HealthyCal.org

As the June 15 budget deadline approaches, rumors that the Legislature will send yet another spending cap to the ballot abound. These rumors are somewhat surprising, since voters haven’t even had the chance to weigh in on the last cap sent to the ballot – ACA 4 of 2010, approved as part of last October’s budget agreement – and the fact that California’s existing cap is arguably one of the toughest in the nation. Details of what may, or may not, be under consideration are well hidden under the cone of silence.

Some key points to consider when evaluating the impact of any such proposal include:

* The choice of a base year. As a widely displayed chart from the Governor’s May Revision shows, General Fund spending would be at a multi-decade low under the budget plan currently under consideration. Thus, locking in spending at the 2011-12 level, or any year in the near future when scarce resources are anticipated to continue, would prevent restoration of recent cuts and prevent the state from investing in public services and institutions that are essential to a competitive future.

* The choice of an inflation factor. As we’ve written before, tying spending to the Consumer Price Index (CPI) is incompatible with the Proposition 98 school spending guarantee, which in normal years – “test 2” – increases based on per capita personal income growth. Per capita personal income typically increases at a significantly greater rate than the CPI. Thus, tying spending to the CPI turns education funding into a budgetary “Pac Man.” Use of the CPI is also problematic with respect to health care. Nationally and here in California, health care costs typically rise more rapidly than the CPI.

* Whether it is really a cap masking as a budget reserve. Proposition 1A of 2009 and ACA 4 of 2010 both functioned as spending limits, but masqueraded as budget reserves. Both were designed to use complicated statistical formulas – linear regression – to prevent revenue growth that typically accompanies an economic recovery from being used to restore budget cuts made during an economic downturn.

* Whether it is really a new infrastructure funding program masquerading as a spending limit. Both Proposition 1A and ACA 4 created new funding streams for infrastructure spending, masquerading as spending “restraint.” Rumors currently floating around the Capitol suggest that this year’s version may include similar provisions. The problem with this is two-fold. First, money ostensibly destined for a budget reserve may not be there when it’s needed, having been spent, rather than deposited in a savings account, or used to pay down debt that might otherwise be paid from the General Fund. Second, such provisions embody a bias towards investment in “bricks and mortar,” rather than the state’s people, historically California’s greatest asset. While ACA 4, which is slated for the 2012 primary ballot, has been touted as a tool to pay down the state’s “wall of debt,” the infrastructure loophole will likely limit the measure’s impact on debt and minimize accumulation of a budget reserve.

* The voters have spoken. Some spending cap proponents also opposed extending the temporary taxes noting that the voters have spoken. By that standard, a spending cap is a “no go” – voters have spoken twice in six years, defeating former Governor Schwarzenegger’s Proposition 76 in November 2005 and Proposition 1A in 2009. As public opinion research suggests, no on Proposition 1A voters supported a balanced approach to balancing the budget, but viewed a permanent straitjacket on state spending to be too large a penalty to pay for a minimal extension of temporary taxes.

California’s recurring budget crisis since enactment of the “Gann Limit” in 1979 should cause anyone who thinks that constitutional spending limits prevent budget problems to take a second thought. As Rudolph Penner, the former head of the Congressional Budget Office, once noted, “The process isn’t the problem; the problem is the problem.” The only realistic solution to California’s budget problem is a balanced one that closes ineffective tax loopholes and provides the revenues necessary to support our core public services and institutions.

Jean Ross is executive director of the California Budget Project.

By Sue LaVaccare

“The eyebrow goes up and it feels like a judgment when I tell them I am attracted to girls. They look confused.”

“The default is always that you are straight, and you have to correct them. It is never an open ended-question. They don’t know what to say when you’re having sex with a woman. That discredits my lifestyle and the risks involved in all types of sexual activity.”

These are remarks from two young women in a recent focus group in Los Angeles County about the experiences of lesbian, gay, bisexual and transgender (LGBT) patients with health providers. Their comments underscore a pervasive but often ignored problem within health care for LGBT populations – a problem that is coming to light more and more through new research and legislation.

LGBT patients, according to a March report by the Institute of Medicine, have unique healthcare needs and concerns – just like other minorities. The UCLA Center for Health Policy Research also revealed in March that older LGBT adults in California have higher rates of chronic disease, mental distress and isolation than heterosexuals.

Why? Because too often LGBT patients receive substandard treatment from medical staff – or skip care altogether, fearing judgment, ignorant questions, blank stares and irrelevant recommendations.

The answer is health professionals who are more knowledgeable about and sensitive to the specific needs of LGBT patients, approaching each patient as an individual, without assumption, judgment or ignorance about what they need or are concerned about. This concept isn’t new. In fact, throughout health care there is a movement to increase “cultural competency”: the degree to which patients and providers can communicate without cultural differences hindering the experience.

And it’s not just political correctness; when health professionals don’t understand or relate to their patients, there is a greater chance for misdiagnoses, lack of diagnoses, improper follow-up and unnecessary procedures – all of which dramatically impact the quality and cost of care. And when people who need care avoid it – because of bad experiences – their outcomes worsen, ultimately requiring more expensive care later on.

The problem, however, is that cultural competency is often thought of as a language or ethnic issue – and only applicable for doctors and nurses. Such shortsightedness discounts the impact that various other medical workers have on a patient’s overall experience.

For example, allied health professionals make up 60 percent of all health workers, including positions that greet and interview patients, check their blood pressure, draw blood, take x-rays, and perform physical therapy. Since California must fill millions of allied health positions in the years to come, how we train these workers is a key opportunity to ensure more effective, culturally competent care.

A huge part of this skill is simply better communications. Workers must engage patients without judgment or assumption, and body language and facial expressions – whether showing confusion or disapproval – are just as powerful as words. But language itself is important too, including knowing the latest terms LGBT patients use for partners, sexual activity, etc.

These can’t be casual, occasional exercises. Teaching these skills and providing expertise specific to LGBT populations must be integrated into mandatory trainings for health workers. That’s why local providers participating in the Los Angeles County Lesbian and Bisexual Women’s Health Collaborative are developing a curriculum for new trainings.

Meanwhile, health providers and training programs must expand their definition of cultural competency – and the types of workers who are trained. And it’s time that the Office of Multicultural Health incorporate LGBT patients and concerns in their work.

More importantly, it’s time to lower the eyebrows of judgment and uncertainty if we truly want to the lower health disparities among LGBT patients – and the overall cost of health care.

Sue LaVaccare, M.A., is co-founder and Steering Committee Member of the Los Angeles County Lesbian and bisexual Women’s Health Collaborative..

By Julia Brownley, Chairwoman of the Assembly Committee on Education

California faces a devastating future because too many students are not graduating or are in remediation classes at college, especially children of color and lower income students. Too many kids are disengaged and don’t care if they drop out, stay in school or just get by.

We also know that students need help to address their health and well-being because children who are hungry, sick, unfit, stressed or who feel disconnected from school will not perform or be motivated to learn. That is why we need to make schools more relevant by supporting legislation that links learning with health.

Yesterday, as chairwoman of the Assembly Committee on Education, I had the pleasure of hearing information gathered by The California Healthy Students Project, which linked student health to student academic success, at a joint oversight hearing by the Assembly Committees on Education and Health.

During the hearing, participants challenged the two committees to work together on implementing strategic, cost-effective reforms across health, education, juvenile justice and nutrition sectors so that students are ready to learn and meet high academic expectations.

As was pointed out by State Superintendent of Public Instruction Tom Torlakson during the hearing, student success requires more than great teachers and challenging curriculum. Students also need to be healthy–physically and emotionally – and feel safe on campus so they can attend school ready to learn and thrive.

The research, which was commissioned by The California Endowment, The James Irvine Foundation, and the William and Flora Hewlett Foundation, confirms what many education and health leaders have long suspected: academic success isn’t just about academics – it’s about safe campuses, good nutrition, mental and physical health and meaningful opportunities. The research indicates that reforms in education, health and safety for students must go hand-in-hand for students to succeed. The opposite is also true; there is a powerful connection between poor health and academic failure.

Research found that health problems and inadequate school environments affect students’ attendance, grades and ability to learn. Specifically:

• Students who miss school or attend while ill don’t achieve as well as others. For example, students with asthma miss 2-18 school days a year, a condition correlated with lower test scores and poorer academic performance;
• Students who regularly eatt breakfast have 50 percent higher test scores on standardized math tests, and have nearly half the absentee rates of students who don’t eat breakfast;
• Students given access to school-based mental health centers showed a 30 percent decrease in absences and failures, and a 95 percent decrease in disciplinary referrals; and
• Students who feel isolated and uninvolved at school are less motivated to achieve and more likely to engage in risky behaviors, including drug and alcohol abuse.

The bottom line is that students cannot learn well if they are sick, hungry, troubled, physically unfit, afraid or feel isolated and alone.

The California Healthy Students Research Project also highlights the disproportionate impact these issues have on lower-income students and students of color who make up the majority of California youth. The environmental conditions that support regular attendance and academic achievement—including safety, caring relationships, high expectations and meaningful participation—decrease in proportion to the percentage of students at a school who are living in poverty, undermining the American dream for major segments of California youth.

Anne Stanton, Youth Program Director of The James Irvine Foundation, in a statement issued after the hearing, pointed out that student health is critical to our youth’s ability to reach their potential—and to advance California’s economic and cultural prosperity. California needs to couple commitment to education reform with strategic investments in the safety and well-being of our young people to close the achievement gap, prepare for successful futures and maintain California’s place as a leader in the global economy.

As state leaders, we must take immediate action and turn this research into policy and practice at the state, local, district and school levels. By better coordinating the activities of state and local government agencies, and community organizations, California can more efficiently use existing resources that support student health, wellness and safety. And, we don’t need to look far to find models for reform; successes are already taking place in communities throughout California. For example, the City of Sacramento created Student Attendance Centers through a partnership among law enforcement, community based organizations and the Sacramento Unified School District. This program has increased student attendance by connecting truant students with comprehensive services to address the problems that are keeping them from going to school. Services include drug treatment, family counseling, tutoring and mentoring.

I agree with the statement issued by The Endowment President and CEO, Dr. Robert K. Ross. Policymakers at both the state and local level need to use these findings and recommendations as a starting point so that every student has an equal opportunity to realize academic success. Health happens in our communities and only through the support of legislative reform and changes in practice in our schools can we achieve positive health and academic outcomes for all children.

Although some of these health and well-being issues are the result of community and family challenges, schools can do things to address them and help students learn better. Solutions range from partnerships with community resources and better coordination of services, to changing school environments to be more supportive of students and their needs, and to better empowering students and families to be part of the solution.

State and local governments and community partners must all do their part by working together and with schools to improve academic results, and Wednesday’s hearing, along with the research produced by The California Healthy Students Project, has brought us one step closer to achieving those goals.

To view the study, visit http://www.childrennow.org/index.php/learn/beingwelllearningwell.

By Kate Karpilow

“Everybody is exhausted just trying to hang on to what exists, with attacks from every direction.”

That’s a quote from a leading child care advocate in California . . . a very tired advocate.

After months of budget battles, California’s child care system was ultimately pared down with a sharp scalpel, as were most health and social service programs.

For child care it was a triple whammy – sharp reductions in reimbursement rates for licensed and unlicensed providers, increased fees and more restrictive income eligibility for parents, and a 15 percent across-the-board cut to all preschool and child care programs (excluding two programs that support parents in welfare-to-work).

“Everyone is shell-shocked” is how another child care champion summed up the field’s stunned reaction to the cuts.

While optimists might hope a new system will rise Phoenix-like from the ashes, it’s hard to imagine demoralized advocates being up to the task of envisioning a new future.

They are plumb tuckered out.

Lost, then, is not only a half billion dollars in resources but also, quite possibly, the enthusiasm and vision of the once vibrant community of activists.

Until recently, California had been a leader in providing child care services. State support began in 1943 when child care centers were opened for our Rosie the Riveters contributing to the war effort.

Following WWII, state leaders kept the centers open, recognizing that many women would continue to work.

In 1978, then-Governor Jerry Brown’s Administration – Brown 1.0 – developed the state’s first – and only – child care master plan.

But that plan was neither comprehensive enough to sustain three decades of growth, nor has it been updated to meet the needs of a state with more people, more single-parent families, more women in the work force, a greater proportion of poor families, and far greater diversity.

Over ten years ago, former state Senator Marta Escutia carried legislation to create a child care master plan. But it was vetoed, twice.

Without a vision, without a plan, the state’s child care system has been pieced together to capture federal funds, to provide child care to parents required to work under federal and state welfare reform, and to implement various pilot projects and administrative structures.

No wonder the go-to analogy for California’s child care system is the patchwork quilt.

So we have a problem – parents that work (or want to) and a fraying, pieced-together system of child care not up to the job of providing reliable, quality and available services.

“Things have to evolve,” said one of the tired advocates I interviewed, “and it’s [going to be] a very unsettling discussion, particularly when the field is on the defensive.”

“It would be great to see some legislative leadership in this area,” she added.

Or perhaps, gubernatorial leadership – an updated child care master plan as an initiative of Brown 2.0.

No doubt it’s hard to think about an ideal system of care in the midst of cuts and unpredictable revenue streams, but that might be the best use of limited time and energy.

And if Governor Brown succeeds in convincing the cranky California electorate that maintaining existing taxes is in their best interest, child care advocates – and the Governor – need to be ready with a vision of how quality child care can be structured and funded.

We can’t depend on a Phoenix to rise above the ashes, but we can, even when we are tired and demoralized, work together to create a child care master plan to guide decisions and investments for child care services.

Because more frayed than the system and more frazzled than the advocates are working parents who, day after day, must piece together care for the children they love.

Kate Karpilow is director of the California Center for Research on Women and Families.

By Dr. Bill Releford

As California continues toward implementation of federal health care reform, efforts to contain health care costs have become increasingly critical, and all parties to the health care delivery system share responsibility.

California health insurers, however, have implemented many procedures and protocols under the guise of cost containment that threaten the doctor-patient relationship and interfere with effective patient care by denying or delaying patient treatment.

These practices carry innocuous-sounding names, such as “prior-” or “pre-authorization,” “pre-approval,” or “step edits,” but the impact can be anything but innocuous.

Prior- and pre-authorization policies – when an insurer requires a doctor to obtain authorization from the insurance carrier before the carrier will agree to cover the cost of medication or treatment – deliver costly bureaucratic hassles that take a physician’s time and attention away from patient care. The fact that each health plan has its own distinct form only compounds the problem and adds to the time physicians must spend navigating the managed care maze in order to get patients access to the treatments they need.

Physicians can spend up to 20 hours per week on average just dealing with pre-authorization requests, and studies have shown the costs to physicians can reach $23.2 to $31 billion a year. Pharmacists also find prior authorization time consuming, spending an average of 4.6 hours a week on requests.

The American Medical Association recently released a membership survey on prior authorization which found that 69% of physicians typically wait several days to receive preauthorization from an insurer for drugs, while one in ten wait more than a week. Additionally, 67% of physicians reported that it is difficult to determine which drugs require prior authorization by insurers.

A recent survey of pharmacists found that 61% of pharmacists knew of an incident when prior-authorization requirements adversely affected patient care.

The problem is even more acute in minority and low-income communities, who are often in a more vulnerable position when it comes to dealing with the health side effects and additional financial costs of a delayed treatment process.

African-American communities in California, for example, consistently lack access to medical care, receive lower quality treatment, and must increasingly battle with health insurers intent on denying them the newest, most effective medications. The result of this unequal treatment is a large-scale health disparity that threatens the well-being of the African-American community.

African-Americans suffer higher rates of chronic ailments such as diabetes, cancer and heart disease than their Caucasian counterparts. African American adults are more than twice as likely as Caucasians adults to be diagnosed with diabetes or suffer a stroke. The Agency for Healthcare Research and Quality found that, for three quarters of health care quality “core measures,” African Americans received lower quality care than Caucasians.

For all California communities, but these at-risk communities in particular, the unnecessary delays that the prior authorization process creates can mean shorter, less productive lives for patients.

California needs common-sense solutions to ensure that patients will not continue to needlessly suffer because insurers have implemented short-sighted, cost-cutting measures that limit the availability of treatments.

Dr. Bill Releford is the founder and CEO of the Black Barbershop Health Outreach Program based in Los Angeles, California.

By Kent Zelas

Public health expert Dr. Anthony Iton says that if you give him your address, he can tell you how long you’re likely to live. His prediction isn’t based simply on homicide rates or disease prevalence. It’s based on the stress of living in neighborhoods that aren’t safe, where, for instance, children avoid playgrounds for fear of stray bullets and adults stay home at night for fear of being assaulted.

Iton, the California Endowment’s senior vice president for Healthy Communities, was addressing an audience of police chiefs, who learned from his presentation that the community conditions that alarm public health officials are sometimes the same conditions that boost crime rates.

It was just one example of common ground among public health and police officials underscored by an executive session convened by Director Bernard Melekian, former Pasadena (CA) Police Chief, who now leads the Office of Community Oriented Policing Services in the U.S. Department of Justice. Melekian has made it a priority to hold these types of discussions as a way to identify new ideas and approaches for more effective community policing strategies.

At the session, which was co-sponsored by The California Endowment and the Center for Court Innovation, police chiefs from across the country, along with social policy experts and public health officials, explored ways to partner to reduce crime, not just as a matter of justice and public safety, but as a public health priority.

The discussion highlighted the common ground between the approaches used by public health officials and police. For example, both respect data and track success by the numbers, whether it’s the rate of assaults or the spread of a flu epidemic. As Ruben Gonzales, Jr., of the Center for the Study of Social Policy said, “Sometimes it’s just semantics that separates the approaches.”

Both also use mapping to chart the “outbreaks” they seek to control. In fact, the location of health and crime outbreaks often overlap as Iton illustrated by comparing maps of violent crime hot spots to geographic concentrations of stress-related killers like heart disease, high blood pressure and cancer.

For even though overall crime rates may decline, they stay higher in areas where a cycle of poverty and lack of community resources leave few positive choices. And even in areas where crime has dipped, said Ron Davis, Police Chief in East Palo Alto, “the fear is still high. Fear may have more of an impact on stress than actual crime rates,” he added.

A public health approach to policing may promise better results in neighborhoods where youth violence is the highest and life expectancy is the shortest. An essential first step in a public health approach is sharing information.

In Milwaukee, a Homicide Review Commission brings together not only law officers investigating a case, but a range of representatives, including community service providers, health officials, community organizers and members of the faith community. “You get a different perspective from each level of these reviews,” she says. By sharing information, participants not only crack individual cases “much as a team of physicians can diagnose and treat patients more effectively by sharing knowledge” but they also identify system-wide weaknesses and recommend changes. “They know our goal is to develop prevention, suppression and intervention strategies,” said Dr. Mallory O’Brien, who has led the commission since supervising its launch in 2004.

The commission makes recommendations about ways to break the cycle of violent crimes in particular neighborhoods. As a recent example, a study of gun violence showed only a short time between a gun purchase and its use in a crime, and that a high percentage of those guns were bought by young black females. In response, a prevention campaign was launched last year in neighborhood beauty parlors, aimed at discouraging young women from buying guns for their men.

Another proactive program that employs a public health model is the California Safe Communities Partnership (also known as CeaseFire) which seeks to intercept crime “carriers,” the small minority of troubled youth that can create a majority of gang violence. Working with the support of the faith-based community and employment and social service agencies, authorities and community leaders meet with gang-involved youth to encourage them “through both moral appeals and threats of serious law enforcement consequences” to stop violence. In this way, CeaseFire works to identify and defuse potentially violent situations before they occur. In Stockton, Calif., the program is credited with reducing gang-related homicides by more than 75 percent, while Salinas has, in a year, seen half the number of shootings and an 80 percent drop in homicides. Similar success has been seen in Boston, Chicago, Cincinnati and Indianapolis.

“If we’re going to work together, when we work with public health, it forces us to be proactive,” said Madison (Wis.) Police Chief Noble Wray. But, he added, while “reactive” crime-fighting—police cracking down on perpetrators—is something policymakers will pay for, getting the funding for proactive policing can be a tough sell.

That was the issue in Milwaukee when the Homicide Review Commission launched in 2004. “We knew the dollars were drying up,” said O’Brien, “so we wanted to focus our investments on identifiable risks.” The result: The districts where the commission operated saw a 52 percent decrease in homicides while others saw only a 9 percent decline. But with the high cost to the public of criminal trials and incarceration, even a small reduction in crime can offset the costs of the public health approach.

The emphasis that police, politicians and the public put on crime rates is one key difference between law enforcement and public health: While public health officials are rarely held accountable for an epidemic of disease, police are routinely blamed for an outbreak of crime.

The preventive approach is “a much more effective form of policing,” said Joseph Brann, the former Hayward (Calif.) police chief and founding director of the COPS Office. “Organizations that are sincerely committed to it are able to reduce staff and crime rates where people have the guts to do it.”

Another challenge lies in getting communities in crisis to trust the police and vice versa. But here, too, the public health approach may offer an advantage. Said Thomas R. Simon of the CDC’s Division of Violence Prevention: “When you think of violence as a public health problem and focus on stopping violence before it starts, you can get more people to the table.”

Long Beach (CA) Police Chief Jim McDonnell agreed: “If you have a tendency to look at crime from a public health standpoint, it takes away some of the demonization away from the people who commit that behavior.” That, he said, is the “first step in making headway with the community. The public health model changes the conversation.”

By Micah Weinberg

Today the California Assembly Health Committee will hold a hearing on a bill that would allow state regulators to reject health insurance rate increases deemed excessive or discriminatory. This hearing will come just six days after the first board meeting of the California Health Benefit Exchange. Many hope that the Exchange will take the lead in holding insurance rate increases down through actively negotiating with insurers. Can active negotiation work in tandem with rate regulation?

Mike Russo, health care advocate and staff attorney for CALPIRG, which is a sponsor of the rate regulation bill, believes it can. In an issue brief, he writes that active purchasing and rate regulation, “combine and complement each other to deliver even better value for consumers.” He further points out that “the large majority of Californians will not get their coverage through the Exchange, meaning the Exchange’s negotiating power will not help them.”

Jon Kingsdale, who ran the insurance exchange for the state of Massachusetts offers note of caution. He uses the analogy of running a supermarket “It’s as if Safeway were simultaneously capping what Del Monte could charge anyone for pineapples, and also trying to work with Del Monte to present, promote and sell their produce on its shelves at the best rates possible.”

There may be tension, therefore, to the extent that there is confusion over the different roles of the state. Most of the plans offered through the Exchange will be regulated not by the independently elected Insurance Commissioner but by Department of Managed Health Care. The Director of this Department reports to the Governor whose Secretary of Health and Human Services also serves on the Exchange Board.

As the Administration sorts through its priorities in regard to insurance sale, on the one hand, and regulation, on the other, it will want to learn from the past including the state’s experience with its ultimately unsuccessful small group purchasing pool, PacAdvantage. This experience suggests first that setting up an exchange is a difficult business and second that it is, in fact, a business. It’s a very different undertaking than traditional government activities such as providing a social safety net or regulating private industry, and it’s worth thinking very seriously about how it intersects with them.

There are many unanswered questions in this regard. If the state negotiates a rate with insurers, how could it deem that rate to be unfair? But if the exchange is effectively exempt from rate regulation, how is that fair to the rest of the market? The plain truth of the matter is that no one quite understands exactly how all of the new pieces created by federal reform will fit together, what kind of incentives they will create, and what kind of outcomes we can expect. All we know for certain is that the new exchanges will be operating within a vastly different legal and regulatory structure than past exchanges.

For example, Russo’s piece states that the Exchange’s negotiating power will not help people outside of this marketplace, but it’s not entirely clear if this is true. In order for a product to be offered through the Exchange, it must be designated as a “qualified health plan.” For a plan to be “qualified,” the health insurer must agree “to charge the same premium rate … without regard to whether the plan is offered through an Exchange or … offered directly from the issuer or through an agent.” So to the extent that the Exchange is able to negotiate a better price for a plan that is available in the wider market, this price will be lower for everyone, not just Exchange enrollees. This is one of the many seemly subtle nuances of the law that may nevertheless have far-reaching implications.

Conversations about healthcare reform do not tend to be ones that are heavy on subtle nuance. The success of this endeavor, though, is far too important for millions of Californians for us to give these issues the attention they deserve. Since the California Health Benefit Exchange is the linchpin of federal reform, legislators should think very carefully before taking any actions, such as passing a rate regulation bill, that might undermine its role or otherwise complicate its activities.

Micah Weinberg, PhD is a Senior Research Fellow, Health Policy Program, with the New America Foundation.

By Bruce Chernof, M.D.

Last month marked the one-year anniversary of the Patient Protection and Affordable Care
Act (ACA). Much has happened in the past 12 months to get the new health law up and
running and positive results – especially for America’s seniors – are beginning to show.

Nearly 4 million Medicare beneficiaries are receiving help with prescription drug costs
and over 150,000 have received a free annual wellness visit. As America’s health care
system starts to find a better balance between treatment and wellness, the wheels of
change towards a more person-centered, cost-efficient system will continue to gather
momentum.

Nowhere is this clearer than in the president’s continued support of the Community
Living Assistance and Supportive Services (CLASS) plan. The Office of CLASS opened
its doors under the leadership of Assistant Secretary Kathy Greenlee and is housed in the
Administration on Aging.

CLASS represents a paradigm shift in how Americans can
plan for their needs as they grow older while helping to decrease reliance on public
programs that are centered on poverty. CLASS is projected to decrease Medicaid costs
by roughly $2 billion at the federal level alone with additional savings to states as well.

CLASS provides an important incremental step to re-imagining the system most of us
will need, promoting independence in a world where we all live longer than we think and
likely face physical challenges.

While implementing CLASS will require modifications
to what is outlined in the law, Secretary Kathleen Sebelius has indicated that she will
exercise the full authority provided to her in the statute to ensure a future of solid
protections for people who will need assistance, while strengthening the financial
viability of the program.

As we look to its launch in 2012, the focus will begin to shift to
raising public awareness about future needs, promoting the benefits of CLASS with
employers, and addressing important questions about premiums and earning thresholds.

Another milestone in this first year of health reform is the establishment of the Federal
Coordinated Health Care Office (CHCO). Americans who qualify for both Medicare and
Medicaid are often among the sickest and most vulnerable users of the health care
system, and these two important programs have never worked well together to address
their needs in a coordinated fashion.

Under the leadership of Melanie Bella, CHCO has
already developed a clear list of existing regulatory barriers that they intend to resolve.
CHCO has also partnered with the Center for Medicare and Medicaid Innovation
(CMMI), making up to $15 million available in planning funds to states in order to jump
start the implementation of new models serving dually eligible individuals.

CMMI has
the broader responsibility of testing and studying the most promising models of payment
and service delivery. Since its launch, the Center has engaged a wide variety of
stakeholders by holding two national Open Door Forum Calls, five in-person listening
sessions in locations throughout the country, five Regional Listening Session Calls, and
participating in the December 2010 Health Affairs convening.

New grants and programs made available through ACA will also help people navigate
health and long-term care programs. In September 2010, the Administration on Aging
and CMS announced $68 million in grants to support community living for seniors and
individuals with disabilities. These funds will help older people and their families
navigate the myriad of options for accessing supports in the community that allow
individuals to remain in their homes. This is particularly critical when older Americans
are seeking to safely transition back to their homes and communities after a hospital or
nursing home stay.

We’ve come a long way, and there is still much to do to transform the way health care
and supportive services are designed and delivered for older people and their families.
The goal is for person-centered and cost-effective care built in a way that services work
together, not operate in their own silos. The sum must be greater than the parts if we are
to have the person-centered system we all want and expect. Ultimately, we don’t have to
grow old alone or in institutions. With a better system, we can spend our later years in
supportive communities and living in the ways we want: healthy, independent and
maintaining a strong sense of identity with age.

Bruce Chernof, MD, is president and CEO of The SCAN Foundation.