It wasn't easy for Maryland to enact its unique healthcare system.

This article was published on Tuesday, October 26, 2021 in Kaiser Health News.

By Elisabeth Rosenthal  

For the past 18 months, while I was undergoing intensive physical therapy and many neurological tests after a complicated head injury, my friends would point to a silver lining: "Now you'll be able to write about your own bills." After all, I'd spent the past decade as a journalist covering the often-bankrupting cost of U.S. medical care.

But my bills were, in fact, mostly totally reasonable.

That's largely because I live in Washington, D.C., and received the majority of my care in next-door Maryland, the one state in the nation that controls what hospitals can charge for services and has a cap on spending growth.

Players in the healthcare world — from hospitals to pharmaceutical manufacturers to doctors' groups — act as if the sky would fall if healthcare prices were regulated or spending capped. Instead, healthcare prices are determined by a dysfunctional market in which providers charge whatever they want and insurers or middlemen like pharmacy benefit managers negotiate them down to slightly less stratospheric levels.

But for decades, an independent state commission of healthcare experts in Maryland, appointed by the governor, has effectively told hospitals what each of them may charge, with a bit of leeway, requiring every insurer to reimburse a hospital at the same rate for a medical intervention in a system called "all-payer rate setting." In 2014, Maryland also instituted a global cap and budget for each hospital in the state. Rather than being paid per test and procedure, hospitals would get a set amount of money for the entire year for patient care. The per capita hospital cost could rise only a small amount annually, forcing price increases to be circumspect.

If the care in the Baltimore-based Johns Hopkins Medicine system ensured my recovery, Maryland's financial guardrails for hospitals effectively protected my wallet.

During my months of treatment, I got a second opinion at a similarly prestigious hospital in New York, giving me the opportunity to see how medical centers without such financial constraints bill for similar kinds of services.

Visits at Johns Hopkins with a top neurologist were billed at $350 to $400, which was reasonable, and arguably a bargain. In New York, the same type of appointment was $1,775. My first spinal tap, at Johns Hopkins, was done in an exam room by a neurology fellow and billed as an office visit. The second hospital had spinal taps done in a procedure suite under ultrasound guidance by neuroradiologists. It was billed as "surgery," for a price of $6,244.38. The physician charge was $3,782.

I got terrific care at both hospitals, and the doctors who provided my care did not set these prices. All the charges were reduced after insurance negotiations, and I generally owed very little. But since the price charged is often the starting point, hospitals that charge a lot get a lot, adding to America's sky-high healthcare costs and our rising insurance premiums to cover them.

It wasn't easy for Maryland to enact its unique healthcare system. The state-imposed rate setting in the mid-1970s because hospital charges per patient were rising fast, and the system was in financial trouble. Hospitals supported the deal — which required a federal waiver to experiment with the new system — because even though the hospitals could no longer bill high rates for patients with commercial insurance, the state guaranteed they would get a reasonable, consistent rate for all their services, regardless of insurer.

The rate was more generous than Medicare's usual payment, which (in theory at least) is calculated to allow hospitals to deliver high-quality care. The hospitals also got funds for teaching doctors in training and taking care of the uninsured — services that could previously go uncompensated.

In subsequent decades, however, hospitals did end runs around price controls by simply ordering more hospital visits and tests. Spending was growing. Maryland risked losing the federal waiver that had long underpinned its system. Also, under the waiver's terms, Maryland's hospitals were at risk for paying a hefty penalty to the federal government for the excessive growth in cost per patient.

That's why in 2014 the state worked with the federal Centers for Medicare & Medicaid Services to institute the global cap and budget system in place today. Dr. Joshua Sharfstein, who was the state's health and mental hygiene secretary, met skeptical hospital administrators to "sell the concept," as he described it, assuring them the hospitals would still get reasonable revenue while gaining new opportunities to improve the health of their communities with money to invest in preventive services.

Studies show the program, which was further revised in 2019, generally worked at keeping costs down and generated savings of $365 million for Medicare in 2019 and over $1 billion in the prior four years. What's more, working with a fixed budget has provided incentives for hospitals to keep patients out, resulting in programs like better outpatient efforts to manage chronic illnesses and putting doctors in senior housing to keep residents out of hospitals through on-site care.

Instituting this type of plan may be politically unacceptable statewide in other places today, given the much greater power now of hospital trade groups and large consolidated hospital networks. "Where hospitals are making money hand over fist, it's a hard sell to switch," Sharfstein said. "But where hospitals are facing economic pressure, there is much more openness to financial stability and the opportunity to promote community health."

Sharfstein thinks the Maryland approach can be especially attractive for financially strapped rural and urban hospitals that treat mostly people on Medicaid and the uninsured.

Though Maryland is an oddity in the United States (the few other states that tried price controls in the 1970s abandoned the experiment long ago), many countries successfully use price guidelines and budget limits to control medical spending. Notable among them is Germany, whose health system is otherwise similar to the United States', with multiple insurers. A landmark 1994 study comparing efforts here and abroad did find that the German system, for example, can be stingier at providing care that is expensive or elective.

But, referring in part to that issue, the study's author concluded that costs are so high in the United States that the country "could probably lower our expenditures and see none of the problems that we found in our study for a number of years."

Data also shows that operating margins, a measure of profit, are generally slimmer in Maryland than those of big health systems in the rest of the country. Johns Hopkins' margin was 1.2% in fiscal year 2019, compared with 6.9% at the Mayo Clinic in Minnesota and 5.8% at the University of Pennsylvania Health System; Stanford Healthcare's was 7.1%.

But those margins can also reflect how much of its income a hospital chooses to spend on things like amenities and executive pay. Living with financial constraints may be at least partly why Johns Hopkins Hospital's main entrance is pleasant but functional, lacking the elegant art-filled marble lobbies I often encounter at its peer hospitals.

My experience demonstrates that excellent care can be delivered to patients by a system that works within financial limits. And that's something America needs.

Elisabeth Rosenthal: erosenthal@kff.org, @rosenthalhealth

St. Luke's, a clinic with a staff of four in a nondescript shopping center, offers an unorthodox combination of concierge-style medicine for the well-off and charity care for the uninsured.

This article was published on Tuesday, October 26, 2021 in Kaiser Health News.

By Bernard J. Wolfson   

MODESTO, Calif. — Britta Foster and Minerva Tiznado are in different leagues as far as healthcare is concerned.

Foster, who married into the family that owns the $2.5 billion Foster Farms chicken company, has Blue Shield coverage as well as a high-octane primary care plan that gives her 24/7 digital access to her doctor for a $5,900 annual fee that also covers her husband and two of their children.

Tiznado is from Nayarit, Mexico, and has no insurance. She gets free primary care visits and steep discounts on prescription drugs, lab tests and imaging.

But Tiznado, 32, and Foster, 48, go to the same place for their care: St. Luke's Family Practice, in this Central Valley city of about 217,000. St. Luke's, a clinic with a staff of four in a nondescript shopping center, offers an unorthodox combination of concierge-style medicine for the well-off and charity care for the uninsured.

The annual fees that St. Luke's collects from Foster's family and some 550 other paying patients help cover free care for a somewhat larger number of uninsured patients, many of them, like Tiznado, Spanish-speaking immigrants who can't get Medicaid because they lack documents.

The clinic does not accept insurance of any kind but requires its paying patients to have coverage for major medical expenses outside its scope of care.

The paying patients, whom St. Luke's calls "benefactors," say they are happy to participate in this "Robin Hood" model. It gives them highly personalized care with great access to their doctors and the emotional satisfaction of supporting those less privileged, the "recipients."

Foster said it's been a "huge, huge benefit" for her family to be able to text or call their doctor at any time and be seen on short notice: "Knowing that their group is here also to serve our community makes it all feel even more important."

Tiznado, who visited the clinic one September morning for a scheduled monitoring of ovarian cysts, said St Luke's "has helped us a lot — economically and in every way. I think if we moved somewhere else, I would continue coming here."

But Tiznado and the other uninsured patients don't get the same 24/7 access that benefactors do. The two groups used separate waiting rooms until the pandemic hit.

St. Luke's is a local response to systemic U.S. healthcare problems including physician burnout, patient dissatisfaction and the fact that millions still lack care. Nearly 3.2 million Californians, including 1.3 million undocumented people, will be uninsured in 2022, although the state is gradually expanding Medicaid coverage to many immigrants. St. Luke's is part of the movement for direct primary care, an alternative for doctors fleeing insurance-dominated medical groups.

Roughly 200 direct primary care practices start up each year in the United States, and there are currently 1,581 of them employing an estimated 3,000 doctors, according to Dr. Philip Eskew, founder of DPC Frontier, which provides resources for doctors who want to make the switch. That's a tiny fraction of the nearly 209,000 primary care doctors in the U.S.

"We are indeed a small movement at this time," Eskew said.

Their biggest challenges are regulatory. If the clinics take fees from people enrolled in Medicare, for example, their doctors must forgo Medicare reimbursement anywhere they practice. And some state regulators may consider direct primary care practices to be health plans and impose terms or restrictions that make it difficult or impossible for them to operate.

Doctors in direct primary care typically charge patients a monthly or annual fee in exchange for enhanced access via phone, text or video, shorter wait times and longer face-to-face visits. And they generally don't accept insurance, thus eliminating the need to chase bills and treatment authorizations.

"In my old practice, we spent almost half our time collecting payments. I thought if we could just get rid of all that overhead, we could spend more time with patients — and it proved true," said Dr. Bob Forester, the conceptual father and co-founder of St. Luke's, who retired earlier this year.

Many direct primary care docs scoff at the high-tech investor-owned firms such as One Medical and Forward Health. They are widely viewed as direct primary care companies, but critics say they are more focused on expanding volume than on offering personalized service.

"Direct primary care is where a physician has a relationship with a patient. We do not have to be accountable to an investor, because our investors are our patients," said Dr. Maryal Concepcion, a family doctor in the remote mountain town of Arnold, California, who recently left a commercial practice to launch her own one-woman direct primary care practice.

St. Luke's paid patients must have insurance to cover hospitalization, surgeries, specialty care, imaging and prescription drugs.

The clinic is often able to find steep discounts for its uninsured patients. For example, Quest Diagnostics charges them only 10% to 15% of its regular price for lab work, said Dr. R.J. Heck, one of the two family physicians at St. Luke's and co-founder of the clinic. It often refers uninsured patients who need operations to Cirugía sin Fronteras, a reduced-rate surgery center in Bakersfield.

St. Luke's recently got a $75,000 grant for imaging, lab tests, X-rays and some prescription drugs from the Legacy Health Endowment, a local foundation. And it works with several radiology groups that provide discounts, Heck said.

Tiznado, who needs periodic ultrasounds for her ovarian cysts, said she pays around $150 for them. "If I did it in another place, it would cost between $900 and $1,200," she said.

St. Luke's nonprofit tax-exempt status encourages donations, including from local corporate benefactors such as Foster Farms and winemaker E. & J. Gallo. Some workers at donor companies are among St. Luke's uninsured patients.

Tax-exempt status also confers a benefit on paying patients: They can take a tax deduction on the portion of their annual fees they don't use for medical care. Every year, St. Luke's sends them a statement that puts a dollar value, based on Medicare prices, on the services they received.

Forester said St. Luke's arose from his concern for the uninsured and his disdain for bureaucratic systems. But "the bottom line," he said, "is that the idea for St. Luke's came in an inspired moment of prayer." He and Heck launched it over 17 years ago as a Catholic-inspired medical office.

However, while Catholic symbols adorn the walls of St. Luke's, many of its patients are not Christian, and Catholic medical doctrine is not central to its practice.

"There's nobody coming in here and looking or telling us what we should or shouldn't do," said Dr. Erin Kiesel, the clinic's other family doctor.

Kiesel said she wouldn't prescribe an abortion, but she would tell somebody where to go if they asked — which nobody has.

Heck and Kiesel took big pay cuts to come to St. Luke's. Kiesel makes about $60,000 less a year than in her previous practice. Having more time with patients, less paperwork and better work-life balance more than offsets the lower pay, she said.

Patients cited the personal relationships they've built with their St. Luke's providers.

Paul Neumann, a patient of Heck's for 25 years who followed him to St. Luke's, said that relationship has been a godsend.

He told of returning from a trip to Rome in 2009 with a case of walking pneumonia. When his wife called Heck the next morning, he came to the house immediately.

Neumann, 84, pays St. Luke's well north of $10,000 a year for himself, his wife and his son's family.

"I'd be happy to write a check twice as large," he said.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Healthcare Foundation.

Bernard J. Wolfson: bwolfson@kff.org, @bjwolfson

The mandates mark the first time nursing homes have been told how to spend payments from the government programs and residents.

This article was published on Monday, October 25, 2021 in Kaiser Health News.

By Susan Jaffe  

Nursing homes receive billions of taxpayers' dollars every year to care for chronically ill frail elders, but until now, there was no guarantee that's how the money would be spent.

Massachusetts, New Jersey and New York are taking unprecedented steps to ensure they get what they pay for, after the devastating impact of COVID-19 exposed problems with staffing and infection control in nursing homes. The states have set requirements for how much nursing homes must spend on residents' direct care and imposed limits on what they can spend elsewhere, including administrative expenses, executive salaries and advertising and even how much they can pocket as profit. Facilities that exceed those limits will have to refund the difference to the state or the state will deduct that amount before paying the bill.

The states' mandates mark the first time nursing homes have been told how to spend payments from the government programs and residents, according to Cindy Mann, who served as Medicaid chief in the Obama administration.

With this strategy, advocates believe, residents won't be shortchanged on care, and violations of federal quality standards should decrease because money will be required to be spent on residents' needs. At least that's the theory.

"If they're not able to pull so much money away from care and spend it on staffing and actual services, it should make a big difference," said Charlene Harrington, professor emeritus at the University of California-San Francisco's School of Nursing who has spent four decades studying nursing home reimbursement and regulation. "I would expect the quality of care would improve substantially."

"The actual effect will be just the opposite," said Andrew Aronson, president and CEO of the Healthcare Association of New Jersey. "By trying to force providers to put more money into direct care, you're creating a disincentive for people to invest in their buildings, which is going to drive the quality down."

Next year, New York's nursing facilities will have to spend at least 70% of their total revenue —including payments from Medicaid, Medicare and private insurers — on resident care and at least 40% of that direct-care spending must pay for staff members involved in hands-on care. In Massachusetts, Gov. Charlie Baker issued rules requiring nursing homes have to spend at least 75% of all revenue on residents' care. New Jersey's law requires its nursing homes to spend at least 90% of revenue on patient care. But its state regulators have proposed that the requirement apply only to Medicaid funding. No final determination has been made.

All three states promise a boost in Medicaid payments to facilities that comply with the laws.

Harrington and other advocates say the measures are well overdue, but they are watching how regulators in each state define direct care, who qualifies as a direct care worker, what counts as revenue and whether it is reported accurately.

Jim Clyne, president and CEO of LeadingAge New York, which represents nonprofit nursing facilities, questions the legality of some provisions in New York's law. "I don't think there's any doubt that it will end up in court," he said.

Aronson said the mandate is based on a misconception — that nursing homes could have kept COVID-19 out of their facilities if they had only marshaled their resources properly. "As long as COVID is in our communities, it will also find its way into our facilities," he said.

But poor infection control practices resulting from inadequate staffing have been the most common violation cited by nursing home inspectors over the years, according to a study released last year by the federal Government Accountability Office. The pandemic did little to change that trend. In August 2020, a frustrated Seema Verma, then-administrator of the Centers for Medicare & Medicaid Services, warned nursing home operators that "significant deficiencies in infection control practices" were responsible for increases in COVID deaths and pleaded with them "to really double down on those practices."

"Philosophically, if a payer wants to tell the provider how to use their funds within certain parameters, I understand that, but that's not what the [New York] law does," said Clyne. "The law goes beyond that. The state is telling the provider how much of other people's money they have to spend on care also, not just the state's money."

Bills paid by Medicare or individuals should be excluded from the state mandate, along with Medicaid funds earmarked for certain purposes such as mortgage expenses, he said.

Medicaid, funded under a state and federal government partnership, provides health insurance to low-income people and typically pays for about 60% of the nursing home care nationwide, usually for long-term residents with chronic health problems. Medicare, funded by federal dollars, insures older or disabled adults, and provides about 16% of facilities' revenue. The rest comes from private Medicare Advantage and other health insurance companies, and individuals who pay for their own care.

"Nursing homes are primarily funded by public tax dollars, Medicaid or Medicare — and the public has a reason to care about how our dollars are being spent," said Milly Silva, executive vice president of 1199SEIU, the union that represents 45,000 nursing home workers in New York and New Jersey, and backed the legislation in both states.

The spending mandates are not a new idea for healthcare. The Affordable Care Act directs health insurers to spend at least 80 cents of every dollar in premiums to pay for beneficiaries' healthcare needs. What remains can be spent on administrative costs, executive salaries, advertising and profits. Companies that exceed the limit must refund the difference to beneficiaries.

Harrington disagrees with industry officials who want to exclude Medicare dollars from the calculation of how much nursing homes must spend on direct care. That would leave a large source of profits untouched, she said, and allow them to use that money "however you want."

Medicare paid nursing homes $27.8 billion in fiscal year 2019, according to the Medicare Advisory Payment Commission, an independent panel appointed by Congress.

Even if only the Medicaid money is affected, though, there's still a big problem in the direct care spending mandate, said Aronson. "Ninety percent of facilities are losing money," he said, because Medicaid payments don't cover the cost of care. In New Jersey, he added, the shortfall is $40 a day per resident.

But some state lawmakers are not convinced. "Medicaid payments may not fully cover the cost of care, but somehow for-profit nursing homes are making money," said New York state lawmaker Richard Gottfried, who has chaired the Assembly health committee since 1987. More than two-thirds of the state's nursing homes operate as for-profit businesses and have been able to hide some of those profits in associated businesses they also own and then hire, he said. They can "use real estate gimmicks and shell contracts to make it look like they're spending money when what they are really doing is just siphoning income into their own pockets," he said. The use of such "related parties" payments has occurred across the country for several years.

To uncover the facilities' true income and expenses, the state mandates require accurate documentation. "If they file false documentation, that will be a felony," said Gottfried.

The spending mandates come at a challenging time for the industry, which is still recovering from the worst of the pandemic and facing a staffing shortage and low occupancy. But New York Assembly member Ron Kim, whose uncle died in a nursing home from presumed COVID, said lawmakers should be able to tell nursing home operators how to spend taxpayers' money. "If they choose to rely on public dollars to deliver care, they take on a greater responsibility," he said. "It's not like running a hotel."

Susan Jaffe: Jaffe.KHN@gmail.com, @SusanJaffe

By Amanda Michelle Gomez October 21, 2021

After four people were murdered in one week in early September — all in the same Washington, D.C., neighborhood — residents made a plea for help.

"We've been at funerals all week," said Janeese Lewis George, a City Council member who represents the neighborhood. "What can we do as a community?"

She was speaking to dozens of people at a vigil site, a tree adorned with teddy bears and candles along a street lined with rowhouses. According to police, the area, known as Brightwood Park, has been plagued by several dozen violent, gun-related crimes over the past year. When Lewis George asked whether the crowd had known anyone who'd been shot, most people raised their hands.

Earlier that day, five council members joined Lewis George in asking Mayor Muriel Bowser for assistance — not in the form of more police, but from the city's first-ever gun violence prevention director, Linda Harllee Harper.

Harllee Harper knows Brightwood Park, having grown up near the heavily Black and Latino neighborhood, which has recently begun to attract white residents, too. She knows the local stories, both good and bad. Some families have lived there for decades, witnessing generational poverty and government neglect. During the 1990s, parts of it were considered a "war zone" because of rampant drug- and gang-related activity. She still lives in the same ward with her husband and son, who plays basketball at the local recreation center with the children of a recent murder victim.

Her investment in finding a solution is clear. "It's not a new development," Harllee Harper told KHN. "My view of gun violence is shaped by how much loss I've experienced. I've had friends who have been killed and I also have had young people that I have worked with be killed."

D.C. began 2021 with two crises: the coronavirus pandemic and a gun violence epidemic. To respond to the latter, Bowser advanced plans to draw on lessons learned from the former. She started by creating a position, one that anti-gun violence groups had long requested and became too urgent to ignore: gun violence prevention director. Enter Harllee Harper, who was appointed Jan. 28.

About three weeks later, the mayor declared a public health emergency over gun violence and created an "emergency operations center" that mirrored the city's COVID-19 response. No part of the U.S. has been spared from an increase in murders during the pandemic. And in the nation's capital the murder toll is outpacing last year's, which reached 198, a 16-year high. Per capita, that's about 29 murders per 100,000 residents.

The City Council has directed unprecedented funding to support the efforts.

Harllee Harper, 56, started her 20-plus-year career at D.C. Public Schools as a substance abuse prevention and intervention coordinator. Most recently, she was senior deputy director for the D.C. Department of Youth Rehabilitation Services, where she helped overhaul the agency.

"I've run programs before, but this was a different level of limelight" than something she would have signed up for on her own, she said.

Nine months into this new role, Harllee Harper's most powerful tool is the mayor's initiative, Building Blocks. Drawing on public health strategies to contain the spread of gun violence, it's designed to treat the immediate symptoms and root causes of community violence.

Its workers operate almost as contact tracers, whose methods have become familiar during the pandemic. They enter targeted communities to form relationships and connect high-risk residents to violence interrupters, who are trained to de-escalate conflict. They also arrange for resources, like drug addiction treatment and housing assistance. The idea is to reach the small number of people who engage in dangerous behavior and invest in them and their neighborhood.

"Hopelessness combined with a gun, combined with substance abuse, is a really bad combination. And I think that's what we are seeing right now," said Harllee Harper.

Building Blocks is up and running in about a third of its targeted 151 blocks — 2% of the city — that were connected to 41% of last year's gunshot-related crimes last year. (Brightwood Park is not on this list but is included in the city's fall crime prevention initiative run by the police department.)

These diverse neighborhoods are home to people who tend to be poorer and lack access to resources and opportunities. Statistics among COVID and murder victims look similar: The same neighborhoods were hit hardest and the vast majority of deaths have befallen Black people.

D.C. stemmed the spread of COVID far more efficiently than the nation as a whole, in part through government action. The city's crash course on public health during the pandemic could mean it's better situated to address gun violence. "We can explain certain things through this public health lens and people can understand it a bit better," said David Muhammad, executive director of the National Institute for Criminal Justice Reform.

He said D.C.'s approach is unique and Harllee Harper's position is rare. "If you claim to want to reduce gun violence in your city, prove it. Whose full-time job is it in your city to do that? In most cities, it is zero," he said. "Don't tell me the police chief. That's a small portion of their job."

For the few dozen cities that have some sort of anti-violence czar, the position is relatively new. Richmond, California, is an exception, with an agency dedicated to reducing gun violence since 2008. Richmond's Office of Neighborhood Safety has been heralded as a model. By 2013, Richmond went from more than 40 homicides a year to 16, according to Giffords Law Center to Prevent Gun Violence — its lowest number in three decades.

Harllee Harper's position is housed not within the public safety agency but the city administrator's office, presumably affording her more authority and oversight of government programs.

And Building Blocks created a mobile app with which its employees can flag requests during walk-throughs of select neighborhoods. An employee could make a request using the city's "311" service line to repair a streetlight that is out, for example, and the agency responsible would prioritize it because it came from Building Blocks.

There's no guarantee these interventions will work, though multiple studies have shown positive outcomes of violence interrupters or infrastructure improvements, such as cleaning and transforming vacant lots and abandoned buildings.

But Daniel Webster, director of the Johns Hopkins Center for Gun Violence Prevention and Policy in Baltimore, said it's important to track successes and failures because efforts like the one Harllee Harper is spearheading don't "always work in all places" and there are lessons to learn when they don't.

"We can't expect the workers to just perform miracles," said Webster.

While expectations are high, Harllee Harper's success depends on whether government and business leaders will respond with the same urgency as they did when the health director requested action.

"The biggest hurdle really is getting all of government to buy into a new day and a new way to get things done," said council member Charles Allen, who chairs a committee that created Harllee Harper's position. "Bureaucracy is not nimble."

"My colleagues in the sister agencies across the city, when Building Blocks calls, they are very, very responsive," said Harllee Harper. "We're working together to create performance metrics for agencies related to gun violence prevention."

Some residents remain skeptical. Residents of the first Building Blocks neighborhood said the follow-up continues to lag. Jamila White, an elected member of the Advisory Neighborhood Commission, said she had several conversations with Harllee Harper and gave her a tour to point out the needs, including quick fixes like adding or fixing streetlights and regular street-sweeping. White has yet to see expedited results, she said, but respects Harllee Harper and admits that no one could address all the issues, many rooted in poverty, alone.

"There's a lot of shared agreement. But you know, having a shared agreement and having political will and power to do something is a different thing," said White.

Amanda Michelle Gomez: amandag@kff.org, @amanduhgomez