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That's the first question of the New Year by my 8-year old daughter while playing with a party horn. I just woke up.
Tag: children
A Kid & His Ukulele
Wish I could play like this kid… Working on it.
Coloring Page of the Week
We do video announcements in our kids church time, so that our volunteer leaders don't have to remember every event or have to read off of notes. This weekend, I am bringing back coloring pages of the week. The children have the option of going to the coloring page table during free time before and after the church program. It is very interesting how the children get into "Coloring Page of the Week" knowing that they have a chance to be highlighted. Maybe I should make a mobile app, where kids can show off their artwork. I typically just take a picture of the coloring page and flash it on the screen during announcements time. This time I threw in some selfies. Thanks Olivia for sharing your coloring page.
Children On Social Media
Social Media and kids
- Predators are rampant on the internet. They are all over the internet in every social media platform: FaceBook, Twitter, Instagram, etc.
- Personal profiles can be easily be created to misrepresent the user. A predator wouldn't typically identify himself as one on his profile. People aren't who they say they are. As I type, I'm looking at a spam account on my Instagram. It's a stock photo of a model. Who knows who the real person is behind the account? I don't. Neither does your child.
- Peer pressure to post things for shock value. We are a "like" hungry society. The more likes and reposts on a post, then the better. People pay money to buy Twitter followers. "Likes," "Favorites," "Repins," and "Reposts," are the fuel that make social media go. That pressure is on our children to fit in their digital world as well as their physical world. One easy way to get attention to internet activity is to promote sex and vulgarity. The pressure is on our children to promote the same things.
A Sunday Scoot Around The Block
Bringing value to a child's life
Thanks to KidMin360 for giving me the privilege of sharing my thoughts on children's ministry. Here's a copy of my last guest blog post. If you work with children, do you ask yourself questions like,
- "When the children leave my church or my classroom or my program, are they glad that they went?"
- "Do I help each child view his true value as an individual? As a person created by God Himself?"
- "When I child is with me, where does he see himself on the scale of importance? Is he a nuisance? Is he even noticed? Is he important and valued?"
My first career, fresh out of college, was as an elementary school teacher. I worked in the public school system as a teacher for over 10 years in inner-city schools. One of my most memorable school years was bookmarked by one 9-year old girl. Yuri was brought into my classroom in the last quarter the of the school year. Actually, she was physically carried into my 4th Grade classroom by the administrator. This girl balled up into a fetal position for the entire day. For at least a week, she spent her days with her head face down on the desk buried inside her folded arms. She responded my attempts to talk to her with complete silence. I was frustrated but was not going to give up. I had just heard a series at church about valuing people.
If I was going to make a connection with Yuri, I knew I had to do something different. After the first bell, I yelled Yuri's name with all the enthusiasm I could muster, as if I were the announcer of a championship boxing match, as all the students lined up in front of their classroom for school. I forgot to inform the rest of my class of my strategy, so they were enjoyably caught off-guard by my antics. After I ceremoniously announced Yuri's name at the start of every school day consistently for two weeks, Yuri began to speak to me through a translator-classmate. She made eye contact, but instead of talking to me, she whispered in her friend's ear what she wanted me to know. I played along with this to keep the communication open. Yuri didn't do any of the classwork but would sneak a smile every once in a while to let me know that she was listening.
The extent of this communication lasted for another couple of weeks. Though this was not uncommon for this part of the city, Yuri's parents were suspiciously unavailable for any school meetings, as our community worker worked tirelessly to get Yuri the help that she needed. Obviously, something was wrong.
One afternoon, about a month after we first met, Yuri approached me as I graded papers on my desk after school. Most of the students had left for the playground except for a couple of helpers cleaning up in the hallway. Without any prompting from me, Yuri began talking to me about herself and what she thought of school for the next 15 minutes. I think I may have squeezed in maybe a few words in this conversation. However, I was quiet for most of our discussion because I had been in shock listening to my student gab with me as if we were best friends. At the end of our conversation, Yuri gave me a hug and said that this was her last day of school, and I was the best teacher she ever had.
At the end of the day, one of our administrators called me in her office to passionately explain what had happened. Social Services had been tracking Yuri's parents for possible neglect and child abuse. To elude Social Services, Yuri's parents withdrew her from the school and left the area. I never saw Yuri again, but the memory of her reminds me to care about what matters most.
Our windows of opportunity to reach children are many times closed a lot sooner than we expect. How do we get our children to see their value in Christ? I can't be just a lesson children learn on a Sunday. We have to value them.
Value children in the program.
There should always be a segment to welcome visitors. Years ago, I went to church in Hawaii. Hospitality is a big part people's culture. When the pastor welcomed the visitors, the congregation exploded in a dance as the band played. A volunteer put a lei around my neck within 5 seconds, and I was surrounded by huggers from every corner. I felt like a million bucks, and I'm an adult! What if we treated every young visitor that way? Are you highlighting children in any other ways? Birthdays? Kid of the week? What are your ideas? Are you putting the ideas in action?
Value children on purpose.
It must deliberate. What if it comes off as phony? It won't be when your interactions with children are genuine. You have to provide training and follow up for your volunteers. Do you think that the employees at Disneyland just automatically know how to positively interact with families just by being employed by Disney? They were trained. Are you training your volunteers to value children?
Value children with passion.
Yes, be over the top in many cases if not all. Enthusiasm is caught not taught. You can provide all the "customer service" type training you want, but it will fall short if you are not leading the way. As the children's ministry pastor, director, assistant, or volunteer you must exemplify passion to your team. You set the tone.
Valuing children must be embedded in the program. It must be on purpose. It must be passionate. When you do those things, it become organic. In other words, valuing children becomes part of your ministry's DNA. When children feel valued, they will view themselves as valuable. What would happen to your children's ministry if the children who participated in it knew their true value in Christ? Are you ready to expand the dynamics of the children's ministry? Many times, we may not see the fruit of our efforts when we reach out to children. Yuri is my reminder that our efforts are never in vain, and that Christ will use us to reach even the toughest hearts.
a Picture of Perseverance
Here's what the Thesaurus lists as synonyms of perseverance:
staying power,
informal stick-to-it-iveness;
formal pertinacity.
This day, over 15 years ago, my son ran this race as was in last place. He was in last place, yet he just kept running as if he were striving for first. He finished and gained the respect and applause of the crowd watching the race. 1 Corinthians 9:24 says to run to win. This day he did.
Revisting Caine's Arcade
I never physically visited Caine's arcade. I drove by months ago, but it was during business hours, so I assumed he was at school. I saw the video again today at the Chick-Fil-A Leadercast and saw the interview with Caine. A lot has happened in a year, and this video has turned into a movement. I love it when a young person has the gumption to follow through on his imagination and when adults believe enough to help make dreams happen. Caine's story is inspiring and Nirvan Mullick's film of it is brilliant. It's a reminder to me to live with vision and have fun along the journey.
Caine's Arcade from Nirvan Mullick on Vimeo.


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Breadman' (centre) gets help promoting his brand
Dr 'Breadman' in the house
TWENTY-THREE-YEAR-OLD medical student Ejay Charles is good with his hands.
This is not surprising since he started honing his skills long before he was tall enough to stand at a table.
"From a tender age I learnt to bake, fry and roast bread," he told
UWIMONA Now
. In Trinidad and Tobago, it is the norm for each household to make its own bread, and Charles's family home was no different. In addition to making different types of bread, Charles also learnt how to bake sweetbread and cakes, among other things.
His skills in the kitchen would bail him out of financial difficulties several years later when he left Trinidad and Tobago to pursue a Bachelor of Medicine, Bachelor of Surgery (MBBS) degree at the Mona Campus. As Charles struggled to pay his bills, he was forced to consider baking as a worthwhile business undertaking.
"My decision to enter the field of entrepreneurship was born out of a place of need," he recalled.
"I was a very persuasive and jovial person so when financial troubles came, I put my skills to work for me by selling," he said.
Charles's first customers were his flatmates and friends, who had previously been drawn to the delightful scent of hot, home-made loaves coming from his kitchen at Rex Nettleford Hall. "I was so overwhelmed by the influx of positive responses that I decided to start selling my loaves, not even sure that I was making a profit at the time. It wasn't long before I got some branding done, and I started marketing using social media forums," he recalled.
His customers started calling him 'Breadman', a name he adopted when he formed his company.
"Things were going well, and I was able to cover a lot of my personal expenses." Charles recalled getting what he called a 'crazy idea' in 2014 to create a concession snack line for the Breadman brand. He expanded the business to include the sale of popcorn, cotton candy, hot dogs and snow cones. He currently employs four UWI students, and operates at various events on The UWI and University of Technology campuses.
"I am able to pay for my accommodation, and afford things I couldn't have in the past. It's the quality of life and the autonomy that I enjoy the most," he admitted.
He is also looking forward to becoming a medical practitioner and expanding his business. "I'd like to continue the Breadman brand with the tagline 'More than just bread'. In addition, in the same way a bank or a fast food chain has a drive-through, I want to also have a 21st century bakery with a drive-through," he said.
"I also have a great appreciation for general surgery, so it's something I have in the back of my mind as a possible specialty."
After medical school, Charles plans to do his internship, work as a general medical practitioner for a few years, start a family and "possibly accomplish some of the bigger entrepreneurial ventures I have written down in my 'Ideas for life' diary".

subset: commoncrawl


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Come to Renys in Topsham this Saturday, February 25th, at 9am Feb 25thOr to Renys in Saco at 1pm…the same Saturday, February 25th... This might be the break you've waited for… on statewide TV!
This will not be the church craft fair that you went to last year...trying to decide between the wooden geese, doilies and the rayon yarn vests in red and green.
This will be the juried creatives fair of Rockland, where artists, artisans, craftspeople, and foodies can sell their wares to folks who are looking for the perfect gift for friends, family and coworkers. Maybe for themselves, too!
We will be located in the gym of the Lincoln Street Center, 24 Lincoln Street, with over 50 booths!
The steeple at Cox Memorial United Methodist Church, Center and Middle Streets, Hallowell will be removed for repairs on Friday, Nov 4th. The plan is to have a crane arrive at 8 AM and take about an hour to get it set up to start the removal process. The restoration steeplejack, Bob Hanscom, already has the rigging in place, so the lift to a flatbed trailer should move swiftly. Then a temporary cap will be lifted in place to cover the hole.
Years ago, the steeple was damaged by lightening, causing the loss of its weathervane. The steeple has suffered other indignities over the years. The trustees finally decided it needed too much work to just be patched in place. It will be removed and taken to the shop of Mr.
The cars and stars of NASCAR race their way back to New England for the SYLVANIA 300 and the second race in the Chase for the NASCAR Sprint Cup on Sunday, September 25. As part of NASCAR's 10-race playoffs, this 300-lap event is sure to be pivotal in deciding the series champion.
Renys Topsham Grand Opening on August 18th!August 12, 2011The big day is finally here! Renys Grand Opening Celebration at the Topsham Fair Mall is Thursday August 18th - Everyone is invited to commemorate the opening of the 16th Renys store in Maine!Just before the doors open at 9:30 am, Topsham City officials will provide a brief welcome, followed by a ribbon cutting to celebrate the opening of yet another great Renys store.
Cross Insurance Center
New Beginnings Inc.
Johnson Hall Theater
WCSH6.com WLBZ2.com
One Congress Square, Portland, ME, 04101
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Tuesday, 1 June 2010
"A day in my dad's life" by Victor
Hello everybody
My dad gets up at eight o'clok.
He watches TV at eight five.
He has breakfast at the half past eight.
He has a shower at ten o'clock.
He returns home and we feed the ducks at the park.
After that, we go back home and my father and I see the TV and my mother does the cooking.
Later we see a movie.
After that, we left home and walked.
At dinner time, we watch TV and then we went to sleep.
bye friends. =-)
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Orthopedic Trauma is a term used to describe an injury to the musculoskeletal system as a result of a serious and sudden injury. One of the most common orthopedic trauma injuries is a clavicle fracture, commonly referred to as a broken collarbone. Clavicle fractures are most often a result of a direct blow to the shoulder, such as the result of a fall or car accident. A clavicle fracture can be very painful and may make arm movements difficult to perform.
What is a Clavicle?
To most, the clavicle is better known as the collarbone. It is located between the ribcage and the shoulder blade and connects the arms to the rest of the body.
Symptoms of a Clavicle Fracture
If you have experienced orthopedic trauma to the clavicle and experience any of the symptoms below, contact an orthopedic trauma specialist. There is a risk of mistreatment otherwise.
- A grinding sensation when you attempt to raise your arm
- A bump near the break
- A deformity in the area
- Bruising and swelling
- Tenderness near the collarbone
- Sagging of the shoulder (either downward or forward)
- Severe pain and inability to lift the arm
Treatment Options for Clavicle Fractures
In many cases, broken collarbones are able to heal without surgery. If a clavicle fracture occurs, your orthopedic trauma surgeon will evaluate your condition and determine the best method of treatment. Non-surgical treatment options may include one or more of the following:
- Pain Medication to aid in alleviating the pain associated with the fracture
- Physical Therapy to regain shoulder and arm strength
- Arm Support, such as a sling, to keep your arm and shoulder in the proper position while the injury heals
In more serious situations, surgery may be necessary. Surgical treatment options may include surgery to add plates and screws or pins to hold the repositioned bone in place to promote proper healing.
Follow Up Care for a Clavicle Fracture
After a fracture to the clavicle, it can take several months for the injury to heal. Most patients are able to return to their regular activities after 3 months of healing, once approved by their orthopedic trauma specialist. It is important to speak with your doctor before returning to certain activities, such as sports. While your fracture is healing, there is a higher chance for re-injury.
Learn More
If you are suffering from an injury to your collarbone, contact the orthopedic trauma specialists at South Shore Orthopedics today for evaluation. Our team is dedicated to providing patients with fracture care using conservative, non-surgical treatments when able. Request an appointment today.


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Retail pak New Millennium Audio 2002
CS ISBN 1590070119 $39.95 Twelve cassettes
This 1846 classic brings Dumas's saga of the Three Musketeers to a close. It contains everything from the suspense of a plot to displace the king, to the low comedy of the portly Porthos's inability to get a suit made that fits him. The high point, as with all of these swashbuckling tales, is in the action and the emotion, specifically a battle between Porthos and Aramis and more than eighty of the king's guard, and the deaths of the heroes that follow. The pace is leisurely, the narrative rich, and Christopher Cazenove performs the novel's more than twenty characters with a grace and agility worthy of a Musketeer. G.T.B. (c) AudioFile 2002, Portland, Maine [Published: AUG/SEP 02]
Retail pak New Millennium Audio 2002
CS ISBN 1590070119 $39.95 Twelve cassettes
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Citramax IPA
A West Coast style IPA dry-hopped with organic Citra hops to impart intense tropical and citrus fruit aromas. This brew...
Our hopped up, refreshing, seasonal IPA with flavors galore! This showcase of Centennial and Citra hops is brightened up by additions of mango fruit for a tropical-hoppy character from start to finish.
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You are currently browsing the category archive for the 'Medicaid' category.
The website 538.com has posted an essay (found here) about the great state of Alabama. Unlike most click bait-y articles that Alabamians seem to be attracted to on Al.com (i.e. What are the 11 greatest barbecue places within 30 miles of Bryant-Denny stadium?) but instead an in-depth look at healthcare in Greene County, Alabama. Greene county is currently the least populated Alabama county (9,045 people, 81.5% black or African American). In 1860, the county had about 30,000 people. Well, kinda depends on your definition. 23,598 of those "people" were actually enslaved human beings. Although the math works out to approximately 4 enslaved humans for every 1 "person," in fact it was almost 7000 enslaved humans were owned by about 50 folks. As described in the Encyclopedia of Alabama, this was not a bad thing
In the decades leading up to the Civil War, Eutaw experienced a golden era as the mercantile and legal center of the Black Belt. The first courthouse, built in 1838, burned in 1868. The current courthouse was built in 1993.
The county is in a region of the state known as the "black belt", named not for the color of the population but for the color of the soil. The slow slide to economic despair over the last 150 years has taken a toll on the region. Immediately after the civil war, the region was home to 40% of the "citizens" of Alabama. The systematic oppression of former slaves and the descendants of former slaves has lead to the growth and development of many civil rights leaders, blues musicians, and story tellers. It has also lead to a bunch of people moving away. The region, once the economic engine for the region, is now home to 12% of Alabama's population. In the words of one Percy County resident
"The only reason people come to town now is for funerals, and they leave as soon as they're over 'cause there's nothing to do and nowhere to stay," said Walker, 64, the son of sharecroppers
For those who have stayed, economic prosperity has been an uneven proposition. The racial makeup of the Black Belt region was 52.2% African American, 45.8% White, 0.2% Native American.
The poverty rate among [Wilcox] county's white population is just 8.8 percent, which is lower than all but five counties. The poverty rate among the county's much larger black population is 50.2 percent. The 41.4 percentage point gap is the largest in the state.
Other Black Belt counties have a similar dynamic. Lowndes County has a 4.1 percent white poverty rate – the lowest in the state – but a 34.5 percent black poverty rate. In Perry County, the white poverty rate is 8.1 percent, while the black poverty rate is 32.7 percent. In Marengo County, it is 5.6 percent and 40.8 percent respectively.
So why worry about these folks? Can't they continue to vote with their feet?
"The Black Belt is a road map," said Patrick Sullivan, a professor at the Rollins School of Public Health at Emory University who previously worked on HIV surveillance at the Centers for Disease Control and Prevention. "That's what's so tragic and so compelling. It's an endgame depiction of what happens when you have social and structural inequalities. It's the vestiges of slavery and inequality, and in the long run those things do play out as health inequalities." Sullivan and colleagues have studied why HIV rates are so much higher among African-Americans and Latinos than other racial groups3 and found that health insurance is the most important mediating factor. People in both racial/ethnic groups are more likely to be poor and have less education, which are related barriers, but insurance coverage is where the local and federal government could improve access to treatment, Sullivan said.
Alabama is not a Medicaid expansion state. Our Doctor-Felon-Former-Governor decided it was a political chance he did not want to take, even after his re-election into a term limited position. Remember, adults who are employed but make less that 138% of poverty uninsured are not eligible for Obamacare. In counties like Greene, where 40% of the population is below the poverty level, that is a lot of folks, almost all of them black. When the median household income is $20,000, people are going to choose food when having to decide regarding food vs insurance, every time. So what is the right thing to do? In the words of my friend and colleague John Waits, quoted in the article:
"Nothing happens without Medicaid," Waits said. "It is the No. 1, the No. 2, it is the top 10 solutions."
I'm beginning to think this is about something other than partisan politics.
Frandal Wright, who went 27 years without health insurance before getting HIP 2.0 coverage last year, makes his $1 monthly payment at the Wal-Mart in Anderson.
Because the store is on the other side of Anderson from where he lives, Wright tries to pay as much as he can at each visit to minimize the number of times he has to make the trip. Right now, he says, he's trying to find someone to give him a ride to make his payment and determine if he has enough money to make a lump sum payment.
"I'm a little behind now because I almost forget about it," said Wright, 46. "I want to pay for the whole year. I'm trying to do that this time. I'll probably give them $20 if the Lord blesses me."
Do Indiana's poor Medicaid recipients really have skin in the game?
As I viewed my electricity bill today I was told by Alabama Power "You pay on average $5 a day for your electricity." This means I have "skin in the game." I have the power to determine if I pay nothing per day or $20 per day. Well, only a little as it turns out. It seems that Alabama Power won't let me come off the grid easily, so I will end up paying something no matter what. Also, my major non-air conditioner power usage corresponds to my use of the clothes dryer. I can minimize the use of the dryer by hanging a clothesline, I suppose, but elect not to. What I have decided is that I cannot do without electricity. So, although I have skin in the game, I can't say "no, thank you, I'm using a cheap alternative to electricity so go away Alabama Power." I rely on the Public Service Commission to negotiate fair rates and rely on the government to force my appliances to become energy efficient. Oddly, as appliances become more energy efficient, rates per kilowatt hour tend to go up. I now have less skin in the game (using efficient appliances less frequently still costs the same because I pay more per kilowatt hour) but still reflexively try to use less electricity. Modern life is confusing at times.
Many folks have asked me what I think is going to happen with health care. Conventional wisdom is that the people appointed dictate policy. Seema Verma, who helped design the Medicaid expansion in Indiana, is the new director of CMS (the agency responsible for Medicaid and Medicare). The buzzwords for poor people and perhaps all sick people will likely be "personal responsibility."
Ms Varma has written on the philosophy she has used to design the system in Indiana (article found here). It seems that this is not just about making sure poor, sick folks have needed care but importantly involves bootstrap repair as well:
[M]any of Medicaid's enrollment and eligibility policies, which might make perfect sense for certain vulnerable populations, are not always appropriate for able-bodied adults possessing different capabilities and earning potential. Able-bodied adults need coverage, but not the same set of policy protections.
One of the precepts of President Lyndon Johnson's War on Poverty, from which Medicaid arose, is that government assistance should exist to provide a temporary pathway for people to lift themselves out of poverty toward a state of self-sufficiency.
The recipients are given a Health Savings Account and are required to make their personal contribution to teach them responsibility (as was the client in the anecdote above). Finding frequent rides to the insurance payment window and personally making a payment which provides continued access to lifesaving insulin and health failure medications, apparently, is freeing:
HIP respects the dignity of each member by setting a fair expectation of personal investment and engagement in his or her own well-being. Contributions are a way for members to demonstrate personal responsibility, but they also encourage members to stay engaged with their health plan, providers, and overall personal health. Because HIP Plus members' own dollars are at stake, they have "skin in the game" and therefore an incentive to make cost-conscious health care decisions.
Well, maybe not…Turns out that for "frequent flyers" hospitals are seeing to it that the $1 premium is being paid. Because, if you miss a payment, you are kicked out. So it does seem that someone has skin in the game, just maybe not the patient.
As a pragmatist, I believe that the motive is unimportant if the desired result is achieved. Results to date are mixed. Ms Varma points out that those who have paid their premium continuously (folks with "skin in the game") are more likely to have a primary care doctor, less likely to go to the ED, and more satisfied with their care. Critics point out that enrollment is not by any means what it should be as many folks can't get a monthly ride to pay their dollar. Also, less that half of folks who were enrolled knew that they even HAD a health savings account much less how to use it. As they say, further study is needed.
In my professional experience, people believe they are healthy until they are sick. A monthly trip to Walmart to pay a dollar is likely not to change that. I hope that we choose to look at real measures of health and not try to do social engineering with our healthcare dollars.
Uwe Rheinhart, a noted health economist, was asked to predict what would become of healthcare under Trump leadership. He said "My hunch is that the "replace" in what is coming will reflect that conservative vision. It is bound to spell more hardship for the poor, the old, and the sick." I am afraid that that is what "skin in the game" means.
My mother: Oh, there are some people in this place you wouldn't believe. They don't even know where they are
Me: Well, in Alabama, they could't be there at all. If your memory slips too bad, you are considered too sick for assisted living and have to be moved out.
My mother: Well that makes sense.
Me: No, back to independent living. It is illegal to provide assisted living those with memory problems in Alabama
My mom and dad moved from Louisiana to Marietta Georgia after The Storm (on the Gulf Coast we now date everything by August 29, 2005. That's the day Katrina made landfall in Louisiana). They were in Baton Rouge and were in their late 70s when the storm hit. They had their own home and could drive without too much effort to get necessary items and run routine errands. They had lived in their house for 53 years and were comfortable.
Post Katrina, their lives changed substantially. Baton Rouge almost doubled in size from the influx of New Orleans refugees. What was a simple chore (driving to the store) became a nightmare of left turns into rapidly moving oncoming traffic unimpeded by traffic lights. They were older people living in a first ring suburb in the sunbelt south. If you were older with failing reflexes you had to make the best of it. Without a car there was no food, no doctor, no post office.
They moved into an independent living community for older individuals in Marietta (by my sister). It is like what my kids used to call a college "wonder dorm," only for older folk. Separate apartments, common areas for dining and socializing. Difference is that in college the turnover is dictated by the ebb and flow of college life. At the facility my folks are in, folks tend to stay. They stay, that is, until they lose their independence or they pass away. On my weekly phone calls I hear tales of which person is losing touch with reality. "Mr Soandso is grabbing everyone." I'll hear one week then two weeks later "Remember Mr Soandso, well they had to take him away." Ambulances are a regular occurrence with the inevitable return of the resident just a little less functional than before he or she left. If only a little confused when they leave, they are a lot confused when they return. Soon, they are removed to another facility. My folks can't help but wonder when the inevitable will catch up with them as well as they notice their memory slipping with age.
Why have we not come up with a better way? As I told my parents, in Alabama it is even worse because, with any type of dementia, regular assisted living is out. Alabamians have to move into a "specialty care assisted living." There are only about 300 of those in the state with a total of 3000 beds. To quote a recent article:
The quality of care can vary significantly from one facility to another. The best assisted living facilities provide comfortable and healthy homes for patients in early and moderate stages of physical and mental decline. But inspection reports reveal that many fail to adequately staff facilities and train workers caring for patients – leading to falls, errors, abuse and even death.
In Alabama, we have 89,000 people living with dementia. With only 3000 beds, what happens to the rest of these folks? Some are admitted to the nursing home, losing their independence prematurely. In fact, the Alabama Medicaid crisis is precipitated in part by the $808 million spent annually on dementia care (about 20% of the budget). Most are cared for at home by a "volunteer" caregiver. In Alabama it is projected that 302,000 caregivers provide care for these folks. This is $4 billion of unpaid care with a huge toll on the caregiver's health.
The baby boomers changed our society. We embraced the car. We became much more mobile. Little remained untouched. Boomers are now hitting their seventies. Inevitably they will lose their independence. Inevitably, many will lose their cognitive functions. Will they (and their caregiver children) demand better care for those who are aging out? For my sake I hope so.
Healthcare is almost 20% of our economy. A future President Clinton or a future President Trump will, through executive action, have a lot to say about how that money is spent. Commonwealth fund (found here) has an exceptional comparison of the two candidates' proposals and how they would effect the budget. If you care about fiscal responsibility, for the record, the balance sheet is found below:
So, the Trump plan is not, despite what he claimed in the debate, the way to fiscal solvency.
Kaiser Family Foundation has put together a specific list of issues (found here) that folks appear interested in and has evaluated each camp's claims. The Cliff's notes version is as follows:
Health insurance coverage and cost – Issues include overarching reform of health system remains unpopular in a partisan manner. Affordability hampered by a glitch where family coverage became more expensive, "cost sharing" was not controlled by the law, enrollment was not implemented well, and transparency provisions not implemented. Market place competition is limited, especially in rural areas.
- Clinton
- supports policies to maintain and build upon the ACA.
- increase premium subsidies in the marketplace so no participant is required to pay more than 8.5% of income for coverage.
- fix the "family glitch" and allow people to buy coverage through the marketplace regardless of their immigration status.
- make a public plan option available in every state and give people the option of buying into Medicare starting at age 55.
- invest $500 million annually in outreach and in-person assistance to enroll more uninsured in coverage, and she would enforce ACA transparency provisions.
- authorize the federal government to review and disapprove unreasonable health insurance premium increases in states that do not have such authority, repeal the Cadillac tax.
- proposed new private plan standards to waive the annual deductible for at least three sick visits per year, limit monthly cost sharing for prescription drugs to $250, and protect against surprise medical bills when patients inadvertently receive care out of network.
- proposed a new refundable tax credit of up to $5,000 to subsidize out-of-pocket health expenses (including premiums in marketplace plans) for all Americans with private insurance.
- Trump
- complete repeal of the ACA, including the individual mandate to have coverage.
- create high risk pools for individuals who have not maintained continuous coverage.
- provide a tax deduction for the purchase of individual health insurance.
- promote competition between health plans by allowing insurers to sell plans across state lines; an insurer licensed under the rules of one state would be allowed to sell coverage in other states without regard to different state laws that might apply.
- promote the use of Health Savings Accounts (HSA), and specifically would allow tax-free transfer of HSAs to all heirs.
- would also require price transparency from all hospitals, doctors, clinics and other providers so that consumers can see and shop for the best prices for health care procedures and other services.
Medicaid – Issues include states' concerns regarding financing and unwillingness to expand to those too poor to qualify for a tax rebate required coverage
- Clinton
- encourage and incentivize states to expand Medicaid by providing states with three years of full federal funding for newly eligible adults, whenever they choose to expand.
- would also continue to make enrollment easier and launch a campaign to enroll people who are eligible but not enrolled in coverage.
- Trump
- supports a Medicaid block-grant and a repeal of the ACA (including the Medicaid expansion).
- would cover the low-income uninsured through Medicaid after repealing the ACA.
- The House Republican Plan, which is part of a larger package designed to replace the ACA and reduce federal spending for health care, would offer states a choice between a Medicaid per capita allotment or a block grant.
Medicare – Issues include prescription drug costs, fate of provisions in ACA, public option for those 55-64
- Clinton
- supports maintaining the current structure of the Medicare program and opposes policies to transform Medicare into a system of premium supports. On the issue of prescription drug costs
- supports allowing safe re-importation of drugs from other countries, allowing the federal government to negotiate drug prices in Medicare, especially for high-priced drugs with limited competition, and requiring drug manufacturers to provide rebates in the Medicare Part D low-income subsidy program equivalent to the rebates provided under Medicaid.
- does not support repealing the ACA or any of the Medicare provisions included in the law; rather, she supports expanding the law's value-based delivery system reforms.
- proposed to allow people ages 55 to 64 to buy into Medicare.
- Trump
- No position on the issue of Medicare program restructuring or whether to allow older adults ages 55 to 64 to buy in to Medicare.
- supports repealing the ACA, which would presumably mean repealing the law's Medicare provisions.
- supports allowing safe re-importation of prescription drugs from other countries.
Prescription drugs – Issues are pricing (generally more expensive in US than in other countries despite being manufactured in the same facility) and out-of-pocket costs (many plans have gone to a cost sharing rather than a deductible strategy
- Clinton
- proposes prohibiting "pay-for-delay" deals whereby companies make payments to competitors for agreeing to delay market entry
- increasing funding for the FDA Office of Generic Drugs to reduce their approval backlog
- reducing the market exclusivity period for biologics
- and directing the FDA to prioritize biosimilar drugs with few competitors. To address price increases for generic drugs
- proposes to establish consumer oversight in federal agencies
- penalize drug companies for unjustified price increases
- allow importation of lower-cost drugs from countries with similar safety standards.
- She also supports eliminating tax deductions for direct-to-consumer advertising
- requiring FDA approval of advertisements
- tying federal support for drug companies to their investment in R&D
- increasing transparency of the additional value new drugs have over existing treatments
- allowing Medicare to negotiate drug and biologic prices. To address OOP spending on prescriptions,
- proposes a $250 per month cap on cost sharing for covered drugs; and a rebate program for low-income Medicare beneficiaries that mirrors those in Medicaid.
- Trump
- supports allowing importation of drugs from overseas that are safe and reliable but priced lower than in the U.S.
- supports greater price transparency from all health providers, especially for medical exams and procedures performed at doctors' offices, clinics, and hospitals, but does not specify whether this policy would also apply to retail prescription drugs, which typically are not considered services or procedures.
Opioid epidemic – Issues include increased use (1 in 20 nonelderly adults used opioids for nonmusical purposes), increased addiction ( 2 million non elderly adults with of the level of opioid use increases to the level of opioid use disorder, often referred to as abuse, dependence, or addiction), increases in overdose deaths (those involving opioids have quadrupled since 1999).
- Clinton
- released a $10 billion (over ten years) plan to fight drug addiction.
- includes a federal-state partnership to support education and mentoring programs
- development of treatment facilities and programs
- efforts to change prescribing practices, and criminal justice reform.
- direct federal action to increase funding for treatment programs
- change federal rules regarding prescribing practices
- enforce federal parity standards
- promote best practices for insurance coverage of substance use disorder services
- issue guidance on treatment and incarceration for nonviolent and low-level federal drug offenders.
- released a $10 billion (over ten years) plan to fight drug addiction.
- Trump
- Will build a wall on the U.S.-Mexican border
- will help stop the flow of drugs and thus address the opioid epidemic.
- Will build a wall on the U.S.-Mexican border
Reproductive health – Issues include access to preventive services, publicly funded family planning, and abortion services
- Clinton
- supports policies that protect and expand women's access to reproductive healthcare, including affordable contraception and abortion.
- defends the ACA's policies, including no-cost preventive care and contraceptive coverage. promised to protect Planned Parenthood from attempts to defund it and would work to increase federal funds to the organization. called for the repeal of the Hyde Amendment which she believes limits low-income women's access to abortion care.
- would appoint judges to the Supreme Court who support Roe v. Wade, ensuring a women's right to choose an abortion.
- Trump
- called for defunding Planned Parenthood if they continue to provide abortion
- would redirect their funding to community health centers.
- He states he is pro-life but with exceptions when the pregnancy is a result of rape, incest, and life endangerment.
- has promised to appoint pro-life justices to the Supreme Court that seek to overturn Roe v. Wade
- would also work to make the Hyde Amendment permanent law
- would sign the Pain-Capable Child Protection Act, legislation that would sharply limit access to later term abortions.
- would also repeal the ACA, which would eliminate minimum scope of benefits standards such as maternity care in individual plans and coverage of no-cost preventive services such as contraceptives in private plans.
- called for defunding Planned Parenthood if they continue to provide abortion
Are you going to provide free clinics for sick underprivileged children? Will you do in Alabama what you do on mission trips to other states and countries?
Senator Jim McClendon, explaining why he is sponsoring not one but TWO lottery bills
The legislature in Alabama is meeting in special session starting today to see if they can find more money for the General Fund budget. The budget passed in the regular session was about $100 million short for what was needed to maintain the Medicaid program at its current bare bones level. Medicaid and corrections are the major programs funded by this complicated and convoluted budget process and, as you can imagine, the constituency tends to be silent. The legislature comes back into special session today to determine whether Alabama will become the first state to reduce Medicaid funding below the threshold required for the match.The funding possibilities are as follows:
- Governor Bentley's proposal- a $225 million lottery, with proceeds going to the General Fund. Would require constitutional amendment. Money not available for about a year.
- Jim McClendon's bill, which would include electronic lottery machines in four counties – Greene, Jefferson, Macon and Mobile – with a bond issue to pay for Medicaid in the coming year. Would require constitutional amendment.
- House Minority Leader Craig Ford, D-Gadsden, said he'll bring a lottery-only bill that would set aside lottery proceeds for education. Another Ford bill would include casino gambling as well. Would require constitutional amendment. Money not available for about a year.
- The legislature may create a compact with the Poarch Creeks, allowing them to offer more types of gambling in exchange for an annual fee or a cut of the proceeds. Critics worry that under federal gaming regulations, a lottery could open the door to Creek expansion without a compact. Unclear how this would work. Likely would draw a lot of attention form the feds.
- They may opt to use the BP money to fill the gap this year, leaving the hard work for next year.
- They may, and possibly will, do nothing and allow Medicaid to become a non-compliant program
If they fail to act. the feds will do one of two things. Because the program's recipients are disproportionately poor and of color, the feds may sue under the Fourteenth Amendment and require us to find $100 million to maintain a $6 billion program, maintain access to healthcare for ALL Alabamians, and not force the layoffs of tens of thousands of individuals who work in healthcare. Conversely, the Supreme Court has ruled that Medicaid is an optional program. The feds may just allow us to opt out and allow our natural experiment to continue. Let's see how many folks will come to Alabama instead of Ecuador for mission work.
I will be appearing at a press conference on Friday, August 5th as a representative of the Alabama Academy of Family Physicians. Beside me will be representatives from the Alabama Academy of Pediatrics, the Alabama Hospital Association, and the community. We will share the following message. This message is being shared in across the state in a series of press conferences beginning Monday:
On August 1st (tomorrow), Alabama begins applying cuts to the state's Medicaid system that will impact the quality of care all Alabamians receive. In Alabama, Medicaid:
- Provides health coverage for eligible children, pregnant women, and severely disabled and impoverished adults
- About 1 million Alabamians
- More than half the births in Alabama
- About 47 percent of Alabama's children
- About 60 percent of Alabama's nursing home residents
These cuts are devastating and dangerous. Because Alabama already operates a bare bones program, the following will occur:
- Reduction of payments per visit to primary care physicians by 50% beginning tomorrow
- Reduction of reimbursement rates for ambulatory surgical centers, all other specialty physicians, dentists, optometry, hearing and other programs
- Elimination of the prescription drug coverage for adults for the first time
- Elimination of adult eyeglasses
- Elimination of outpatient dialysis
- Elimination of prosthetics and orthotics
- Elimination of Health Home and Physician case management fees
- Consideration of a pharmacy preferred provider program
As a result of the Medicaid cuts put in place August 1, my colleagues in primary care are being put between a rock and hard place. Medicaid rates will not cover the cost of keeping the practice open. My primary care colleagues will either accept fewer Medicaid patients, limit the number of office locations, lay off staff – including nurses and other clinical staff. In some cases they will make the very tough decision of closing their practice and moving to a state that has a more hospitable practice environment.
So what? Turns out primary care doctors are the economic engines of small communities and provide economic vitality to all communities. Combined, we support 83,095 jobs and generating $11.2 billion in economic activity, according to a report by the Medical Association and the American Medical Association. Specifically:
- Jobs: Each physician supported an average of 9.5 jobs, including his/her own, and contributed to a total of 83,095 jobs statewide.
- Output: Each physician supported an average of $1.3 million in economic output and contributed to a total of $11.2 billion in economic output statewide.
- Wages and Benefits: Each physician supported an average of $758,744 in total wages and benefits and contributed to a total of $6.7 billion in wages and benefits statewide.
- Tax Revenues: Each physician supported $46,148 in local and state tax revenues and contributed to a total of $404.9 million in local and state tax revenues statewide.
When these cuts take effect, doctors will leave. Consequently it much more difficult for any patient in the state – including those on private insurance like Blue Cross/Blue Shield – to make an appointment with a doctor of their choice at a time convenient for their schedule. Jobs will leave these towns, towns will die.
Isn't Medicaid full of fraud? Turns out, not. In fact state lawmakers recently conducted an extensive review of Medicaid's funding and operations. Our program is one of the most frugal health plans available.
What needs to happen? In order to protect the state's fragile healthcare system from collapse and ensure that all Alabamians have access to the doctor of their choice, legislators must find a long-term, sustainable solution to fund Medicaid, and shore up funding for the coming year.
How can you help? Visit IamMedicaid.com for more information and go HERE to contact state leaders to let them know how you feel. Encourage them to protect Alabama's healthcare system by fully funding Alabama Medicaid. Let them know that you are concerned and you vote!
Q: How many magicians does it take to change a light bulb?
A: Depends on what you want to change it into.
Turns out, weekends are especially hard. On weekdays, I would get up, do chores (mostly dog and chicken related), go to work, then come home. Either Danielle would have supper ready or, increasingly, we would go out because it was too much hassle cooking for two. Then I would settle down to do a little work and Danielle would do her thing until it was time for bed. Our days would overlap mostly at supper. The weekends, though, would be when we did OUR thing.
Danielle: Remember, tonight is Art Walk Friday
Me: Ok, but I'll be about 6 because I have patients
Danielle: Well don't be late because we're meeting folks at the Bike Shop for dinner at 7:30 and I have to see the show at the Skinny Gallery. And then tomorrow we have to go to the symphony, and then…
Even on days like this when I was on call, we would carefully plan our trips and errands around my rounding schedule.
Now I have had to change my weekend routine. Change, as they say, is inevitable.
Q: How many Marxists does it take to change a light bulb?
A: None. The light bulb contains the seeds of its own revolution.
Ranking things seems to be the new "news." Almost everyone has put together a list of best and worst based on some criteria or another. My kids tell me these are called listicles. having the list without information in the title, so I understand, encourages folks to "click" ensuring more ad revenue. USA Today's offering today was "The least healthy cities in America." As everyone in America clicked to find out how their city fared, we in Mobile were (dis)honored to be #4:
4. Mobile, Ala.
>Premature death rate: 490.3 per 100,000
> Adult obesity rate: 36.1%
> Pct. adults without health insurance: 12.9%
> Poverty rate: 19.9%
The average Mobile adult feels in poor mental shape for five days a month on average, far longer than the 3.5 days the average American feels in such a state. Poor mental health outcomes in Mobile may be tied to multiple unhealthy behavioral and socioeconomic factors in the area.
Mobile's 36.1% obesity rate and 29.6% inactivity rate are both far higher than the corresponding national figures. Additionally, nearly one-fifth of area residents live in poverty, and 7.0% of the workforce is unemployed, each some of the highest such figures in the country.
Wow. For those with a memory for these things, in 2013 Business Insider tagged us the 3rd most miserable city in 2013. At the time I pointed out
The results of that survey, Perkins said, made it clear that Mobilians suffer from poor mental and physical health in large part because the city's built environment is not conducive to being active. Access to healthy foods in poor neighborhoods is also poor, he said.
If Mobile wants to work its way off these lists, it'll take change (see figure). We'll need to invest in infrastructure such as parks and bike lanes so people make healthier choices. Increase the minimum wage so folks have time to use these amenities to get and stay healthy. Expand Medicaid so folks are not one illness away from bankruptcy. Focus our care delivery system on health instead of on making money off of illness. In other words, while change may not be inevitable for Mobilians, it is the only way to get off of these lists.
Or, we could just double down on our football success:
At ALABAMA: It takes five, one to change it, three to reminisce about how The Bear would have done it, and one to throw the old bulb at an NCAA investigator.
"It is one of the happy incidents of the federal system, that a single courageous state may, if its citizens choose, serve as a laboratory; and try novel social and economic experiments without risk to the rest of the country."
The state of Alabama continues to deny its citizens access to expanded Medicaid. One of the arguments made by Alabama state Senator Tripp Pittman, a harsh critic of government in general and Medicaid in particular, is that the states are not given enough flexibility. He blamed the poor for the "excessive" cost of care, in fact, and suggested that if more control were given to the state the undeserving could be weeded out. Then, as one does with weeds, left in a pile on the side of the road to wilt I suppose.
An inside look of how the state of Alabama would REALLY handle this serious responsibility can be seen in the trial of our Speaker of the House, going on now. For those who don't watch Rachel Maddow or read the New York Times, the state has its Governor under grand jury investigation and its Supreme Court Chief Justice under judicial review. These, however, are not the worst. Mike Hubbard, the Speaker, has been under indictment for 23 felony counts involving violations of the ethics laws he authored. It has taken two years for this to come to trial. In the interim he has been reelected to his seat and reelected as Speaker by his "peers." Several of his peers have already pled guilty and are scheduled to testify. Others will likely plead the fifth.
It is an interesting set of charges. He is charged with taking money as a lobbyist (unregistered) from a gas company and then passing laws to push business in their direction. He is also charged with using his position as head of the Republican party to push business towards his formerly failing company. These are all your typical corrupt politician charges and his defense is one of confusion about the illegality of the actions ("I don't know what he was talking about," says defense attorney Baxley, it's all "mumbo jumbo and gobbledygook.") combined with the good-old-boy defense ("What he didn't show was the parts of the ethics law that offers exceptions for friendships in business dealings," Baxley said). Makes for fun theater.
The most serious charges and the ones that likely have gotten the feds interested are the ones regarding Medicaid. As a program that costs the state under a billion dollars and brings six billion dollars into the state, a bunch of money is available for folks to use for "bidness." Speaker Hubbard, as documented in the New Republic, saw a huge opportunity. As the revenue stream for the general fund (which funds Medicaid) is diminishing and folks like Senator Pittman have no compunction to raise taxes, controlling medication costs seemed to be the natural course of action. Speaker Hubbard called a meeting and:
So three legislators, two lobbyists, and a handful of staff privately decided, after the briefest of deliberations, to enact a policy that would give a $20 million monopoly over the state's Medicaid drug business to a corporation that had no experience running such a program, a move that would impact the lives of the 600,000 poorest and least powerful people in Alabama—children, senior citizens, people with disabilities.
Afterwards the group discovered to their surprise that one of the Speaker's clients was involved in this Medicaid medication management scheme and would have benefited significantly.
The former chief of staff also urged Hubbard not to vote on the budget bill because it "looked bad," but Hubbard said it would send up "too many red flags." The language was later stripped in committee.
His current defense? "No harm, no foul" and/or "we stuck it to them city slickers."
So in this one laboratory of democracy, even with significant federal oversight, Medicaid money seeps out around the edges to enrich a small number of folks. Imagine what'll happen when the oversight is less. My prediction: It'll be HUGE for some people, very few of those being the poor and the sick.
"Last year (2015), the Science and Security Board moved the Doomsday Clock forward to three minutes to midnight, noting: 'The probability of global catastrophe is very high, and the actions needed to reduce the risks of disaster must be taken very soon.' That probability has not been reduced. The Clock ticks. Global danger looms. Wise leaders should act—immediately."
Bulletin of the Atomic Scientists, 2016 Doomsday Clock update
Here in Alabama, it is one minute to healthcare catastrophe. The legislature passed, the governor vetoed and got caught in a sex scandal, the legislature overrode and made law a bill which reduces Medicaid to a level not seen in any of the other 49 states. The program exists as a federal-state partnership and Alabama's partner has every right to back out if we don't hold up our end of the bargain.
So what, you say, I have Blue Cross.
As fellow Alabama physician Pippa Abston documents, everything is connected. Our doomsday clock has been inching closer and closer to midnight ver since 2003 when Governor Riley failed to pass a funding package to deal with the problem. In the interim we have cut mental health services to the bone, have reduced services that maintain the elderly in their home, have reduced payments such that eight rural hospitals have closed and another 2 dozen are on the critical list. The next tick of the clock spells disaster. Woman's and Children's Hospital in Mobile, 71% Medicaid. Children's of Birmingham, 57%. Midnight is only a minute away.
In the cold war era we actually planned to survive the nuclear holocaust. Fallout shelters stocked with food, instructions on how to "duck and cover" and other propaganda gave us a sense of bravado in the face of certain annihilation. We were fortunate that the balloon never went up because our survival was never guaranteed. In fact, policy makers were well aware of the futility of their efforts.
Today and tomorrow are the day when we decide whether to let clock click to zero for health care in Alabama. Don't believe in the false security of private insurance. Our system is built on Medicaid. Call your state senator and tell him or her you support using BP money for Alabama Medicaid.
Alabama is still poised to unleash the Death Angel. The night after we wrote that post I suffered a tragic loss. Danielle Juzan, my wife and silent collaborator of 33 years was stricken and died of a heart attack at the age of 55. As you can see from the attached article, she was a wonderful, passionate woman who pushed me to stand up and do the right thing regardless of the personal or professional consequences. She was also a marvelous writer and those who have read this blog over the years will never know how much she added to these posts.
She was a fixture in the local community and fought hard for improvements to Mobile, Alabama. Her attachment to our community was what made this work so important. Over the years I have looked at several jobs in places that are better positioned to provide healthcare for all citizens. Each time Danielle would give me the reasons not to leave our house (we just got the garden where it needed to be, we are getting a dog park, etc) and ask me if we couldn't stay in Mobile a while longer. I would agree that we had a nice life despite the seeming callousness of the public officials and we would go back to tilting at the windmill that is improving the care of the underserved in Alabama.
As I grieve, I continue to check my e-mail and am thankful for the hundreds of expressions of sympathy that I have received. For those of you who read this, thank you so much. While nothing will make it better, it is comforting to know that Danielle has touched so many.
Immediately after her death we were challenged in a message as to accuracy of the position that Medicaid (not the expansion, access to Medicaid at all) saves lives. The commenter suggested that the evidence for improved health was wanting. He pointed out that before the passage of the ACA, Oregon randomly gave several thousand people who were uninsured Medicaid coverage and followed them and several thousand uninsured for a couple of years to see what would happen. The results were as follows:
Medicaid coverage resulted in significantly more outpatient visits, hospitalizations, prescription medications, and emergency department visits. Coverage significantly lowered medical debt, and virtually eliminated the likelihood of having a catastrophic medical expenditure. Medicaid substantially reduced the prevalence of depression, but had no statistically significant effects on blood pressure, cholesterol, or cardiovascular risk. Medicaid coverage also had no statistically significant effect on employment status or earnings.
The science is pretty clear, access to health insurance over a two year period for relatively healthy people improved some aspects of their lives but is no panacea. How these findings are interpreted depends on if you live in a red state or a blue state:
A great deal of controversy exists about reducing the number of uninsured people in the United States through Medicaid expansion. Advocates for Medicaid point to evidence showing that Medicaid has been an essential part of the nation's safety net, providing access to comprehensive health care for the nation's most vulnerable.
Critics of Medicaid, on the other hand, believe Medicaid has put a tremendous strain on state budgets and increased dependency on government programs. They argue for state-based solutions that place more emphasis on subsidizing enrollment in private insurance for the low-income uninsured. The findings from the Oregon Health Insurance Experiment are cited by both sides as evidence in support of their positions.
Oregon did not take away coverage from required populations. This was coverage provided to folks who would not have been Medicaid eligible otherwise. Alabama is poised to take coverage away from patients on dialysis, patients with complex seizures, and premature infants. It will be a different experiment.
Kaiser has synthesized the evidence on Medicaid's contribution to the health of the population and it is as follows:
- Consistently, research indicates that people with Medicaid coverage fare much better than their uninsured counterparts on diverse measures of access to care, utilization, and unmet need.
- Children with Medicaid and privately insured children compare quite closely in their access to and use of preventive and primary care. The uninsured do not have access to such care due to expense
- As distinct from access to primary care, access to specialty care has emerged in some research as a weakness in Medicaid relative to private insurance.
- Compared with both privately insured people and the uninsured, Medicaid beneficiaries have much higher rates of ED use. However, a substantial body of research investigating this disparity more closely indicates that poorer health and access challenges in Medicaid both play important roles in explaining Medicaid's higher ED visit rates.
- Research investigating the quality of care received by Medicaid beneficiaries is limited, but two new analyses, one focused on health center care and the other on hospital care, indicate that the care received by people with Medicaid coverage tracks closely with benchmarks for high quality.
- One study found statistically significant but small differences at the national level between the shares of Medicaid and privately insured adults who received perfect hospital care which was more related to regional differences.
Their conclusion is as follows:
In its totality, the research on Medicaid shows that the Medicaid program, while not perfect, is highly effective. A large body of studies over several decades provides consistent, strong evidence that Medicaid coverage lowers financial barriers to access for low-income uninsured people and increases their likelihood of having a usual source of care, translating into increased use of preventive, primary, and other care, and improvement in some measures of health. Furthermore, despite the poorer health and the socioeconomic disadvantages of the low-income population it serves, Medicaid has been shown to meet demanding benchmarks on important measures of access, utilization, and quality of care.
For you, Danielle. Continue to help me keep fighting the good fight.


text:
Smile and keep moving, everything will be fine.
Remembering that everything happens for a reason, sometimes that reason is not apparent straight away.
I believe that it is always to take you to a better place and to propel you forward.
Sometimes it feels tough, but that is where you learn your lessons to make you stronger and a better person.
Learn to let go, ride the rollercoaster, enjoy the ride and smile knowing that eventually you will be where you are meant to be when you are ready. #wisewords#freedomintraining.
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Furniture Manufacturer Case Study Part 2
In my last post we began our discussion of a case study of a ready to assemble (RTA) furniture manufacturer using TOC to turn-around their struggling business. Because their product was so well received by their customers, orders to this company had accelerated to the point that their capacity had been exceeded. I also gave provided a link to the full case study, for those of you interested in reading it:
As I explained in my last post, this small manufacturer was facing the same problems that many small companies face, in that demand for their growing line of RTA furniture was nearly beyond their ability to produce it, even though they had two full shifts in operation. The order backlog at the manufacturing plant was steadily increasing and their lead time stretched to more than three weeks.
As a result of this lead time extension, other orders would become further behind schedule and these constant changes led to mistakes and quality problems. The employees on the shop floor began questioning whether the leadership knew what they were doing as priorities on them were constantly changing. In addition, there were lengthy set-ups on some of the equipment, so wherever possible, components were manufactured in larger batches. As a result of these larger batches, the work-in-process (WIP) ballooned higher and higher which further extended lead times, causing the company to consider an expensive plant expansion.
Through a series of coincidences, the GM was introduced to the Theory of Constraints and read Eli Goldratt and Jeff Cox's best-selling business novel, The Goal. The GM had explained that reading this book was a real eye-opener for him. Even though his company was in no danger of being shut down, like the fictitious company in The Goal, he recalled that it was almost as if the book had been written about his company. Let's now begin to explain just what this company did to turn itself around.
The Goal
After reading The Goal, the GM decided to send his Production Manager and Systems Manager/Specialist to a two-day TOC workshop. The Production Manager explained that both had been required to read Goldratt's book prior to attending the workshop, but neither one was sure of what they were in for or what to expect. But by the end of the first day's session, they both knew they were on to something different, but something very valuable. Even before the end of the workshop, they were both recognizing that many of the current methods and procedures being used at their plant had been developed around controlling costs and keeping spending under control and not doing things that made money for their company. In fact, they both believed that their cost-based actions they had been doing before this workshop hadn't been helping them at all.
The workshop taught them that the first step was to identify which of their several busy resources was the Drum (i.e. the bottleneck or system's constraint) because this resource controlled their rate of production. After some debate, they had concluded that their Grooving line should be selected as their best candidate. They didn't waste a lot of time collecting and analyzing lots of data to find their constraint. They had concluded that since the grooving line fed their packaging area, if they decided to tie the packaging flow to the grooving line, then maybe the packaging would suffer and potentially damage the total plant throughput. They made this change, held their breath and tried it. By the second day, all doubts about their change were removed as the packaging department was hitting record output!
Systematically, this company set about applying the methods they had learned in the workshop in order to manage their production facility more effectively. The Production Manager explained that this workshop was never intended to give them all of the "how to's," but once the basic concepts were clear, the people in their shop just made it all happen. From my own experience, this is exactly what typically happens. The basic points of TOC are very easy to learn and apply because they are all based on common sense teachings.
The actual implementation involved all of the management and the shop floor workers, making sure that the grooving line was being used effectively and was kept running. They then synchronized all other production activities to their selected constraint just to keep material flowing smoothly to and from the line, to packaging and then onto shipping. Everyone was clearly surprised and very excited at the outcome/results of their changes.
Next Time
In my next post, we will continue on with more changes this company made and present some results of their changes. As always, if you have any questions or comments about any of my posts, leave me a message and I will respond.
Until next time.
Bob Sproull
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Think intro. The thinker in a blender of guessing and your daily worry of every thing possibly going wrong and whether you will survive the weight of expectations. I have seated the fight of proving myself to the back of the car and take pleasure in the smaller uncomplicated things in life like maintaining decent moustache, wearing funky clothing and smiley face at funny conversations I overhear. I think it's been a time of discovering that there is a time for everything and taking time to be incognito is not laziness but a wise decision. Just a birthday coming ahead. Some make a big deal out of it saying its a thoughtful celebration of a person becoming an adult or an excuse to party hard and drop good wishes on the ageing person.
Hello josh you are getting older and I hope more good looking too as you hit 21. Maybe time to do some party planning and come out of incognito mode. Prefer coke to beer but willing to be convinced if there is good trade offs.
In there from griffith it's nearly o week. Pretty excited and keen to exercise flabby brain and experience the campus life bar tipsy nights. Yes I am a proud nerd and strange too but I like being different. Been like that my whole life.


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Joey asked me recently as I was down stairs putting my latest project together, "Harm, haven't you made enough pillows?" I looked at him bewildered and said, "Ha, you can never have enough pillows!" It's still freezing in No. Dak. lately and there isn't anything we can do outside yet. We can't mow the lawn, can't plant, can't weed, can't play in the sun…we are limited to the indoors still. So of course, I keep not only a clean house, but have to do something while hanging around so my go-to is always cross-stitching.
Quoteable Pillows
26 Apr 2016 Leave a comment
in Cross-stitching, Sewing Tags: at home, black, Cross-stitching, fabric, gift, handmade, homemade, pillow, quote, Sewing, simple, white
Valentine's Pillow and such…
22 Jan 2013 1 Comment
in Sewing Tags: envelope, leaves, pillow, pink, red, trunk, Valentine's Day, white
Well, I totally feel like the most terrible friend, EVER!! You see, one of my best-friends since oh about 3rd grade sent me a Christmas present full of yummy German chocolate, from Germany and I, I sent her nothing in return. We have NEVER exchanged gifts in our entire lives and the one year I am not prepared for the "just in case" she sends me something. Ugggghh, sometimes I feel like I can't win. In any case I thought it would be just as awful to go out and buy something just to have a sent present to her, late. How obvious would it be to have a present sent after the fact, just not my style. So I decided I would make her a Valentine's Day present! Ya know that pillow I made for my cousin, Cami? Well here is a duplicate, just some scraps chosen from a Valentine's Day charm pack.
The Wedding
18 Oct 2012 Leave a comment
in Vacation Tags: cake, wedding, white
I realize that it has been about a few weeks or better since I have posted and although there have been no fun crafting activities with school back in full swing, our wedding photos have arrived and wanted to share!
I know that none of my family reads my blog; however, I want to give a huge thank you to my parents for hosting this delightful event at their home. We definitely had a cost-effective wedding! My mother, bless her heart, planned every single detail out and made it the day of my dreams!! I love her so much!!
Also a huge thank you to Smokin on Site catering, that was the most delicious BBQ I have ever had in my life!!
A mighty "thank you" to our photographers, who were FREE!! They may be amateurs but they captured everything we wanted anyways. Our DJ who gave us a heck of a deal, my cousin!, who kept the party rockin until 2AM and the dance floor full the entire time!
Enjoy the photos!
17 Jul 2012 4 Comments
in Sewing Tags: apron, blue, Marine, red, Sew4Home, Stars, vintage, white
After about a month on hiatus from my sewing machine, I was getting the itch to create something. Since my mom and sister's birthday are coming up and just so happen to land on the same day of each other, I found for my mom a super cool Marine pattern, sparkley star and sandstone patterns to create the most adorable apron, ever! My little brother is a Marine so I felt that this pattern would be fitting for my mom!


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I ARE DROID "The Winter Ward" LP
23 USD / In stock.
Lowrider's main man Peder Bergstrand's other band, I ARE DROID - considered one of the top 10 records of 2013 by numerous blogs, the Obelisk among them.
Gatefold LP with huge bonus art print poster by brilliant illustrator Kilian Eng. Pressed on 180 g white vinyl!


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The Orlando/Orange County Convention & Visitors Bureau's newest salvo in the battle to attract tourists in a slumping economy is a half-year offer of discounts at area hotels and attractions.
The package includes 50 free offers and runs through June 30. There are two blackout periods: Easter week and Memorial Day weekend. Offers include free hotel room nights and admission to rides and attractions.
The offer is part of the bureau's 2009 promotional campaign launched last month called Orlando Makes Me Smile. Information on the program, called Bundles of Free Smiles, is available on the Web at www.bundlesoffreesmiles.com.
Hotel properties participating in the campaign include Rosen Shingle Creek, Orlando World Center Marriott, Westgate Resorts and WorldQuest Resort. Universal Orlando Resort, Walt Disney World Resort and Southwest Airlines are offering discount vacation packages. Attractions offering discounts include SeaWorld Orlando, Boggy Creek Airboat Rides, Orlando Balloon Rides and Pirate's Dinner Adventure.


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Show more
How did the Greeks view foreign peoples? This book considers what the Greeks thought of foreigners and their religions, cultures and politics, and what these beliefs and opinions reveal about the Greeks.
About the Author
Thomas Harrison is Professor of Classics and Ancient History at the University of Liverpool.
This volume ... is wide-ranging and sparkles with the intelligence both of the authors Harrison has chosen and of Harrison himself.
This book should be obligatory reading.
Also in this series
View all in the Edinburgh Readings on the Ancient World series →


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Abt Card
High-gloss, warm white side panels and doors beautifully offset the chocolate brown glass top. This contemporary style truly captures the cosmopolitan vibe of trendsetting Miami. This cabinet may be mounted to the wall by simly removing the feet and attaching the wall mounting accessory.
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When globalisation became the trend a couple of decades back, I guessed it would have a great impact on countries like Australia with a small manufacturing base. Surprisingly, however, it's not been as bad as I expected.
It seemed to me that to remain competitive we would have to reduce our standard of living. In the same way that when you mix cold and hot water, the cold gets warmer and the hot gets colder to establish a new temperature, I expected our market to have to adjust downwards. That hasn't necessarily been the case ... yet.
With the mooted closure of GMH Holden's plant and the current income crisis faced by QANTAS Airways, perhaps the days are coming when Australian workers will need to be less fussy about work conditions and how much salary they are paid. We already employ thousands (or perhaps tens of thousands) of foreign workers on 457 Visas, mostly in retail and hospitality positions because Australians either don't want the lower paid jobs or don't work as well. All this at a time when we are paying the dole to healthy, young Australians who could work if necessity required it.
Governments can't bail out every industry that can't compete. What must happen is that we must become competitive by lowering our costs of employment and production, a panacea that nobody really wants. As we slowly lose our competitive advantage, it may be absolutely necessary for our survival.
What do you think?


text: So I promised I would write about making New Year's Resolutions. The truth is that I don't believe in them. They never work. Either you're like me and think that you have the whole year to take care of it, and then never even start because 'how could it be December already?'. Or you start hardcore on January 1st, and then it's over by March or when life throws you a curveball, making us feel that we once again have […]Continue Reading


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Pure X "You're In It Now"
Pure X, formerly Pure Ecstasy, are an Austin base garage rock, lo-fi sounding band. Great stuff. We've been talking about them for a while, and are so thankful to finally have our hands on the new album. Their debut album, Pleasures, is scheduled to be released July 5th.


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SUBMIT A BUSINESS PLAN If you would like to submit a business plan for our review, please send a short summary of the concept to click here. Along with the summary, please include a cover page with the following information:
- Company name
- A 50 word or less description of the product or service the company offers.
- Name of Company Contact Person
- Phone number
- E-mail address
- Fax number


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Dash-cam video still missing from Mission mayor's accident
By Gregg Romero Wendorf
MISSION – Longtime Mission Mayor Norberto "Beto" Salinas has categorically denied, contrary to rumors being bandied about during this runoff election cycle, that his auto accident at approximately 3:30 a.m. May 5 was related to the consumption of alcohol.
Mission City Manager Martin Garza has confirmed that the mayor phoned him shortly after the accident – the mayor ran off the road and hit a telephone pole – and he detected nothing irregular in the tone of the mayor's speech (no slurring of words, etc.), and that as far as he is concerned, the mayor received no special treatment from city staff or the Mission PD just because of who he is.
Garza didn't return three phone messages (three days in a row) requesting comment about the crash until this reporter left a message on the mayor's cell phone that his city manager wasn't returning phone calls related to the crash. It was Mayor Salinas, after all, who said call the city manager for confirmation that what he was saying was true – his accident was not alcohol related. It was shortly after the voice mail was left on Mayor Salinas's cell that City Manager Garza finally phoned. Coincidence, who knows.
Read the entire story on the e-Edition of our newspaper. http://www.etypeservices.com/Advance%20News%20JournalID455/


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About a week after my mom lost her battle to Pancreatic Cancer, I began to get feeling back in my limbs. My heart was aching, my mind racing and my body desperately trying to figure out what normal was going to look like. Like how I was going to go to work, the gym, take care of my family and pretend I didn't see the giant white elephant?
In a few hours of regaining feeling of the floor underneath me, I knew that pretending anything wasn't going to be the answer. What I needed was a distraction with a purpose. Something I could do everyday for a while that would connect me to mom, while also honoring her. That was when I remembered what a friend of mine had done, and I decided to embrace it and make it my own.
Miles for Mama.
My mom began running later in life when my dad suggested they train for a marathon together. That's right, a marathon. Skip the 5K, don't bother with the half thing…and go for the gold. 26.2 miles. She wasn't a runner; she was a long-since retired HS cheerleader, about to be on the other side of all that cheering. While the training was often brutal, the exhilaration of running 26.2 miles with strangers yelling you go girl as they read her shirt, completely hooked her. She ran the NYC Marathon 8 times with dad by her side and one year, just 3 weeks after the NYC finish line, they ran the Philadelphia Marathon just to see if they were still trained-up!
My idea was to run 30 consecutive days, to honor her 30 months of surviving cancer. I didn't know if it was going to be easy or hard, but I was going to do it as gracefully as mom did, with no complaints other than her sweet words: "I'm a little tired."
How hard could it be? It was running. It wasn't cancer, chemo, hair loss, burning of my skin, nausea or a question of my life plan. It was just running. Or wasn't it?
Friends I barely knew began joining me feeling touched by my mom's survival story. I was overwhelmed. One friend began running every day even though she said the last time she ran was in high school was when they made her run around the track. Another friend, hundreds of miles away and a survivor as well, ran through all kinds of weather just to honor a woman she only knew through stories. I was speechless and began to lace up.
The thing is that while I am a runner, I never run more than 2 or 3 days in a week. I don't know why exactly, but I have a lot of reasons. Not excuses exactly, but reasons: My tendinitis acts up if I run more than that, I train for triathlons and need to bike and swim, I can't always get to the gym and sometimes it is too hot or cold and well, I need days off during the week. I can't just train every single day without a break. So there. I said it.
But this was not going to be about my reasons or excuses. This was going to be about honoring a commitment, like my mom's commitment to live. Not to survive with cancer, but to live in vibrant colors.
I declared that 3 times a week I would actually run and the other days I would lace up and go for a short jog. It seemed like I was making it too easy, but I had a distraction and purpose and was committed.
However, on Day 14, the snow fell heavily, with the winds whipping everywhere, and no plow trucks to be seen. I could hear my little voice yelling from down below, as I laced up, put mom's ear buds into my ears and pressed play. The Bee Gees lulled through my head, and I could see her beautiful smile as she whispered, 'Just go slow, watch where you step and if you need to walk…that's okay too.'
And I headed out.
And this was how it went. I am now at Day 29 and I am awestruck by the loud racket filling my head. How could something so simple be so hard? Some days I only commit to a 6 minute run around the block in the rain, snow or whatever the universe has in store, but it isn't that that amazes me. It is how often I don't wanna occurs like a real thing. And it is then that I realize how hard she worked to keep living, in spite of all that she felt.
Thankfully my complaints aren't louder than my desire to be connected to my mom, to bandage up my bleeding heart, and to give myself something to do other than curling into a ball and giving up. Thankfully she lives deep inside of me.
And thankfully, on those days I feel the closest connection to her as I hit the streets. I swear I can hear her clear her throat as my feet hit the pavement. I can hear her little feet barely lifting up off the ground and I can hear her sweet voice say, 'It's okay. I'm a little tired too, but let's run anyway.'


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Congratulations! Here are the search results for all local florists near me. Scroll to find a florist or easily refine your search results of local florists by category, geography or florist ratings. Click the "Map View" tab so display the results on a map to find the closest florist to me. Enhance your floral experience and look for the "Verified" florist banner on your local flower shop listing.
1 Result
Baie Verte Flower Shop is a local florist offering same day flower delivery in Baie Verte, NL. Order flowers online or call if you need to send flowers to Nfld And Labrador Canada. Remember to mention floristopia
Baie Verte, Nfld And Labrador A0K 1B0
view phone709-532-8031
view fax709-532-8041


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Yes it is time to release a new design....
Remember a little while back I was stitching the Christmas Joy bag? - well like many things I do, I got a little carried away in the moment and decided just one bag was not enough so how about these? - Peace, Hope, Wishes and Joy a sweet set of four Christmas Gift Bags in red and white.
I think a stitched bag to pop a little gift in is better than wrapping paper any day (especially for sewing friends) and these little bags are so quick and easy to make, it is hard to stop at just one...
So the challenge is on, I wonder how many of my Christmas gifts will be wrapped in a special handmade gift bag this year? - after a quick reality check, my guess is not too many but it's the thought that counts, right??
The pattern called "Christmas Gift Bags" has just been released - the special treat is it comes with iron on transfers for the stitchery design, which means less time tracing and more time stitching - just perfect!
Of course it wouldn't be a pattern release without a giveaway. To be a part of the fun just leave a comment on this posting between now and next Friday (October 3rd) and four lucky winners will each receive their own Christmas Gift Bags pattern.
Enjoy the fun!
These are your two words
"to provide"


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A record label has managed to pull off a feat that no other group of music aficionados has ever managed to accomplish in the past: Bringing the complete audio mix of NASA's infamous Voyager golden records to turntables around the globe.
History of NASA's Voyager Golden Records
Nasa first put together an album of audio, human voice messages and images in 1977 to communicate the story of Earth to any extraterrestrials that might have been listening from space. The golden records were ambitiously placed aboard voyagers 1 and 2 in hopes of discovering life outside our planet. The original voyager soundtrack was carried by a vintage 12-inch gold-plated disk which acted as a phonographic record to play the selected images and audio portraying the beauty of nature and diversity of culture on Earth.
The golden records weren't the first time-capsules to be sent out into the deep space on rockets, but they were the most ambitious ones to date, put together by a selected committee in NASA under the chairmanship of Carl Sagan.
NASA's website says that Sagan and his committee collected an assortment of 115 images for the project along with an audio selection containing sounds of the birds chirping, waves lapping against the shore, thunder, wind, and various other animal voices. Several human messages telling the story of mankind, as well as greetings in more than 50 different languages were also recorded and added to the album.
Where Are the Voyagers Now?
The original record also contained a written message from then-President Carter and General Waldheim, who was the secretary general of the United Nations. It's been almost 40 years ever since the recording was mounted on a rocket and sent off into the deep space with hopes that someone out there, hundreds of thousands of light years away, would discover the messages some day and try to make contact with Earth.
The two voyagers that carried the golden records were sent into space to tour the entire solar system. Apart from taking the Earth's message to any extraterrestrial being out there, the probes also captured fascinating imagery of Earth's neighboring planets including Saturn, Neptune and Jupiter.
The probes, which travelled at a speed of 35,000 miles per hour, flew between stars and sent back images of unique deep-space objects to Earth. The Voyagers are now billions of miles away from Earth and are meant to stay in space forever, drifting in the Milky Way, playing the messages on the golden record until the end of time – or until an alien discovers the probe and interprets the messages on the tape.
A Kickstarter Project to Sell Golden Records to the Public
Although, NASA has not been able to establish contact with the extraterrestrial, at least the people of the Earth will now be able to enjoy the entire audio experience of NASA's golden records for the first time in four decades, thanks to the efforts of one record company named Ozma Records which began as a Kickstarter project and has now received enough funding to manufacture more than 10,000 copies of the Voyager Golden Record for everyone who backed their fundraiser.
The copyrighted clips of the original audio used on the Golden Record were handed over to CBS Records by NASA years ago and Ozma Records has been making efforts since 2016 to retrieve as much of the original audio as possible. When the founders of the Record first pitched their idea on Kickstarted, they thought that they would need no more than $200,000 to make the idea work, but they ended up raising $1.3 million in total.
Almost two years later, the group has unearthed the entire master tape, gotten permission to use the track and made thousands of copies of it to sell worldwide. The company's website is selling the vinyl records in a complete box set for $98 apiece. The website allows music lovers to pre-order their records but the deliveries will only begin mid-February.