been working to convince Minnesota employers to voluntarily comply with the law. Working with business prior to the law taking effect on January 1 may help avoid enforcement problems when the law does take effect. In particular TakeAction’s sites have been set on the Target Corporation, a Minnesota-grown company and the nation’s second largest retailer.

Even before the Ban the Box legislation passed, TakeAction worked for three years to convince Target to take leadership on providing fair employment opportunities to people who had been incarcerated.  TakeAction has mobilized formerly incarcerated community members affected by chronic unemployment and used a variety of tactics, including protests at Target’s corporate headquarters, shareholder activism, and filing legal complaints against the company. All of their efforts to pass Ban the Box legislation and to engage Target were led by ex-offenders who have struggled for years to find work. TakeAction trained ex-offenders to become effective advocates, to tell their stories in a way that moved policymakers, business executives, and the public.

After the Ban the Box law was signed earlier this year, TakeAction also began to talk directly with top Target executives. On October 24, 2013 before an overflowing room of 400 people, TakeAction’s efforts bore real fruit. The Target Corporation committed to financially supporting a free legal clinic for people with criminal histories and to supporting hiring practices that remove barriers to employment. Most significantly, Target agreed to remove the criminal history box from its job applications – across the United States! 

TakeAction’s approach is an excellent example of how a campaign led by those directly impacted can create meaningful change on first the state and then the national level on an issue like employment. Congratulations to TakeAction Minnesota on this important national victory! 

Community Catalyst manages the Roadmaps to Health Community Grants program, funded by the Robert Wood Johnson Foundation. The program is an important component of the County Health Rankings & Roadmaps program and supports two-year state and local efforts among local coalitions of community organizations, policymakers, business, education, health care, and public health professionals who are working to create positive policy changes that address the social and economic factors that impact the health of people in their community.