Moderate Republicans have outmaneuvered conservatives in the Montana legislature to give a Medicaid expansion bill here a real chance of passing. Its prospects have been in doubt since the legislative session began in January.

The bill faces a crucial debate and vote on the state House floor Thursday. If the Republicans who joined with Democrats to overcome attempts to kill it don’t stray, it has the votes to pass. Pending the governor’s signature and approval from the federal government, the bill would make Montana the 29th state – plus the District of Columbia — to expand Medicaid.

As in 2013, the last time Montana’s every-other-year legislature met, Republicans hold strong majorities in both houses. An attempt to pass Medicaid expansion in 2013 failed.

So no one was really surprised this year when Democratic Gov. Steve Bullock’s Medicaid expansion plan was shot down in its first committee hearing last month.

But a similar bill subsequently brought by Republican Sen. Ed Buttrey of Great Falls won every Senate Democrat’s support, and seven Republican votes, enough to send it to the House.

Like the governor’s proposal, Buttrey’s bill would accept federal funds under the Affordable Care Act and extend benefits to non-disabled adults without children, proposals that are non-starters for many conservative Montana Republican lawmakers. But unlike the Democratic proposal, it would require recipients to pay premiums and participate in “workforce development” programs aimed at moving people off of Medicaid and into jobs that pay enough to qualify for federal subsidies to buy private coverage on HealthCare.gov.

Buttrey’s bill faced an uphill battle when it got to the House. It landed in the same committee that killed the governor’s bill, headed by conservative Republican Rep. Art Wittich of Bozeman.

“That this compromise is widely shared is hogwash,” Wittich said after his committee heard more than four hours of testimony Tuesday. Proponents who came to speak included hospital and business interests. Opponents, organized with the help of the Koch brothers-funded group Americans for Prosperity, turned out a larger group than testified against even the governor’s bill.

“The reality is that 85 percent of the Republican caucus does not support [Buttrey’s bill],” Wittich said. “They were never consulted. They were never negotiated with.”

The committee’s Republican majority then voted to give the bill a “do not pass” recommendation on Tuesday. That meant it would need a supermajority of 60 House members to vote to keep the bill alive, an insurmountable hurdle.

That’s when Democrats fired a “silver bullet,” and hours of legislative gymnastics around arcane procedural rules over two days began.

In the early days of the legislative session in January, leaders from both parties agreed to give each other six “silver bullets” to “blast” pet bills out of unfavorable committees and onto the House or Senate floor for broader debates and votes.

House Republican leadership argued the Democrats couldn’t do that with the Medicaid bill, but eventually 11 members of their party split and sided with Democrats, bringing the Medicaid expansion bill to the full House, which will debate it and vote on it Thursday night.

Republican representatives are sure to face strong pressure to vote against the bill. Critics deride it as implementation of the loathed Obamacare. On the other hand, lawmakers have heard testimony from people like 54-year-old pizza delivery driver Max Naethe of Kalispell, Mont., who has diabetes and heart problems. He makes too much to qualify for Medicaid, but too little to get an Affordable Care Act subsidy for private insurance premiums.

“I don’t think anything Obama is a good idea,” Naethe says, but, “there are people out here whose lives literally hinge on this bill. It’s crucial that this be pushed through.”

Nor are all Montana Democrats entirely comfortable with the only Medicaid expansion bill left before them, written as it is by a Republican.

“There are lots of things in the bill that, quite frankly, I struggled to accept,” said House Minority Leader Chuck Hunter. “But I think [it’s] in the spirit of having something that works for both sides of the aisle to accept.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

At an Institute for Family Health center near Union Square in New York City, medical student Sara Stream asks a new patient named Alicia what brings her in. It’s been many years since the 34-year-old patient, who arrived last summer from Guatemala, has seen a doctor.

Her list of ailments is long.

“I have trouble seeing, headaches, problems with my stomach,” says Alicia, who declined to use her full name, because she is in the country illegally. “I feel depressed.”

Stream takes the problems one by one, carefully asking follow-up questions about when symptoms started, when they recur, where they’re felt, and what Alicia thinks the causes might be. Stream is using a translator, who also happens to be her supervisor, Dr. Amarilys Cortijo. As the symptoms pile up, Cortijo steps in.

“A lot of the symptoms she has are somatic,” says Cortijo. “We’ll have to deal with the complaints and try to get to the root, which is probably all the emotional turbulence that is taking place.”

Cortijo works for the Institute for Family Health and is co-director of two student free clinics — one the Institute runs in the Bronx with volunteer students from Albert Einstein College of Medicine and this one, downtown, which the Institute runs with volunteer students from New York University School of Medicine. Many other medical schools around the country run similar clinics that treat uninsured people for free. They typically meet once a week, taking in a few dozen patients per session, and treating several hundred patients over the course of a year.

The programs are among the most popular extracurricular activities at medical schools, and at some institutions almost all students volunteer at some point during their training.

Students do everything. First- and second-year students perform more administrative tasks, such as running the reception desk, coordinating lab tests and follow-up treatment and fund-raising. Third- and fourth-year students see patients, with faculty physicians overseeing all formal diagnoses and prescriptions.

At the NYU clinic, students increasingly have had to help drum up business. Many of the core patients in the Union Square area picked up Obamacare coverage, leading to a 25 percent decline in visits last year.

“A lot of our patients had been freelance people, who were the most likely to benefit from the changes in health coverage,” says Dr. Sarah Nosal, co-director of the program.

So NYU students have had to go out recruiting in a way they didn’t need to before, heading to churches and community centers in neighborhoods farther away, to let people like Alicia know about the free healthcare they could get if they come to the clinic.

“[The students have] reached out to communities where undocumented people were and made them aware of our resources,” Nosal says.

But these free clinics are not major venues for taking care of the uninsured. Most of the close to 2 million uninsured people in New York state and 1 million in the city get health care in emergency rooms, city hospitals or community health centers — if they get it at all.

Still, Dr. Neil Calman, head of the Institute for Family Health, said the clinics perform a valuable service for both patients and future physicians.

“This is an opportunity for medical students to get involved in the business end of seeing what health care is like for people who don’t have the same kind of access that they have to it,” he says. “It’s really a learning experience.”

Stream and Cortijo quickly realize Alicia has too many problems for student trainees to take on so Alicia will become Cortijo’s patient at one of her offices in Harlem or the Bronx.

That’s one less patient for the free clinic, though there are plenty of others in line behind her.

For Stream, there’s a satisfying difference between treating patients at the flagship NYU hospital and at the free clinic.

“Here, a patient may not have seen a doctor in the past 10 years. Patients may not have ever have seen a doctor,” she says. “While they’re here I want to figure out what’s wrong and how I can help them the most because we don’t know when they’re going to see a doctor again.”

Stream is in her last semester. After that, whether she keeps seeing uninsured patients will depend on where she does her residency and where sets up shop.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

It seems like every firefighter you ask in Houston can rattle off examples of 911 calls that didn’t even come close to being life-threatening:

“A spider bite that’s two or three weeks old,” says Jeff Jacobs.

“A headache, or a laceration,” says Ashley Histand.

Tyler Hooper sums it up: “Anything from simple colds to toothaches, stubbed toes to paper cuts.”

The Houston Fire Department logged more than 318,000 incidents last year, but only 13 percent of them were actual fires. The rest were medical calls, making a career in firefighting seem more like a career in health care.

Hooper drives the busiest ambulance in the city, based in a southside firehouse three miles east of the old Astrodome. Last year it answered more than 5,000 calls, and some of those were pretty frustrating, he says.

“We make a lot of runs to where it’s not an emergency situation,” he says.  “And while we’re on that run, we hear another run in our territory, it could be a shooting, or a cardiac arrest, and now an ambulance is coming from further away and it’s extending the time for the true emergency to be taken care of.”

Hooper says the area his ambulance serves has many lower-income residents who don’t have insurance. But even those that do have coverage don’t always have a regular medical provider or a car to get to appointments.

“They don’t know they could walk into certain clinics without appointments or without insurance,” he says. Calling 911 is “just what they’ve always done or what they’ve been taught.”

City officials hope to break that cycle with a program designed to connect these residents in their homes with a doctor, via the emergency medical technicians and firefighters who answer the call.

On a recent morning, Hooper drove through the rain to answer a call at an apartment complex near Hobby airport. Susan Carrington, 56, sits on her couch in a red track suit, coughing and gasping.

“Have you seen your doctor?” Hooper asks. Carrington shakes her head.

“No? Okay,” Hooper says.

Carrington doesn’t have a regular doctor. She called 911 because she got “scared.” It hurt to breathe, and the cough had been bad for four days, she says. In January, she had visited an ER for similar symptoms and had been given an antibiotic for pneumonia.

“Based on your vital signs, everything looks stable to us,” Hooper says. “Your lungs are clear, your blood pressure’s great, your pulse is good. Everything looks good.”

Previously, Hooper might have taken Carrington to the ER, just to be safe. But now he has an alternative – a computer tablet loaded with a video chat application.

He launches the app and Dr. Kenneth Margolis appears on the screen. He is seated in the city’s emergency management and 911 dispatch center, almost 20 miles away. Hooper swivels the laptop screen toward the couch, bringing doctor and patient face-to-face.

“Ms. Carrington, I’m a doctor with the fire department,” Margolis begins. “So you’re having a cough and feeling weak and having some trouble breathing, is that right?”

“Yes, sir,” Carrington says.

“And it hurts when you breathe and cough?”

“Yes.”

The questions continue, with Margolis able to watch Carrington’s face and reactions.

Margolis agrees an ER visit isn’t necessary. Instead, he schedules an appointment for her at a nearby clinic for the next morning. He also arranges a free, round-trip cab ride.

The intervention is known as Project Ethan, an acronym for Emergency TeleHealth and Navigation. It rolled out across all city firehouses in mid-December.

“I think a lot of people are very surprised that they can talk to a doctor directly and have been very happy with that,” says Dr. Michael Gonzalez, the program’s director and an emergency medicine professor at Baylor College of Medicine.

Gonzalez says the idea is to direct patients such as Carrington to primary care clinics, instead of automatically bringing them to the emergency room, where ambulances can be tied up for precious minutes — even an hour — as EMTs do paperwork or wait for a nurse to admit the patient.

By diverting some patients to clinics, ambulances can stay in the neighborhoods and overloaded emergency rooms can focus on urgent cases.

Across the country, emergency medical services can’t keep up with the demand, said Dr. Richard Bradley, chief of the Division of Emergency Medical Services and Disaster Medicine at UT Health in Houston.

“I think that the Ethan approach is really a novel idea and really quite a good,” said Bradley, who is not involved in the project. “One of the advantages of having an emergency physician on the other end of the line is you’ve got someone who is best suited to be able to look for subtle indicators of what may be an emergency.”

Other cities have experimented with programs to relieve the burden on emergency responders. Some programs analyze 911 data to identify “super-utilizers,” and send teams into their homes to arrange needed services such as transportation and follow-up care after hospitalization. Those home-visit programs are often called “community paramedicine,” especially if they use paramedics to problem-solve the medical issues.

Other cities have tried to divert 911 callers by using nurse hotlines. Houston has also tried that approach, but firefighters complained it took too long, and patients never spoke directly with the nurse.

Gonzalez says a key component of the telemedicine program is that it doesn’t just turn patients away from the emergency room. It offers an alternative — a doctor’s appointment that day or the next, and transportation there and back. City health workers also follow up with Ethan patients to identify other issues that may be leading them to use 911 inappropriately.

The program costs more than $1 million a year, but the city has secured some grants and federal funding to help cover those expenses.

But Gonzalez predicts the program will eventually reap far more in savings for the region’s overburdened emergency system.

A 2011 study of Houston-area emergency rooms showed 40 percent of visits were for primary-care related problems. Treating those problems in the ER cost, on average, $600 to $1,200 per visit, compared to $165 to $262 if the patients had been treated in an outpatient clinic. If all those ER visits could be diverted to a clinic, the savings would be more than $2 million.

Firefighter Alberto Vela recounted the experience of one woman who typically called 911 up to 40 times a month, often for very simple things, such as to get a prescription refilled. On one of those calls, he tried the video chat with her.

“I was so surprised by how long it took, it took maybe six to seven minutes, tops” to deal with her issue, Vela said. “It was awesome, and then we left the scene and were making more calls after that.”

Vela believes the program helped the woman find a regular clinic and transportation, because he hasn’t visited her home for months. “I would ask others shifts, ‘Hey, did you meet this lady?’ The other shifts said they hadn’t heard from her either. “And that’s very rare. So it’s working,” Vela said.

This story is part of a reporting partnership with NPR, Houston Public Media and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

FOR IMMEDIATE RELEASE
April 8, 2015

Alaska nurses endorse national union affiliation with AFT
AaNA Labor Program announces new partnership in Alaska

The Alaska Nurses Association (AaNA) Labor Program formally announced today that it has agreed to affiliate with the American Federation of Teachers (AFT) Nurses and Health Professionals.

The announcement was made jointly by AaNA Labor Council Chair Donna Phillips in Anchorage and AFT President Randi Weingarten in Washington, D.C. The two organizations had been in discussions for several months, culminating in a meeting of the two leaders in Anchorage in late March.

In voting over the last two weeks, registered nurses in bargaining units represented by the labor program overwhelmingly affirmed the earlier decision of the AaNA Labor Council board to seek affiliation with the AFT. The affiliation was also approved by the AFT executive council in a special meeting Tuesday.

“We are excited and honored that Alaska’s nurses have put their confidence in the AFT, as a voice and fighter for nurses and for quality health care,” Weingarten said. “Alaska’s nurses will be joining our union of professionals, 1.6 million members strong, including 113,000 members working in the health care industry across the nation, as we continue to fight for quality care, safe staffing levels and high professional standards — and demand that hospitals and health care facilities put patients before profits. We look forward to working with our new Alaska members to ensure they have the tools and conditions they need to care and advocate for the people they serve.”

Phillips said the announcement concludes the process that began 18 months ago when the Alaska nurses launched an initiative to investigate possible affiliation with a national union and to identify and review possible partners.

“We sought a national union with a record of representing registered nurses, one that is active in the AFL-CIO and a partner that will give AaNA members a voice in the national policies that affect their work every day,” Phillips said. “We are professionals — and the AFT is the preeminent union of professionals in American labor today.”

The AFT Nurses and Health Professionals division members include 85,000 registered nurses in 19 states. The Alaska affiliation will add more than 1,300 nurses in three bargaining units to that membership.

“An affiliation with the national union will provide AaNA with training and mentoring opportunities for new and existing leaders, professional development for our members, assistance with new organizing efforts and support for AaNA’s existing bargaining units,” Phillips said. The partnership with the AFT ultimately will give Alaska nurses a role in the national union’s policies and programs for registered nurses and other health care professionals.

As they join the AFT family, Weingarten said, “Alaska’s nurses will find a welcoming home, joining their colleagues who devote their lives to making a difference every day for the patients, students and many others they serve. Our members deserve — as frankly do all American workers — respect and dignity for the work they do.”

Changes in the health care industry, particularly recent trends toward mergers and acquisitions that have produced several large multistate and nationwide care-provider systems, led the AaNA General Assembly to adopt a resolution in 2013 to investigate affiliating with a national union.

Two large provider systems operating in Alaska employ many AaNA members. The two systems are Providence Health & Services Alaska, which is part of the third-largest not-for-profit health system in the United States, as well as PeaceHealth Medical System, which operates the Ketchikan Medical Center, as well as other facilities in Alaska, Oregon and Washington. AaNA’s third bargaining unit represents nurses at Central Peninsula General Hospital in Soldotna.

Phillips said the new partnership with the AFT will help strengthen the voices of nurses currently in contract talks with Providence Alaska Medical Center in Anchorage.

Weingarten noted that as a result of the previous affiliation of the National Federation of Nurses, AFT affiliates in Oregon and Washington state already represent nurses at other hospitals in both the Providence and the PeaceHealth systems. In Alaska, the AFT already represents thousands of state and local public workers; faculty and classified staff in the university, community and technical college system; and teachers and paraprofessionals in public schools, all of whom are affiliated with the AFT’s state federation, the Alaska Public Employees Association/AFT — one of the oldest and largest public employee unions in the state.

“We are pleased that Alaska’s nurses have made the decision to affiliate with the AFT,” said APEA/AFT President Cecily Hodges. “Nurses share the commitment to quality services and professional standards that are central to the mission of public employees, educators and the many others who make APEA/AFT an important voice in Alaska.”

AaNA’s Phillips emphasized the shared values and experience that led to the choice of the AFT. “The AaNA Labor Council sought to learn what a national union organization could provide to the Alaska Nurses Association Labor Program,” Phillips said. “Ultimately, the labor council team concluded that the AFT was the best fit for AaNA’s Labor Program membership, our history and our vision for the future.”

About the Alaska Nurses Association
The mission of the Alaska Nurses Association is to advance and support the profession of nursing in Alaska. AaNA is a voice for and represents 11,955 nurses across the state of Alaska by working to improve health standards statewide; promoting access to health care services for Alaskans; fostering high standards for and the professional development of nurses; advancing the economic and general welfare of nurses; and empowering nurses to be dynamic and powerful leaders in health care and political communities. More information is available at www.aknurse.org.

About the American Federation of Teachers
The American Federation of Teachers is a union of professionals that champions fairness; democracy; economic opportunity; and high-quality public education, health care and public services. The AFT represents 1.6 million members, including nurses and health care professionals, pre-K through 12th-grade teachers; paraprofessionals and other school-related personnel; higher education faculty and professional staff; federal, state and local government employees; and early childhood educators. More information is available at www.aft.org.

# # #

Computers are everywhere in medicine. If you have an operation, your surgeon might study the best practices online before the procedure. If you are diagnosed with a difficult-to-treat cancer, chances are your doctor will use an online database to find an appropriate clinical trial.  And, if you develop a rash, you’ll probably use the Internet to find out what it might be.

Donald Lindberg, the outgoing director of the National Institutes of Health National Library of Medicine, had a hand in making these resources widely available. Since he joined the NLM in 1984, he saw the promise in putting research online so that doctors could have the latest medical advancements at their fingertips. And he wanted that same option for patients as they’ve become increasingly engaged in navigating their own care.

“When I first arrived at NLM, I didn’t come prepared to change anything, but technology was changing all around all of us,” Lindberg said. “We’ve had to make major changes or else we would have become obsolete.” The National Library of Medicine, which is the world’s largest medical library, was founded in the 1800s and initially sent out a monthly guide to medical research. As technology has evolved, so have the methods the library uses to disseminate information to patients and providers.

He still remembers his early days at NIH, when information-sharing technology involved phone companies and point-to-point transmissions. But the advent of computers and the World Wide Web changed all of that.

Lindberg, who pioneered the first use of computers in medicine in the 1960s, was involved during his 30-year tenure with almost every government-funded sorting initiative of new and old medical information — the 1998 creation of Medline Plus for consumers to find out general medical information; the 1997 creation of Clinicaltrials.gov, the largest global registry for these types of studies; and the management and installment of Visible Humans, an online library of digital images based on the anatomy of a man and woman.

Lindberg, who retired April 1, recently spoke with KHN’s Lisa Gillespie about his NLM experience and what he thinks is next on the horizon. An edited transcript of their conversation follows.

Q:  What are some of the biggest changes that took place during your time at NLM and shaped the experience of being a doctor or patient?

A:  The introduction of computer interpretation of EKGs in the study of the heart was one piece of pavement in the road of success for computers. That was greeted pretty much with support from patients and doctors, though doctors were [also] concerned in making sure the stuff was right. I would say most are not experts [in interpreting this technology], especially in the case of general practitioners. It was a big deal for a computer to do that, and it was rapidly accepted.

Q:  You were involved in the creation and roll out of many systems to help doctors and patients. Which ones have made the greatest impact?

A:  Medline Plus, a database that tells you things like what chemicals and drugs get into mother’s milk, has had a lot of influence. If you’re lactating, it is of great interest. The major change in our whole field was Human Genome Project. That project has produced millions and even billions of facts that would only achieve meaning if they were put together to answer questions, [which was done through Medline Plus].

A very current one is clinicaltrials.gov.  [The concept] started at the National Institutes of Health, and even there, if you asked “how many clinical trials are going on?” there was no answer. There wasn’t even a list. We were surprised to discover that. … Everyone agreed there should be records [of trials]. In Israel, for instance, they saw what we were doing and said it was going to take too much money to do it [themselves], so they started putting their records in our system. Clinicaltrials.gov now has 150,000 trials [listed in the global database].

Q:  As NLM created and implemented computer applications, did health care providers shape what information was shared and how technology was used?

A: At one point, I was trying to do things the nurses would like. The chief of nursing came to me and said the computer was a wonderful thing. I asked her what she liked about it, and she said, “well, it’ll give me an alphabetized list of names on the ward.” That’s not a great accomplishment, but it’s what they wanted. We tried to keep our eyes out for things like that.

Q:  What are the biggest technological innovations you’ve seen?

A:  The idea of telemedicine is a very powerful one, and it’s been with us for a long time. Once we get improved gear [for its use], there will be a new application that I couldn’t have thought of. Take tele-dermatology. There aren’t enough experts. …  So the basic idea is that once you have digital cameras, you send [case information] to an expert who will look at it and give an opinion. A dermatologist told me once about a patient who had obvious dermatitis problems and had spent five years going to doctors who couldn’t treat it. The guy was unemployable because his condition was so severe that he couldn’t move around. And it got cured [using telemedicine].

Q:  What are your predictions for the future? Especially at the NLM?

A:  The idea of the informed patient will dominate changes. You can’t underestimate patients. [Now] versus when I got started … they’re willing to participate in medical-decision making. Back then, patients didn’t want an active role in their own management. Smart doctors now encourage it. That will make a big difference. Now they [are starting to] understand prevention … and they’ll understand end-of-life care. How aggressive the treatment is should be based on the patient’s wishes, but they have to understand [the choices].

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.