Sentinel Colorado's Generations 2021

Expanding insurance coverage is priority for Medicare-Medicaid chief

By Julie Rovner, Kaiser Health News

The new head of the federal agency that oversees health benefits for nearly 150 million Americans and $1 trillion in federal spending said in one of her first interviews that her top priorities will be broadening insurance coverage and ensuring health equity.

“We’ve seen through the pandemic what happens when people don’t have health insurance and how important it is,” said Chiquita Brooks-LaSure, who was confirmed by the Senate to lead the Centers for Medicare & Medicaid Services on May 25 and sworn in on May 27. “Our focus is going to be on making sure regulations and policies are going to be focused on improving coverage.”

It is an abrupt switch from the Trump administration, which steered the agency to spearhead efforts to repeal the Affordable Care Act and scale back Medicaid, the federal-state program for those with low incomes.

Brooks-LaSure, whose agency oversees the ACA marketplaces in addition to Medicare, Medicaid and the Children’s Health Insurance Program, said she is not surprised at the robust takeup of ACA insurance since President Joe Biden reopened enrollment in January. The administration announced last month that more than 1 million people had signed up already.

“Over the last couple of years, I’ve worked with a lot of the statebased marketplaces and we could see the difference in enrollment when the states were actively pushing coverage,” she said. A former congressional and Obama administration health staffer, Brooks-LaSure most recently was managing director at the consulting firm Manatt Health. “I believe that most people who are not enrolled want” coverage but may not understand it’s available or how to get it, she said. “It’s about knowledge and affordability.”

Brooks-LaSure also suggested the administration would support efforts in Congress to ensure coverage for the millions of Americans in the so-called Medicaid gap. Those are people in the dozen states that have not expanded Medicaid under the Affordable Care Act who earn too little to qualify for ACA marketplace coverage. Georgia Democratic Sens. Jon Ossoff and Raphael Warnock, whose GOP-led state has not expanded the program, are calling for a new federal program to cover those who fall in the gap.

Brooks-LaSure said she would prefer states use the additional incentive funding provided in the recent American Rescue Plan toward expanding their Medicaid programs, “because ideally states are able to craft policies in their own states; they’re closest to the ground.” But if states fail to take up the offer — none have so far — “the public option or other coverage certainly would be a strategy to make sure people in those states have coverage,” she said.

Also close on her radar is dealing with the impending insolvency of the trust fund that finances a large part of the Medicare program. Last year’s economic downturn and the resulting loss in employees’ withholding taxes is likely to accelerate the date when Medicare’s hospital insurance program will not be able to cover all its bills.

Brooks-LaSure said she is sure she and Congress will be spending time on the issue in the coming year, but those discussions could also provide an opportunity for officials to reenvision the Medicare program and consider expanding benefits. Democrats in Congress are looking at both lowering Medicare’s eligibility age and adding benefits the program lacks, including dental, hearing and vision coverage.

“I hope that we, when we are looking at solvency, really focus on making sure we keep the Medicare program robust,” said Brooks-LaSure. “And that may mean some changes that strengthen the program.”

Spotlight on how police treat disabled people

By Leigh Paterson, Kaiser Health News

Nearly a year after police officers in Loveland, Colorado, injured an elderly woman with dementia and then laughed at footage of her arrest, two of those officers are facing criminal charges while the rest of the department undergoes additional training. The fallout has drawn national attention to a problem that experts say is widespread across law enforcement agencies: Police often lack the skills to interact with people with mental and physical disabilities.

Last June, a Walmart employee called police after Karen Garner, 73

at the time, tried to leave without paying for $14 worth of items. Soon after, Officer Austin Hopp’s body camera video showed, he pulled over beside her as she walked down a road and wrestled her to the ground in handcuffs after she failed to respond to his questions. Afterward, Garner’s lawyers say, she sat in jail for several hours with a dislocated and fractured shoulder as Hopp and two other officers laughed while watching the body camera video. According to a federal complaint, Garner has dementia and also suffers from sensory aphasia, which impairs her ability to understand. Her violent arrest has other elderly people worried about potential en-

counters with police, Loveland resident June Dreith told Police Chief Robert Ticer during a public meeting last month.

“They are now seriously afraid of the police department,” Dreith said. Hopp resigned and faces felony charges of assault and attempting to influence a public servant — a charge related to allegations of omissions when reporting the arrest — as well as official misconduct, a misdemeanor. Another officer, Daria Jalali, also resigned and is charged with three misdemeanors: failure to report excessive force, failure to intervene and official misconduct. Neither has entered a plea in court. A third officer, who watched the video

with them, resigned but has not been charged.

An independent assessment of the Loveland Police Department by a third-party consultant is underway. The city and involved officers face a federal lawsuit, filed by Garner in April, alleging excessive use of force and violations of the Americans With Disabilities Act. Ticer declined to be interviewed, but through his public information officer he characterized the Garner incident as a problem with an individual officer, not with the department’s operations.

“Our training currently, in the past and present, is always to make sure our officers are up to speed on as much training as they can on how to interact with people in crisis who may have mental health issues,” Ticer said during the public meeting in May at department headquarters.

Loveland’s police department, like many others, requires officers to be trained to respond to people with mental illness and developmental disabilities. But no national standards exist. That means the amount of training law enforcement officers receive on interacting with disabled people varies widely.

“On the whole, we’re doing terrible,” said Jim Burch, president of the National Police Foundation, a nonprofit organization focused on police research and training. “We have to do much, much better at being able to recognize these types of issues and being more sensitive to them.”

While comprehensive data on the frequency of negative interactions between police and people with mental disabilities is lacking, interactions with the criminal justice system are common. The Bureau of Justice Statistics has estimated about 3 in 10 state and federal prisoners and 4 in 10 local jail inmates have at least one disability.

“There’s a very large number of people that police are coming into contact with that have an intellectual disability or mental health challenge,” Burch said. “Do we have a systemic problem? We think that we do.”

Colorado requires a minimum of two hours of training on interacting with people with disabilities, although legislation aims to improve on that by creating a commission to recommend new statewide standards.

Loveland’s officers are certified in crisis intervention training. The department also has a co-responder program, which pairs law enforcement officers with mental health clinicians, although this team was not called during Garner’s arrest. Since that incident, questions remain about the department’s readiness to interact with disabled citizens.

“We could always use more and more training. We could train every single week for eight hours a day, but we could do that all the time and never go out on calls,” said Sgt. Brandon Johnson, who oversees training. “It’s just balancing our available workforce and our time and our service to the community and our staffing levels.”

Loveland police officers are now undergoing Alzheimer’s awareness

training, and five staff members will be trained as de-escalation instructors, department officials said.

Training on how to interact with disabled people varies, but the basics include identifying such individuals early in an encounter instead of relying on use of force.

“It’s scary, because you don’t know why they’re not following your commands,” said Ali Thompson, a former deputy with the Boulder County Sheriff’s Office who now serves on the Colorado Developmental Disabilities Council. “So, your adrenaline starts pumping and you think … ‘They’re not listening to my commands because they have a warrant or because they have a gun on them,’ or you come up with all of these scenarios to explain it.”

Garner’s rough arrest is “not an isolated incident by any means,” Thompson said. She said she would not have thought to attribute noncompliance to conditions like autism or dementia when she was a young patrol officer.

“We need to start bringing those possibilities into those ‘what if’ scenarios,” Thompson said.

In addition to teaching how to identify disabled people, organizations such as the International Association of Chiefs of Police help prepare officers for such situations by showing them how to speak in short phrases, refrain from touching, and turn off sirens and flashing lights. Research on which disability-specific efforts actually reduce bad outcomes is scant, but experts point to other types of curricula as relevant, too, including crisis intervention training, instruction on de-escalating tensions and sessions on mental illness.

“Just training in and of itself is not going to create that long-term change that we are hoping for,” said Lee Ann Davis, director of criminal justice initiatives at The ARC, a national disability advocacy organization.

That means going beyond officer training to address the many areas in which people with disabilities are not being identified and supported, she said. One of The ARC’s programs, Pathways to Justice, brings in not only law enforcement officials but also attorneys and victim service providers for instruction.

“So our goal is to help communities understand that this is a communitywide issue, that there’s not one specific spoke within the criminal justice system or in our communities that can address it adequately alone,” Davis said.

Johnson, the Loveland sergeant in charge of training, said officers have been engaged for years in community outreach such as supporting the Special Olympics.

Despite the actions of the three officers who resigned, Johnson believes the department is adequately prepared to interact with disabled citizens. At the same time, he acknowledges limitations.

“We have to be the first responder. We have to have a good foundational understanding of all of it,” he said. “But we’re also not … we’re also not experts.”

Is your living room the future of hospital care?

By Julie Appleby, Kaiser Health News

Major hospital systems are betting big money that the future of hospital care looks a lot like the inside of patients’ homes.

Hospital-level care at home — some of it provided over the internet — is poised to grow after more than a decade as a niche offering, boosted both by hospitals eager to ease overcrowding during the pandemic and growing interest by insurers who want to slow health care spending. But a host of challenges remain, from deciding how much to pay for such services to which kinds of patients can safely benefit.

Under the model, patients with certain medical conditions, such as pneumonia or heart failure — even moderate covid — are offered high-acuity care in their homes, with 24/7 remote monitoring and daily visits by medical providers.

In the latest sign that the idea is catching on, two big players — Kaiser Permanente and the Mayo Clinic — announced plans this month to collectively invest $100 million into Medically Home, a Boston-based company that provides such services to scale up and expand their programs. The two organizations estimate that 30% of patients currently admitted to hospitals nationally have conditions eligible for in-home care. (KHN is not affiliated with Kaiser Permanente.)

Several other well-known hospital systems launched programs last

summer. They join about two dozen already offering the service, including Johns Hopkins Medicine in Baltimore, Presbyterian Healthcare Services in New Mexico and Massachusetts General Hospital.

But hospitals have other financial considerations that are also part of the calculation. Systems that have built sparkling new in-patient facilities in the past decade, floating bonds and taking out loans to finance them, need patients filling costly inpatient beds to repay lenders and recoup investments.

And “hospitals that have surplus capacity, whether because they have newly built beds or shrinking populations or are losing business to competitors, are not going to be eager about this,” said Dr. Jeff Levin-Scherz, co-leader of the North American Health Management practice at consultancy Willis Towers Watson.

Medicare gave the idea a boost in November when it agreed to pay for such care, to help keep non-covid patients out of the hospital during the pandemic. Since then, more than 100 hospitals have been approved by Medicare to participate, although not all are in place yet.

Tasting opportunity, Amazon and a coalition of industry groups in March announced plans to lobby for changes in federal and state rules to allow broader access to a wide range of inhome medical services.

“We’re seeing tremendous momentum,” said Dr. Bruce Leff, a Johns Hopkins Medical School geriatrician who has studied and advocated for

the hospital-at-home approach since he helped establish one of the nation’s first programs in the mid-1990s.

Leff and other proponents say various studies show in-home care is just as safe and may produce better outcomes than being in the hospital, and it saves money by limiting the need to expand hospitals, reducing hospital readmissions and helping patients avoid nursing home stays. Some estimates put the projected savings at 30% over traditional hospital care. But ongoing programs are a long way from making a dent in the nation’s $1.2 trillion hospital tab.

While the goal is to shift 10% or more of hospital patients to home settings, existing programs handle far fewer cases, sometimes serving only a handful of patients.

“In a lot of ways, this remains aspirational; this is the early innings,” said Dean Ungar, who follows the insurance and hospital industries as a vice president and senior credit officer at Moody’s Investors Service. Still, he predicted that “hospitals will increasingly be reserved for acute care [such as surgeries and ICUs].”

Challenges to scaling up include maintaining the current good safety profile in the face of rapid growth and finding enough medical staff — especially nurses, paramedics and technicians — who travel to patients’ homes.

The attraction for insurers is clear: If they can pay for care in a lower-cost setting than the hospital, with good outcomes, they save money.

For hospitals, “the financials of it

are, frankly, a little tough,” said LevinScherz.

Those most attracted to hospital-at-home programs run at or near capacity and want to free up beds.

Even so, Gerard Anderson, a health policy professor at Johns Hopkins University Bloomberg School of Public Health, said hospitals likely see the potential, long term, for “huge profit margins” through “saving a lot of capital and personnel expense by having the work done at home.”

But Anderson worries that broad expansion of hospital-at-home efforts could exacerbate health care inequities.

“It’s realistic in middle- and upper-middle-class households,” Anderson said. “My concern is in impoverished areas. They may not have the infrastructure to handle it.”

Suburban and rural areas — and even some lower-income urban areas — can have spotty or nonexistent internet access. How will that affect the ability of those areas to participate, to communicate with physicians and other hospital staff members miles away? Proponents outline solutions, from providing patients with “hot spot” devices that provide internet service, along with backup power and instant communication via walkietalkie-type handsets and computer tablets.

Social factors play a big part, too. Those who live alone may find it harder to qualify if they need a lot of help, while those in crowded households may not have enough room or privacy.

Another possible wrinkle: Not all patients have the necessary human support, such as someone to help an ill patient with the bathroom, meals or even answering the door.

That’s why both patients and their caregivers should get a detailed explanation of the day-to-day responsibilities before agreeing to participate, said Alexandra Drane, CEO of Archangels, a for-profit group that works with employers and provides resources for unpaid caregivers.

“I love the concept for a resourced household where someone can take this job on,” said Drane. “But there’s a lot of situations where that’s not possible. What If I have a full-time job and two children, when am I supposed to do this?”

The programs all say they aim to reduce the burden on families. Some provide aides to help with bathing or other home care issues and provide food. None expects family members to perform medical procedures. The programs supply monitoring and communication equipment and a hospital bed, if needed.

Patients are typically visited in their homes daily by various health workers. Physicians make home visits in some programs, but most employ doctors to oversee care from remote “command centers,” talking with patients via various electronic gadgets.

Medicare’s payment decision gave momentum to such goals. But the natural experiment it created with its funding ends when the pandemic is declared over.

Research Goals:

Investigate how structural changes in the brain correlate to cognitive decline

Collect and analyze fluid biomarkers for the detection of inflammation and Alzheimer’s diseaserelated risk factors

Examine the relationship between concussion and the aging process

Participants will receive:

• Compensation provided

• Snacks and refreshments

• Medical screening; neurological exam

• Optional review of cognitive assessment scores with investigator after completion of 1 year follow-up visit

https://www.coloradoagingbrain.org/imtab/

PI: Brianne M Bettcher 19-1423