The federal government is poised to shower billions of dollars on Rhode Island’s health providers over the next decade due to the looming expansion of Medicaid under President Obama’s Affordable Care Act.

The health law expands Medicaid, the joint federal-state health insurance program for the poor, to cover childless adults who make up to 138% of the federal poverty level, currently $15,856. A new study by the Rhode Island Public Expenditure Council projects that roughly 40,000 more Rhode Islanders will sign up for the program between the start of the expansion on Jan. 1, 2014, and the end of 2023.

Yet Rhode Island taxpayers will need to spend just $450 million in local matching funds to get $3.15 billion in federal money (seven times as much) to cover the newly enrolled 40,000, according to RIPEC. That’s thanks to the extremely generous terms of the Medicaid expansion: the federal government will pay at least 90% of the cost for patients added under Obamacare, compared with only 51% for the current members.

Rhode Island’s Medicaid program spent $1.8 billion in federal and state dollars to cover 224,000 people during the 2010-11 fiscal year. Medicaid accounts for roughly a quarter of Rhode Island’s entire state budget.

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By Ted Nesi

PROVIDENCE, R.I. (WPRI) – Concern is growing about potential job losses at Lifespan, the nonprofit parent of major medical facilities including Rhode Island Hospital that is the state’s largest private employer, WPRI.com has learned.

A Lifespan spokeswoman confirmed Friday morning that the hospital chain is experiencing a financial shortfall, saying its finances ran “significantly below budget” during the first five months of its current fiscal year.

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By Dan McGowan

PROVIDENCE, R.I. (WPRI) – More than one in four Providence children who entered kindergarten last fall had elevated levels of lead in their blood, leaving them more likely to be chronically absent, repeat a grade or perform poorly on standardized tests, according to a report released by The Providence Plan.

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Excitement ricocheted across Twitter Monday night when Republican Mitt Romney mentioned Rhode Island in one of his debate answers, a rare presidential-level cameo for this deep-blue state.

Echoing a frequent talking point from conservatives, Romney pointed to the Medicaid waiver that the outgoing Bush administration granted Governor Carcieri in early 2009 to explain why he wants to give states more control over the program.

“States like Arizona, Rhode Island have taken these, these Medicaid dollars, [and] have shown they can run these programs more cost-effectively,” the former Massachusetts governor said.

As the chart at right shows, Rhode Island has one of the most expensive Medicaid programs in the country, which partly explains why local policymakers have been so intent on finding ways to curb its costs. Yet the impact of the waiver remains in dispute nearly four years after it was approved.

Romney’s comments have led to a flurry of fact-checking, particularly from liberals who oppose Republican proposals to block grant Medicaid. Politico’s Jason Millman weighed in Wednesday with a story questioning Romney’s claims (emphasis mine):

The Romney Medicaid plan would cap the growth of the program’s spending to the consumer price index plus 1 percent and essentially give states a lump sum to spend as they see fit. The Rhode Island and Arizona Medicaid programs, while enjoying more flexibility, are still backstopped by the federal government. …

In the case of Rhode Island, the Global Waiver it obtained in 2009 wasn’t intended to control costs, as a Lewin Group report commissioned by the state explained last December. “The Global Waiver is not a block grant meant to control costs but a demonstration aimed to improve health care quality built on the core foundation of shared state and federal costs,” the report said. …

The Lewin report said it was too early to assess the full impact, but it did find the Global Waiver had saved about $23 million in the first three years — well short of the $100 million in savings predicted when President George W. Bush’s administration approved the waiver.

Health and Human Services Secretary Steven Costantino gave a mixed verdict last year. “I think many of the things we could’ve done without the waiver,” he told McClatchy. “The more important question is, would we have done it?”

To get the case for the Medicaid waiver’s importance, read the Ocean State Current’s Justin Katz, who highlights a key piece of context – the waiver went into effect in January 2009, when the economy was in a tailspin. Within a month that led President Obama to sign the stimulus law, which had a significant impact on Medicaid spending in every state, including Rhode Island. The months after the Medicaid waiver went into effect were not a normal policymaking period.

To get the case against the waiver as a national model for block grants, read the Center on Budget and Policy Priorities’ Jesse Cross-Call and Judith Solomon’s March 2011 study and their March 2012 follow-up. For a shorter summary, try Cross-Call’s new blog post: “The Truth Behind Rhode Island’s Medicaid Waiver.”

(chart: Center on Budget and Policy Priorities)

By Ted Nesi

PROVIDENCE, R.I. (WPRI) – Rhode Island officials say it’s “full speed ahead” for the state in implementing President Obama’s health care law locally after the U.S. Supreme Court upheld it as constitutional. More than 50,000 more residents are expected to sign up for Medicaid at a cost of $1.9 billion over five years.

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• Related: Q&A: Lt. Gov. Roberts on what’s next for health reform in RI (June 28)

Ferguson (r) with Costantino and Roberts

“Is this the happiest day of my life? Pretty much!”

That’s what a smiling Christine Ferguson told me at a press conference this morning when I asked how it felt Thursday to see the health policy she developed as a senior aide to the late U.S. Sen. John Chafee upheld as constitutional by the U.S. Supreme Court.

Ferguson, who started working for Chafee’s son on Monday as head of Rhode Island’s new health insurance exchange, said unequivocally that President Obama’s signature accomplishment is what she drafted for Republicans two decades ago. ”It is based on the John Chafee bill of 1993,” she said. “It is pretty much exactly how we envisioned it.” She added: “I think it’s a great day.”

Ferguson was a key architect of the Health Equity and Access Reform Today Act of 1993, introduced by the senior Chafee that year as the Republican alternative to the Clinton administration’s so-called “Hillarycare” proposal. (Oddly enough, Hillary Clinton’s 1993 proposal was crafted in partnership with a Rhode Islander, too – Ira Magaziner of Greenhouse Compact fame.)

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There’s some irony in Governor Chafee’s appointment on Thursday of Christine Ferguson as director of Rhode Island’s new Health Benefits Exchange, the agency that will run the state’s Affordable Care Act health insurance marketplace.

In the 1990s, Ferguson worked for Chafee’s father, Republican U.S. Sen. John Chafee, as a health policy advisor. In that role, she was a key architect of the Health Equity and Access Reform Today Act of 1993, Chafee’s GOP alternative to President Clinton’s health reform legislation.

“Christine Ferguson of my staff and Sheila Burke of Senator [Bob] Dole’s staff have been absolutely essential in preparing this legislation,” Chafee said on the Senate floor when he introduced the bill in November 1993. “Without their knowledge and drive and energy, we would not have this bill today.”

At the center of Chafee’s 1993 bill was a provision requiring every American to purchase health insurance by January 2005 – an individual mandate. The same policy has now become anathema to conservatives, who are hopeful the U.S. Supreme Court will rule it unconstitutional before the end of this month.

Ferguson may be one of the few constants in the two-decade health care debate – someone who put forward an individual mandate as a Republican aide in the 1990s and will now run an insurance exchange reliant on the mandate, put into law by a Democratic president and implemented by a center-left independent governor.

• Related: Today marks the first anniversary of – ‘Chafeecare’ (March 23, 2011)

The late John Chafee makes a prominent cameo in this week’s New Yorker, as Ezra Klein writes about how the individual health-insurance mandate went from Republicans’ preferred policy to conservative heresy.

Klein notes the mandate made its first legislative appearance in the Health Equity and Access Reform Today Act of 1993, which Rhode Island’s Republican U.S. Senator proposed in November 1993, during the fight over President Clinton’s health care bill – and it’s been part of the debate ever since:

After the Clinton bill, which called for an employer mandate, failed, Democrats came to recognize the opportunity that the Chafee bill had presented. In “The System,” David Broder and Haynes Johnson’s history of the health-care wars of the nineties, Bill Clinton concedes that it was the best chance he had of reaching a bipartisan compromise. …

Ten years later, Senator Ron Wyden, an Oregon Democrat, began picking his way back through the history — he read “The System” four times — and he, too, came to focus on the Chafee bill. …

What is notable about the conservative response to the individual mandate is not only the speed with which a legal argument that was considered fringe in 2010 had become mainstream by 2012; it’s the implication that the Republicans spent two decades pushing legislation that was in clear violation of the nation’s founding document. …

Senator Orrin Hatch, who had been a co-sponsor of the Chafee bill, emerged as one of the mandate’s most implacable opponents in 2010, writing in The Hill that to come to “any other conclusion” than that the mandate is unconstitutional “requires treating the Constitution as the servant, rather than the master, of Congress.”

Now, 19 years after John Chafee first proposed a federal individual mandate for health insurance, the country is waiting to find out whether the U.S. Supreme Court will declare his idea unconstitutional.

• Related: Today marks the first anniversary of – ‘Chafeecare’ (March 23)

Rhode Island’s jobs crisis is now in its fourth year, and there is little reason to expect a recovery anytime soon. That’s particularly bad news for the tens of thousands of unemployed Rhode Islanders, one in three of whom had been out of a job for a year or more in 2010.

The lack of a steady paycheck is a burden and in of itself, but McClatchy’s Daniel Lippman reports it’s not the only reason to be concerned about what long-term unemployment is doing to people:

As Americans such as Banks struggle to find jobs, long-term unemployment is wreaking a psychological toll across the United States, with experts and a number of studies saying the jobless are especially at risk of depression, increased anxiety and physical ailments. …

Experts also warn that if the United States ignores the issue, the country will pay a price in the future with increased costs for mental health coverage. …

Jerald Jellison, a professor of psychology at the University of Southern California, said that when people lost their jobs, they tended to withdraw from society, shy away from seeing friends and stay holed up at home. …

But that behavior is usually self-defeating, because often the best way to get back into full-time work is by reaching out to friends and contacts to scope out promising leads.

A further complication for many unemployed people is that the longer they haven’t been earning paychecks, the harder it becomes to find work, as employers often look down on people who don’t currently hold jobs.

Want to live a long time, Rhode Islanders? If so, new research suggests men should move to Washington County and women should head for Bristol County.

Washington County men can expect to live 78.1 years, while Bristol County women can expect to live 82.6 years, researchers at Seattle’s University of Washington report in a new study. Lives are shortest in Providence County, where men live 75.7 years, and Kent County, where women live 81 years.

Rhode Island men have increased their lifespans significantly faster than women over the past two decades, but women can still expect to live five years longer, the study showed.

Male life expectancy in the state was 76.6 years in 2007, an increase of 4.4 years since 1987, while female life expectancy was 81.6 years, an increase of 2.6 years. Until now, the most recent data available had been from 1999.

The study examined the wide health disparities that exist between Americans in different parts of the country. It cited obesity and tobacco use as among the risk factors that caused earlier deaths in places like Appalachia, the Deep South and Northern Texas as compared with the East and West Coasts or the northern Plains.

Life expectancy in some U.S. counties is only now at the same level as the healthiest countries reached in 1957:

Five counties in Mississippi have the lowest life expectancies for women, all below 74.5 years, putting them behind nations such as Honduras, El Salvador, and Peru. Four of those counties, along with Humphreys County, Miss., have the lowest life expectancies for men, all below 67 years, meaning they are behind Brazil, Latvia, and the Philippines.

Women live the longest in Collier, Fla., at 86 years on average, better than France, Switzerland, and Spain. Men live the longest in Fairfax County, Va., at 81.1 years, which is higher than life expectancies in Japan and Australia. Women are also living long lives in Teton, Wyoming; San Mateo and Marin, California; and Montgomery, Maryland. For men, long life spans also can be found in Marin, California; Montgomery, Maryland; Santa Clara, California; and Douglas, Colorado.

Washington County is among the places in the nation where men live the longest, ranking No. 83 out of 2,355. Providence County was lowest but still ranked No. 648. For women, top-ranked Bristol County came in at No. 78, while bottom-ranked Kent County came in at No. 531.

One of the report’s authors, Christopher Murray, offered further thoughts in an interview with Bloomberg:

He called for more investment in public-health programs and increased emphasis on primary care so doctors can catch and control high blood pressure and cholesterol levels.

“Eighty-five percent of counties in the U.S. are not keeping up with what’s possible for women, and 81 percent of counties in the U.S. are not keeping up for men,” Murray said in a telephone interview. He defined “what’s possible” as progress made in the top 10 countries, including Canada, Australia and Japan, in extending human lifespan. …

The institute will next track specific causes of death to the county level, Murray said. Focusing on preventable causes of death, such as tobacco use, obesity, blood pressure and modifiable parts of the diet, will help lead to improvements in life expectancy, he said.

“These are major risks that account for a huge part of the pattern we see, and for which there are known primary care or public health strategies that can be used,” Murray said.

(painting: Nicolaes Maes [1656], via Wikipedia)

Last week, The New York Times and the Projo published long examinations of Rhode Island’s hotly debated Medicaid waiver. This week, McClatchy’s Washington bureau (formerly Knight-Ridder’s) weighs in under a Providence dateline.

I don’t see much new in the story, to be honest – it’s another attempt to weigh the claims of waiver lovers like former Carcieri aide Gary Alexander against criticisms from liberal groups like the Center on Budget and Policy Priorities.

If anything, Alexander’s main argument in favor of the waiver – that it saves lots of money – seems like the weakest one its supporters can marshal, since the cap on Medicaid spending was set above forecasts and the state is also getting extra federal funding from it.

A more convincing one might be along the lines of Justice Brandeis’ old “laboratories of democracy” argument. From McClatchy:

Many feared that Rhode Island would use its waiver to impose waiting lists for services, limit benefit packages and tighten eligibility for services. But that hasn’t happened, Costantino said.

Instead, the state used the added flexibility from the waiver to beef up home-care services, overhaul hospital payments, tailor benefit packages to specific populations and inject competition into contracts for program goods and services. It also required most Medicaid enrollees to join managed-care networks.

Critics say Rhode Island could have done most of these things without its unique waiver. It’s a fair criticism, Costantino said.

“I think many of the things we could’ve done without the waiver,” he said. “The more important question is, would we have done it?”

(chart: Center on Budget and Policy Priorities)

After the Department of Health picked three winners from the 18 applicants who wanted to sell medical marijuana at Rhode Island’s first compassion centers, officials there refused to name the other six applicants it found to be qualified or release the scores each received, despite my colleague Walt Buteau’s request.

The department’s spokeswoman, Annemarie Beardsworth, told me its legal counsel had determined that “individual scores of the applicants are considered to be part of the deliberative process and therefore are not public record.”

“Not public record,” eh? Them’s fightin’ words. (Not that I blame Beardsworth, who’s just the messenger here.) So on Monday I filed a formal APRA request to obtain the compassion center documents. Under Section 7 of Rhode Island’s Access to Public Records Act, the department then had 10 days – until April 4 – to respond.

Happily, I received a response today. Less happily, it informed me the department is exercising its right to a 30-day extension under the same section of the law.

The reason cited was “the nature of the materials requested and the complexity of the issues that are raised relating to your request,” Adelita Orefice, a veteran bureaucrat who’s now executive director of the department’s Division of Environmental Health Services and Regulation, told me in her letter.

The new deadline is May 2. I’ll keep you posted.

More public records coverage on Nesi’s Notes:

• With no info-nudists, RI needs public records laws (March 21)
• There’s a reason we call them ‘public’ records (Jan. 13)
• RI public records act enshrines the right to ‘No’ (Jan. 6)

A year ago today, President Obama signed the late U.S. Sen. John Chafee’s health care reform plan into law.

Sure, most people know the legislation as the Affordable Care Act – or, in less supportive circles, “Obamacare.” But when you get away from all the partisan bickering over the law, its actual nuts and bolts bare a striking similarity to the Health Equity and Access Reform Today Act of 1993, which the Rhode Island Republican proposed during the heat of President Clinton’s fight over health policy.

Don’t believe me? Check out this Kaiser Health News chart comparing John Chafee bill’s with competing Republican and Democratic proposals from 2009. As Kaiser’s Maggie Mertens pointed out in a February 2010 interview with one of Chafee’s co-sponsors, former Sen. Dave Durenberger of Minnesota:

In fact, the key provisions in the Chafee bill may seem familiar, as they bear a strong resemblance to those in the current Democratic Senate bill, and now in President Barack Obama’s proposal. A mandate that individuals buy insurance, subsidies for the poor to buy insurance and the requirement that insurers offer a standard benefits package and refrain from discriminating based on pre-existing conditions were all in the 1993 GOP bill.

Durenberger says the reason many of these ideas have been shunned by today’s Republicans, even called unconstitutional by some, is that political times have changed. “The main thing that’s changed is the definition of a Republican,” he said.

The bill Chafee crafted wound up being Democrats’ last, best hope for passing something comprehensive by the summer of 1994. “I trust John Chafee,” Sen. Ted Kennedy told fellow Democrats even as the legislation’s prospects dimmed. In the end, though, his bill died along with every other effort to pass major health legislation during that Congress.

Chafee’s ideas didn’t die, though – his top health policy aide, Laurie Rubiner, went on to work for Hillary Clinton, helping shape the health plan that Clinton unveiled during her presidential campaign – which also influenced Obama’s.

The American Enterprise Institute’s Norm Ornstein, an authority on all things congressional, emphasized the link between Chafee’s proposal and Obama’s amid the long legislative battle of 2009-10. “It is basically a marriage between Mitt Romney’s Massachusetts-care, and even more the John Chafee-David Durenberger-Chuck Grassley-Bob Dole alternative of 1993-’94 built around managed competition,” he told PBS’s Charlie Rose. (Orrin Hatch and Richard Lugar were also Chafee co-sponsors, at least initially.)

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The Chafee administration has tapped Dr. Michael Fine of HealthAccessRI fame to succeed Dr. David Gifford as interim director of the R.I. Department of Health. Giffords’ resignation takes effect Friday.

Fine is an interesting thinker, as I learned whenever he featured in my former colleague Marion Davis’ coverage of health issues back at PBN – and he’s not someone who’s tied to conventional thinking.

As evidence of that, check out his most recent book, “The Zero Calorie Diet: How to Eat Right – or Not at All,” which was published last year. Here’s how Davis explained his ideas in a story about “Zero Calorie Diet” last year:

Stop eating. Or eat a lot less, and change your life so food is less of a presence, and when you do eat, it’s a shared pleasure with your friends and family.

Fasting – the “zero-calorie diet” – has two places in that life, Fine suggested: as an occasional “penitence” for our culture’s excesses, and as a way to learn how little food we really need.

The typical American, he notes, has enough energy reserves to survive for three to six months, though he’s not urging anyone to test that. The point is to realize that once the body adjusts, usually within 12 to 36 hours, it’s surprisingly easy to not eat.

Not that it was easy for Fine, at least at the beginning of his long fast. He had fasted for short periods before, he notes in his book, and he knew to drink plenty of fluids, and to wait to adjust. Still, he felt awful by day three, and that led him to a key insight: Water is incredibly important, but it’s not enough – our bodies also need salt.

Good for Meagan Blanchette. The 16-year-old from Coventry lost 60 pounds over a year and a half, and her success story got a write-up in USA Today:

At age 13 and 60 pounds overweight, Meagan Blanchette of Coventry, R.I., decided she was fed up with being too heavy.

But today, at age 16, after losing all that extra weight and keeping it off for more than two years, she is among the first teens included in the Adolescent Weight Control Registry, a new research project being announced today.

Meagan and her mom, Lisa, are sharing what they learned about Meagan’s weight loss in the new registry, which will compile data from those ages 14 to 20 who have lost at least 10 pounds and kept it off one year.

Weight gain is a serious issue for teens and young adults. Heavy teenagers often experience huge weight gain in their 20s, according to a study out last week.

“Parents constantly come up to me and say, ‘My teenager is overweight,’ and ask for my advice. It would be nice to have data with which to answer them,” says Rena Wing, one of the founders of the new registry and a professor of psychiatry at Brown University. “An important goal of this registry is to learn what role parents have played in helping these adolescents achieve their success.”

Brown’s Alpert Medical School and The Miriam Hospital are looking for more adolescents who have lost at least 10 pounds and kept it off for at least a year to take part in their new registry. More information is available here.