Reg's Blog

Senior and Post-Acute Healthcare News and Topics

Obamacare/ACA: Where it is at, why and where next

A number of my regular readers and clients routinely ask for my thoughts/analysis on where the Reform Act/Affordable Care Act/Obamacare is at, particularly in-light of the recent one-year delay in the employer mandate.  Given the complexity of this subject and the scope of the overall law, a single post won’t cover the subject adequately.  In compiling my notes, research, etc., the logical approach is to address this subject in four posts;

  • The economic, social and political environment
  • The implications for providers
  • The implications for consumers/employers
  • The “best guess” of what happens next, post-the mandate delays, etc.

This first post, not to state the obvious, is focused on the economic, social and political environment that envelopes the legislation and is impacting its course.

Like the legislation or not or like or not its intent,  the ACA is a fascinating window into current social, economic and political realities.  It by its legislative intent, is a governmental attempt to address a number of social, political and economic factors within one large, overarching piece of law.

  • The rate of spending or expenditures relegated to healthcare in the U.S.
  • The cost of and access to, health insurance for a subset of individuals not covered or inadequately covered through traditional entitlement programs (current or former eligibility tests applicable) or traditional health plans (employer sponsored primarily).
  • The government’s role in assessing the adequacy and quality of provider programs.
  • Certain innovations deemed worthy of further exploration that in theory, will improve efficiency, care delivery and thus, quality as measured via outcomes.
  • The legislative mechanics to accomplish the above (authorizations, funding, delegation to various agencies, creation of other governmental entities for implementation and administration, etc.).

Structurally, the ACA is overlaid across existing governmental programs such as Medicare and Medicaid.  It does virtually nothing to change these programs, their benefits, their funding, etc. Arguably, the most the ACA does to these programs is fine-tune certain elements and add some subtle adjustments to payments and disclosure requirements for providers.  The most notable change within the ACA occurs within Medicaid as the ACA expands the definition (financial) of eligibility allowing people with greater financial means (up to 133% of the federal poverty limit effective in 2014) to participate in the program.

Politically, the need for the ACA was expressed (condensed) as an intervention to increase the number of people in the U.S. with health insurance coverage (reduce the number of uninsured) while simultaneously, “bending the cost curve” on Medicare and other entitlement programs (the rate of spending).  Both intents are laudable.  The latter may be somewhat attained but the cost curve bend, not and certainly, not as a result of the ACA.

The primary reason the ACA will have negligible impact or frankly, none at all in changing federal outlays for healthcare is that it doesn’t address, by legislative language or other, any specific funding and benefit elements of current entitlement programs, save to actually expand benefit eligibility (Medicaid).  It further ties the government to enhanced levels of funding in order to effectuate the expansion.  Additionally, the economic and social factors at play in the U.S. don’t coalesce around the legislation and in fact, are polar opposite to the legislation.

The driving elements of increasing expenditures, current and future, under Medicare and Medicaid are economic and social factors that can’t be adjusted by legislation.  Legislation or policy at its best can only respond to these factors via incentive and alignment but essentially, in the U.S., government fiat doesn’t work to adjust economic and social factors.  Our system of government and enterprise, even with greater regulation and oversight, can’t alter certain mercantile and social forces at play.  Principally;

  • An increasing percent of the population, even without changes to eligibility criteria, is eligible for federal entitlement benefits.  This is fundamentally the case for both programs – Medicare and Medicaid.  The aging population alone is the principal driver for increasing Medicare enrollment.  The economic shift in labor and payroll, an increasing driver for Medicaid eligibility.  These factors can’t be changed by policy unless the policy changes the eligibility in such a manner as to constrain growth.  The ACA did not do that.
  • The economy in the U.S. is in a period of adjustment and it has been now for the past twenty plus years.  This period is continuing and will for at least another twenty or thirty years.  The U.S. is no longer a production-based economy in the traditional sense; it is a consumptive, service based economy.  Economic activity is heavily influenced today by consumer behavior (consumptive) and as it has shifted toward an  employment locus in a service sector, the wage profile is different and lower than what was realized in the former production economy.  See the manufacturing industry as an example, particularly the assembly line style.  Today, the overall number of jobs are fewer, demand higher skills, and are slowly replaced by innovation and automation.  The fear is not overseas manufacturing usurping jobs but onshore technology advances eradicating jobs.  Manufacturing will remain a vital portion of the U.S. economy although not as relevant when viewed as a labor source in quantity.
  • Socially, we have come to expect government to be an arbiter in the distribution and production of health care and health benefits. We expect interventionist policy and the government to employ distributive justice for our care.  One only needs to look at the coverage breadth for government programs compared to private programs to see this evolution.  Gone are the days when private, employer sponsored plans can be considered “Cadillac” coverage compared to government entitlement programs.  Today, the inverse is true as employer plans have scaled options, imbedded greater increments of cost-share, and narrowed provider choices.  Oddly enough, the ACA is an evolved governmental effort to reach into the “private sector” and lay-over, a mandate for expanded coverage, benefits, and conditions – very similar to a government run, entitlement based infrastructure (e.g., no pre-existing condition limitations, no lifetime benefit caps, mandated coverage and benefit levels for group plans, etc.).  If government is, and I believe it is, a reflection or mirror if you will. of present-time, social expectations then one can readily conclude that the ACA exists because the dominant social trend current demands government intervention in health care.

Politics in the U.S. has evolved as well.  The political environment is about wins and losses in and across party divisions and sub-interest groups.  Broad consensus is rarely attainable on issues of substance.  The ACA evolved as a result of a point-in-time shift in central governance – a movement toward an ideological trend that government can and should be more involved in social imbalance.  The truth however is that the present wave of social imbalance, the slow decline of a “middle-class” isn’t fixable by government policy and redistribution.  This shift has occurred as a result of a changing world economy and in the opposite, government policy which hasn’t evolved.  In short, the change in social structure has arisen gradually, across multiple administrations and the trends have been present since the mid-70s.  Government can’t fix or legislate a re-balance.

In order to frame the life or death or evolution of the ACA going forward, the environmental factors of politics, economy and social expectations need dissection. For example, the political environment remains fractured so the likely remedy legislative is as we see today; subtle shifts around the edges, delays, and partial recalibration mostly coming via administrative rule-making and executive order rather than legislation.  While party balances in power may shift moderately, a ground-swell shift is unlikely – the electorate too disjointed and divided for this to occur.

Socially, the structures of society continue to shift.  People are more mobile.  Traditional jobs more scarce especially those with benefits.  Education is required but not necessarily in the form of traditional four-year degrees for many new and evolving jobs. The ability to earn a family supporting or for that matter self-supporting wage without special training or skills is eroding quickly, save for farming to a certain degree.  Wages will not inflate to any large degree for quite some time again, except in certain industries where scarce labor-skill is operative.  Child bearing occurs later and today, in rising numbers within single parent, non-intact couples. Saving rates remain low although personal debt levels have declined but this is likely temporary.  And finally, most individuals don’t view their income allocation toward health care as favorable and would prefer, a greater amount of their income be available for discretionary spending.  As long as this view, not supported economically, remains prevalent, the pressure on government to subsidize or create cheaper health care will remain high.

Economic trends and economies are changing and will continue to evolve for another decade plus.  This essentially means that labor-levels and employment levels are different and will remain different and thus, higher levels (historic) of unemployment, under-employment, income and non-participation will remain.  These factors cause governments to fund entitlements and support programs.  This will change over time as new sub-economies evolve and social structures adjust.  Expectations move and production shifts to balance a mixed demand for different services, goods, and commodities world-wide.  Today, the imbalance however is palpable as fossil fuel production has moved geographically, food production and distribution as well, and manufacturing re-structuring to a heavy industry third-world production and high-tech production and design residing in first-world countries  The U.S. economy will be different and thus so will be standards of living, valuations on real property, consumer behavior,, and credit and investing.  How this shapes the ACA going forward, I’ll delve into in the next series of posts.

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August 17, 2013 Posted by | Policy and Politics - Federal, Uncategorized | , , , , , , , , | 2 Comments

Assisted Living, PBS and the Lessons Learned

Since last week, I’ve fielded a number of questions/inquiries stemming from the PBS segment on Assisted Living.  Interesting, a number of the queries have come from sources tangential to the industry (policy folks, trade associations, advocacy groups, etc.).  Thematically, these sources are looking for answers as to “why” and “what can be done”.  Aside from ill-advised regulations, my perspective is the best fix is an industry driven effort.

One could over-simplify by saying, “don’t take anyone as a resident that needs more care than can be or should be provided in Assisted Living” but that’s not practical.  Residents change throughout their stay, sometimes rather abruptly.  The most complex changes, and those that represented the focus of the PBS piece, are cognitive and behavioral.  While medications exist to ameliorate or control certain behaviors, the medications have side-effects and are ideally, the final, last course of behavior management.  In all instances, behavior medication should only be given in a setting where a Registered Nurse is present and assessments and monitoring can occur (remember, only Registered Nurses can assess by license authority).

The lessons learned or should have been learned and the counsel I have provided to clients and inquisitors alike is as follows;

  1. Be clear with residents and families on admission, what kind of staff are on-site and immediately available.  This communication should frame then, the services that can and will be provided.
  2. Be clear with resident physicians on the same information.  Don’t encourage or allow physicians to become comfortable with providing orders for PRN (as needed) medications if the same medications require a professional assessment prior to administration, unless the facility has RN coverage on each shift.  Effectively, this means that PRN orders for anxiolytics, hypnotics, anti-psychotics, narcotics, etc. are inappropriate without access to an RN for an assessment.
  3. Beef-up pre-admission screening and assessments with qualified, licensed personnel to fully understand, prior to admission and re-admission, the care needs of the resident.  In many cases, I advise going to the resident’s current place of residency prior to admission.
  4. Make certain that any public (written in particular) or oral representations of Assisted Living as an alternative to nursing home care are gone and certainly, not made or implied. Assisted Living is not a substitute for institutional care if the institutional care is truly required.
  5. Create specific assessment and re-assessment periods to address care changes more frequently.  I like quarterly reviews for Memory Care residents and no less than semi-annual for Assisted Living (non-Memory Care).  I also like mandatory 30-45 days post admission, again at 90 days and then semi-annual.  I also like this schedule to repeat whenever a resident is hospitalized and returns or returns after an SNF stay.
  6. Utilize evidence-based, best practice protocols for AL and Memory Care.  AMDA is a good resource.  Provide physicians with the information as well.
  7. Develop and utilize, a solid orientation and training program for staff.  For Memory Care, there are some good resources available today from Leading Age, AHCA and ALFA.  For facilities and organizations that are heavily invested in Memory Care, I also recommend exploring and using, TCI or CPI to augment training (specialized training in dealing with aggressive and combative behaviors).
  8. Be focused on staff levels based on care needs of residents.  If increasing or integrating more professional staff is not an option, be vigilant on discharge planning or transition planning.  Bottom-line: If you can’t effectively meet resident needs 24/7, say so and start discharge planning.  Have sufficient numbers of staff trained and available, even PRN if required, to address resident care challenges.

For facilities/organizations capable of going to the “next” level, either by size or by financial status, I recommend the following as true “game-changers” for Assisted Living.

  1. Contract with a “house doctor” or Medical Director.  Build a system that integrates elements of medical oversight and engagement with your resident population and staff.
  2. Expand the care team to include social workers, in Memory Care a psychologist or psychiatrist (or RN extender), a dietician, qualified activities professionals, and rehabilitation therapists.
  3. Employ a building or program administrator with appropriate degrees and training plus a demonstrable history of working in a post-acute/long-term care environment.  Paying a bit more is worth it for someone with appropriate training and education.
  4. Become active participants in state and national trade associations.  Encourage staff to participate as well.  I also encourage networking with other professional organizations such as the Alzheimer’s Association.
  5. Hold regular family meetings or focus groups to both inform and solicit feedback.  I like at least semi-annual.
  6. Connect with a local home health provider for staff augmentation when residents need more care, temporarily or until discharge.  I also recommend connecting with a hospice agency.
  7. Contract for pharmacy consultations on all residents and if possible, have a pharmacist as a resource to Memory Care staff.

Final Word: Communicate and be clear with residents and families regarding the services that are “truly” available and where the “appropriateness” line resides for the organization/facility.  Don’t ever extend beyond what staff can provide and what the organization is capable of delivering on a consistent almost constant basis.  Recognize that resident care needs change and that limitations exist as to what ALFs can and should provide.  Be clear, be compassionate, and be honest – within the community and the organization.

August 6, 2013 Posted by | Assisted Living, Uncategorized | , , , , | 1 Comment

Healthcare and the Fiscal Cliff

The Fiscal Cliff stories are everywhere and as a result, lots of misinformation, conjecture, and supposition of deals, no deals and what happens next abound within the media.  The economist in me can’t help but opine on the economics at stake but for this purpose, I’ll take only a slice of the overall issues; a healthcare slice.

Suffice to say, the issues on the table are polarizing and complex as the intricacies of policies current, past and yet in transit are all actors in a grand ideological play.  If for example, I chose to take each possible issue that is part and parcel to the Fiscal Cliff discussions singularly, elaborating on what the issue is, why it is part of the discussions, and the pros and cons of addressing the same temporarily or permanently, I would pen the equivalent of War and Peace.  The healthcare elements are complex enough and below, I’ve done my best to summarize and focus.

  • Obama Care/PPACA: This is the grandaddy of conundrums at the table, ideologically and practically.  The ideological issues are clear while the economic implications are muddy and tied to issues within the Fiscal Cliff discussions.  Taking this issue in two big chunks for sanity and brevity, the discussions tilt on separate axis’: Deficits and Taxes.  Sequestration which is part of the Fiscal Cliff discussion (cuts in federal spending), impact Medicare and are a direct result of rising federal deficits and the debt ceiling (yes, its back) debate.  The primary driver of current deficit levels is entitlement spending.  Within and inextricably linked to the Fiscal Cliff discussion is renewed discussion regarding entitlement spending, the debt ceiling, etc. and thus, costs associated with the PPACA.  As Congress controls funding for federal programs, an unavoidable discussion regarding Medicare and Medicaid spending is embedded within the Fiscal Cliff/debt ceiling discussion and thus, core elements of the PPACA are on the table (metaphorically).  The second chunk of PPACA impact is its phase-in of new taxes.  Here’s where things get horribly complicated. First, the PPACA imputes an additional Medicare tax on individuals that earn over $200,000 and families that earn over $250,000 (.9%).  This tax applies only to “people” not employers.  In addition, the PPACA imputes a 3.9% tax on investment income for individuals and families.  Investment income is defined as dividends, capital gains, rents, royalties, etc.  This tax applies to any individual with a Modified Adjusted Gross Income of $200,000 or families at $250,000. The Fiscal Cliff twist or dilemma?  If no compromise on current tax rates is attainable and the rates rise to pre-Bush levels, a person earning over $200,000 per year could pay capital gains tax (including the PPACA portion) of 23.8% (currently 15%) and a dividend tax of 43.4% (currently taxed at individual tax rates or approximately, 35%).  This implication alone has many economists fearful of signficant market reactions and potential pullback from investors enough to create a recession.
  • Medicare Cuts: This element of Fiscal Cliff discussions contains known and unknown elements.  The known elements involve Sequestration cuts if unresolved, equal to approximately a 2% Medicare cut in provider payments and the evaporation of the present “doc fix” funding, netting in January to a 27% cut in physician and other Part B provider payments. Without resolution, both occur automatically.  The unknown elements center around the debt ceiling and the structural deficits current and projected in entitlements, principally Medicare and Medicaid. In a recent Fitch outlook, Fitch indicated that while the healthcare industry outlook at present is stable, deficit reductions, increased taxes, etc. could drastically change industry fortunes to negative and quickly.  Fitch notes that margins today are small and capital levels reasonably adequate but fortunes can change quickly with margin erosion via cuts and unmeasured structural changes to Medicare and Medicaid funding.  Given that numerous provisions across healthcare arising from the PPACA are presently in-play (hospital readmission penalties and medical device taxes for example), the industry is already under a certain amount of constraint.
  • Healthcare and the Economy: Healthcare today is a $3 trillion economy, larger in scope than the entire Canadian economy (GDP) of $1.74 trillion. In fact, only three other nations in the world have a larger total economy than the U.S. healthcare economy (Germany, Japan and China). The Fiscal Cliff implications for healthcare also hold enormous economic implications for the U.S.  Simply, if the U.S. economy moves closer to a total stall or recession, the impact on healthcare is enormous.  The two largest entitlement programs are tax funded and a reduction in tax revenues via additional economic slow-down, further employment rescission, etc. places not only additional deficits into Medicare and Medicaid but additionally, removes paying patients from the system.  More deficits in Medicare and Medicaid place greater burden on policy makers to cut spending.  Economic weakness moves patients away from seeking care and ultimately, shifts the health risk profile of the population.  This shift is insidious and fraught with long-term implication as it is typified by undiagnosed and ill-treated chronic diseases – already a major problem in the U.S. Any further long-term erosion of population health status due to persistent underemployment, unemployment, etc. pushes the unresolved care burden incrementally higher (more expensive).  The net result is a sicker population overall, one that becomes ridden with chronic illness, disability, etc.  Further, additional burdens for providers arise in the form of patients seeking too much urgent and emergent care; expensive and often, under or not reimbursed adequately, if at all.  Given that the economy remains in an overall fragile state of recovery and the last series of years have been straining on providers, any inability on the part of Washington to resolve the Cliff issues with certainty and equanimity bodes poorly for providers and patients alike.

November 30, 2012 Posted by | Policy and Politics - Federal, Uncategorized | , , , , , , , , | 3 Comments

Leading Age Annual Conference and Convention

Not that I am opposed to answering dozens of e-mails with the same or similar question, I thought it best to post this reply with a uniform answer.

YES, I will be at Leading Age in Denver, in October.  And YES, I am speaking on Tuesday, October 23rd.  My session is between 8:00 – 9:30 AM and the topic/subject matter is focused on the development and use of Economic Value Propositions in marketing strategy. I am happy to connect with folks but my time is a bit limited as I fly in from Charleston on Sunday and fly back out shortly after my session.

September 26, 2012 Posted by | Uncategorized | 2 Comments

R&R: Recharging the Old Battery

Sorry everyone – no trends this week (not that there aren’t any).  Bumping around the Illinois, Iowa and Wisconsin circuit this week and today, I’m out of gas and headed for a golf course.  Time to lay low a bit, recover and recreate.  On my radar when I return to action post Labor Day are all of the following (and then some).

  • Political news abounds – convention season in full swing and healthcare smack-dab in the middle of the growing debate.
  • Some interesting dynamics coming out on hospital observation stays.
  • Hospice, hospice, and hospice – fraud, utilization, census shifts, etc.
  • Medicaid managed care and the Wellpoint dynamic.
  • Omnicare, Sunrise acquisition, PBMs and the fairly massive transitions of former brand medications headed to generics.
  • Home health and why this industry has trended so poorly as of late.
  • Other cool stuff too (if you’re a fan of health policy and economics)!

Until next week – a fairway beckons!

August 31, 2012 Posted by | Uncategorized | | Leave a comment

CBO Score on Post-Court ACA Implications Due Today

Later today, the Congressional Budget Office is set to release an updated “score” of the Affordable Care Act (PPACA) incorporating the decision of the Supreme Court.  The fundamental reason for the update is the Court’s decision to invalidate a provision within the Act that would have penalized states via reduced federal Medicaid funding should one or more opt to not participate in Medicaid expansion.  As I have written over the past week or so, this revised score from the CBO should be fascinating, especially when spun politically by both parties.

In advance of today’s release (earlier estimates had the release pegged for yesterday), Douglas Holz-Eakin and his group the American Action Forum (Holz-Eakin is a former CBO head) provided their score of the ACA and the Medicaid expansion opt-in, opt-out scenario.  Per their estimates, if six states decided to opt-out of expansion, the associated cost increase is between $72 and $80 billion between 2014 and 2021.  If all states opted out (won’t happen), the associated cost increase over the same time frame is between $562 and $627 billion.

The reason for the cost increase estimate lies on the cost difference between newly eligible participants via expansion not being cared for within the state Medicaid system and thus using federal subsidies to buy insurance through the exchanges, at commercial insurance pricing. There is a cost difference between the two with Medicaid grant funding to a state lower (even at the Act’s full funding level) than federal subsidy through the exchange.  Holz-Eakin estimates that in the six state opt-out scenario, 4.4 million individuals will not participate in Medicaid and 3.2 million (people over 100 percent of the Federal Poverty Level)  will thus purchase subsidized insurance through the Exchange.

I’ll provide additional updates once I receive and review, the revised CBO score.

July 24, 2012 Posted by | Uncategorized | , , , , , | Leave a comment

An Omission from Friday

Every once in a while, I make a mistake (rare I think but others when asked, would convey a different sentiment).  This gaff is really an omission; a missed thought from Friday’s post on “What’s Trending”.  In reviewing my notes (the mess that they can be), I noticed I forgot to include a “watch” tip for Monday, July 23.  This is the day that the CBO is set to release its findings on the costs (go forward implementation) associated with the Supreme Court’s ruling on the PPACA.

What I’ll be looking for up to the release and after, are the following issues.

  • This is political stuff on steroids as the election battle heats up, deficit talks are imperative given the looming automatic cuts ($1.2 trillion) and the “fiscal cliff” created by the lapse point of current tax cuts.  What the CBO opines on the financial impact of the PPACA post Court ruling will fuel one side’s argument “pro law” or the other’s, “pro repeal”.  While the CBO is hardly accurate with their estimates, their veil of political impartiality gives them a certain amount of credibility for argument’s sake.
  • Medicaid is now equivalent to a two-ton gorilla in the debate and the various governors are all taking sides (albeit cautiously in some cases); pro-expansion or anti-expansion.  I’m not sure that the CBO numbers will change too many positions but I’ll read with interest the conclusions.  The developing rub is the costs that the states will bear for expansion.  Some estimates suggest that, given current funding requirements under the law, the costs will be minimal to the states – a less than 3% increase in Medicaid costs.  Others state that even a 3% growth on top of an existing Medicaid deficit is too onerous.  Their argument is bolstered by the “double tax and fund” argument of having their state taxpayers pay more to underwrite the federal funding promises.  In short, many are convinced that the federal funding promises are shallow or hollow without additional tax revenues to cover the outlays.
  • The trick for the CBO is how to estimate who plays and who does not.  The Court left states and opt-out clause and thus, CBO estimates can vary widely on the cost outlay if a multitude of states choose to opt-out of expansion and let the Feds fund private insurance contracts or subsidies for the newly eligible Medicaid participants.  The unknown is the cost of insurance as opposed to the subsidy paid to the state under Medicaid.  Some early estimates of a scenario such as this suggest the Government could spend as much as $100 billion more per year.

On a final note, providers have yet to fully weigh in.  I am tracking physician and hospital reactions but both groups are in a bit of a wait-and-see posture.  Hospitals in states that seem vehemently opposed to expansion tend to be the most concerned for fear of undercoverage and a continued burden of unfunded care.  Some in states with current high levels of uninsured and disproportionately high levels of poverty (the window area targeted by expansion) are likely the most cautious about what “next”.

July 16, 2012 Posted by | Uncategorized | , , , , , , | Leave a comment

CMS, Proposed ACO Regulations and a Post-Acute Analysis

Late last week, CMS (Centers for Medicare and Medicaid Services) issued the proposed regulations for Accountable Care Organizations (ACOs). As is typical with CMS and all things PPACA related, the document is nearly 500 pages. I have read and begun to digest (creating of course, indigestion) the entirety of the document. As I have prepared copious notes and questions more than answers, it will take me another day or so to formulate a coherent analysis, particularly as the information pertains to post-acute providers. Given my workload at the moment, I will endeavor to have a post up by Friday at the latest.

Hearing also from lots of sources continued questions on RUGs IV, questions regarding new hospice requirements, and of course, questions regarding the latest budget release from House Republicans and implications for Medicare, Medicaid, and the PPACA, I have more than a bunch to sift through and ultimately, post thoughts on and hopefully, some guidance. Suffice to say, these are interesting times for health care providers and the sands are shifting constantly. A significant shift toward a faster death for the PPACA will undoubtedly reform what we “think” we know today about ACOs, Medicaid and even Medicare. Stay tuned and feel free as many of you do, to drop me a note regarding a topic, your insights, or a question that I may be able to answer or steer you to an answer/resource.

April 6, 2011 Posted by | Uncategorized | , , , , | Leave a comment

Company E-Newsletter Posted Yesterday

My firm’s E-News was posted yesterday at http://apexhealthcareconsultants.info  Articles this month include;

  • Senate Begins Hearings on CCRCs
  • States Starting to Feel the Burden of FMAP Loss
  • Healthcare M&A Update
  • Medicare SNF and IRF Rates Increase
  • Monthly Economic Outlook

July 27, 2010 Posted by | Uncategorized | Leave a comment

Medicaid Expansion and the PPACA

Article I wrote for the National Healthcare Reform Magazine on the implications for Medicaid as a result of the expansion provisions under the health care reform law. Click on the link below (or copy and paste) to view the article.

http://healthcarereformmagazine.com/article/health-reform-and-medicaid-expansion.html

July 13, 2010 Posted by | Uncategorized | , , , , , , , | 2 Comments