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Severe Shortage Of Home Health Workers Robs Thousands Of Proper Care

Acute shortages of home health aides and nursing assistants are cropping up across the country, threatening care for people with serious disabilities and vulnerable older adults.

In Minnesota and Wisconsin, nursing homes have denied admission to thousands of patients over the past year because they lack essential staff, according to local long-term care associations.

In New York, patients living in rural areas have been injured, soiled themselves and gone without meals because paid caregivers aren’t available, according to testimony provided to the state Assembly’s health committee in February.

In Illinois, the independence of people with severe developmental disabilities is being compromised, as agencies experience staff shortages of up to 30 percent, according to a court monitor overseeing a federal consent decree.

[caption id="attachment_723078" align="alignright" width="370"] Renzo Viscardi (center), pictured with his parents Anthony Viscardi and Cheryl Dougan, relies on round-the-clock care from home health aides. (Courtesy of Cheryl Dougan)[/caption]

The emerging crisis is driven by low wages — around $10 an hour, mostly funded by state Medicaid programs — and a shrinking pool of workers willing to perform this physically and emotionally demanding work: helping people get in and out of bed, go to the bathroom, shower, eat, participate in activities, and often dealing with challenging behaviors.

It portends even worse difficulties to come, as America’s senior citizen population swells to 88 million people in 2050, up from 48 million currently, and requires more assistance with chronic health conditions and disabilities, experts warn.

“If we don’t turn this around, things are only going to get worse” said Dr. David Gifford, senior vice president of quality and regulatory affairs for the American Health Care Association, which represents nursing homes across the U.S.

“For me, as a parent, the instability of this system is terrifying,” said Cheryl Dougan of Bethlehem, Pa., whose profoundly disabled son, Renzo, suffered cardiac arrest nearly 19 years ago at age 14 and receives round-the-clock care from paid caregivers.

Rising Demand, Stagnant Wages

For years, experts have predicted that demand for services from a rapidly aging population would outstrip the capacity of the “direct care” workforce: personal care aides, home health aides and nursing assistants.

The U.S. Bureau of Labor Statistics estimates an additional 1.1 million workers of this kind will be needed by 2024 — a 26 percent increase over 2014. Yet, the population of potential workers who tend to fill these jobs, overwhelmingly women ages 25 to 64, will increase at a much slower rate.

After the recession of 2008-09, positions in Medicaid-funded home health agencies, nursing homes and community service agencies were relatively easy to fill for several years. But the improving economy has led workers to pursue other higher-paying alternatives, in retail services for example, and turnover rates have soared.

At the same time, wages for nursing assistants, home health aides and personal care aides have stagnated, making recruitment difficult. The average hourly rate nationally is $10.11 — a few cents lower than a decade ago, according to PHI, an organization that studies the direct-care workforce. There is a push on now in a handful of states to raise the minimum to $15 an hour.

Even for-profit franchises that offer services such as light housekeeping and companionship to seniors who pay out-of-pocket are having problems with staffing.

“All the experienced workers are already placed with families. They’re off the market,” said Carrie Bianco, owner of Always Best Care Senior Services, which is based in Torrance, Calif., with franchises in 30 states.

Finding new employees was so difficult that Bianco started her own 14-week training program for caregivers nine months ago. To attract recruits, she ran ads targeting women who had left the workforce or been close to their grandparents. In exchange for free tuition, graduates must agree to start working for her agency.

“There’s much more competition now — a lot of franchises have opened and people will approach our workers outside our building or in the lobby and ask if they want to come work for them,” said Karen Kulp, president of Home Care Associates of Philadelphia.

Hardest to cover in Kulp’s area are people with disabilities or older adults who live at some distance from the city center and need only one to two hours of help a day.  Workers prefer longer shifts and less time traveling between clients, so they gravitate to other opportunities and “these people are not necessarily getting service,” she said.

It isn’t possible to document exactly how common these problems are nationally. Neither states nor the federal government routinely collect information about staff vacancy rates in home care agencies or nursing homes, turnover rates or people going without services.

“If we really want to understand what’s needed to address workforce shortages, we need better data,” said Robert Espinoza, vice president of policy at PHI.

Hard Times In Wisconsin

Some of the best data available come from Wisconsin, where long-term care facilities and agencies serving seniors and people with disabilities have surveyed their members over the past year.

The findings are startling. One of seven caregiving positions in Wisconsin nursing homes and group homes remained unfilled, one survey discovered; 70 percent of administrators reported a lack of qualified job applicants. As a result, 18 percent of long-term facilities in Wisconsin have had to limit resident admissions, declining care for more than 5,300 vulnerable residents.

“The words ‘unprecedented’ and ‘desperate’ come to mind,” said John Sauer, president and chief executive of LeadingAge Wisconsin, which represents not-for-profit long-term care institutions. “In my 28 years in the business, this is the most challenging workforce situation I’ve seen.”

Sauer and others blame inadequate payments from Medicaid — which funds about two-thirds of nursing homes’ business — for the bind. In rural areas, especially, operators are at the breaking point.

“We are very seriously considering closing our nursing facility so it doesn’t drive the whole corporation out of business,” said Greg Loeser, chief executive of Iola Living Assistance, which offers skilled nursing, assisted living and independent living services in a rural area about 70 miles west of Green Bay.

Like other short-staffed operators, he’s had to ask employees to work overtime and use agency staff, increasing labor costs substantially. A nearby state veterans home, the largest in Wisconsin, pays higher wages, making it hard for him to find employees. Last year, Iola’s losses on Medicaid-funded residents skyrocketed to $631,000 — an “unsustainable amount,” Loeser said.

Wisconsin Gov. Scott Walker has proposed a 2 percent Medicaid increase for long-term care facilities and personal care agencies for each of the next two years, but that won’t be enough to make a substantial difference, Loeser and other experts say.

The situation is equally grim for Wisconsin agencies that send personal care workers into people’s homes. According to a separate survey in 2016, 85 percent of agencies said they didn’t have enough staff to cover all shifts, and 43 percent reported not filling shifts at least seven times a month.

Barbara Vedder, 67, of Madison, paralyzed from her chest down since a spinal cord injury in 1981, has witnessed the impact firsthand. Currently, she qualifies for 8.75 hours of help a day, while her husband tends to her in the evening.

“It’s getting much, much, much more difficult to find willing, capable people to help me,” she said. “It’s a revolving door: People come for a couple of months, maybe, then they find a better job or they get pregnant or they move out of state. It’s an endless state of not knowing what’s going to happen next — will somebody be around to help me tomorrow? Next month?”

When caregivers don’t show up or shifts are cut back or canceled, “I don’t get proper cleaning around my catheter or in my groin area,” Vedder continued. “I’ll skip a meal or wait later several hours to take a pill. I won’t get my range-of-motion exercises, or my wheelchair cushion might slip out of place and I’ll start getting sore. Basically, I start losing my health.”

[caption id="attachment_723079" align="alignright" width="370"] Debra Ramacher is executive director of Wisconsin Family Ties, an organization for families of children with emotional, behavioral and mental disorders. Her daughter Maya, 20, pictured in 2015, has cerebral palsy, epilepsy and other significant disabilities. (Courtesy of the Ramacher family)[/caption]

Debra Ramacher and her husband have been unable to find paid caregivers since June 2015 for daughter Maya, 20, and son Michael, 19, both of whom have cerebral palsy, epilepsy and other significant disabilities. The family lives in New Richmond in western Wisconsin, about 45 minutes from the Minneapolis-St. Paul metropolitan area.

“At least three agencies told me they’ve stopped trying to hire personal care aides. They can’t find anybody and it costs them money to advertise,” said Ramacher, executive director of Wisconsin Family Ties, an organization for families with children with emotional, behavioral and mental disorders.

“It’s incredibly stressful on all of us, living with this kind of uncertainty,” she said.

Every few months, Ramacher tries to find caregivers on her own by putting ads up on Craigslist, in local newspapers and on job boards.

“We get a few bites,” she said. “Most recently, two people came and interviewed. One never got back to us; the other got a better job that paid more.”

In the meantime, she and her husband are being paid by Medicaid to look after Maya and Michael.

“We don’t want to be the caregivers; we want to have our own life,” Ramacher said. “But we don’t have any option.”

KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.

Pre-Obamacare, Preexisting Conditions Long Vexed States And Insurers

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For most of his life, Carl Goulden had near-perfect health. He and his wife, Wanda, say that changed 10 years ago. Carl remembered feeling “a lot of pain in the back, tired, fatigue, yellow eyes — a lot of jaundice.”

“Gray-like skin,” Wanda added. His liver wasn’t working, she explained. “It wasn’t filtering.”

Carl was diagnosed with hepatitis B. He is now 65 and on Medicare, but back then he had a flower shop in Littlestown, Pa., so he had been buying health insurance for his family on the market for small businesses and the self-employed.

The medications to manage Carl’s hepatitis cost more than $10,000 a year — and if he ever needed a liver transplant, as some people with hepatitis eventually do, the costs could be formidable. Thank goodness they had health insurance, the couple thought.

But then, Carl said, “the insurance renewals went way up.”

After a few years, he could no longer afford to buy the coverage — more than $1,000 a month — and maintain his business. So he dropped the insurance.

“I was devastated,” he said, “because I didn’t know when my liver might fail.”

Teresa Miller, Pennsylvania’s insurance commissioner, said that steep increase in insurance rates was legal. And before the Affordable Care Act became law, a patient like Goulden might have had a hard time buying another policy. He likely would have been turned down by private insurers because he had a “preexisting” medical condition.

A family like the Gouldens would “just have been out of luck,” Miller said.

Pennsylvania: The Wild, Wild West 

Before the ACA, states had differing approaches to handling preexisting conditions.

Pennsylvania was typical. Until the ACA mandated that insurers treat sick and healthy people equally, buying insurance seemed as lawless as the Wild West.

Insurers couldn’t overtly kick people off a plan if they got sick, but they could find ways to charge them much more, even those whose chronic condition wasn’t that serious — such as acne. For individuals looking to sign up in the first place, “an insurance company could simply decline to offer you insurance at all because of your preexisting condition,” Miller said.

Insurers who did offer a policy to someone with a preexisting condition might have done so with a catch — the plan could require a waiting period or might exclude treatment for that condition.

“So, let’s say you had diabetes, for example,” Miller said. “You might have been able to get coverage for an unexpected health care need that arose, but you’d still be on your own for any treatment and management of your diabetes.”

From the perspective of an insurance company, these practices were intended to prevent the sick from signing up for a health plan only when they needed costly care.

Pennsylvania tried to partially solve this problem by creating a scaled-back health plan, called adultBasic, for those with incomes too high to qualify for Medicaid who didn’t have any coverage. Household incomes had to be less than 200 percent of the federal poverty level, which at that time would have been $21,660 for an individual. More than 40,000 people were signed up in 2011, and nearly half a million were on the waiting list,  but the plans didn’t include coverage for mental health care, prescription drugs or more than two nights in a hospital. Even so, Miller said, the strategy proved too expensive for the state.

“That program was spending $13 million to $14 million a month when it was shut down,” she said.

High-Risk Pools

More than 30 other states dealt with preexisting conditions by setting up what are called high-risk pools, a separate insurance plan for individuals who couldn’t get health coverage in the private market.

These plans could be lifesavers for some people with conditions like cancer — which can cost tens if not hundreds of thousands of dollars to treat.

The experiences with high-risk pools varied, but states faced challenges, said John Bertko, an insurance actuary with the state of California. And the main problem was the high cost.

“The one in California, which I was associated with, limited annual services to no more than $75,000, and they had a waiting list. There was not enough money,” Bertko said. “The 20,000 people who got into it were the lucky ones. At one point in time, there were another 10,000 people on a waiting list.”

The pools also had catches: Premiums were expensive, as were out-of-pocket costs. And plans often excluded the coverage of preexisting conditions for six months to a year after the patient bought the policy.

New Jersey: Preexisting Conditions Covered, With A Catch

Around that same time, across the Delaware River, the state of New Jersey was trying something different.

“Insurers could not take health status into account,” said Joel Cantor, director of Rutgers’ Center for State Health Policy who has been analyzing the New Jersey experience.

Before the ACA, New Jersey was one of just a handful of states that prohibited insurers from denying coverage to people with preexisting conditions. Insurers also weren’t allowed to charge people significantly more for having a health issue, and the plans had to offer robust coverage of services.

There was a one-year waiting period for coverage of a preexisting condition, but a larger issue became cost. The entire individual market in New Jersey became expensive for everyone, regardless of their health status, Cantor said. Because there was no mandate to have health insurance coverage, those who signed up tended to need it, and healthy people did not enroll.

And so, “the prices went up and up,” he said. And the premiums and enrollment “went down and down.”

The state tried to address this in the early 2000s by introducing a “skinny” health plan, Cantor said.

“By that I mean very few benefits,” he explains. “It covered very, very limited services.”

The plan was affordable and really popular, especially among the young and healthy people, and about 100,000 people signed up. But if a person had a health need, many costs shifted to the individual.

“It left people with huge financial exposure,” he said.

That’s, in part, why the ACA included a rule that insurance plans now must offer good benefits and be available to everybody. In exchange, insurers have the mandate and subsidies — so that everybody will buy in.

Cantor said these experiences point to an ongoing quandary: A small portion of people consume a big chunk of health care costs. It’s hard to predict who will cost a lot — or when.

This story is part of a partnership that includes The Pulse, NPR and Kaiser Health News.

How to Meet Your Protein Needs without Meat

Eating a vegetarian diet can be very healthful and rewarding. However, most vegetarians—including soon-to-be vegetarians and their meat-eating loved ones—are concerned about getting adequate protein. Most people are accustomed to getting protein from meat, but what else contains protein? Aren't plant-based proteins "incomplete" or lower quality? Fortunately, with a bit of extra attention, you won't have any trouble meeting your protein needs just because you give up meat. There are so many protein-packed vegetarian options! Did you know that most foods, including vegetables, have some of the essential muscle-building nutrient? Without looking closely, it is easy to miss some great sources. (Who knew a cup of broccoli had 3 grams!) Nuts, seeds, soy products, cereal, eggs and dairy are all good meatless protein choices. These groups of food each contain different amino acids (the building blocks of proteins) and different levels of protein quality. There is no need to consume certain foods in special combinations as nutritionists once thought! When your diet includes a variety of each of these types of foods, you can rest assured that you're consuming all the amino acids you need for muscle growth and cell repair.  Pin this graphic for easy reference and scroll down for more details. Nuts Nuts provide a good dose of protein along with some heart-healthy fatty acids and antioxidants (vitamins A and E). They are also packed full of fiber. Take your pick! Many nuts have a significant source of protein ready to work for your body. Peanuts, almonds, pistachios, cashews, and pine nuts are among the highest in protein, while chestnuts and hazelnuts, although they do still have some protein, are the lowest. Think out of the box when you’re adding nuts to your diet. They can be grated, toasted, ground or eaten raw and are great when combined with salads, wraps, soups and stews and baked goods. But pay special attention to portion size! Nuts are a great source of many nutrients, but do come with a hefty dose of calories, thanks to the healthy fats they contain. A single serving is just 1 oz! Many nuts are best when stored in a refrigerator, which helps keep their fats from going rancid (for up to 6 months).   Nuts, 1/4 cup Protein Calories Fat Peanuts, raw 9 g 207 18 g Almonds, dry roasted 8 g 206 18 g Pistachios 6 g 171 14 g Hazelnuts 5 g 212 21 g Pine nuts 5 g 229 23 g Cashews, raw 5 g 197 16 g Walnuts 4 g 164 16 g Seeds Seeds are another great way to grab a few grams of protein and many other nutrients. Healthful unsaturated fats, as well as phytochemicals, make seeds a powerhouse for heart disease and cancer prevention. Just a quarter cup of pumpkin seeds (also called pepitas) has 8.5 grams of protein. Add this amount to a salad or eat them plain for a quick snack. Sunflower seeds are easy to add to pasta or salads, or sandwich wraps, while sesame seeds are easily ground and sprinkled onto steamed veggies for a protein dusting.   Seeds (1/4 cup) Protein Calories Fat Hemp seeds 15 g 232 18 g Pumpkin seeds, roasted 9 g 187 16 g Flaxseed 8 g 191 13 g Sunflower seeds, roasted 8 g 205 18 g Sesame seeds, roasted 6 g 206 18 g Legumes Dried peas, beans and lentils belong to a group of food known as "pulses" or "legumes." Aside from soybeans, these plants have a very similar nutrient content, which includes a good dose of protein. On average, they have about 15 grams of protein per cup, and tagging along with the essentials protein are fiber and iron. Adding beans, lentils and dried peas to your meals is a great way to replace meat (a beef burrito can easily become a black bean burrito, for example) while still getting your much needed protein. Add pulses to soups, salads, omelets, burritos, casseroles, pasta dishes, and more! Make bean dips (such as hummus, which is made from garbanzo beans, or black bean dip) to spread on sandwiches and use as protein-packed dips for veggies or snack foods.   Legumes, 1 cup cooked Protein Calories Fiber Soybeans 29 g 298 10 g Lentils 18 g 230 16 g Split peas 16 g 231 16 g Navy beans 16 g 258 12 g Garbanzo beans (chickpeas) 15 g 269 12 g Black beans 15 g 227 15 g Kidney beans 15 g 225 11 g Lima beans 15 g 216 13 g Pinto beans 14 g 234 15 g Soy Soybeans are a complete protein that is comparable in quality with animal proteins. Eating soybeans (and foods made from soybeans) has been growing trend in America for only five decades, but this protein-rich bean has been a staple in Asia for nearly 4,000 years! This plant powerhouse is used to create a variety of soy-based foods that are rich in protein: tofu, tempeh, textured vegetable protein (TVP, a convincing replacement for ground meat in recipes), soymilk and "meat analogs," such as vegetarian "chicken" or faux "ribs" are all becoming more popular as more Americans practice vegetarianism. To learn more about using tofu, read Tofu 101. To learn how soy may impact your health, click here.   Soy Foods Protein Calories Fat Soybeans, 1 cup cooked 29 g 298 10 g Tempeh, 4 oz cooked 21 g 223 13 g Edamame, 1 cup shelled 20 g 240 10 g TVP, 1/4 cup dry 12 g 80 0 g Soy nuts, 1/4 cup roasted 11 g 200 1 g Tofu, 4 oz raw 9 g 86 5 g Soy nut butter, 2 tablespoons 7 g 170 11 g Soymilk, 1 cup sweetened 7 g 100 0.5 g Soymilk, 1 cup unsweetened 7 g 80 0.5 g Grains In a culture that focuses largely on wheat, it's easy to overlook the many types of other grains available to us. Some of these grains are very high in protein and can be included in your diet for both whole-grain carbohydrates and muscle-building protein. Quinoa is unusually close to animal products in protein quality, making it an excellent grain to replace white rice or couscous. It can also be cooked and mixed with honey, berries and almonds in the morning for a protein-packed breakfast. Other grains high in protein include spelt, amaranth, oats and buckwheat. Choose whole-grain varieties of cereals, pastas, breads and rice for a more nutritious meal.   Grains Protein Calories Fiber Amaranth, 1 cup cooked 9 g 238 9 g Quinoa, 1 cup cooked 9 g 254 4 g Whole wheat pasta, 1 cup cooked 8 g 174 6 g Barley, 1 cup cooked 7 g 270 14 g Spelt, 4 oz cooked 6 g 144 4 g Oats, 1 cup cooked 6 g 147 4 g Bulgur, 1 cup cooked 6 g 151 8 g Buckwheat, 1 cup cooked 6 g 155 5 g Brown rice, 1 cup cooked 5 g 216 4 g Whole wheat bread, 1 slice 4 g 128 3 g Sprouted grain bread, 1 slice 4 g 80 3 g Dairy If you consume milk products, dairy is a great way to add some extra grams of protein to your day. Low-fat milk, cheese and yogurt are easily accessible, quick to pack and fun to incorporate into many meals and snacks. Whether you’re drinking a cup of skim milk with your dinner or grabbing some string cheese before you run errands, you can pack about 8 grams of protein into most servings of dairy. You’re also getting some bone-building calcium while you’re at it! Keep in mind that low-fat varieties of milk products are lower in calories and fat, but equal in calcium to the full-fat versions; low-fat varieties may also be higher in protein.   Dairy Protein Calories Fat Fat-free cottage cheese, 1 cup 31 g 160 1 g 2% cottage cheese, 1 cup 30 g 203 4 g 1% cottage cheese, 1 cup 28 g 163 2 g Fat-free plain yogurt, 1 cup 14 g 137 0 g Low-fat plain yogurt, 1 cup 13 g 155 4 g Parmesan cheese, 1 oz grated 12 g 129 9 g Whole milk yogurt, 1 cup 9 g 150 8 g Goat's milk, 1 cup 9 g 168 10 g 1% milk, 1 cup 8 g 102 2 g Swiss cheese, 1 oz 8 g 106 8 g 2% milk, 1 cup 8 g 121 7 g 3.25% (whole) milk, 1 cup 8 g 146 8 g Low-fat cheddar/Colby cheese, 1 oz 7 g 49 2 g Part-skim mozzarella cheese, 1 oz 7 g 72 5 g Provolone cheese, 1 oz 7 g 100 8 g Cheddar cheese, 1 oz 7 g 114 9 g Blue cheese, 1 oz 6 g 100 8 g American cheese, 1 oz 6 g 106 9 g Goat cheese, 1 oz 5 g 76 6 g Feta cheese, 1 oz 4 g 75 6 g Part-skim ricotta cheese, 1 oz 3 g 39 2 g Eggs Eggs contain the highest biologic value protein available. What this means is that an egg has a near perfect combination of amino acids within its shell; when assessing protein quality of all other foods (including meat), nutrition experts compare them to the egg. This doesn’t mean that all other sources of protein are less healthful or less important but does mean that an egg is an awesome way to get a few grams of protein. At 6 grams for one large egg, there are endless ways to add it to your diet. Salads, sandwiches, breakfasts or snack—an egg can fit in anytime!   Eggs Protein Calories Fat Egg, 1 boiled 6 g 68 5 g Egg white, 1 cooked 5 g 17 0 g Liquid egg substitute, 1.5 fl oz 5 g 23 0 g As you can see, protein is EVERYWHERE in our diet, and even without meat you can get enough every day; you just have to look in the right places! For more ideas for using these various plant-based proteins, check out our dailySpark series, Meat-Free Fridays for recipe and cooking ideas! Selected Sources Information Sheet: Protein from The Vegetarian Society (VegSoc.org) Various nutrient profiles from The World's Healthiest Foods (WHFoods.com) Want to learn more about going meatless? Check out SparkPeople's first e-book! It's packed with over 120 delicious meat-free recipes, plus tips and tricks for going meatless. Get it on Amazon for $2.99 and start cooking easy, wholesome veg-centric meals the whole family will love!Article Source: http://www.sparkpeople.com/resource/nutrition_articles.asp?id=158

Best and Worst Salad Toppings

A few years back I typed up a list of New Year’s resolutions on a small piece of cardstock, laminated it, and put it in my wallet. On that list was the resolution to eat a salad every day, simply because eating salad always made me feel like I was doing something good for myself. After all, salad provides several vitamins and can fill you up while reducing your caloric intake. What could be healthier than a big, fresh salad? Unfortunately, many things, as I later found out. Salads can run the gamut of healthiness, depending on what is in them. Although that big bowl of greens may be packed full of antioxidants and fiber, it can also be laden with fat, cholesterol, and sodium—not to mention an overabundance of calories. Some restaurant salads can even contain more calories than a cheeseburger! Luckily, like most things in life, a salad is the outcome of several small decisions. To make sure you don't sabotage your healthy diet unintentionally, choose wisely the next time you order a salad from a restaurant or visit the salad bar. When dining out, don't be afraid to ask questions, make special requests (extra veggies, dressing on the side, light cheese) and ask about substitutions (like grilled chicken for breaded). Most restaurants will be happy to accommodate you as long as their kitchen is stocked with the ingredients you want. Here’s how to choose wisely next time you're making a salad at home or choosing one from a menu. Lettuce The foundation of most salads, lettuce adds substance, crunch, water, and fiber for very few calories—only about 10 per cup. But if you want all that and vitamins, too, toss out the iceberg and toss in the romaine, mixed baby greens and spinach. While iceberg lettuce is lower in nutrients (and still makes a decent choice if it's the only thing available), these other greens are rich in vitamins A, C and K, manganese, and folate. Protein Adding protein, such as lean meat, tofu, eggs or beans, will help bulk up your salad and keep you full longer. Unfortunately, many protein toppings are deep-fried, breaded and greasy, which adds unnecessary calories plus cholesterol, sodium and fat to your salad. Skimp on fattier toppings such as bacon and fried (breaded) chicken strips, and go for lean proteins instead. Grilled chicken, canned beans of all kinds, chickpeas, tofu, hardboiled eggs (especially whites), or water-packed tuna are leaner choices. Nuts and seeds are popular in salads, too, and while they’re a healthy source of good fats and some protein, they’re not exactly low-cal. If you choose to add them, watch your portions (1/2 ounce contains more than 80 calories). Cheese Restaurants know that people love cheese, so they tend to pile on multiple servings of it on their salads. It might be tasty, but it sends the calorie counts sky high! While cheese is a nutritious food that adds flavor, calcium, and protein to a salad, enjoy it in moderation due to its high fat content. Just a half-cup of cheddar cheese (the amount on many large restaurant salads) contains 18 grams of fat and 225 calories. To keep calories in check, use a single serving of cheese (approximately 2 tablespoons). Choose low-fat varieties as much as possible to save on saturated fat and calories. A smaller amount of a stronger-flavored cheese, such as Brie, feta, chevre, gorgonzola, sharp cheddar or bleu cheese will go a long way in helping you cut down on your portions. Pile on the Veggies Vegetables like bell peppers, grated carrots, sugar snap peas, and tomatoes provide flavor, fiber, and vitamins for few calories. Grated carrots, for example, have only 45 calories in a whole cup, and there are only about 20 calories in an entire red bell pepper. When building your best salad, use as many veggies as possible for extra filling power—and a nice crunch! Practice moderation when it comes to starchy vegetable toppings like corn and potatoes, which are higher in calories. And remember to go for a variety of colors to ensure you're getting several different nutrients and antioxidants in your salad bowl. Don't Forget the Fruit Don't leave fruit on the sidelines! Fresh, canned and dried fruits add a sweetness that can help temper the slightly bitter taste of greens and veggies. They also provide color and texture (not to mention nutrition) to your salad bowl. Chopped apples, pears, grapes, or mandarin oranges (canned in juice—not syrup—and drained) are excellent salad toppers. Chewy dried fruits (cranberries, raisins) work well, too, but they are also high in calories (so only use a sprinkle!). Avocados (and the guacamole made from them) are creamy and nutritious thanks to their heart-healthy fats, but they're also a concentrated sources of calories. Keep your use of avocado to a minimum if you're watching your weight. Crunchy Toppings Sesame sticks, crispy noodles and croutons are salty and crunchy but conceal lot of hidden fat. Better options include water chestnuts, apple slivers, a small serving of nuts, crumbled whole-grain crackers, and homemade croutons. To make your own low-fat croutons, just slice a large clove of garlic and rub it over both sides of a piece of whole-grain bread. Cut the bread into cubes and then brown it in the toaster or conventional oven. Dressing A very healthy salad could go very wrong with one too many shakes of oil or dressing. The main issue with dressing is its fat and sodium content—and the fact that people have trouble controlling their portions. Two tablespoons is an appropriate serving of dressing, but most restaurants serve much more than that, whether mixed in to your salad or served on the side. Those calories add up fast. When dining out, always ask for dressing on the side and dip your fork into the dressing before picking up your bite of salad. Caesar, ranch and other cream-based dressings (when not specified as low-fat) are calorie bombs worth avoiding. Look for dressings specified as "low-fat" that contain no more than 60 calories per serving. You can also add flavor for minimal calories by using salsa, vinegar or lemon juice. Salad may be the symbol of healthy eating, but not every salad is healthful—or diet-friendly. The healthfulness of your next salad depends on the simple choices you make when topping or dressing it. Perhaps my greatest discovery about salads was that because you can customize them so easily, you could make a huge main-course salad for a very small amount of calories. Pile in the lettuce and veggies, add a moderate amount of lean protein, sprinkling some cheese and a little something crunchy and measure a portion-controlled side of dressing, and you’ve got a dinner that won’t leave you feeling hungry.Article Source: http://www.sparkpeople.com/resource/nutrition_articles.asp?id=1388

30 Ways to Revitalize Your Lunch Break

Lunchtime doesn't have to be bland or boring, just as it doesn't have to be a frenzied time to run errands or multitask. Our printable calendar provides 30 ideas to add a little adventure to your midday break. Click here to download and print your Adventurous Lunch Break Calendar. (You need Adobe Acrobat Reader to download this PDF.) If you think your friends or family members might benefit from these heart-healthy tips, share this calendar with them by clicking the "Share" button below.Article Source: http://www.sparkpeople.com/resource/nutrition_articles.asp?id=1336

Umami: What You've Been Missing!

You've slimmed down your recipes, made healthy food swaps, and integrated vegetables into your meals. But do you ever feel like your food is missing something? When you finish eating, do you ever wonder why a meal just didn't hit the spot? You're probably missing umami. You've probably heard of the four basic tastes: bitter, sour, sweet and salty. Well, "umami," which means "yummy" in Japanese, is another distinct taste. Commonly found in fermented or aged foods, umami (pronounced ooh-mah-mee) adds that "mouth feel" to food. It makes your food feel richer, more delicious and more decadent. A key component in Chinese and Japanese cuisine, umami is starting to gain importance in Western cooking. American cooking tends to rely on fat or salt to get that feeling, but there are other, healthier ways to give your food and meals a little more oomph. Ever notice how parmesan makes pasta taste so much better? Or how much tastier ketchup makes your burgers? The parmesan, the tomatoes, and the beef all contain umami. Think about Japanese miso soup or almost any Chinese food. They're delicious and satisfying, thanks to umami-rich seaweed, fish, and soy sauce. Many foods are considered to have umami, including familiar foods like pepperoni pizza and hamburgers! And many condiments that seem to add "empty" calories (ketchup, steak sauce and Worcestershire sauce) actually help food feel more satisfying when you eat it. Here's a list of some umami rich foods:

By adding more of these foods to your meals, you can boost your satisfaction and potentially eat fewer calories overall and avoid overeating. A little goes a long way, and many foods rich in umami should be used as seasonings rather than main ingredients because they can be high in sodium and fat. Try adding a pinch of Romano cheese to steamed veggies or adding asparagus or mushrooms to your salad. If you're feeling decadent, put a pinch of crumbled bacon or a couple of sun-dried tomatoes in an egg white omelet. That could be just what hits the spot! Article Source: http://www.sparkpeople.com/resource/nutrition_articles.asp?id=1348

Health Care Worries Pull Crowd To Conservative Ohio Rep’s Town Hall

LIMA, Ohio — Speaking over constituents’ often-hostile shouts and angry murmurs, one of Congress’ most conservative Republicans told a tense town hall meeting here Monday that less government regulation — not more — is the solution to their rising health care premiums.

“What we want to do is make sure we have the best health care system in the world and bring back affordable insurance plain and simple. That’s what I’m trying to do. That’s what we continue to focus on,” said Rep. Jim Jordan, the co-founder of the House’s conservative Freedom Caucus. Its firm opposition to the GOP’s plan to replace the Affordable Care Act forced party leaders last month to yank their bill from a vote on the House floor.

But on the eve of Congress’ return to Washington after a two-week Easter recess, Jordan offered no clues to his party’s next move on a health care bill or the prospects for a government shutdown if Congress fails to agree before the Friday deadline on a bill to provide short-term funding to keep it operating.

More than 200 people attended the Ohio congressman’s 2 1/2-hour meeting, mostly pummeling him with questions and personal stories about their health care. Jordan heard from constituents with sick children, veterans who couldn’t access Veterans Affairs’ care and nervous families who feared what could happen to them if federal Medicaid funding is cut, among others.

Seated on black folding chairs in a windowless hall of the Lima Veterans Civic Center, many in the audience followed a practice that’s been common this year at congressional members’ town hall meetings — holding up red signs when they disagreed with Jordan and, less frequently, green signs when they agreed. Jordan, unruffled by opposition, drew laughs once when he referred to a woman in the crowd as “gentlelady,” in the formal way that male members of Congress sometimes address female members when the House is in session.

Tobias Buckell told the congressman the ACA’s mandate that insurers cover preexisting conditions had made it possible for both his wife, Emily, and him to have careers as freelancers — he as a science fiction writer and Emily as an e-book designer. Buckell, the father of twin 8-year-old daughters, told Jordan the only way he could risk that career choice was because he was able to buy insurance through the law’s exchanges. He has a genetic heart condition that he said had made him virtually uninsurable before.

“We’re going to be moved to a high risk pool, we’ll pay three times as much our current rate … how will that help me?” asked Buckell, 38.

Though the most vocal members of the crowd were largely in disagreement with Jordan’s views, a quiet minority in the front of the room shook their heads and waved green signs in agreement when the congressman responded to a question by saying he did not believe health care is a universal right.

[caption id="attachment_723898" align="alignright" width="270"] (Rachel Bluth/KHN)[/caption]

“I do not believe health care is a right. Rights are not given to us by the government, rights come from God, although Jim acknowledged that the American people have come to accept it as a right,” said Linda Gentry, a 66-year old constituent who works for an insurance company.

Of the 17 questions Jordan was asked, 13 related to health care. Lisa Robeson, the event’s moderator, estimated that around half of the 45 questions submitted in advance focused on the topic.

Jordan’s comments on the federal government’s role in solving the opioid crisis brought what might have been his audience’s most negative reaction of the night.

Ohio has been especially hard hit in recent years. It led the nation in opioid overdose deaths in 2015, according to the Kaiser Family Foundation, while Dayton, just an hour and a half south of Lima, topped a criminal justice group’s national ranking of America’s most drugged-out cities last year.

“I’m not convinced the federal government giving more money will solve the problem,” Jordan said. Instead of a “grand scheme” handed down from Washington, he suggested churches, schools and families are best equipped to handle the opioid epidemic – a remark that raised a sea of red signs across the room.

Jordan’s 4th District touches the northern part of the state near Lake Erie, and includes rural areas and suburbs of Columbus, the state capitol. He has been the district’s congressman since 2007 and he has little reason to be alarmed by contentious town halls. Jordan was reelected last November with more than 68 percent of the vote.

By the end of Monday’s town hall, some of Jordan’s constituents were divided on whether they’d heard what they came to find out.

“It’s clear to me that there is sort of a vague idea what the Republican replacement would be, and I don’t think we got a statement about that,” said Robert Kemp, 62, a health care economist that also rose to speak in favor of universal health care.

Barbara Mayer, 81, a retired teacher, didn’t mind the lack of specificity. She said it was unfair for people to demand comment on a measure that hasn’t been finalized yet.

“They’re quoting things about what Trump’s bringing out and it isn’t even public yet,” Mayer said. “People aren’t giving the new Congress a fair trial.”

Reluctant Patients, Hispanic Men Pose A Costly Challenge To The Health System

BALTIMORE — Peter Uribe left Chile at 21 with his wife and 2-year-old daughter, landing in Baltimore and finding steady work in construction. His social life revolved around futbol, playing “six or seven nights a week in soccer tournaments,” he said.

A couple of years after his arrival, he broke his foot during a game and afraid of the cost, didn’t seek medical care.

“Some of my family warned me that if I went to the hospital and couldn’t pay the bill, I’d get a bad credit record,” said Uribe, 41, who made about $300 a week and had no health insurance. “I wanted to buy a car or a house someday.” Instead, he hobbled through workdays and stayed off the field for three years; the residual pain is sometimes disabling, even two decades later.

For reasons both economic and cultural, Hispanic men are loath to interact with the health system. Women across all races are more likely to seek care than men. But the gender gap in the Hispanic community is especially troubling to health care providers. Studies show that Latino men are much less likely than Latinas to get treatment.

That is true even though Hispanic men are more likely than non-Hispanic whites to be obese, have diabetes or have high blood pressure. Those who drink tend to do so heavily, contributing to the group’s higher rates of alcoholic cirrhosis and deaths from chronic liver disease. Many take risky jobs such as construction workers and laborers, and are more likely to die from on-the-job injuries than other workers, government data show.

Hispanics’ share of the population is expected to widen from nearly a fifth now to a quarter by 2045. As that number grows, researchers worry that the nation could face costly consequences as long-ignored conditions lead to serious illness and disability.

“It could literally break the health care system,” said José Arévalo, board chairman of Latino Physicians of California, which represents Hispanic doctors and others who treat Latinos.

And now, some medical professionals fear the effects of President Donald Trump’s crackdown on illegal immigrants.

“When the community faces this kind of stress, I worry that people will do unhealthy things, like abuse alcohol, to deal with it,” said Kathleen Page, co-director of Centro SOL, a health center at Johns Hopkins Bayview Medical Center, and founder of the city’s Latino HIV Outreach Program. “That means they may not work as much,” she added. “They’ll have less money, which means they’re less likely to seek care.”

Welcomed by Baltimore officials, immigrants have driven the city’s Hispanic population, tripling it to 30,000 since 2000.

Here, as elsewhere, evidence suggests that for many Hispanic men, seeking health care is an extraordinary event. Hospital data show they are more likely than Hispanic women, white women and white men to go to the emergency room as their primary source of treatment — a sign that they wait until they’ve no choice but to get help.

Some care providers say medical institutions haven’t done enough to keep Hispanic men healthy, or to persuade them to get regular exams.

“There’s been an ongoing need for institutions to become more culturally attuned and aware of bias,” said Elena Rios, president of the National Hispanic Medical Association, which represents the nation’s 50,000 Latino physicians.

There are some significant differences in health risk and illness rates among Hispanic subgroups — Puerto Ricans are more likely to be smokers, for example. Compared with Hispanics born in the U.S., those born elsewhere have much lower rates of cancer, heart disease and high blood pressure. Overall, Hispanics live longer than whites.

But these advantages may be dissipating as Latinos become Americanized and adopt unhealthy habits such as smoking and diets high in fatty, processed foods.

“I tell people we live longer and suffer,” said Jane Delgado, a clinical psychologist and Cuban-American who serves as president of the National Alliance for Hispanic Health.

Researchers who investigate gaps in cancer testing have found that all ethnic groups and genders have seen a decrease in late-stage colon cancer diagnoses and deaths in recent years — except Hispanic men, who get screened at the lowest rates of any race or ethnic group.

Often, health problems arise after immigrants come up against an insurance barrier. A few years after Jose Cedillo came to Baltimore from Honduras, the 41-year-old cook noticed his legs were often numb or painful. Worried about finances, he eschewed treatment and continued to work, before finally going to a clinic where he was diagnosed with diabetes.

In the seven years since, his health has so deteriorated he can’t work, is frequently homeless and spends long stints in the hospital. As an immigrant who came to the U.S. illegally, he is not eligible for government-paid insurance or disability payments. And he can’t afford medicine. Instead, he said, “I’ll drink alcohol to numb the pain.”

[caption id="attachment_723487" align="aligncenter" width="770"] Jose Cedillo, a 41-year-old former restaurant worker from Honduras struggles to get health care for his diabetes. His immigration status compounds his issues and often finds himself without a job and homeless on the streets of Baltimore. (Doug Kapustin for KHN)[/caption]

Part of the problem is that Spanish speakers are underrepresented among medical professionals. After arriving here, Uribe’s family members frequently brought along an English-speaking nephew or niece when they could afford to see doctors. Otherwise, “we’d travel a long ways to find a doctor who spoke Spanish,” he said.

Hospitals frequently lack cultural understanding and bilingual staffing, administrators admit. Though Latinos make up nearly 20 percent of the population, only 5 percent of physicians and 7 percent of registered nurses are Hispanic. That gap has widened as more Hispanics have come to this country during the past three decades, according to a UCLA study released in 2015.

“Too often, people don’t understand what you’re saying, they don’t know what you’re going to charge them, what dietary restrictions you might place upon them,” said James Page, vice president for diversity at Johns Hopkins Medicine. “It creates a trust issue for Hispanics. We’ve got to get better at serving them.”

That is particularly true in mental health. Only 1 percent of psychologists in the U.S. are Hispanic, meaning that Spanish-speaking men who do seek therapy will probably struggle to find it.

In Baltimore, there is only one Spanish-language support group for men who suffer from anxiety and depression, local psychologists and Latino advocates say. The city employs one Spanish-speaking substance abuse counselor. A small handful of bilingual social workers citywide offer reduced-rate counseling sessions, and only three psychiatrists offer therapy sessions conducted in Spanish.

For Peter Uribe, the key to maintaining his family’s health is getting help paying for care. His wife and brother both suffer from epileptic seizures, and his brother’s despondency caused Uribe to become depressed, he said. In 2015, he obtained insurance for his family through a charity program. With the help of now-affordable medicines, his wife’s seizures waned, and he sought help for chronic depression. Since he now speaks English, finding counseling help is easier.

In January, after intervention from a Latino advocacy group, the charity renewed the Uribes’ policy for two years. Peter Uribe calls it a godsend:

“I honestly have no idea what we’d do without it.”

Michael Anft is a Baltimore-based journalist and writer whose work regularly appears in AARP: The Magazine, The Chronicle of Higher Education and other publications. Daniel Trielli, a data journalist at Capital News Service at the Philip Merrill College of Journalism, contributed to this report.

The Annie E. Casey Foundation supports KHN’s coverage of health disparities in east Baltimore.

CHIP Offers Families With Seriously Ill Kids More Financial Protection Than ACA Plans

Kids with chronic conditions are especially vulnerable to health insurance changes, relying as they often do on specialists and medications that may not be covered if they switch plans. A new study finds that these transitions can leave kids and their families financially vulnerable as well.

The research, which examines the spending impact of shifting chronically-ill kids from the Children’s Health Insurance Program (CHIP) to policies offered on the health law’s marketplaces, found that their families’ out-of-pocket costs would likely rise, in some cases dramatically, following a change to marketplace coverage.

The study comes at a time when health insurance issues are on the front burner in Congress. Republican lawmakers are pushing for fundamental changes to the marketplaces and to the Medicaid program. At the same time, Congress must soon decide whether to extend CHIP when its funding ends in September.

Together the state-federal Medicaid and CHIP programs insure nearly 46 million low-income children in the United States. CHIP covers kids whose family income is low but too high to qualify for Medicaid. The eligibility levels  vary by state. Half of states set the upper income eligibility limit at 255 percent of the federal poverty level or higher — about $52,000 for a family of three.

Both programs provide comprehensive coverage for children with little or no out-of-pocket cost to families.

Since passage of the Affordable Care Act in 2010, some policy analysts have advocated moving children who are enrolled in CHIP into marketplace plans and dismantling the CHIP program. But earlier evaluations found, as did this study, that CHIP coverage was better and cheaper than marketplace coverage, said Joan Alker, executive director of the Georgetown Center for Children and Families.

CHIP is much smaller than Medicaid, with more than 8 million children enrolled, roughly 2 million of whom have one of six chronic health conditions, including asthma, attention deficit hyperactivity disorder, diabetes, epilepsy, mood disorders and developmental disorders such as autism, according to the study, which was published in the April issue of Health Affairs.

Using data compiled from state CHIP programs and marketplace plans for 2016 and health care use data from the federal Medical Expenditure Panel Surveys from 2008 to 2013, researchers simulated the annual out-of-pocket costs for children with these six chronic conditions if they were enrolled in CHIP versus one of the plans sold on the marketplaces operated by the federal government.

The spending differences were stark. For every chronic condition and at every income level, cost sharing was higher for children enrolled in marketplace plans than for those in CHIP.

Take the case of asthma, the most common condition that researchers modeled. For a child with asthma whose family income was between 100 and 150 percent of the federal poverty level, or about $20,000 to $30,000 for a family of three, annual out-of-pocket spending on deductibles and copays would be $284 in a marketplace plan, compared with $27 in CHIP — a difference of $257. At higher incomes, the out-of-pocket spending differences were greater. Families with incomes between 251 and 400 percent of the federal poverty level, or about $51,000 to $81,000 for a family of three, would pay $1,227 out-of-pocket annually if they were enrolled in a marketplace plan but just $84 in the CHIP program — a difference of $1,143.

“The lowest income families were relatively well protected by cost-sharing reductions” in marketplace plans, said Amy Davidoff, a senior research scientist in the Department of Health Policy and Management at the Yale School of Public Health, who is one of the study’s co-authors. Those cost-sharing subsidies, which reduce a plan’s deductible, copayments and coinsurance, are available to marketplace customers with incomes up to 250 percent of the federal poverty level — about $51,000 for three people. These subsidies are the subject of a lawsuit, however, and their fate is unclear.

As family income rises, however, the gap between the out-of-pocket costs for the two different types of coverage increases and becomes quite substantial, Davidoff said. “For these families, it would be huge barrier,” she said.

About 97 percent of children on CHIP belong to families with incomes below 250 percent of the poverty level.

The deductible — the amount that people have to pay on their own before insurance covers most services — was a significant factor in the cost differences. The average deductible in marketplace plans for families with incomes between 251 and 400 percent of poverty was $3,126. None of the CHIP programs for families at that income level had deductibles, the study found.

Noting that CHIP has a history of strong bipartisan support, Alker said she is hopeful that it will be extended. “I think it would be very hard for Congress to let CHIP expire,” she said, “and put those children into the marketplace, when according to their leaders it’s about to fold.”

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

HHS, States Move To Help Insurers Defray Costs Of Sickest Patients

As congressional Republicans’ efforts to repeal and replace the Affordable Care Act remain in limbo, the Trump administration and some states are taking steps to help insurers cover the cost of their sickest patients, a move that industry analysts say is critical to keeping premiums affordable for plans sold on the law’s online marketplaces in 2018.

This fix is a well-known insurance industry practice called reinsurance. Claims above a certain amount would be paid by the government, reducing insurers’ financial exposure and allowing them to set lower premiums.

Two states — Alaska and Minnesota — that have seen double-digit increases in ACA plan premiums this year have already moved to implement reinsurance policies, and Oklahoma is making plans to seek federal approval to set up a program. The Idaho legislature also recently passed a health care reinsurance law, and Maine is considering taking similar action.

The Trump administration has told other states they should consider doing the same. On March 13, Health and Human Services Secretary Tom Price sent a letter to all 50 governors soliciting proposals for reinsurance and other options to help cover the costs of consumers with expensive medical conditions.

Long an advocate for more state control of health insurance, Price said the administration is “seeking to empower states with new opportunities that will strengthen their health insurance markets.”

“This is one practical way the administration and states can work together to reduce premiums,” said Matthew Fiedler, a health policy specialist at the Brookings Institution. “While it’s the insurers who get the [support] directly, reductions in insurers’ claims costs ultimately translate into lower premiums for consumers.”

The focus on reinsurance comes as insurers must tell state and federal regulators no later than June 21 whether they will participate in the ACA’s marketplaces in 2018, and what plans they will offer at what price. This issue is separate from other highly publicized efforts underway to preserve federal payments to insurers to cover the costs of deductibles and copayments for low-income enrollees.

The federal law offered the security of a reinsurance program to insurers during its first three years. It helped reduce premiums among insurers by 10 percent in 2014, the last year the impact was analyzed, according to the Congressional Budget Office.

But the ACA reinsurance program ended this year. That helped drive premiums up by an average 22 percent across the country, raising concerns about the stability of the state-based marketplaces — also called exchanges — that provide insurance for people who don’t get it through work or public programs such as Medicare or Medicaid.

Now officials from both political parties are eyeing another part of the health law to help reprise and finance reinsurance programs.

In his letter, Price encouraged states to consider a special provision — known as a Section 1332 waiver — that went into effect this year and opens an avenue for them to pursue exemptions from ACA rules as long as the state plan maintains equivalent or better coverage levels for residents and doesn’t raise federal spending.

The Trump administration is betting that some states can set up reinsurance programs with federal funding. Federal spending on the program would be kept in check because the move will reduce government spending on tax credits that the law gives some low-income exchange customers to help defray the cost of premiums.

Need To ‘Stabilize Things Fast’ 

Consider deep-red Oklahoma. State officials have always held the ACA at arm’s length, leaving the insurance marketplace’s management and details to federal officials. But after rate increases averaging 76 percent this year — second only to Arizona — state officials set up a task force to explore how to put a brake on insurance premiums. The group last month published a multifaceted, 60-page plan for a waiver request. State officials say they will submit the plan to HHS later this year. Among the proposed first steps: reinsurance.

“We are in critical condition,” said Buffy Heater, chief strategy officer at the Oklahoma Health Care Authority. “Reinsurance is a way to stabilize things fast and attract additional insurers and more enrollees.”

Enrollment in the Oklahoma marketplace plan grew just 1 percent in 2017, to 146,300, after fairly robust growth in 2014 and 2015. Still, only about 30 percent of eligible Oklahomans are enrolled, and the number of uninsured in the state grew by 20,000 people in 2017.

Blue Cross Blue Shield of Oklahoma, the only carrier now selling on the state’s insurance marketplace, concurs with Heater’s assessment. The company declined through a spokesman to address state officials’ concern that the insurer was poised to exit the market in 2018. But Kurt Kossen, senior vice president at the Illinois-based Health Care Service Corp., which owns the Oklahoma Blues plan, said in a statement: “We agree reinsurance and well-designed high-risk pools help lower premiums and encourage greater competition.”

The two main health insurance lobbying groups in Washington — America’s Health Insurance Plans and the Blue Cross Blue Shield Association — also support efforts to offer reinsurance.

“We are very much in favor of using reinsurance to help insurers pay for the most expensive claims and to stabilize the marketplaces,” said Kristine Grow, senior vice president for communications at America’s Health Insurance Plans.  

Alaska And Minnesota Spurred To Act

Building on its state-funded reinsurance program for 2017, Alaska has asked the federal government to set aside $51.6 million for a reinsurance pool there for 2018. Lori Wing-Heier, director of the state’s division of insurance, said the state’s $55 million fund this year enabled Premera Blue Cross Blue Shield, the sole insurer left on the exchange, to reduce an expected premium increase of 40 percent to just 7.3 percent.  But the state said it cannot keep up the effort alone and needs federal funding.

In Minnesota, where premiums for marketplace plans spiked by around 50 percent this year, the Legislature enacted a law this month that establishes a $271 million reinsurance pool for that state’s troubled ACA marketplace for 2018 and 2019. The funds are contingent on getting the same waiver from the federal government that Alaska seeks and that Oklahoma plans to pursue.

Consumer complaints about the price hikes for 2017 pushed Minnesota to set up a $326 million fund to bail out insurers and help consumers who didn’t qualify for federal premium subsidies. That state-based reinsurance fund reduced premiums by about 25 percent, said Eileen Smith, a spokeswoman for the Minnesota Council of Health Plans. The state’s Department of Commerce has estimated that the 2018 reinsurance fund will reduce premiums by about 20 percent.

About 4 percent of Minnesotans — 235,000 people — get coverage in that state’s individual marketplace.

Back in Washington, D.C., some lawmakers have newfound fervor for insurance market stability and tools such as reinsurance. In their proposed bill to repeal and replace portions of the ACA, House Republicans included a 10-year, $100 billion fund to offset the burden of high-cost patients.

States would be allowed to establish reinsurance pools or set up separate high-risk insurance pools for patients with expensive medical conditions.

And even as the fate of the legislation to repeal the ACA remains uncertain, a group of Republicans in the House of Representatives this month sought to sweeten the pot with an additional $15 billion fund over nine years to help reimburse insurers for high-cost patients with certain preexisting conditions, such as cancer.

Democrats and health policy analysts immediately criticized this latest proposal.

“It’s not enough money to make a serious dent,” said Tim Jost, a professor of health law at Virginia’s Washington and Lee University and an expert on the health law. While the concept is sound, he said that the proposal is flawed because the House Republicans’ bill creates the need for it with “the other damaging changes it makes to the market.”

Jost, other policy analysts and consumer advocates also take issue with Republican proposals that appear to create equivalency between reinsurance and separate high-risk pools for people with preexisting conditions and high claims. In most states that have tried them, said Lynn Quincy, a health insurance specialist and senior policy analyst at Consumer Union, high-risk pools have failed to offer affordable coverage to people who need care the most.

“Reinsurance is the much preferred option,” Quincy said. “It doesn’t segregate sick people into a separate pool, and reinsurance has proved far more efficient and effective over the years.”

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