The industry is trying to kill the mandate before it takes effect, leaving thousands of residents in homes too short-staffed.

This article was published on Tuesday, December 3, 3034 in KFF Health News.

By Jordan Rau

COVID's rampage through the country's nursing homes killed more than 172,000 residents and spurred the biggest industry reform in decades: a mandate that homes employ a minimum number of nurses.

But with President-elect Donald Trump's return to the White House, the industry is ramping up pressure to kill that requirement before it takes effect, leaving thousands of residents in homes too short-staffed to provide proper care.

The nursing home industry has been marshaling opposition for months among congressional Republicans — and some Democrats — to overrule the Biden administration's mandate. Two industry groups, the American Health Care Association and LeadingAge, have sued to overturn the regulation, and 20 Republican state attorneys general have filed their own challenge.

Consumer advocates, industry officials and independent researchers agree that the incoming administration is likely to rescind the rule, given the first Trump administration's "patients over paperwork" campaign to remove "unnecessary, obsolete, or excessively burdensome health regulations on hospitals and other healthcare providers." Among other things, Trump aided the industry by easing fines against homes that had been cited for poor care.

"The Trump administration has proven itself really eager to reverse overreaching regulations," said Linda Couch, senior vice president for policy and advocacy at LeadingAge, which represents nonprofit elder care providers. "We think it's got a pretty good chance of being repealed, and hope so."

Issued in April, the staffing regulation requires nursing homes to have registered nurses on-site around the clock — something that the industry has endorsed — and to maintain minimum numbers of nurses and aides. Four in 5 homes would have to increase staffing. The requirements would be phased in, starting in May 2026.

Even before the election, many experts and activists had doubts that the rule would be effectively enforced, given the poor results in states that have imposed their own minimums. In New York, California, Rhode Island, and Massachusetts — states with the most robust requirements — many homes remain below the legal staffing levels. Governors have given many homes reprieves, and other homes have found that paying penalties costs less than the increase in payroll for additional staff.

The federal government estimates the average annual cost over a decade to meet the Biden mandate would be $4.3 billion a year, a 2% increase in expenses, though the changes do not include increases in federal Medicare or Medicaid payments.

"Staffing is everything in terms of nursing-home quality," said R. Tamara Konetzka, a professor of public health sciences at the University of Chicago.

While the rule's effectiveness was uncertain, she worried that repealing it would send the wrong message. "We would be losing that signal that nursing homes should try really hard to improve their staffing," she said.

Advocate groups for nursing home residents, who had criticized the Biden administration rule for not requiring even higher staffing levels, have since pivoted and are trying to protect it.

"We're hoping the president-elect will come in and take a look at the science and data behind it and see this really is a modest reform," said Sam Brooks, the director for public policy for the National Consumer Voice for Quality Long-Term Care, a Washington, D.C.-based nonprofit. "We'd be devastated to see it fall."

The Trump transition team did not respond to a request for comment. The Department of Health and Human Services did not respond to requests for comment, but in a court filing it argued that nursing homes should be able to reach the required staffing levels.

"There is more than enough time to identify, train and hire additional staff," the Biden administration wrote.

The quality of care in the nation's 15,000 nursing homes and the lack of adequate staffing for their 1.2 million residents has been a concern for decades. Inspection reports continue to find homes leaving residents lying in their own feces, suffering severe bedsores and falls, contracting infections, choking on food while unattended, or ending up back in a hospital for preventable reasons. Some nursing homes overuse psychotropic medications to pacify residents because they do not have enough workers to attend to them.

Leslie Frane, executive vice president of the SEIU, the Service Employees International Union, which represents health care workers, said in a statement that "far too many nursing home owners will not do the right thing and invest in workers without oversight and binding regulation."

The nursing home industry says many homes cannot afford to increase their workforces, and that, even if they could, there is a scarcity of trained nurses, and not enough people willing to work as aides for an average $19 an hour. A registered nurse earns $40 an hour on average in a nursing home, less than what they could make at a hospital, according to the Bureau of Labor Statistics.

The Biden administration noted in its court filing it was planning to spend $75 million to recruit and train more workers, and that there were more than 100,000 workers who left nursing homes during the pandemic and could be lured back if salaries and working conditions were better.

How many nursing homes could afford the increased cost remains a mystery because of weaknesses in the government's requirements for financial transparency. About half of homes lose money, according to their reports to Medicare, but some nursing home owners grow rich through clandestine maneuvers to siphon profits into their own pockets.

Last month, owners of Centers Health Care, one of New York state's largest nursing home chains, agreed to pay $45 million to settle allegations by Attorney General Letitia James that they diverted $83 million intended for resident care to themselves during the pandemic.

Maryellen Mooney, a spokesperson for the Centers Health Care chain, which denied the allegations, said in a statement that Centers was "committed to fully implementing the settlement terms, including a significant investment in resident care."

About three-quarters of nursing homes are for-profit. The industry, though, highlights the most sympathetic examples: rural nonprofit nursing homes like Kimball County Manor & Assisted Living in Kimball, Nebraska. Its staffing levels for registered nurses are 40% below what the new rule would require, federal data shows.

Sarah Stull, Kimball's administrator, said recruitment had always been challenging and that temporary nursing staffing agencies charged more than double what she paid her own staff.

"We had to pay $65 for a nurse aide during COVID, and that's insane," she said.

The government estimated that about a fourth of the nation's nursing homes would be eligible to apply for hardship exemptions if there were a documented shortage of nurses and aides in their communities compared with the national average.

But Nate Schema, the chief executive of the Good Samaritan Society, which runs 133 nonprofit homes mainly in the rural Midwest, estimated that only seven would be likely to qualify for a hardship waiver.

"Philosophically, they sound great," he said. "But in practicality and how they're put together, they won't do much for us."

Jordan Rau: jrau@kff.org

Nearly 40% have five or more chronic medical conditions, such as heart or lung disease. Almost 30% are believed to have 'probable dementia.' 

This article was published on Monday, December 2, 2024 in KFF Health News.

By Judith Graham

Carolyn Dickens, 76, was sitting at her dining room table, struggling to catch her breath as her physician looked on with concern.

"I don't know," she answered, so softly it was hard to hear. "Going from here to the bathroom or the door, I get really winded. I don't know when it's going to be my last breath."

Dickens, a lung cancer survivor, lives in central Harlem, barely getting by. She has serious lung disease and high blood pressure and suffers regular fainting spells. In the past year, she's fallen several times and dropped to 85 pounds, a dangerously low weight.

And she lives alone, without any help — a highly perilous situation.

Across the country, about 2 million adults 65 and older are completely or mostly homebound, while an additional 5.5 million seniors can get out only with significant difficulty or assistance. This is almost surely an undercount, since the data is from more than a dozen years ago.

It's a population whose numbers far exceed those living in nursing homes — about 1.2 million — and yet it receives much less attention from policymakers, legislators, and academics who study aging.

Consider some eye-opening statistics about completely homebound seniors from a study published in 2020 in JAMA Internal Medicine: Nearly 40% have five or more chronic medical conditions, such as heart or lung disease. Almost 30% are believed to have "probable dementia." Seventy-seven percent have difficulty with at least one daily task such as bathing or dressing.

Almost 40% live by themselves.

That "on my own" status magnifies these individuals' already considerable vulnerability, something that became acutely obvious during the covid-19 outbreak, when the number of sick and disabled seniors confined to their homes doubled.

"People who are homebound, like other individuals who are seriously ill, rely on other people for so much," said Katherine Ornstein, director of the Center for Equity in Aging at the Johns Hopkins School of Nursing. "If they don't have someone there with them, they're at risk of not having food, not having access to health care, not living in a safe environment."

Research has shown that older homebound adults are less likely to receive regular primary care than other seniors. They're also more likely to end up in the hospital with medical crises that might have been prevented if someone had been checking on them.

To better understand the experiences of these seniors, I accompanied Gliatto on some home visits in New York City. Mount Sinai's Visiting Doctors Program, established in 1995, is one of the oldest in the nation. Only 12% of older U.S. adults who rarely or never leave home have access to this kind of home-based primary care.

Gliatto and his staff — seven part-time doctors, three nurse practitioners, two nurses, two social workers, and three administrative staffers — serve about 1,000 patients in Manhattan each year.

These patients have complicated needs and require high levels of assistance. In recent years, Gliatto has had to cut staff as Mount Sinai has reduced its financial contribution to the program. It doesn't turn a profit, because reimbursement for services is low and expenses are high.

First, Gliatto stopped in to see Sandra Pettway, 79, who never married or had children and has lived by herself in a two-bedroom Harlem apartment for 30 years.

Pettway has severe spinal problems and back pain, as well as Type 2 diabetes and depression. She has difficulty moving around and rarely leaves her apartment. "Since the pandemic, it's been awfully lonely," she told me.

When I asked who checks in on her, Pettway mentioned her next-door neighbor. There's no one else she sees regularly.

Pettway told the doctor she was increasingly apprehensive about an upcoming spinal surgery. He reassured her that Medicare would cover in-home nursing care, aides, and physical therapy services.

"Someone will be with you, at least for six weeks," he said. Left unsaid: Afterward, she would be on her own. (The surgery in April went well, Gliatto reported later.)

The doctor listened carefully as Pettway talked about her memory lapses.

"I can remember when I was a year old, but I can't remember 10 minutes ago," she said. He told her that he thought she was managing well but that he would arrange testing if there was further evidence of cognitive decline. For now, he said, he's not particularly worried about her ability to manage on her own.

Dickens worked with special-education students for decades in New York City's public schools. Now she lives on a small pension and Social Security — too much to qualify for Medicaid. (Medicaid, the program for low-income people, will pay for aides in the home. Medicare, which covers people over age 65, does not.) Like Pettway, she has only a small fixed income, so she can't afford in-home help.

Every Friday, God's Love We Deliver, an organization that prepares medically tailored meals for sick people, delivers a week's worth of frozen breakfasts and dinners that Dickens reheats in the microwave. She almost never goes out. When she has energy, she tries to do a bit of cleaning.

Without the ongoing attention from Gliatto, Dickens doesn't know what she'd do. "Having to get up and go out, you know, putting on your clothes, it's a task," she said. "And I have the fear of falling."

The next day, Gliatto visited Marianne Gluck Morrison, 73, a former survey researcher for New York City's personnel department, in her cluttered Greenwich Village apartment. Morrison, who doesn't have any siblings or children, was widowed in 2010 and has lived alone since.

Morrison said she'd been feeling dizzy over the past few weeks, and Gliatto gave her a basic neurological exam, asking her to follow his fingers with her eyes and touch her fingers to her nose.

"I think your problem is with your ear, not your brain," he told her, describing symptoms of vertigo.

Because she had severe wounds on her feet related to Type 2 diabetes, Morrison had been getting home health care for several weeks through Medicare. But those services — help from aides, nurses, and physical therapists — were due to expire in two weeks.

"I don't know what I'll do then, probably just spend a lot of time in bed," Morrison told me. Among her other medical conditions: congestive heart failure, osteoarthritis, an irregular heartbeat, chronic kidney disease, and depression.

Morrison hasn't left her apartment since November 2023, when she returned home after a hospitalization and several months at a rehabilitation center. Climbing the three steps that lead up into her apartment building is simply too hard.

"It's hard to be by myself so much of the time. It's lonely," she told me. "I would love to have people see me in the house. But at this point, because of the clutter, I can't do it."

When I asked Morrison who she feels she can count on, she listed Gliatto and a mental health therapist from Henry Street Settlement, a social services organization. She has one close friend she speaks with on the phone most nights.

"The problem is I've lost eight to nine friends in the last 15 years," she said, sighing heavily. "They've died or moved away."

Bruce Leff, director of the Center for Transformative Geriatric Research at the Johns Hopkins School of Medicine, is a leading advocate of home-based medical care. "It's kind of amazing how people find ways to get by," he said when I asked him about homebound older adults who live alone. "There's a significant degree of frailty and vulnerability, but there is also substantial resilience."

With the rapid expansion of the aging population in the years ahead, Leff is convinced that more kinds of care will move into the home, everything from rehab services to palliative care to hospital-level services.

"It will simply be impossible to build enough hospitals and health facilities to meet the demand from an aging population," he said.

But that will be challenging for homebound older adults who are on their own. Without on-site family caregivers, there may be no one around to help manage this home-based care.

Judith Graham: khn.navigatingaging@gmail.com, @judith_graham

A class-action lawsuit alleges that Florida did not explain to people with Medicaid the reasons for disenrollment and their rights to appeal the decision.

This article was published on Tuesday, November 26, 2024 in KFF Health News.

By Daniel Chang and Samantha Liss

In mid-May, Mandi Rokx had a 3-month-old baby and a letter from a Florida agency warning that they both would be cut from Medicaid, the health insurance program for people with low incomes or disabilities.

Under a Florida law passed in 2021, Rokx was supposed to receive 12 months of continuous coverage after giving birth. But the letter from Florida's Department of Children and Families said their coverage would end May 31.

The explanation: "You failed to complete or follow through with your Medicaid renewal."

Rokx said she didn't understand why the state was cutting coverage. She had provided everything it asked for, she said.

She worried about what losing Medicaid would mean for her daughter, Vernita. Initially after the coverage ended, Rokx said, she paid out-of-pocket for the infant's checkups. She then turned to a free health fair put on once a month by a local nonprofit near her home in Melrose, Florida.

"I just hope she doesn't get sick," she said.

An unknown number of mothers in Florida have abruptly lost Medicaid coverage after giving birth, despite being eligible, according to an ongoing federal lawsuit filed against the state in August 2023. The issue is linked to the state's computer eligibility system, run by Deloitte Consulting, according to trial testimony from state and Deloitte employees. It is yet one more example of problems states and beneficiaries have encountered with Medicaid management systems operated by Deloitte, a giant consulting firm.

As of July, Florida had awarded the global firm contracts valued at more than $100 million to modernize, operate, and maintain the state's integrated eligibility system for Medicaid and other benefits.

Deloitte did not respond to requests for comment about its work in Florida.

In total, 25 states have awarded Deloitte eligibility system contracts, making the company the dominant player in this crucial slice of government business. These agreements, in which Deloitte commits to design, develop, or operate state-owned systems, are worth at least $6 billion, according to a KFF Health News analysis of state contracts.

The KFF investigation found that errors in Deloitte-run eligibility systems can cost millions and take years to fix while denying benefits like health insurance to eligible people.

In response to the investigation, Deloitte spokesperson Karen Walsh said the firm's clients — state governments — "understand large system implementations are challenging due to the complexity of the programs they support and that all IT systems require ongoing maintenance, periodic enhancements and upgrades to software and hardware, and database management."

Senate Democrat John Fetterman of Pennsylvania, which is one of Deloitte's state clients, sees it much differently. "Let's call this what it is: a racket," he said. "This isn't an occasional glitch. It's a pattern of systemic failure. And the worst part? We're paying them billions to do it."

In July, Kimber Taylor of Jacksonville and Lily Mezquita of Orlando testified in a federal courtroom in Florida that state officials removed them from Medicaid even though their pregnancies made them eligible. The class-action lawsuit alleges that Florida did not adequately explain to people with Medicaid the reason for cutting their health insurance, or explain to them that they could appeal the decision before losing coverage.

Florida has denied the allegations in court filings. But the trial revealed problems with the computer system the state uses to determine Medicaid eligibility and inform people that they are no longer eligible. Deloitte did not respond to questions about the trial, in which a judge's decision is pending.

Although Deloitte is not a named defendant in the lawsuit, an employee was called to testify about the firm's role in operating Florida's eligibility system. Harikumar Kallumkal, a Deloitte managing director who is responsible for Florida's system, said that a "defect" may have led to coverage losses for new mothers.

William Roberts, a state worker who reviews Medicaid eligibility decisions, also testified that the agency learned about a "glitch" that cut postpartum coverage for eligible new mothers in April 2023 — the same month Florida launched a Medicaid eligibility review process known as "unwinding," which all states undertook after pandemic-era coverage protections ended in March of that year. Kallumkal testified that Deloitte fixed the problem by April or May 2024.

And yet Rokx's coverage was cut May 31.

During the unwinding, Florida disenrolled nearly 2 million people, including kids, from Medicaid, according to the Centers for Medicare & Medicaid Services.

Patient advocates say flaws in Florida's Deloitte-operated computer system prevented some of the state's most vulnerable residents from getting care they were entitled to receive.

"Florida's Medicaid officials knew from the start of the unwinding period that their system was not handling pregnancy and postpartum Medicaid correctly, and proceeded full steam ahead anyway," said Lynn Hearn, an attorney with the Florida Health Justice Project, a nonprofit legal aid and advocacy group that together with the National Health Law Program represents the class-action plaintiffs. "To this day, we don't know that the problems have been fully corrected. The mothers of this state deserve better from their government."

Medicaid is the largest insurance payer for childbirths in Florida, covering nearly 98,000, or 44%, of all deliveries in 2022, according to the state health department. But it's unclear how many mothers have been cut from the Medicaid coverage they were entitled to receive. Florida's Department of Children and Families on Sept. 9 cashed a check from KFF Health News to cover the processing fee for records it requested about eligible mothers who were disenrolled. As of Nov. 22, the state had not released the records.

The state did provide an estimate during the trial, but that number was not made available by the state to KFF Health News. In a court filing, the plaintiffs cited the state's estimate as showing that 19,802 women were removed from pregnancy coverage as of March 2024, one year after Florida began unwinding. It's unclear how many of these women lost coverage incorrectly. The figure is probably a conservative estimate — it excludes anyone who was removed from coverage because of paperwork issues.

Mallory McManus, deputy chief of staff for the Department of Children and Families, told KFF Health News that after identifying the problem, agency workers "manually corrected cases until necessary system updates were in place." She added that the department also reviewed the system to "ensure there were no gaps in coverage."

McManus said that Floridians who were disenrolled from Medicaid "were properly noticed and provided with information on requesting an appeal."

Rokx, Taylor, and Mezquita ultimately regained their Medicaid coverage after seeking help from the Florida Health Justice Project. Attorneys there have said they are often able to get coverage restored for eligible people by reaching out directly to the state agency's general counsel — an avenue not known to most Floridians.

While the class-action lawsuit awaits a judgment, the problems revealed at trial echo those encountered in other states with Deloitte-run Medicaid eligibility systems, such as Arkansas, Colorado, Florida, Georgia, Kentucky, Michigan, Pennsylvania, Rhode Island, Tennessee, and Texas.

In Texas, according to a July report by the U.S. Government Accountability Office, "about 100,000 eligible individuals had been disenrolled due to eligibility system errors," including denial of postpartum coverage for some eligible women.

The error-plagued systems and widespread denials of Medicaid for eligible people have caught the attention of lawmakers on congressional committees that oversee social programs. They blame state leaders who they say aren't holding vendors like Deloitte accountable.

"As the errors compound, contractors are rewarded with more billing hours and higher payouts," said Rep. Lloyd Doggett (D-Texas). "This is an alarming and unacceptable waste of taxpayer dollars."

Sen. Ron Wyden (D-Ore.), chairman of the Senate Finance Committee, which oversees Medicaid, said that too many people "can't even get in through the front door due to outdated and inaccurate eligibility systems."

And Rep. Kathy Castor (D-Fla.) said that "there's such a pattern of trying to discourage and inappropriately cutting families off of Medicaid in Florida."

"It appears to be intentional," she said, "and I think it clearly is."

Daniel Chang: dchang@kff.org, @dchangmiami

Samantha Liss: sliss@kff.org, @samanthann

CMS says its efforts are working, pointing to the 30% drop in complaint casework.

This article was published on Monday, November 25, 2024 in KFF Health News.

By Julie Appleby

Unauthorized switching of Affordable Care Act plans appears to have tapered off in recent weeks based on an almost one-third drop in casework associated with consumer complaints, say federal regulators. The Centers for Medicare & Medicaid Services, which oversees the ACA, credits steps taken to thwart enrollment and switching problems that triggered more than 274,000 complaints this year through August.

Now, the annual ACA open enrollment period that began Nov. 1 poses a real-world test: Will the changes curb fraud by rogue agents or brokerages without unduly slowing the process of enrolling or reducing the total number of sign-ups for 2025 coverage?

"They really have this tightrope to walk," said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University. "The more you tighten it up to prevent fraud, the more barriers there are that could inhibit enrollment among those who need the coverage."

CMS said in July that some types of policy changes — those in which the agent is not "affiliated" with the existing plan — will face more requirements, such as a three-way call with the consumer, broker, and a healthcare.gov call center representative.

In August, the agency barred two of about a dozen private sector online-enrollment platforms from connecting with healthcare.gov over concerns related to improper switching.

And CMS has suspended 850 agents suspected of being involved in unauthorized plan-switching from accessing the ACA marketplace.

Still, the clampdown could add complexity to enrollment and slow the process. For example, a consumer might have to wait in a queue for a three-way call, or scramble to find a new agent because the one they previously worked with had been suspended.

Given that phone lines with healthcare.gov staff already get busy — especially during mid-December — agents and policy analysts advise consumers not to dally this year.

"Hit the ground running," said Ronnell Nolan, president and CEO of Health Agents for America, a professional organization for brokers.

Meanwhile, reports are emerging that some rogue entities are already figuring out workarounds that could undermine some of the anti-fraud protections CMS put in place, Nolan said.

"Bottom line is: Fraud and abuse is still happening," Nolan said.

Brokers assist the majority of people actively enrolling in ACA plans and are paid a monthly commission by insurers for their efforts. Consumers can compare plans or enroll themselves online through federal or state marketplace websites. They can also seek help from people called assisters or navigators — certified helpers who are not paid commissions. Under a "find local help" button on the federal and state ACA websites, consumers can search for nearby brokers or navigators.

CMS says it has "ramped up support operations" at its healthcare.gov marketplace call centers, which are open 24/7, in anticipation of increased demand for three-way calls, and it expects "minimal wait times," said Jeff Wu, deputy director for policy of the CMS Center for Consumer Information and Insurance Oversight.

Wu said those three-way calls are necessary only when an agent or a broker not already associated with a consumer's enrollment wants to change that consumer's enrollment or end that consumer's coverage. It does not apply to people seeking coverage for the first time.

Organizations paid by the government to offer navigator services have a dedicated phone line to the federal marketplace, and callers are not currently experiencing long waits, said Xonjenese Jacobs, director of Florida Covering Kids & Families, a program based at the University of South Florida that coordinates enrollment across the state through its Covering Florida navigator program.

Navigators can assist with the three-way calls if a consumer's situation requires it.

"Because we have our quick line in, there's no increased wait time," Jacobs said.

The problem of unauthorized switches has been around for a while but took off during last year's open enrollment season.

Brokers generally blamed much of the problem on the ease with which rogue agents can access ACA information in the federal marketplace, needing only a person's name, date of birth, and state of residence. Though federal regulators have worked to tighten that access with the three-way call requirement, they stopped short of instituting what some agent groups say is needed: two-factor authentication, which could involve a code accessed by a consumer through a smartphone.

Unauthorized switches can lead to a host of problems for consumers, from higher deductibles to landing in new networks that do not include their preferred physicians or hospitals. Some people have received tax bills when unauthorized policies came with premium credits for which they did not qualify.

Unauthorized switches posed a political liability for the Biden administration, a blemish on two years of record ACA enrollment. The practice drew criticism from lawmakers on both sides of the aisle; Democrats demanded more oversight and punishment of rogue agents, while Republicans said fraud attempts were fueled by Biden administration moves that allowed for more generous premium subsidies and special enrollment periods. The fate of those enhanced subsidies, which are set to expire, will be decided by Congress next year as the Trump administration takes power. But the premiums and subsidies that come with 2025 plans that people are enrolling in now will remain in effect for the entire year.

The actions taken this year to thwart the unauthorized enrollments apply to the federal marketplace, used by 31 states. The remaining states and the District of Columbia run their own websites, with many having in place additional layers of security.

For its part, CMS says its efforts are working, pointing to the 30% drop in complaint casework. The agency also noted a 90% drop in the number of times an agent's name was replaced by another's, which it says indicates that it is tougher for rival agents to steal clients to gain the monthly commissions that insurers pay.

Still, the move to suspend 850 agents has drawn pushback from agent groups that initially brought the problem to federal regulators' attention. They say some of those accused were suspended before getting a chance to respond to the allegations.

"There will be a certain number of agents and brokers who are going to be suspended without due process," said Nolan, with the health agents' group. She said that it has called for increased protections against unauthorized switching and that two-factor authentication, like that used in some state marketplaces or in the financial sector, would be more effective than what's been done.

"We now have to jump through so many hoops that I'm not sure we're going to survive," she said of agents in general. "They are just throwing things against the wall to see what sticks when they could just do two-factor."

The agency did not respond to questions asking for details about how the 850 agents suspended since July were selected, the states where they were located, or how many had their suspensions reversed after supplying additional information.

Julie Appleby: jappleby@kff.org, @Julie_appleby