Hawaii’s Long Term Health Care Bill Could Serve as a National Model

Originally published in The American Prospect on January 12, 2016.
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Hawaii may soon become the first state in the union to offer universal long-term care for seniors, as state legislators prepare to roll out a bill that would tackle the nation’s elder care crisis head-on.

Slated for introduction in the 2016 legislative session, Hawaii’s innovative bill could become a national model for states looking for ways to help families afford the high costs of elder care. Across the country, as millions of baby boomers hit retirement age, they are beginning to feel the strain of paying for health care. A full 10,000 Americans have turned 65 every single day since 2011, and will continue to do so until 2030—a trend that is dramatically altering the demographic landscape of the United States.

“There’s an important role for government to play,” says Kevin Simowitz, the political director for Caring Across Generations, a national organization that aims to help people age with dignity and independence. “Most people simply don’t have the individual means to pay for the care they need.”

These population trends have been particularly marked in Hawaii. While the number of seniors aged 75 and older increased by 47 percent nationally between 1990 and 2012, Hawaii saw a 116 percent increase in that age cohort during this same period.

A coalition of retiree groups, labor unions, and religious organizations in Hawaii has been leading the public campaign for Hawaii’s new health care program.

“I think if we have enough push from the public we can make it happen because the will of the people, I would hope, will supersede all potential barriers,” says Clementina Ceria-Ulep, the chair of the Nursing Department at University of Hawaii at Manoa, and a leader with Faith Action for Community Equity, a faith-based community organization.

Aloha State residents boast a distinct cultural tradition of caring for and cherishing their “kapuna”—a Hawaiian word that refers to the elderly. Indeed, Hawaiian leaders have been reckoning with the challenges of elderly care for far longer than most states on the U.S. mainland.

Now, after decades of debates, state audits, and legislative campaigns, Hawaii residents and lawmakers say the time is right for action on the proposed universal care benefit. Supporters of the bill argue that it would not only help ease the financial burden on families caring for seniors, but also create more high-quality home care jobs for the mostly women and immigrant workers who tend to shoulder these responsibilities.

“Hawaii has a tradition of being at the forefront of health care policy,” says Simowitz, of Caring Across Generations. “Long before the Affordable Care Act, Hawaiians had a plan to make sure that workers had quality affordable health care. This would not be the first time they’ve done something a little bit provocative and groundbreaking.”

Simowitz says that the idea of a universal long-term care program could spread to other states, in the same way that grassroots movements to promote paid sick leave and increase the minimum wage have taken off.

“It is a breakthrough to have legislators move this conversation from kitchen tables in peoples’ houses to conference tables at the legislature,” he says. “We need this to be a public policy conversation.”

Hawaii’s program would work like this: Every person who files a Hawaii state income tax for ten years would be eligible to receive $70 a day, for a total of 365 days. The benefit would be underwritten by a slight increase in the state’s General Excise Tax, a tax on all businesses’ gross income. Hawaii’s thriving tourist industry would help boost the fund. That’s because tourists, who also pay the General Excise Tax, would fund roughly 35 percent of the long-term care program but would never claim the benefit themselves.

“Our target was to look at what it would cost to help someone get four hours of home or community care,” explains Dr. Lawrence Nitz, a political science professor at the University of Hawaii at Mānoa, who conducted research on long-term care financing for the state. “Seventy dollars means you could plan to go to work, you could take time to meet your child’s teacher. It’s enough to help people avoid losing their jobs, while still balancing care responsibilities.”

Most people need some form of long-term care as they get older. Long-term care refers to assistance with activities of daily living, such as bathing, eating, using the toilet, and getting dressed. It also includes help with tasks like shopping, cooking, and cleaning.Despite a common misconception, Medicare does not cover the cost of long-term care services, meaning that the majority of Americans must pay out of pocket.

Hawaii’s proposed social insurance program would not cover the cost of nursing homes or assisted living facilities, which can easily reach $100,000 per year. However, it would offer more money and flexibility to families that are already providing long-term care.

In 2011, the AARP’s Public Policy Institute found that the average caregiver is a 49-year-old woman who works outside the home and spends nearly 20 hours per week providing unpaid care to a parent over nearly five years. The report found that two-thirds of family caregivers are women, and that the total economic value for all this unpaid work was an estimated $450 billion annually.

Hawaii State Senator Roslyn Baker plans to introduce the long-term care bill in the upcoming legislative session. It’s not the first time that Baker, who has been active in elderly care issues since the 1990s, has introduced long term care legislation. But now, due to growing political support and a string of research studies supporting the program’s the feasibility, Baker predicts that the bill has a good chance of passing.

“We think the timing is right, even though it’s an election year,” Baker told The American Prospect. “We’re going to work to help people understand exactly what the funding mechanism is, how small a tax burden it is, and just how it will help lots and lots of people afford the care they need.”

‘Housing First’ Policy for Addressing Homelessness Hamstrung By Funding Issues

Originally published in The American Prospect on January 27, 2015.
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In an era of shrinking financial resources, policymakers, providers, and activists who work on homelessness prevention and care in the United States have been forced to develop new strategies. There was a time when officials at the Department of Housing and Urban Development (HUD) saw it as their responsibility to provide both housing and supportive services for homeless individuals, but now HUD now is refocusing its budget predominately on rent and housing—with the hope that other local, state, and federal agencies will play a greater role in providing supportive care. However, whether other organizations will actually be able to pick up those costs and responsibilities remains unclear.

The first major federal legislative response to homelessness was the McKinney-Vento Act of 1987, which passed both the House and Senate with large bipartisan majorities. The McKinney Act—which Bill Clinton later renamed the McKinney-Vento Homeless Assistance Act—provided funds not only for emergency shelter, transitional housing, and permanent housing, but also for job training, primary health care, mental health care, drug and alcohol treatment, education programs, and other supportive services. The consensus was that homelessness is a complex problem whose solution requires more than simply a roof and a bed.

The statutory goal of the McKinney Act was to gradually move homeless people toward stable housing and independence—a model that came to be known as “Housing Readiness.” Though this sprung from well-meaning intentions, it eventually became clear that this “gradual” approach frequently led to unwise and unfair ways of distributing welfare.

“We had this system that said homeless people essentially have to earn their way to permanent housing,” explained Ed Stellon, the senior director of the Midwest Harm Reduction Institute, and someone who has worked within the substance use and mental health treatment systems for more than 20 years. “Homeless people had to earn their way into transitional housing, make progress on certain goals, and finally when they were deemed well enough, they would earn their spot in permanent housing.”

A different model, known as “Housing First”, has been gaining steam over the past decade. What at first sounded revolutionary now feels fairly obvious: The Housing First approach posits that the only requirement for housing should be homelessness—that shelter is a right, not a privilege. “Plus, if you have conditions like out-of-control diabetes, congestive heart failure, or schizophrenia, housing is actually part of the solution,” adds Stellon. “It’s hard to make any meaningful progress on these chronic conditions without stable housing.”

Though exact estimates are hard to come by, HUD recently reported that as of January 2014, the chronically homeless numbered some 84,291, with 63 percent of those individuals living on the streets. HUD says this number has declined by 21 percent, or 22,937 persons, since 2010—in large part because of the embrace of Housing First. (Some, however, have accused the federal government of using data gimmicks to paint a more cheery picture of progress than has actually been made.)

Nevertheless, the reality is that at the same time policymakers are embracing the idea of Housing First, fewer affordable housing units exist than ever before. According to the National Low Income Housing Coalition, federal support for low-income housing has fallen 49 percent between 1980 and 2003, and the Joint Center for Housing Studies found about 200,000 rental units are destroyed annually. Research also suggests that a supply of 8.2 million more units would be needed to house extremely low-income households, up from a gap of 5.2 million a decade earlier. Though Congress recently authorized funding for the National Housing Trust Fund—an entity that was created in 2008 to fund affordable housing proects—its budget is nowhere near large enough to meet the demand.

“We’re not doing enough to expand housing availability, and HUD can’t expand its services unless Congress allocates it more funding,” says Barbara DiPietro, the director of policy for the National Health Care for the Homeless Council.

Given the fiscal climate, HUD is looking for new ways to spend its increasingly limited budget. Consequently, the agency is moving away from the supportive services that, through the McKinney-Vento Act, once accounted for most of its spending. In 1998, for instance, 55 percent of HUD’s budget was spent on supportive services, and 45 percent was awarded for housing. By 2013, just 26 percent of HUD’s competitive homeless assistance funds went to supportive services, and 66 percent was spent on housing. According to Ann Oliva, director of HUD’s Office of Special Needs Assistance Programs, the department’s goal now is to help local communities become more strategic with existing resources and available opportunities.

To do this, HUD has been working closely with other federal agencies, especially the Department of Health and Human Services (HHS), the Department of Veterans Affairs (VA), and the U.S. Interagency Council on Homelessness. In 2008, a joint program known as HUD-Veterans Affairs Supportive Housing (HUD-VASH) launched, combining housing vouchers for homeless veterans provided by HUD, with case management and clinical services provided by the V.A. Experts agree that HUD-VASH has been quite successful in helping both vets and their families, and it’s typically held up as the poster child for future interagency collaborative efforts. However, the program came with additional appropriated dollars, and it is typically easier to convince Congress to fund programs for impoverished military veterans compared to other downtrodden groups.

One of the most significant recent changes to homelessness policy has come through the expansion of Medicaid—a key feature of the Affordable Care Act. Now that nearly all individuals with incomes up to 138 percent of the federal poverty level are eligible for health insurance in states that opt for the expansion, agencies are scrambling to enroll thousands of homeless people so that they may benefit from new streams of mandatory government spending.

But Medicaid is, at its heart, a program controlled by the states. And with some states still vigorously opposed to expanding Medicaid—despite the ACA’s mandate for the federal government to pick up nearly all of the tab for the expansion—let alone some of the flexible legislative adaptations that HHS is encouraging, consistent and widespread changes to supportive services seem unlikely in the near future.

Though Medicaid expansion presents great opportunities for providing services to the homeless, some are concerned that the more flexible federal dollars currently set aside to work with homeless people will eventually just be funneled into the larger health insurance pool, with little, if any, allocated to doing what it takes to bring those with no homes into the government support system, which is needed in order to provide preventive care.

“Going out four or five times to visit with a woman living alone under a bridge, just trying to form a relationship and build trust with her so she will feel comfortable coming in to get more help—those types of health encounters are not typically billable through health insurance,” adds Stellon, who says outreach can be one of the hardest things for him to fund. “In our current system, it’s easier to pay for someone’s amputated fingers than to build a human relationship.”

Ultimately, there is only so much the government can do to advance the goal of Housing First with a depleting stock of housing units and a shrinking budget for supportive services.

“It’s a big mistake to come up with a good solution like Housing First and then to hamstring it because we don’t actually have the money for it,” says Todd Stull, the clinical director at a JOURNEYS | The Road Home, an organization that provides services and shelter to families and individuals in Illinois’s North and Northwest suburban Cook County. “One of the worst things you can do is get someone into housing for a short period of time and then they lose it. Then they lose trust in the providers.”

“We have not done well as a nation taking on poverty and implementing policies needed to address homelessness,” says Dr. Sam Tsemberis, the founder and CEO of Pathways to Housing, a national organization that first pioneered the Housing First model in 1992. “So we end up taking care of homelessness out of desperation, but we’ll be taking care of homelessness forever if we don’t take care of poverty.”

“We need more money,” adds DiPietro. “Until then, we’re just rearranging the priority list.”

Time for a Plan C

Originally published in The Washington Monthly on November 26, 2013.
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After years of fighting to make Plan B available without a prescription to girls of any age, the discouraging announcement that Norlevo, a European drug identical to Plan B, loses effectiveness in women who weigh more than 165 pounds and is completely ineffective for women who weigh more than 176 pounds, casts a dark shadow on what was previously celebrated as a victory for women’s health and empowerment. The racial and economic disparities of those who can benefit from Plan B turn out to be much starker than previously understood.

Manufacturers of the European drug announced that they will be updating their packaging information to reflect the weight limits, but it’s unclear yet whether the U.S. will make similar changes to the American version.

When the Obama Administration decided this past June to allow a federal district judge’s ruling to stand—which said that girls younger than 17 should be allowed to purchase plan B over the counter—it seemed like hard-won triumph for the scientific community and women’s rights organizations.

Planned Parenthood Federation of America president Cecile Richards, called the government’s decision to drop the appeal “a huge breakthrough for access to birth control and a historic moment for women’s health and equity.”

Yet this turns out to be a far greater “breakthrough” for some women than for others.

People knew Plan B was hard for poor people to access before this announcement. It’s expensive! One package typically costs between $30 to $65, which can be hard to raise on very short notice. In an economy where nearly 2/3 of the 3.6 million minimum wage workers are women, the affordability of Plan B is already a difficult if not impossible expense.

And, as one might expect, American women often come in over this new weight range. According to the Centers for Disease Control and Prevention, the average weight of American women during the years of 2007-2010 was 166.2 pounds. The average weight of non-Hispanic black women aged 20-39 was 186 pounds, and among Mexican-American women, 78 percent were overweight or obese.

To sum up: Plan B is an ineffective and often unaffordable emergency contraceptive for many American women, particularly minorities.

According to the Guttmacher Institute, in 2006, black women had the highest unintended pregnancy rate of any racial or ethnic groups. At 91 per 1,000 women aged 15-44, it was more than double that of non-Hispanic white women.

Plan B is not an abortion pill, like RU-486, which must be administered in a doctor’s office. Instead, it prevents the fertilization of an egg—which is why it must be used within about 120 hours of intercourse. The drug has been available by prescription since 1999, and contains levonorgestrel, a synthetic version of the hormone progestin. Levonorgestrel has been used in birth control pills for more than 35 years; Plan B contains a higher dose and is taken as two separate doses 12 hours apart.

But drug makers say they’re unsure if increasing levonorgestrel levels further would boost its effectiveness for women over 165 pounds. A spokeswoman for the European drug said, “A dose increase of levonorgestrel is not proven to be a solution for this problem.”

The spokeswoman recommended women with higher weight consider intrauterine devices (IUDs) as an alternative. Yet IUDs are even more expensive, costing anywhere from $500-$1000.

As the abortion fight wages on around the country, with more and more states and cities looking for ways to limit access to abortions or ban them entirely, the fact that a safe and legal abortion alternative is ineffective for many women is rotten news.

At least under the Affordable Care Act, women do have more options than they did several years ago. Birth control and preventive services like mammograms are now covered (barring more legal challenges); insurance premiums are now equal across genders.

But unplanned pregnancy is still a problem—even birth control isn’t 100% effective.

The U.S. Department of Health and Human Services’ Healthy People 2020 campaign aims to reduce unintended pregnancy by 10%, from 49% of pregnancies to 44% of pregnancies, over the next 10 years. According to the Guttmacher Institute, about half of the 6.7 million pregnancies in the United States each year (3.2 million) are unintended.

An emergency contraceptive that disproportionately benefits wealthier and skinnier Americans cannot be the only (relatively) affordable option. If we truly want to help reduce unplanned pregnancy and improve all women’s health and equality, then we need a plan C.

Common sense on Plan B.

Originally published in the Baltimore Sun on April 9, 2013.

Last week, a federal district judge in New York ruled that girls younger than 17 should be allowed to purchase the Plan B contraceptive pill over the counter. Unlike the Obama administration, Judge Edward Korman got this one right. The 2011 decision by Health and Human Services Secretary Kathleen Sebelius to restrict access for younger girls not only denied them a safe and legal means to prevent unwanted pregnancy but ignored all scientific evidence that supported its access.

Emergency contraceptive pills, commonly known as “Plan B,” are drugs that work to prevent pregnancy if taken shortly after sexual intercourse. Plan B, which has been available by prescription since 1999, contains levonorgestrel, a synthetic version of the hormone progestin. Levonorgestrel has been used in birth control pills for more than 35 years; Plan B contains a higher dose and is taken as two separate doses 12 hours apart.

Given that teen pregnancy rates in the United States, while declining, are still high for an industrialized nation, the need for easier access to all forms of safe and effective contraception is great. And there is no question that Plan B is safe; aspirin is more dangerous and susceptible to misuse. For that reason, the Food and Drug Administration recommended in 2011 that Plan B be made available over the counter without a prescription.

Nonetheless, President Barack Obama defended Ms. Sebelius’ decision to reject the FDA recommendation, saying at the time that he believed the nation should exercise “common sense” when deciding what medicines to allow over the counter. White House spokesman Jay Carney reiterated that line on Friday, again calling it a “common-sense approach.”

Common sense would be to make decisions based on reputable scientific research, as Mr. Obama had pledged to do during his first inaugural address, when he said he would “restore science to its rightful place” in policymaking. Instead, “common-sense” effectively means “compromise” with those whose real agenda is to erode access to contraception and those who mistakenly think Plan B has something to do with abortion.

Plan B is not an abortion pill, like RU-486, which must be administered in a doctor’s office. Instead, it prevents the fertilization of an egg, which is why it must be used within about 120 hours of intercourse. Nonetheless, Plan B has become a target of abortion-rights foes and those who think that increasing access to contraception somehow leads to promiscuity.

The Obama administration’s decision to reject the Food and Drug Administration’s advice on Plan B was a surprising one for a president who has otherwise done much good for the cause of women’s health care. Under the Affordable Care Act, women can now receive free birth control; they can get preventive services like mammograms, new baby care and well-child visits without co-pays; and there are greater crackdowns on discriminatory insurance premiums based on gender.

The only conceivable explanation for the president’s decision was that it was an attempt, amid a re-election campaign, to avoid fueling the trumped-up narrative that his efforts to extend contraception access amounted to a “war on religion.” Judge Korman called the ban “politically motivated, scientifically unjustified and contrary to agency precedent.” His decision was supported by scientists, experts, women’s reproductive health groups and the American Academy of Pediatrics, which had advised its members to issue blanket Plan B prescriptions to teen girls as a means to get around the Obama administration policy.

This ruling comes at a time when women’s reproductive rights are being put at risk in state houses across the country. North Dakota recently passed legislation to ban any abortion after six weeks, the strictest such measure in the nation. It trumped legislation passed in Arkansas earlier this year to ban abortions in the 12th week of pregnancy, and it is about to be leapfrogged by a Kansas bill that defines life as beginning at fertilization.

It is unclear yet whether the Obama administration will try to fight the Plan B ruling. Mr. Carney said in a news conference that the president’s opinion “has not changed.” But now, the president doesn’t even have the excuse of political expediency to justify his position. The science is clear, and so are the public health benefits of making Plan B widely available. The president should let this decision stand.