Archstone Foundation: Funding to Help Prevent Elder Abuse in California and Inform the Field

August 30th, 2011

This foundation, located in Long Beach, California, focuses its grant making on older people. Its funding priorities are fall prevention, elder abuse and neglect, and end-of-life issues. In addition, Archstone also makes grants for “emerging and unmet needs within the field of aging.” The funder’s website notes that it accords highest priority to grant proposals pertaining to Southern California.

“Elder abuse is a devastating but often overlooked problem in our society,” according to a University of Southern California (USC), Leonard Davis School of Gerontology, news article. Writer Jonathan Riggs mentions long-time actor Mickey Rooney’s testimony before a congressional committee on this subject; Rooney was a victim of such abuse, Riggs says in the June article.

The Affordable Care Act of 2010 defines such abuse as “the knowing infliction of physical or psychological harm or the knowing deprivation of goods or services that are necessary to meet essential needs or to avoid physical or psychological harm.” (See Subtitle H—Elder Justice Act in the lengthy law!)

Citing the research of others, USC Mary Pickford Foundation Professor of Gerontology Kate Wilber says in the USC article that more than one in seven older adults is a victim of elder abuse each year. According to a summary of interventions that have been used to prevent such abuse, there is “little evidence” that “most efforts to prevent or address abuse work,” she noted.

The article announces that the Archstone Foundation recently awarded $200,000 in funding for Wilber and colleagues at the Davis School. They will use the money to determine whether the forensic center model is effective at preventing abuse and to do a cross-site evaluation of how effective California’s four elder abuse forensic centers (in Los Angeles County, Orange County, San Diego, and San Francisco) are.

Elder abuse forensic centers use a multidisciplinary team of professionals (including medical and mental health professionals, lawyers, and ombudsmen) who comprehensively examine alleged cases of abuse and consult on and prosecute cases of abuse of the elderly and of other dependent adults, according to the Los Angeles County center.

The Davis School evaluation, which is also using some funding from the National Institute of Justice, will compare and contrast the four centers and disseminate the lessons that the centers have learned.

This funding is part of a larger $350,000 grant that Archstone awarded to USC’s Keck School of Medicine in late 2010.

The forensic center evaluation is relevant to policy, as the Affordable Care Act (ACA) includes a provision called the Elder Justice Act of 2009, which aims to prevent elder abuse. The ACA embraces the forensic center model and has authorized $26 million in federal funding for such centers. Evaluation results will be helpful to communities interested in replicating this model in response to the Elder Justice Act, the USC Keck School’s proposal to the Archstone Foundation noted.

Jim Toedtman in the April 1 issue of the AARP Bulletin reported that the federal government has had a bigger role in preventing, investigating, and resolving elder abuse since the 2010 enactment of the Elder Justice Act. However, Toedtman also said that the federal response to elder abuse had been “fragmented” and that state agencies had been “swamped” with the increasing number and greater complexity of elder abuse cases as the U.S. population lives longer.

Related resources:

Institute of Medicine (IOM), Workshop on the Social and Economic Costs of Violence: The Value of Prevention,” April 28–29, Washington, D.C. XinQi Dong spoke at this workshop about U.S. policies, legislation, and programs on elder abuse. Dong is a senior policy and research adviser to the federal Administration on Aging, as well as associate director at the Institute for Healthy Aging, and an associate professor of medicine, both at Rush University Medical Center (in Chicago). (Title was current as of time of the workshop.) The workshop was part of the IOM’s Forum on Global Violence Prevention; funders of that forum include the Centers for Disease Control and Prevention (CDC), Robert Wood Johnson Foundation, Fetzer Institute (an operating foundation that does not accept unsolicited proposals), Kaiser Permanente, and many others.

“Shining a Light on Elder Abuse and Neglect,” Chris Langston, December 2, 2010, on the John A. Hartford Foundation’s HealthAGEnda Blog. Langston discusses the elder abuse prevention work of Terry Fulmer, who is Erline Perkins McGriff Professor and dean of the College of Nursing at the College of Dentistry at New York University, and XinQi Dong (the physician mentioned above). Fulmer and Dong have received funding from the Hartford Foundation.

Long-Term Care: What Some Foundations Are Funding

August 29th, 2011

I have compiled here some recently released content on long-term care. A poll funded by the SCAN Foundation was released just this month.

New Poll Results

Two-thirds (66 percent) of Californians age forty and older who were surveyed said they are worried about affording long-term care for themselves or a family member, according to a poll commissioned by the SCAN Foundation. That concern is non-partisan. Regardless of political party affiliation, the percentage of those worried is 62 percent or more. For that question, the statewide survey also looked at results for a subset of the entire dataset: respondents from four metropolitan areas. Interestingly, people in Sacramento were less worried about affordability of long-term care than those in Los Angeles County, San Diego, and the Bay Area; I am not sure why.

The UCLA Center for Health Policy Research collaborated with the foundation on the design of the poll and interpretation of its results.

Forty-two percent of those polled said that they could not afford to pay for even one month of care in a nursing home.

Among other findings, 85 percent of those polled said they either do not have long-term care insurance or are not sure whether they do. I asked a SCAN Foundation staffer for help interpreting that result: She responded, “Since you have to sign up for and pay an extra premium for [long-term care] insurance, it is likely that almost all of those who ‘don’t know’ are not insured.”

Amazingly, 90 percent of those polled said they had not heard of the federally administered, voluntary, Community Living Assistance Services and Supports Plan (more commonly known as the “CLASS Plan”), a long-term care plan that is funded by enrollees’ premiums, not by taxes. Another good thing about the CLASS Plan, the government says, is that “pre-existing medical conditions will not disqualify someone from enrolling.” (Read more here about eligibility for, and services covered under, the CLASS Plan.) This plan is part of the Affordable Care Act of 2010. Once respondents were presented with a description, most of them had a favorable opinion of the CLASS Plan. That sounds like the federal government needs to get the word out.

Future health care costs are also a concern: 63 percent of respondents are worried about how they are going to afford those.

SCAN cited some interesting factoids:

• the U.S. Department of Health and Human Services (HHS) says that 70 percent of Americans over age sixty-five will need long-term care services at some point.

• the average cost of nursing home care in California is $6,500 a month.

• the cost to have a licensed personal care aide come into the home on a part-time basis to help an elderly person who has a chronic illness with daily activities is running about $2,000 a month in California.

The survey aimed to better understand health care and long-term care issues confronting middle-aged voters as California confronts its current budget problems and an aging population, the UCLA center explained. The center cites a projection that the number of Californians older than age 60 will almost double in the next twenty-five years.

Steven Wallace of the UCLA Center commented in a press release that most Californians will need long-term care, but, unfortunately, most residents “are not planning for it and the government is cutting back on affordable options that could help.” According to the release, the fiscal year 2012–2013 state budget cut several key services that help those with long-term care needs (whether they are elderly or disabled) to stay in the community.

Lake Research Partners and American Viewpoint conducted the poll of nearly 1,500 registered California voters in June. The two firms drafted the survey questions and did the initial analyses of responses.

Recent publications:

“Health Policy Brief: The CLASS Act,” Health Affairs Policy Brief, by Joanne Kenen, May 12, The Robert Wood Johnson Foundation funded this brief.

“Improving California’s Aging Services and Long-Term Care System: Blueprint for Partnerships between California Foundations and State Policymakers,” April report, released June 15. Because of California’s ongoing fiscal problems, effective partnerships between the public and private sectors are needed, says a press release. And the California foundations sponsoring this short report are well positioned to partner with the state. This is because they have shown their dedication to improving aging and long-term care services and programs in the Golden State, and they “are willing to make available their expertise and resources, as is uniquely possible” for each funder, to California policy makers (Governor Jerry Brown [D] and the 2011–2012 state legislature), the document explains.

Seven foundations sponsored this “blueprint” document: the Archstone, California Community, California HealthCare, Gary and Mary West, and SCAN Foundations; the California Endowment; and the Health Trust. Consultant Deborah Reidy Kelch worked on this document.

Related resources:

“Enough Is Enough,” Larry Minnix, August 12, in “Letters from Larry” series on the website of LeadingAge (formerly the American Association of Homes and Services for the Aging). Minnix, who heads the association, asks, “What will it take for the nursing home to gain the respect it now deserves?” He states that “it is time [for long-term care payers] to pay for quality.” He also includes a concise and reasonable list of what is needed to improve (1) the care in nursing homes, (2) the economics of nursing home care, and (3) the reputations of nursing homes.

The Harry and Jeanette Weinberg Foundation, Older Adults program, includes priority areas in informal caregiver support (grants will not be awarded in this area until after March 2012) and promotion of the professional long-term care workforce. The foundation is located in Owings Mills, Maryland. Please note this foundation’s funding limitations.

Read about the Weinberg Foundation’s Family and Informal Caregiver Support Program, a three-year initiative that began in September 2009.

An Accountable Care Community in Akron, Ohio: Collaborating to Create a Healthier Future

August 23rd, 2011

Editor’s note: You’ve heard of an Accountable Care Organization, haven’t you? Now read about a new initiative—an Accountable Care Community—in this northeastern Ohio city.

In response to chronic health conditions, the Austen BioInnovation Institute in Akron (ABIA), its founding members, and numerous community organizations have joined to launch a first-of-its-kind Accountable Care Community, which will use the full force of the Summit County, Ohio, community to combat the region’s health concerns.

The effort, focused on improving health status and health care delivery and lessening the burden of disease, was announced at a summit in June. The kick-off event gathered national and regional health and wellness thought-leaders to discuss the idea and to start to build the initial framework of a comprehensive approach to health promotion and disease prevention, access to care and services, and health care delivery. The project, launched by the ABIA, is striving to focus Akron-area public, private, and philanthropic resources toward achieving improvements in population health and to closing gaps in health delivery, through aligned or coordinated efforts and pioneering approaches.

The ABIA, a unique biomedical innovation institute, was founded in 2008 by Akron Children’s Hospital, Akron General Health System, Northeast Ohio Medical University, Summa Health System, the University of Akron, and the John S. and James L. Knight Foundation, which committed an initial $20 million grant to launch the collaboration. Through this support and the backing of the institute by the City of Akron (Ohio) and County of Summit (Ohio), the ABIA has provided the convergence force needed to align Akron’s diverse institutions that are involved in health.

In forming an Accountable Care Community in Akron, the ABIA aims to share resources and build stronger community coalitions that will create not only a healthier Northeast Ohio, but also a replicable model for other communities.

In response to the health needs of the local community as well as the goals set by Healthy People 2020, the Accountable Care Community initiative is focusing its efforts on chronic conditions, such as diabetes, obesity, asthma, and hypertension.

Buttressed by partnerships of diverse members working cooperatively for a common goal, the ABIA initiative strives to leverage Akron resources from multiple sources to achieve a greater impact on the health of the community than any one organization could have alone. The initiative’s success will be tied closely to the trust and cooperation of the partners, who by banding together should be able to achieve broader and more meaningful results.

The Accountable Care Community effort is at the forefront of developing healthier communities and has great importance in light of recent health care reforms at the national level, including the increasing prominence of Accountable Care Organizations (ACOs). The ABIA is taking the concept of ACOs a few steps farther by expanding it into the entire community by linking to and leveraging the joint ABIA-Wellness Council of Summit County. The council was created in 2010 as a way to unite multiple community sectors around a shared vision of optimum wellness for Summit County, Ohio, residents. By mobilizing diverse partners in coordinated and collaborative efforts, the Wellness Council, as a component of the Accountable Care Community, aims to improve the physical, social, intellectual, emotional, and spiritual health of the community.

One of the goals of this public-private-philanthropic coalition, the Accountable Care Community, is to avoid the expenditure of funds on overlapping programming and services. This broad-based coalition can monitor and streamline efforts across multiple sectors. The overall goal of the Accountable Care Community is to effect changes across the range of determinants of health (for example, income and social status, genetics, physical environment, and social support mechanisms) and to make community efforts more efficient by strengthening links between existing programs, capitalizing on resources, and building novel solutions to chronic health issues.

The ABIA hopes to provide a full spectrum including health promotion and disease prevention, access to health and social services, and health care delivery. We hope to achieve a unified approach to health promotion, provide residents with access to high-quality care and services, and design efficient care delivery models for the region. The Accountable Care Community initiative takes the concept of a coalition to a new level by drawing together a number of area entities in a comprehensive approach to sharing programming, resources, and personnel. This approach should achieve health improvement, close gaps in care delivery, and measure the effects of innovation. The Accountable Care Community coordinates health promotion and disease prevention services and manages chronic diseases through outreach to every community outpost that may affect the health of individual residents in the Akron area.

The initiative’s steering committee is developing a White Paper, expected to be released in September, to further guide the development and implementation of the Accountable Care Community. Ultimately, through that initiative, we hope to develop a sustainable health model for the Akron region that will lessen the burden of disease and achieve a level of success that can be replicated across the United States.

Kaiser Permanente and UCSF Genomics Project Reaches Major Milestone Yielding Important Data

August 18th, 2011

Read about this exciting project involving more than 100,000 Kaiser Permanente health plan members. Because this is a new area for me (I mostly write about health policy and what foundations are funding in that area), I wanted to find a good definition of genomics that is easily understandable by the nonscientist:

Genomics. . . describes the study of all the genes in a person, as well as interactions of those genes with each other and with that person’s environment. . . . All human beings are 99.9 percent identical in genetic makeup, but differences in the remaining 0.1 percent may hold important clues about the causes of disease. Source: The Centers for Disease Control and Prevention’s (CDC’s) Genomics and Health: Frequently Asked Questions web page.

Also, the January 30 issue of Parade magazine, in an article for laypersons, quoted a scientist who referred to genomics as a new science that could even help prevent the common cold, based on a patient’s “genetic individuality.” The scientist explained there that some people may benefit more from certain treatments, or better tolerate certain drugs, than other people would.

Kaiser Permanente and University of California, San Francisco (UCSF) Institute for Human Genetics researchers have genotyped the DNA and analyzed the chromosome tips of more than 100,000 Kaiser Permanente members in Northern California who agreed to be part of this groundbreaking research, according to a July 21 press release. Chromosome tips, or “telomeres,” may show the degree of aging in a person’s cells and may be a “marker” (a distinctive indicator) for age-related conditions. The average age of participants was sixty-five, and DNA was extracted from samples of their saliva.

Why does this matter? The lead investigators, Cathy Schaefer and Neil Risch, noted in the release that this first phase of the project has yielded high-quality, genome-wide genetic data of a large number of people in a diverse population. (According to the National Human Genome Research Institute at the National Institutes of Health [NIH], a genome-wide association study is an approach used “to associate specific genetic variations with particular diseases.” This involves “scanning the genomes from many different people and looking for genetic markers that can be used to predict the presence of a disease.” Once the markers are identified, “they can be used to understand how genes contribute to the disease and [to] develop better prevention and treatment strategies.”)

Schaefer explained that the genotyping project, which was funded by a two-year, $24.8 million NIH grant, has accelerated research into a range of conditions, such as Alzheimer’s disease, cancers, cardiovascular disease, diabetes, and mental disorders. The NIH awarded the grant to the Kaiser Permanente Research Program on Genes, Environment, and Health and the UCSF Institute for Human Genetics.

Data resulting from the project may help researchers to figure out genetic factors that explain differences in the ways people respond to medications. Physicians could then prescribe the best medicine for patients individually “with less trial and error, based on their genetic background,” the release noted. Also, this information may help researchers learn why some patients develop certain symptoms and others do not—this could lead to new treatments, Schaefer said in the release.

Researchers will link project data with California environmental data and with health-related information, including longitudinal data from Kaiser Permanente’s electronic health record (EHR), “the world’s largest civilian electronic health record,” the researchers said in the release.

Next, the genotyping project’s data will be processed and catalogued so that other researchers can access it in late 2012.

The Research Program on Genetics, Environment, and Health has received funding from the NIH, the Robert Wood Johnson Foundation (RWJF), Wayne and Gladys Valley Foundation (which funds only in the East Bay area of California), Ellison Medical Foundation (started by entrepreneur Larry Ellison—founder of Oracle, the software company—and based in Bethesda, Maryland), and Kaiser Permanente itself.

Related resources:

CDC, Public Health Genomics, Genomics and Health, Frequently Asked Questions,

Institute of Medicine, Implications of Genomics for Public Health: Workshop Summary, Lyla M. Hernandez, editor (Washington: National Academies Press, 2005). Read the “Opening Remarks” by Larry Gostin.

NIH, National Human Genome Research Institute, Talking Glossary of Genetic Terms,

People Post: Who’s Working Where? Staff Changes at Foundations

August 11th, 2011

Read below about some comings and goings at foundations around the country.

Abraham Daniels has joined the Sierra Health Foundation. He is in charge of the foundation’s new health initiative that aims to strengthen the main health care safety net in the Sacramento, California, region, according to Sierra’s newsletter. Most recently, Daniels was director of the Healthy Community Immunization Coalition and California Immunization Registry of Greater Sacramento, a program of the Community Services Planning Council. Daniels is a graduate of Sierra’s Health Leadership Program.

Anna Gosline has been appointed director of policy and research at the Blue Cross Blue Shield of Massachusetts Foundation. She will be focusing on the issue of affordability of health care, especially for low-income and vulnerable populations. The past year she was project manager for a group of economists, political scientists, and public health specialists commissioned by the Vermont legislature to examine that state’s health care system and develop ideas for state health reform. The team, which was led by Bill Hsiao of Harvard School of Public Health, ended up recommending comprehensive, single-payer health reform, according to the foundation’s June 30 press release. Gosline is among the authors of a recent Health Affairs article on Vermont health reform. She is also a former journalist, according to Harvard’s website.

Owen Heleen has been appointed senior director of grant making, a new position, at the Blue Cross Blue Shield of Massachusetts Foundation. Among his duties will be overseeing all of the foundation’s grant making. He was at the Rhode Island Foundation for more than ten years, most recently as vice president for grant programs. At one time Heleen directed that funder’s grant making and community leadership activities in health, a June 30 press release noted. Also during his time at the Providence-based foundation, Heleen was responsible for policy initiatives related to health insurance reform and to building capacity for primary care. Heleen has been a guest blogger for GrantWatch Blog. Read his post here.

Missouri Foundation for Health promotions. Three program officers at the foundation have been promoted to new director positions, according to a June 8 press release. Web Brown is now program director—services delivery; he is working on foundation grant making related to effective delivery of health care services in Missouri. Kathleen Holmes, now program director—systems development, is focusing on grant making related to expanding the health care workforce, enhancing health information technology (IT), and improving Missourians’ understanding of health information (health literacy). Matthew Kuhlenbeck, who was named program director—community health and prevention, is working on grant making related to health promotion and disease prevention in communities with the greatest need in the state. The director positions align with the Missouri Foundation for Health’s new grant-making structure, which will be effective in 2012, the release noted.

Fay Twersky will join the William and Flora Hewlett Foundation, as a senior fellow, in October. Twersky will be working with Paul Brest, the foundation’s president, and other staff to refine and consolidate efforts to measure the progress and effectiveness of the grants Hewlett awards, according to a press release. She will be at the foundation just one year. Twersky has worked for the Bill & Melinda Gates Foundation and is a noted speaker and author, Hewlett says. “Fay Twersky is simply one of the most knowledgeable and strategic thinkers in the field of philanthropy,” Brest commented in the release.

As previously reported in GrantWatch, Tadataka (“Tachi”) Yamada retired from the Bill & Melinda Gates Foundation, where he was president of the foundation’s Global Health Program. Yamada has joined Frazier Healthcare as a senior executive in residence, according to a June 24 press release. Frazier provides capital to emerging and high-growth health care companies. Yamada’s work at Frazier involves looking for opportunities to launch and expand “game-changing healthcare companies both in the U.S. and in emerging markets.” The release also explains that Yamada is splitting his time between working for Frazier and being a board member and adviser to the chief executive officer of Takeda Pharmaceuticals.

I missed this staff change when it happened a while back. Marsha Lillie-Blanton left the Henry J. Kaiser Family Foundation after a number of years on the staff there. The role of race and ethnicity in health care was among her areas of expertise while at the foundation. (She also served on the editorial board of Health Affairs at one time.) She is now at the Centers for Medicare and Medicaid Services (CMS), where she is at the Center for Medicaid, CHIP (Children’s Health Insurance Program), and Survey and Certification. Her title is director, Division of Quality, Evaluation, and Health Outcomes within the Children and Adults Health Programs Group. These government titles are quite a mouthful! Good wishes to Marsha.

Readers: Personnel news is normally covered in my GrantWatch column appearing in Health Affairs (print and online). However, because of an abundance of peer-reviewed articles under consideration for the next few issues, I may not be writing a column until much later this year, which would make this news somewhat stale.

Please let me know of personnel changes at foundations.

The Three Most-Read GrantWatch Blog Posts during July 2011

August 8th, 2011

In reverse order, number three in the rankings was on Medicaid, and number two was on health reform (certainly not surprising). Number one (the most-read post during the month) was a round-up of posts from other foundation-related blogs. In case you missed the Health Affairs GrantWatch Tweet and/or e-alert when they were sent out, the list of most-read posts follows.

1. Foundation Blogs Round-up: Health Reform, Global Health, HIV/AIDS, End-of-Life Care, & More , by Lee-Lee Prina, June 23. Here I list posts that caught my eye and originally appeared on other blogs—most of them run by foundations. (The foundation blogs mentioned are on GrantWatch Blog’s “Blogroll.” Is your foundation’s blog listed there (See right-hand side of the page?) Other topics covered in my round-up post are health care for the elderly, home health care, Medicare, substance abuse, and telehealth. Foundation blogs from Alaska (Rasmuson Foundation) to New York (Commonwealth Fund and others) are represented. I do enjoy coming up with these lists as it allows me time to quickly scan other blogs!

2. “How to Educate the Public about the ACA: Recommendations from CaliforniaSpeaks,” by Tom Campbell of AmericaSpeaks; Jesse Sostrin of Wilshire Health and Community Services, as well as AmericaSpeaks; and Barbara Masters, independent consultant and former public policy director at the California Endowment, June 6. The authors report on a project, funded by the Blue Shield of California Foundation, to educate Californians about the new federal health reform law. The project held forums that used AmericaSpeaks’ Twenty-first Century Town Meeting format. This is the second month in a row that this post was on the most-read list!

3. Research on Medicaid: What Have Foundations Been Funding? By Lee-Lee Prina, July 14. Here, I offer a sampling of recent foundation-funded work on Medicaid. I mention a working paper on the Oregon Health Insurance Experiment; New York Medicaid; Medicaid spending and how it can be cut; and the Alliance for Health Reform’s briefing to educate congressional staffers about this federal-state program, which will play an even bigger role under health reform. Links to the abstracts of a couple of recent Health Affairs papers on Medicaid are provided.

The Colorado Health Symposium’s Debate Over Repealing and Replacing the ACA

August 3rd, 2011

The Colorado Health Foundation sponsored a debate this past week as part of its annual symposium. The conference sold out, as it has many other years. GrantWatch Blog asked Grace-Marie Turner of the Galen Institute, a participant in the debate and a former journalist, to write a post containing her observations.

Resolved: The Affordable Care Act should be repealed and new approaches to health care reform explored.

Three of the four presenters debating the resolution before a capacity audience of health professionals agreed that the Affordable Care Act of 2010 (ACA) should be repealed and replaced.

And yet the lone debater who argued that the law should be preserved won the debate in a landslide. The audience, voting in real time on keypads, disagreed with the resolution by a margin of 79 percent to 21 percent. The debate, held on July 27, was part of the thirtieth annual Colorado Health Symposium, which was held in Keystone, Colorado.

Len Nichols, director of the Center for Health Policy Research and Ethics at George Mason University, won the debate with his argument that, while the ACA is imperfect, “If this law fails, no other Democratic president in our lifetimes will ever tackle health reform again.” He added, “This is our one chance to do this.”

T.R. Reid, former Washington Post correspondent and author of The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care, forcefully argued that the ACA falls far short of its goal of achieving universal coverage, leaving at least twenty million people uncovered. As a result, these “free-riders” will continue to get health care that the rest of us pay for and will continue to drive up the cost of care. “If France can achieve universal coverage, certainly we can do it!” he emphasized.

Following the debate, Lynn Parry, past president of the Colorado Medical Society, said, “Most of the people here tonight already support the health reform law. The real debate, then, for us was between Len Nichols and T.R. Reid,” Parry said. “They both agree that we need universal coverage, but we wanted to hear their views about whether the health reform law is the best way to get there. We all know we have to figure out how to spend a lot less money and cover a lot more people.”

Jon Caldara, president of the Colorado-based Independence Institute, asked the members of the audience to raise their hand if they have homeowner’s insurance, then car insurance, and then life insurance. Virtually all in the audience raised their hand each time. Then he asked how many of them expect to file a claim on those policies this year. No hands went up.

He used the example to show that health insurance is indeed different, because people expect to use this insurance regularly. Yet, he argued, the cost of the policy is generally hidden from the insured, so people expect to cycle bills for even the most routine health care services through health insurance, driving up the cost of insurance dramatically.

Caldara said what people need in a health crisis is real insurance. His family’s personal experience with his one-year old daughter’s fatal brain tumor ten years ago and his seven-year-old son’s Down’s syndrome have given him enormous respect for the quality of health care delivered in this country. “In no other country would my children have been able to get the extraordinary care they received.” But he said he fears that we are putting this high-quality care at great risk with the health reform law’s centralized government control.

I told the audience at the symposium that I am particularly concerned about the law’s impact on vulnerable Americans, described in more detail in a book I co-authored titled Why ObamaCare Is Wrong for America. Current Medicaid recipients, most of whom have few, if any, other options for coverage, will soon be forced to compete for care from a limited number of Medicaid providers with the sixteen to twenty-five million people added to the program under the reform law. The ACA could shred the safety net because it does not increase capacity or make desperately needed structural reforms to Medicaid—it simply drives more people into the program. I agree with Edward Miller of Johns Hopkins Medicine who argued in a 2009 Wall Street Journal article, in its Opinion section, entitled “Health Reform Could Harm Medicaid Patients,” that our system simply doesn’t have the capacity to absorb so many more patients so quickly. The most vulnerable will be harmed the most. I said that we absolutely do need health reform but argued that the ACA builds on dysfunctional systems in both the private and public sectors, and it will cause a cascade of negative consequences:

* Employers are looking for the exits and could send tens of millions of people who have job-based coverage now to the exchanges for subsidized insurance, causing the cost of the law to soar in a time of severe governmental budgetary crisis.

* While states have major responsibilities to implement the ACA, the majority are rebelling, with twenty-eight states challenging the law in the courts. States face at least $118 billion in new mandated costs during the first decade of full implementation of the ACA.

* The ACA, with its 159 new boards and commissions and programs, moves power over decisions away from doctors and patients and toward technocrats in Washington who will try to regulate our health sector into functionality. A true patient-centered system would recognize the reality that medicine is moving toward personalized care, not centralization, and health care financing must support rather than fight that trend.

I argued that the focus instead should be on solutions that concentrate energy and resources on the uninsured and the most vulnerable in society. I said that we could get much closer to universal coverage with properly structured subsidies that don’t disrupt the coverage that tens of millions of people have today.

T.R. Reid, while an admirer of government health systems in other countries, concluded that we must respect the culture of the United States and work toward reform that includes both private- and public-sector programs but which gets to universal coverage. Only then, he said, would we be able to eliminate the problem of free-riders who drive up the cost of care for everyone.

I pointed out that the cost of uncompensated care is estimated at $43 billion a year, representing 1.7 percent of our $2.6 trillion in health spending—in my opinion, hardly a reason for such dramatic centralization of our health sector.

Len Nichols said that the ACA provides tremendous opportunities to experiment with new care delivery and financing models. He suggested that if providers don’t like the regulations that have come out for Accountable Care Organizations, for example, they could just ignore them and design their own. He implored, “We have to make the incentives work.”

Jan Kief, speaker of the house of the Colorado Medical Society, said afterward, “The debate was fascinating and challenged the views of many people in the room, forcing us to think outside the box. It’s clear that putting extra pressure on a dysfunctional system could create real chaos.”

Kavita Patel, fellow at the Brookings Institution, commented, “The debaters went beyond the political rhetoric of ‘repeal and replace’ with a substantive dialogue about the important subtleties of health reform.”

There was not a single point of difference in the number of people who agreed and disagreed with the debate resolution when votes were tabulated before and after the debate. But there was movement inside the numbers, and I swayed the most votes—from 3 percent who originally agreed with me to 9 percent who agreed at the end of the debate. (And I won the coveted box of Colorado peaches, as a result.)

The 2011 Colorado Health Symposium, entitled “State of Health: Seizing Opportunities, Achieving Results,” attracted 450 attendees. Many more people were turned away. Colorado Health Foundation President and CEO Anne Warhover moderated the debate and chaired the conference. Chris Adam, president of Engaged Public, facilitated the interactivity.

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