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Health Reform

A health care Q&A with Gov. Deal

Gov. Nathan Deal visits WellStar Cobb Hospital in Austell last year. Photo courtesy of Andrea Briscoe

Gov. Nathan Deal visits WellStar Cobb Hospital last year. Photo courtesy of Andrea Briscoe

Nathan Deal has been involved in many high-profile decisions on health care while serving as Georgia’s governor.

Deal, who is running for re-election this year, has staked out his opposition to the Affordable Care Act (often called Obamacare) and to expanding the state’s Medicaid program. He has also supported changes to the health plan covering state employees and educators, following a wave of criticism that occurred after a new benefits framework debuted Jan. 1.

Georgia Health News recently emailed questions to Deal on a wide range of  major health care issues in the state. We received his reply Monday,  shortly before the scheduled close of the 2014 General Assembly.

In his answers, he discusses pending legislation, the federal law on ER care, the financial struggles of rural hospitals, and what he sees as ways the state can improve its health care system.

Here are GHN’s questions and Gov. Deal’s responses:


Q: What is your biggest accomplishment as governor in the field of health care?

A: When Washington tried to levy the huge taxpayer burden that is the Affordable Care Act on Georgians, I could not allow for billions of dollars of our state budget to be diverted from our schools and our citizens. By mitigating that disastrous impact on our state — an additional 620,000 people on Medicaid rolls and billions of dollars — we are keeping our budget balanced and protecting the people of Georgia.

Q:  As governor, you have blocked Medicaid expansion in Georgia. House Bill 990 would require legislative approval for any such expansion in the state. Do you support this legislation?

A: Yes, just the expansion of Medicaid would cost Georgia an additional $2.5 billion over 10 years. This will have major budgetary impacts so it only makes sense to have our state legislature play a part in the decision making process.

Q:  Do you foresee any circumstances under which you would support an expansion of Medicaid?

Gov. Nathan Deal

Gov. Nathan Deal

A: No, not under current conditions. I am doing everything in my power to rebuild our school funding as we come out of the Great Recession. We simply cannot afford the $2.5 billion in new spending that the expansion would require without a severe impact on public education. The federal administration needs to start acknowledging the Supreme Court ruling and look at other alternatives that don’t force new spending by the state. I have often discussed the advantages of a block grant. States need more flexibility in order to make their program work for their unique population rather than a one-size-fits-all Washington mandate. When I was a congressman, I served as chairman of the health subcommittee of Energy and Commerce. The need for flexibility is not new to me, but serving in my role as governor has only reinforced the notion that states can operate more efficiently with flexibility.
Q: HB 707 would prohibit employees of any state unit from spending state funds to advocate for Medicaid expansion. It would also bar the University of Georgia from operating its current navigator program, which hires and trains people to help consumers use the health care exchange. Do you support this legislation?

A: It is my policy to not comment on pending legislation that is not part of my legislative agenda.

Q: You recently commented that changes to the federal EMTALA law (requiring hospitals to treat arriving ER patients) can help reduce health care costs. Can you expand on those comments?

A: I have always been a supporter of promoting primary care and preventative care as opposed to emergency room visits for non-emergency circumstances. In the case of a true medical emergency, people should always have access to emergency rooms. However, for non-emergency situations, we should encourage those people to seek treatment in a more cost-effective setting, thus opening beds and reserving resources for those in most critical need. Because there is some confusion on this issue, let me be clear: No one’s going to be denied service. None. This isn’t about blocking doors to health services. It’s about opening new doors that yield better health outcomes at a fraction of the price of emergency rooms. The onus is on us to make sure these non-emergency resources are available and convenient to the populations in need of service.
Q: Four rural hospitals have closed in Georgia over the past two years. Can the state of Georgia do anything to prevent more from closing?

A: I recognize the critical need for hospital infrastructure in rural Georgia, as they save lives and maintain our communities. Hospitals large and small have all felt the impact of the recent economic downturn. While support that these hospitals received has diminished, I am hopeful that as the economy improves, so does the flow of funding and contributions that keep our rural areas thriving. We will continue to monitor the situation with the Department of Community Health.

Q: The changes to the State Health Benefit Plan that began in January have sparked a wave of criticism from educators, state employees and retirees. Will the pending switch to a co-pay system alleviate the members’ concerns?

A: The intention of those changes was to lower out-of-pocket health care costs for state employees. The SHBP already covered 100 percent of preventative care visits, and these improvements give employees an additional layer of security so they can do the right things to stay healthy. I believe the changes address the core concerns of our employees, but the Department of Community Health will continue to monitor and evaluate the situation.

Q: Medical marijuana has suddenly become a high-profile topic in the General Assembly. Do you support this legislation that would create a mechanism to help children with seizure disorders?

A: As I said previously, it is my policy to not comment on pending legislation that is not part of my legislative agenda.

Q: What can be done to improve the health care system in Georgia?

A:  Since taking office, I have focused on the need for additional health professionals in Georgia. We have been increasing the number of residency slots in hospitals across the state. Georgia taxpayers help fund a promising young Georgian’s pre-K, K-12, post-secondary and graduate-level medical education only to see them perform their residency outside of our state and not return. That doesn’t provide value for Georgians paying taxes. It doesn’t make sense for Georgians needing care and it isn’t fair to young Georgians looking to begin medical careers. We must ensure that no doctor trained in Georgia is forced to leave the state to complete his or her medical education. There is still work to be done, but we are making strides on this front. Individuals in Georgia can also play a major role in improving their own health by being active in their healthcare decisions. This means taking advantage of all the preventative care opportunities to improve the well-being of themselves and their families.





Insurance ‘navigators’ feel like they’re swimming against the tide


Protesters in Coweta County rally against the UGA navigator program in November. Photo courtesy of  the Newnan Times-Herald.

Back in December, with the deadline approaching for people to enroll for Jan. 1 coverage in the new insurance exchange, an event was scheduled to inform Greene County residents about the program.

The event was to feature a health insurance “navigator,” a person trained and licensed to inform people about the Affordable Care Act and guide them through exchange enrollment. This particular navigator, Kimberly Jenkins, was one of a dozen working under a federal grant to the University of Georgia.

Greene County would seem to be a promising venue for such an information session, since 19 percent of its residents have no health insurance. “A lot of people could benefit in this community,” said David Daniel Jr., the county’s extension agent for agriculture and natural resources.

But this particular gathering did not work out as planned.

Daniel said he tried to distribute flyers for the event in many locations — including a hospital, a drugstore and many medical offices — but the only place that agreed to put one up was the Greene County Public Library.

“I left them with a couple of doctors’ offices, but no one put them out,” Daniel said. “It’s kind of understandable. It’s still one of those issues that no one wants to touch. With things being the way they are now, everybody’s got to be politically correct. No one wants to go out on a limb to make it work or to help it work.”

And if that lack of response was not annoying enough, the session had to be called off at the last minute because Jenkins became ill. It has not been rescheduled so far.


Many people skeptical of Obamacare


The misfired effort in Greene County was partly a matter of bad luck, of course. But the whole incident seems to sum up the roadblocks that navigators face in Georgia. The ACA, also known as Obamacare, is complex and controversial. People who are trying to raise awareness about it are in an uphill battle.

The problems for the navigators began early, with the bungled October 2013 debut of, the federal exchange website. Navigators were supposed to help people use the exchange, but most Americans could not get access to it. Repairs on the site took weeks.

At the same time, a controversy over policy cancellations led to a nationwide wave of bad publicity about the ACA in general. Many people became wary of having anything to do with Obamacare.

Photo of the Georgia Capitol BuildingAnd in Georgia, members of the Republican-led political establishment have remained firmly opposed to the ACA. They fought the health law before it was passed, tried unsuccessfully to repeal it and supported legal challenges to it. In the General Assembly, GOP lawmakers are now seeking to bar the public state universities or colleges from helping to implement it. (That would appear to eliminate the UGA navigator program.)

Health and Human Services Secretary Kathleen Sebelius, visiting Atlanta on Monday, defended the navigator work, saying of the UGA program: “I can’t imagine a more important job than letting people know what the law says, and what their rights and benefits are.’’

Navigators themselves have become a focus of ACA opponents. Late last year, an ACA information session in Coweta County was the target of a protest by Georgians for Healthcare Freedom and the Coweta Tea Party. Some protesters carried signs reading “Navigators get out.”

Though the Coweta demonstrators were few in number and peaceful, the safety of navigators is a top concern, said Sheri Worthy, the principal investigator for the grant that funds the UGA navigator program. Since the protest, the UGA faculty members who supervise the navigators posted in rural areas have decided to cut back on big, open events and concentrate on individual enrollment.

“We really refocused our efforts to work with individuals and doing small, focused events in trusted venues,” Worthy said last month during a presentation on the UGA campus.

All told, UGA’s 12 navigators have held 365 educational activities in communities throughout Georgia.


Enthusiasm for the mission


Jenkins, the navigator whose illness forced the cancellation of the Greene County public information session, said she is trying to reschedule it, and hopes to work next time with St. Mary’s Good Samaritan Hospital in Greensboro.

County official Daniel, who distributed flyers the last time, said he is still trying to determine the “most efficient way to get information out in a timely manner.” A newcomer who has been on the job for only seven months, he acknowledged that printed notices may not be the way to go.

Greene County resident Mary Miller said she gets most of her news from local newspapers such as The Breeze and Lake Oconee News. She said she did not hear any talk about the planned event in December and did not see any advertisements for it.

But she’s familiar with the ACA effort. “I’ve heard talk about it at work,” said Miller, a real estate agent who has insurance. “There’s certainly word around that they are trying to get people to sign up for it.”

Jenkins is responsible for disseminating health care information to about 100,000 people living in 12 of Georgia’s 159 counties. She tries to visit a county once or twice a week and devotes the rest of her time with to individual appointments with people trying to get insurance through An appointment typically lasts one hour as she walks the person through the application and answers any questions.

It’s a slow process, but Jenkins said she is making it work by visiting several counties in one day and spreading the word wherever people gather. She regularly attends churches in the community and enrolls people after services.

“I’ve enjoyed it,” Jenkins said. “Just being able to help and meet different people.”

Becoming part of the existing “community system” is crucial to reaching rural people, according to Sharon Gibson, the cultural trainer for the navigators. She instructs navigators to work with the leaders in the community and the popular groups that already operate there.

The hostile response to the ACA, made worse by the implementation problems last fall, has been a hurdle for Jenkins. She said people are often skeptical until they see the premiums for health coverage.

“Once they see the prices associated with the claims, they are generally happier, so I urge them to do the application,” she said.

Georgians can sign up for health insurance until March 31, when 2014 enrollment closes. The navigators and extension agents are working to sign people up by the deadline. After that, they will continue to educate people about health insurance in general.

“It doesn’t matter who they are — white, black, Latino — people in rural communities are wary of change,” said Gibson. “There’s a lot of TV and radio and that’s confusing. A lot of what our navigators do is address misconceptions.”


Lindsey Cook is a senior at the University of Georgia,  studying journalism, computer science and new media. She is an AP-Google scholar and her work has appeared in The Washington Post, The Atlanta Journal-Constitution and Online Athens.



Carter: ‘Reduce the size of our uninsured population’

State Sen. Jason Carter (D-Decatur) recently announced that he is running to become governor of Georgia, attempting to follow in the footsteps of his grandfather Jimmy Carter, who was governor of the state from 1971 to 1975. 

Carter sat down this week with GHN to discuss a range of health care issues, including the Affordable Care Act, the criticism of the State Health Benefit Plan, and the financial struggles of rural hospitals.

 (GHN is also reaching out to Gov. Nathan Deal for a similar interview on health care topics.)

 Here is the Carter interview:



Q: What are your thoughts about House Bill 990, which would require legislative approval for any expansion of Medicaid in Georgia?

A: I think it’s essentially a political bill. If you examine the bill by looking at the problem that it’s attempting to solve, it’s very difficult to discern what the Legislature believes that problem to be, other than they’re worried that I’m going to get elected governor . . .

The politics are real and I think are at the forefront of it. I think the thing that’s amazing to me is that the governor would agree to give up the ability to respond in an appropriate way to the situation that’s there, to operate the state government as an executive. And I think that’s part of a pattern that this governor’s leadership style has been essentially one of passing the buck on important issues. And I think that’s a problem. This bill is indicative of that pattern.

Q: You’re in favor of Medicaid expansion?

A: What I believe is that we have to look at this problem critically. I think expansion should be on the table … and make sure those folks [eligible for coverage] can get either private insurance on the exchanges or get a Medicaid-like expansion — it all has to be on the table. I think we will do one of those things if I’m elected governor.

Q: Are you going to make expansion and health reform issues in your campaign?

A: There are sort of two sides to this coin. What you’re talking about on some level is, what are the politics of it? And on another level, what’s the moral value, or what’s the correct policy option?

I’m not sure what the politics are, but I’m going to do what I think is right, no matter what.

I think that it makes economic sense for our state to ensure that we draw down our tax dollars and bring them back to Georgia to improve the health options that our citizens have, to improve the economics of our hospitals, to inject a giant amount of money into the economy.

The jobs impact of taking the billions of dollars back and not rejecting our own tax dollars is huge. Plus, it ripples out to having more productive, healthier citizens.

My impression thus far of the governor’s campaign is that they’re going to talk about “Obamacare” a lot. I think [with] the national dialogue on Obamacare, there are going to be books written about it. It has become whatever it has become as this political animal.

The bottom line is the Affordable Care Act [Obamacare] was passed by Congress, signed by the president and affirmed as constitutional by the Supreme Court. It is the law of the land, no matter what.

What has happened in my view is what we’ve seen in Georgia is that all the Washington politics about Obamacare have been imported. It doesn’t matter if I support 100 percent of the Affordable Care Act or not. There are things I would change, there are things the president would change. The question we have to confront as governor, is what’s best for the state, given the federal law.

This governor came from being in Congress for two decades and can’t let go of the Washington politics, and wants to use Georgia’s tax dollars and Georgia’s health and sacrifice it on this Washington politics altar of Obamacare, and say, we are not going to do this because of Washington politics, instead of looking at this, and say, what makes sense? We have to look as governor at what’s best for the citizens of Georgia.

To me, it is examining the best way to do an exchange, rather than just rejecting it. [Georgia, like a number of other states, lets the federal government run its exchange.] And examining the best way to take the health care dollars and reduce the size of our uninsured population.

Q: Can you comment on the argument that expansion will cost the state too much money?

A: What’s interesting to me about this rhetoric about the federal government is that it’s pick-and-choose. We don’t like Obamacare because Obamacare is unpopular. That’s pure politics. We like deepening the Savannah Harbor with federal dollars because, well, that is popular.

Georgia today under the current leadership is one of the most dependent states on the federal government in the country, and yet we sit here and blast the federal government all day, while we grow more and more dependent on it. Half of the time we’re begging for federal dollars.

I think we have to strengthen our state government in ways that make sense. We have to invest in the future. To the extent that we’re going to participate or not participate in federal programs, we need to look at what they are doing for our state. Are we investing in our future? Are we getting stronger? When we build roads, when we invest in our infrastructure, when we deepen the Savannah port, I think those things strengthen our state. I think it strengthens our state by injecting billions of dollars into our health care system to reduce the size of our uninsured population. Those things are investments in our future that don’t make us more dependent on the federal government.

We pay our federal tax dollars in Georgia, yet we’re going to try to pick and choose based on politics when we get the benefits of those tax dollars? That doesn’t make sense.

Q: There was another rural hospital that closed in Georgia last week – Lower Oconee Community Hospital in Wheeler County. That makes four to close in Georgia in two years. What are your thoughts on that issue?

A: It is a major crisis for a community when a hospital closes. Lower Oconee in Glenwood had 100 employees and 25 beds. The problem in a community like that when a hospital closes is not just that you’re losing health care options and not just that you’re losing jobs. The economic impact a hospital has in a community like that is gigantic. It also ripples out beyond that. If it takes 30 or 40 minutes to get to a hospital from that spot, it’s harder to put a factory or mill there. You’ve got someone operating a nail gun, you have someone operating a piece of machinery, and you’re nowhere close to a hospital. It makes it more difficult. Those things about rural Georgia and rural hospitals are incredibly important to me and to those communities.

We have to find a way to make those hospitals economically viable and sustainable. One piece of that, I believe, is to use our federal tax dollars that we’ve already paid that are waiting for us to reduce the size of the uninsured population. That uninsured population is just a giant hole in [hospitals’] budgets.

We have to find ways to have sustainable economic models for those hospitals going forward. It’s not just reducing the uninsured population. It’s also finding an appropriate mix of services that are going to work in those areas. I understand there are ways to approach that issue through the regulatory environment. It doesn’t have to be to open up [the certificate of need rules]. I think we can explore regulatory solutions. We haven’t seen that yet from this administration. This being an election year, as soon as we start talking about things, the administration has acted. Hopefully we’ll see some of that in a short period of time.

Q: The health plan that covers state employees and teachers has come under sharp criticism since changes were launched in January. What’s your view of this situation?

A: First of all, I’m on that same health plan. I not only heard complaints from citizens, but complaints from my wife. A very important constituent (laughs) . . . [Both Carter, as a state legislator, and his wife, a teacher, are eligible for the state health plan.]

I believe that we have to have options — more options than we have now. I think the outcry from teachers and others has been intense and powerful. And you saw, all of sudden it’s an election year, and we’re seeing a huge amount of responsiveness from the governor’s office. The flip-flop on whether we needed to use the reserves from the State Health Benefit Plan is not shocking, it’s just politics as usual.

We’ve spent $100 million out of the reserve fund as an attempt to placate the anger. It doesn’t actually solve the problem. We’re going to continue to hear from a great number of people, led in part by the teachers, that this is not enough. We’re talking about real options that need to be there.

The State Health Benefit Plan is a symptom of a much deeper-seated problem, which is the current leadership of our state doesn’t believe they need to take care of those teachers. They don’t have a respect for the work that gets done, and the desire to recruit and retain and support the best possible workforce that they can.

I think one other aspect of the current leadership’s ideology that is indicated by this decision is they don’t run the state with the belief that it can succeed as an entity. They’re so against “government” as a concept that they don’t believe in its success. If that’s true, you’re running a multi-thousand-employee entity with serious morale problems, with disrespect for the employees. . . . You end up with decisions like this that result in a backlash.

Q: Medical marijuana is an issue that seems to have come out of the blue, yet there’s momentum in the General Assembly to allow its use for children. Do you have a position on that?

A: I agree with you that it was an interesting and surprising development, given the makeup of the Legislature. I think the fact that it was a very conservative Republican from Middle Georgia who has led the charge is interesting.

But I personally tend to be a libertarian on things like this. . . . If you have a carefully crafted piece of legislation that’s going to minimize the unintended consequences, then I wouldn’t have a problem getting on board with it.

When you talk about the health outcomes for the kids that they’ve been discussing, you have to put those facts first, and whatever ideology there is, second, or not at all.

Q: Is health care going to be a big part of your campaign?

A: Part of a campaign is meeting people where they are.

Health care is an undeniably important part of our policymaking. The state government has a huge impact on the health care industry and the health care of its citizens. There are major problems that we’re confronting. There’s no doubt in my mind that it will be an important, crucial part of my governorship.

How the campaign plays out is too hard to know.

Q: Anything you want to add about health care?

A: I think it’s important that people get good information about the health care policy discussions because it’s so opaque.

If I buy a car muffler, I know exactly what it costs. If you go get an MRI, I haven’t found anyone who tells me how much it costs.

Q: The prices could vary by hundreds of dollars.

A: Not only that, but to different patients. Having a good, well-informed discussion about it is really important.

Q: Can the state do anything about making health care prices more transparent?

A: Yes, I think that the state can do that. Part of the problem is that [there is] so much volatility into the system with the staggered rollout of the different parts of the Affordable Care Act, we have to take a minute so see where that’s going to go. We don’t know what it’s going to do to costs.

But once we settle in, and understand what the [impact of] the federal law is going to be, I think there’s a variety of things the state can do, certainly from an informational standpoint. It’s not easy, but I do think transparency is one of the things that almost always helps.



Patient classification — a complex subject, but too important to ignore

corridor in hospital / Flur im Krankenhaus

The wife of a retired Atlanta physician recently got a stunning lesson when her husband spent some time in a hospital.

“We realized there might be a problem when he was not served breakfast along with the other patients,” she said.

That was when they were told he had not actually been admitted to the hospital.

“But he’s in a hospital bed, and he’s here in the hospital,” responded the wife.

“Yes,” a nurse explained. “It can be confusing.”

The wife, who is requesting anonymity due to privacy concerns, got another shock when the hospital bill arrived. During her husband’s hospital stay, he had received the same routine medications he took at home, but the amount the couple was being charged for those drugs far exceeded what they paid at their pharmacy.

The lesson the couple learned is that being “hospitalized” can mean different things.

Many Medicare patients are placed under “observation status’’ when they arrive at a hospital. That means they are considered outpatients and are not formally admitted, even if they are given a bed.

For a patient under observation status, Medicare reimburses the hospital differently. And that may increase the out-of-pocket costs that Medicare patients face. (But if the patient has a Medicare Advantage Plan, such as an HMO, cost and coverage may vary.)

Hospitals may get an indirect financial benefit when they place people on observation status.

For instance, a patient who is formally admitted to a hospital counts as a readmission if he or she has recently been discharged from that facility. An outpatient does not count as a readmission even if he or she has been discharged recently. This is important because readmission statistics affect a hospital’s bottom line. If the facility records a high number of Medicare patients being readmitted within 30 days of a discharge, it faces federal penalties on its reimbursements.

As hospitals try to avoid the costly problem of too many readmissions, the patient may be caught in the middle.


The vanishing inpatient


Keith Lind, senior policy adviser for AARP Public Policy Institute, said recently that a national study found that both one-day inpatient stays and inpatient stays of all lengths declined by about 16 percent during the study period. But at the same time, the report said, “the ratio of observation use to inpatient stays per 1,000 beneficiaries increased by 94 percent.”

Hospital Outpatient Entrance SignSometimes financial complications arise for patients, as when a Medicare patient is transitioned from being “observed” in the hospital to being treated in a skilled nursing facility, such as a nursing home or a rehabilitation unit.

The patient must first have been an inpatient for at least three full days for Medicare to pay toward the skilled nursing facility stay.

To help Medicare beneficiaries, CMS urges patients to question every hospital stay and find out if they are listed as inpatients or outpatients. But often a patient may be too ill to ask Medicare-related questions, and the family will sadly discover the difference when the skilled-care bill arrives.

Dr. Cheryl McGowan, a Georgia family medicine physician, recalls the situation at a hospital where she trained. Sometimes residents would admit a Medicare patient from the emergency room to an inpatient unit, but then learn that the patient did not meet the hospital’s criteria for inpatient admission. The physician would then be asked to change the patient’s status to observation.

A patient kept for observation may later qualify for inpatient admission, depending on the results of tests or changes in physical status during his or her stay, McGowan said. Such changes in patient designation can lead to confusion for everyone.

One CMS example illustrates some of the many variables: If a Medicare patient arrives in the emergency room with chest pain and the hospital keeps the patient two nights for observation, Medicare Part A, for inpatient hospital care, pays nothing. But Medicare Part B, for outpatient care, covers lab tests, EKGs, and certain other items, just as if the patient had been seen in a physician’s office.

Part A and Part B have been referred to as a full menu vs. à la carte. The à la carte or individually charged items can add up rather quickly under Part B. Hospitals get lower rates for room and board. But services such as X-rays, MRIs and the like are reimbursed individually, which helps the hospital.

To further complicate things, there is the two-midnight rule.

Last year, the federal Centers for Medicare and Medicaid Services issued a new policy on observation status. When a physician expects to keep the patient in the hospital for a period of time that does not cross two midnights, the services should be paid under Part B, or outpatient services.

Carol Levine, who heads the United Hospital Fund’s Families and Health Care Project, said at a recent Washington briefing that this two-midnight rule “continues to leave patients and families exposed to high and unexpected costs associated with what seems like an ordinary hospital stay.”

That’s because stays lasting less than two midnights will not be presumed to qualify as inpatient stays — and instead will be paid under Part B, which covers only outpatient services.

The co-pay for an individual service under Part B won’t be higher than Part A, but an overall total of the Part B patient co-pays might be. Costs can rise when they are individually billed, as opposed to the “package” pricing found under Part A.


Observation wards?


Today, hospitals must make patients aware of their inpatient or outpatient status. For example, if the physician writes an inpatient admission order and a hospital review changes the status to outpatient, there must be written notification of the change.

But do Medicare patients always understand the significance of a changed classification? As noted above, even some medical professionals admit it’s confusing.

smslogoPhysicians who are trying their best to deliver good care can be as frustrated as patients with the current situation. Dr. William Silver, the president of the Medical Association of Georgia (MAG), said the organization joined a number of state and national medical societies to push through a resolution urging the AMA to press for repeal of the two-midnight rule “because it only exacerbates the heavy and unreasonable administrative burden that’s been placed on physicians by the federal government and other third-party payers.”

In a joint letter to CMS in November, the American Medical Association and the American Hospital Association suggested a delay in enforcing the new two-midnight rule until Oct. 1, 2014. In the meantime, CMS has extended the delay in enforcement through March 31.

A potential solution that may protect the interest of hospitals and physicians is the establishment of hospital observation units.

On a recent PBS NewsHour program, Dr. Michael Ross, associate professor of emergency medicine at Emory University School of Medicine, and co-author of a study published in Health Affairs, said patients may require less than 24 to 48 hours of observation. The article suggests a unit just for those being observed may actually cut costs for the patient and the hospital, depending on the individual’s diagnosis and treatment.

But a further concern was brought up by Susan Reinhard, senior vice president at AARP: How will a hospital cover the cost of increased observation nurses if nurse-patient staffing is based on inpatient beds?

Reinhard says about a third of the hospitals in America already have dedicated observation units.

Ross and Reinhard, based on their research, say the majority of hospitals send patients to empty beds somewhere in the facility, a situation that offers less than the optimal setting for observation. They both wonder whether some of these patients are observed for far too long and should be formally admitted earlier.


Judi Kanne, a registered nurse and freelance writer, combines her nursing and journalism backgrounds to write about public health. She lives in Atlanta.


Mobilizing for enrollment: Veterans and the health care law

Vietnam War veterans gather in Washington, D.C., at a memorial.

Vietnam War veterans gather in Washington, D.C., at a Vietnam memorial.

How does the upcoming rollout of Obamacare affect Georgia’s 770,000 military veterans?

Are their VA benefits changing? What should veterans do if they’re uninsured now?

The Department of Veterans Affairs earlier this month sent out a letter to veterans explaining their options under the Affordable Care Act. Nationally, 8.7 million veterans are enrolled in the VA health program.

First, the 2010 law won’t change VA benefits. And if a vet is enrolled in VA health care, that coverage meets the standards for the health reform law’s insurance requirement. So that veteran will not face any penalties for not having health insurance in 2014.

That’s one reason the Department of Veterans Affairs expects to see its veteran patient population grow by about 66,000, a senior VA official told Congress in April.

According to the Urban Institute, there are an estimated 1.3 million uninsured veterans under age 65 in the United States, constituting roughly 10 percent of the nonelderly veteran population nationally. The estimate in Georgia is about 56,000 veterans without health insurance.

Most uninsured veterans are eligible for VA health care, federal officials say.

In the recent letter, the VA urges all qualified people who have no coverage to enroll in its health care system. There are no enrollment fees, monthly premiums or deductibles, and most veterans have no co-pays. (Some vets who have sufficient means pay modest co-pays.)  Because enrollment takes time due to the need to verify eligibility, it’s best to sign up quickly.

Not everyone who has served in uniform qualifies for VA health care. “It’s a common misconception that everyone gets VA coverage,’’ says Amanda Ptashkin of the consumer advocacy group Georgians for a Healthy Future.

One major group who do not meet the basic eligibility requirement for VA care are Reserve or National Guard vets who served on active duty for training purposes only.

(In recent years, it has become common for Reserve and Guard members to be called up for active duty and sent on assignment just like members of the regular military. If they are on active duty long enough, these troops can earn standard VA benefits. But from the 1950s through the ’80s, Guard and Reserve members were rarely called up, and many served for years without earning enough active-duty time to qualify for benefits. )

Overall, a veteran’s eligibility is determined by length of active service, type of discharge, service-connected disabilities, and income level, among other factors. Contrary to one common myth, war service is not required; there are many peacetime veterans in the VA health system.

veteranBut not all veterans who are eligible for VA care are enrolled. Genevieve Kenney of the Urban Institute’s Health Policy Center, who has co-authored studies on uninsured veterans, says that one possible explanation is that some uninsured vets who could qualify may not be aware that VA coverage is available to them.

Kenney adds that ACA-related changes — such as the availability of trained navigators, the screening of applications for a variety of programs, along with the fact that VA coverage will satisfy the individual mandate, could raise veterans’ enrollment in VA services.

More than 300,000 children of veterans and more than 600,000 spouses of veterans are uninsured, and most are not eligible for VA care, Kenney notes.

She says that more than 40 percent of uninsured veterans and over 50 percent of uninsured family members report having unmet health care needs.

Veterans who aren’t eligible for VA – and their families — could go to the health insurance exchange, or marketplace. But another option, gaining Medicaid coverage, is limited in states that aren’t expanding the program. Georgia has rejected Medicaid expansion.

Ironically, in states that don’t expand Medicaid, the poorest adults don’t qualify for the subsidies in the health insurance exchange.

About 20,000 low-income uninsured veterans would be eligible for Medicaid if Georgia expanded the program, but at the same time won’t receive subsidies in the health insurance exchange either.

“It doesn’t seem like it’s a big enough issue for people who object to the ACA,’’ says Tim Sweeney, director of health policy for the Georgia Budget and Policy Institute.

In Georgia, there are three VA hospitals and more than 20 clinics throughout the state.

Here are some ways to enroll in VA care or determine your eligibility:


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