Similar to “Iowa nice,” “quality of life” is one of those terms that is difficult to define but that everyone can identify because they know it when they see it. It’s the reason why many native Iowans who were attracted the natural beauty of Colorado or Oregon or the urban excitement of Chicago or Seattle come home. What was once predictable and boring suddenly becomes safe and welcoming.
Quality of life as a metric often boosts Iowa to the upper reaches in various state comparisons. Last month, CNBC released its list of top states for business, which placed Iowa a comfortable 10th. It’s familiar territory for Iowa, which usually hovers near the top 10 (12th last year, 11th in 2013), though in 2010 the state hit sixth. Similar results have been seen in lists from Forbes and CEO magazine, among others.
In the CNBC rating, which was led by Minnesota and dominated by the Upper Midwest (#6 North Dakota, #7 Nebraska, #11 South Dakota and #15 Wisconsin), Iowa ranked in the top 10 states for three metrics: cost of doing business (fifth), quality of life (ninth) and overall economy (10th).
At the other end of the scale was the quality and availability of Iowa’s workforce (44th), a measure that offered the greatest possible points in CNBC’s weighted methodology. Hurting Iowa the most in this area: the state’s ongoing struggle to hang on to college graduates who receive a good education (Iowa ranked 18th on that measure) but choose to start their careers elsewhere (recent surveys from the University of Iowa and Iowa State University show about 50 percent of graduates leave the state).
This is a situation that IHA works to address through the Iowa Hospital Education and Research Foundation (IHERF) Health Care Careers Scholarship program. In addition to providing support to students in high-need careers, the program also requires students to work one year in an Iowa hospital for each scholarship awarded (they can receive up to two of the $3,000 awards). In this way, IHERF scholarships help stabilize Iowa’s workforce and improve the state’s overall business climate.
Iowa hospitals also contribute to the state’s other strengths by lowering the cost of doing business (health care in Iowa is among the most affordable in the nation and, by extension, so is health insurance) and developing the overall economy (hospitals are a large, reliable and growing part of Iowa’s economy and help keep the state’s unemployment rate enviably low).
Among the top 10 states in the CNBC report, it’s interesting that Iowa is comparable in quality of life to Colorado and Washington and far better than Texas, Utah and North Carolina – locations that Iowa college grads find very appealing. It’s also notable that access to high-quality health care and overall population health are significant factors in the quality-of-life metric.
Clearly, Iowa is a great place to live and, by extension, a great place to do business. Hospitals contribute to both by providing high-value health care and employing a highly educated, highly professional workforce whose talents impact lives and communities in countless, often immeasurable ways.
As for those young people who take their college degrees and stream out of Iowa each year: a state can’t be all things to all demographics, as the CNBC results show. In most ways that affect quality of life for most people, Iowa has its priorities straight and is playing to its strengths, including an excellent health care system that, perhaps more than any other industry, ensures that Iowa will always be among the best places to live and work.
The recent U.S. Supreme Court decision in King v. Burwell definitively silences constitutional critics of the Affordable Care Act (ACA) and reaffirms that millions of Americans will continue to receive access to health insurance for the foreseeable future.
With that debate now settled, national attention returns again to the state-by-state decision of whether to expand Medicaid benefits under the ACA. Iowa remains one of the 29 states (plus the District of Columbia) that has expanded Medicaid to all adults meeting the federal poverty standards and, as has been previously reported, the positive impact of that effort is clear.
Not only has the Iowa Health and Wellness Plan provided 130,000 Iowans with access to health insurance, but hospital charity care has declined by almost one-third, which helps decrease costs throughout the entire health care system. In addition, quality metrics are improving across the board and the average patient length of stay is declining. Iowa Medicaid expansion is a textbook success story.
But that all could be undermined by the looming specter of Medicaid managed care coming to Iowa in 2016.
Despite promises of bringing efficiency and improved access to the Medicaid population, Iowans have seen no real details yet regarding how this plan is to be implemented – and the implementation is scheduled to take place within the next six months. The managed care organizations (MCOs) that will be entrusted with more than $4 billion of state Medicaid resources haven’t even been announced. And the examples of other states that have hurled “full-steam-ahead” into similar experiments hasn’t produced the overall savings or quality results that Iowa hospitals are clearly generating today.
Of particular concern to Iowa hospitals is the expectation outlined in the Medicaid managed care request for proposals of significant hospital utilization reductions. As one of the bidding MCOs posed to the state: “We have not seen annual managed care discounts in other states as deep as Milliman is expecting in Iowa…what other managed care programs lead Milliman to believe that it is attainable to save over 30 percent (in hospital utilization) and 40 percent in emergency room (use)?”
To put that in context, a 30 percent Medicaid utilization reduction would mean more than $240 million in Medicaid revenue declines for Iowa hospitals – including both Prospective Payment System and Critical Access Hospitals. What would losses of that amount mean to your hospital and community? What would such declines mean to your ability to continue providing innovative care management strategies to the patients you serve?
Additionally, because hospitals are the only health care providers mandated by law to treat all those seeking care, one could logically expect access to primary care to erode and those charity care reductions to reverse.
How the overall hospital community responds to these questions is an IHA priority, with membership workgroups already meeting this summer to identify policy questions and solutions. But individual community hospitals will also need to be evaluating how managed care will change how they deliver services and how turning Iowa’s Medicaid program over to out-of-state insurance interests in any way serves patients.
Ultimately, this isn’t a question about how to better manage Iowa’s state government; it is a question of whether or not the government truly supports reforming the health care system and providing improved access to care for all citizens.
Or is the state’s government merely interested in cutting support for Iowa health care providers?
(This article, by Debra Venzke, was reprinted with permission of the University of Iowa College of Public Health.)
Health care access, obesity, teen pregnancy, mental health, physical activity – these are just a few of the health concerns identified by Iowa hospitals in their Community Health Needs Assessments (CHNAs). The needs vary from community to community, but one issue – obesity – is cited as a top health priority in almost every report.
In fact, a review of CHNAs from 300 randomly selected U.S. hospitals showed that obesity was the number-one health condition identified as a community health need, according to the Health Research & Educational Trust. Obesity-related diseases such as diabetes, cardiovascular disease, and hypertension were also highly ranked health priorities.
A Culture of Health
As of 2012, the Affordable Care Act requires non-profit hospitals to conduct CHNAs every three years in conjunction with community partners. They must then develop and implement strategies that address the issues identified. That means hospitals are now playing an even bigger role in population health.
“Community hospitals have always addressed broader community health issues within their missions of service,” says Keith Mueller, professor and head of health management and policy in the University of Iowa College of Public Health. “Now that mission has enhanced meaning because payment systems penalize hospitals for unnecessary re-admissions, which can be prevented through integrating hospital and community services.
“Likewise, hospitals are rewarded for keeping people healthy, which happens when hospitals are part of integrated local delivery systems, which most now are,” Mueller continues. “So, the long-standing service mission and financial incentives are aligned to motivate hospitals to be local leaders in promoting a culture of health in their communities.”
Putting Plans into Action
To address nutrition and obesity-related needs, many hospitals’ action plans include offering exercise classes, nutrition counseling, runs/walks, free health screenings, and education programs. Some creative new endeavors are being put into place as well.
For example, UnityPoint Health Finley Hospital in Dubuque offers a free cooking program, “Cooking with the Cardiologist,” three times per year in partnership with Hy-Vee Food Stores. A Finley cardiologist and a Hy-Vee dietitian teach participants how to prepare and modify dishes that are heart-healthy and tasty.
Proposed actions from Van Diest Medical Center in Webster City include creating a community education series on topics such as reading food labels, touring a grocery store, and discussing healthy portions and restaurant options, and promoting and expanding a farmers market.
Crawford County Memorial Hospital in Denison is partnering with the Hospital Foundation of Crawford County to sponsor a Healthy Desserts recipe contest at the county fair to encourage residents to consider lifestyle changes to reduce obesity rates.
A Growing Garden Movement
Several Iowa hospitals have established on-site gardens that not only provide healthy food and opportunities for education, but also places for patients, staff, and visitors to relax and enjoy nature.
Buchanan County Health Center in Independence added a garden to its campus in spring 2014. Local school children were able to sample the fresh produce as part of a program that educates kids about healthy eating and exercise. The produce was also used in the hospital cafeteria and sold at a mini farmer’s market on the hospital’s campus.
Winneshiek Medical Center (WMC) in Decorah is home to an extensive “edible landscape.” The organic vegetable and flower garden was established in 2009 under the guidance of the Pepperfield Project, a non-profit organization dedicated to cooking and gardening education programs. The Pepperfield team maintains and harvests the hospital garden’s mix of vegetables and perennials.
“Last year we used about 1,700 pounds of produce from the garden in the cafeteria and patient meals,” says Joetta Redlin, WMC’s director of nutrition services. “If we have an excess of product at the end of the week, we have a Bountiful Harvest sale in the cafeteria to sell the produce at reduced cost so it doesn’t go to waste.
“Patients visit the garden and really find it a peaceful respite,” Redlin continues. “Staff can visit the garden over their lunch break as well. We offer several small varieties of tomatoes in a ‘U-pick’ area that the staff can eat with their lunch. I think the community views it as a beautiful landscape as well as beautiful produce.”
A Proactive Approach to Health
In 2014, Mercy Cancer Center in Des Moines also established a vegetable and herb garden.
“Our healing garden is on the property of our outpatient cancer center where patients receive radiation therapy and chemotherapy,” explains oncology dietitian Crystal Tallman, who oversees the garden with another dietitian. “Last year, we harvested approximately 400 bags of produce that we distributed to our cancer patients and their families. We also provided recipes to give patients ideas of how to incorporate the produce into their diet.”
The center plans to significantly expand the garden this year with additional raised beds, seating, and a water feature.
“Many people think of hospitals and cancer centers to be reactionary type locations; you visit them only when you get sick,” says Tallman. “I believe having a garden on-site is a proactive approach to health and sends the message that Mercy encourages healthy eating, which can contribute to reducing chronic disease risk.”
A while back, a certain Iowa newspaper ran an online quiz of sorts, using a slide show of building exteriors and interiors and challenging readers to determine which images were from hotels and which were from hospitals. Suffice to say, the buildings were quite extravagant and none were located in Iowa.
This is illustrative of an attitude with which hospital leaders have become well acquainted. Sometimes the attitude lives just below the surface, as with this misdirected “quiz.” Other times, it reveals itself more blatantly through half-informed critiques that accuse hospitals of crossing some ill-defined line of financial restraint.
Of course, being on the receiving end of half-informed attacks and ill-defined limits, all generously provided by those well outside the industry, is a fact of life for hospitals. And it’s not really the outsiders’ fault – well, not completely – because hospitals live in a business world unlike any other.
This is why folks struggle to compare health care with other industries. Is health care like the auto industry, because of similar struggles and solutions with regard to efficiency? Is health care like the airlines, because safety is paramount? Is health care like retail, because retailers are suddenly health care providers? Perhaps health care is most like the auto body repair industry, which is driven largely by insurers and specialty suppliers and, because of that, is far from transparent.
The answer is “none of the above” because no other business functions in an environment that combines a large-scale non-profit enterprise with a massive (relatively), labor-intensive service provider; a highly-skilled, highly-regulated professional staff and a high-profile, community-based organization that is held accountable by everyone from the local coffee klatch to the president of the United States. Perhaps the real answer to “what is a modern hospital” is “everything.”
But let’s return to the hotel comparison, because that raises a question: What’s wrong with a hospital being like a hotel? Good hotels are, after all, customer-centered and value-conscious. Good hotels have learned that the little things matter, especially in the world of Twitter, Yelp and Google. Good hotels know that it’s all about relationships and those must be cultivated beyond building walls and dates of stay.
But then the question becomes: Fine, maybe hospitals should act like hotels, but do hospitals have to look like hotels? One might respond with a question: Are the two really separable? Can a hospital have the service excellence of a Ritz Carlton but the aesthetics and comfort of the Bates Motel? Doesn’t seem likely. And even if a hospital could manage it, who would go there?
Some people want to pretend that surface features don’t matter in certain applications, usually taxpayer-funded spaces like schools, police and fire stations, government offices and infrastructure. But we now know it does matter for both the people who work (and learn) there and the people who visit; it’s a matter of self-respect and community pride (not to mention productivity).
Hospitals may be the last stand for the “it doesn’t matter how they look” crowd. Somehow, some people have failed to see the important healing qualities of thoughtful architecture, natural light, pleasing color palettes, comfortable furniture and inspiring artwork. They view hospitals as unsightly “institutions” that should fade into the background.
On the contrary, whether measured economically or socially, hospitals are centerpieces of their communities and at the forefront of quality of life wherever they are located – and they should look the part.
But this time around, unlike three years ago when the court rejected a constitutional challenge to the law’s individual mandate, the case, King v. Burwell, focuses primarily on statutory interpretation.
The issue is whether section 36B means what it seems to say if read literally and in isolation from the rest of the law: that Affordable Care Act subsidies are available only to people “enrolled … through an exchange established by the state.”
And the different interpretations have proven dicey — so much so that each side in the case is having trouble explaining away the evidence supporting the contrary position.
Solicitor General Donald Verrilli and other defenders of the subsidies have failed to suggest any very plausible reason — other than sloppy draftsmanship, on which Verrilli has not much relied — why Congress said “established by the state” if it intended that subsidies also be available in the federally established exchange.
On the other hand, ACA opponents who read “established by the state” literally have produced little evidence that the law’s drafters deliberately and quietly planted in an obscure subclause the words that could become the seeds of the law’s destruction.
Plaintiffs in the case suggest that the drafters inserted these four words in order to pressure states to establish their own exchanges. But the legislative history offers scant evidence of this intent. And the three dozen states in question either failed to notice or disregarded it.
How these explanations sway the justices — or at least five of them — will determine whether the language drafted by Congress means that nearly 6.4 million low-and-middle-income people are not eligible for the overhaul’s tax subsidies because they live in a state that chose to rely on the federal government’s healthcare.gov, rather than establish its own online insurance marketplace. The subsidies make insurance affordable to many of the people who seek Obamacare coverage because they don’t get health coverage through their employers.
If the court rules that the subsidies are available only in states — mostly blue — that established their own exchanges, insurance markets in the other three dozen or so states might collapse. Unless Congress or the states reliant on healthcare.gov were to move fast to limit the damage, few people in those states would buy individual insurance. Those who did would likely have health problems and premiums would soar.
Many ACA opponents say that section 36B “means what it says,” as conservative Justice Antonin Scalia implied at the March 4 oral argument, even if the wording “may not be the statute [Congress] intended” and even assuming that it might “produce disastrous consequences.”
To the contrary, say Verrilli and other supporters, the law’s overall text, structure, design and history make clear that Congress intended to make subsidies available in all 50 states. They say the challengers’ interpretation would defeat the law’s purpose of making health insurance widely affordable. The Internal Revenue Service came to the same conclusion in an interpretive rule, to which Verrilli argued the justices should defer if in doubt.
As in 2012, the stakes in King v. Burwell are so high that Obama has made it clear that he would attack any decision that would cripple the health law as legally indefensible and politically motivated.
“[T]his should be an easy case,” Obama said June 8. “Frankly, it probably shouldn’t even have been taken up … based on a twisted interpretation of four words. … I’m optimistic that the Supreme Court will play it straight.” The next day, he added (without specific reference to the court) that “it seems so cynical to want to take health care away from millions of people.”
These shots across the court’s bow came even though Scalia and Justice Samuel Alito had strongly suggested during the argument that they would vote against the administration’s position.
Alito also suggested the possibility of delaying until 2016 the effective date of any decision against the administration. Such a delay, he said, would give the states and Congress time to avoid the disruption that would be caused if the court ruled the premium subsidies now available in the three-dozen states using healthcare.gov are illegal.
Justice Clarence Thomas, who was silent as usual during the arguments, is expected to vote with Scalia and Alito. The four liberal justices — Ruth Bader Ginsburg, Stephen Breyer, Sonia Sotomayor and Elena Kagan — seemed poised to line up with Obama. So the president will win if either Chief Justice John Roberts or Justice Anthony Kennedy sides with him.
While Kennedy’s vote is still up in the air, ACA supporters were cheered by his assertion to the lawyer challenging the subsidies that “there’s a serious constitutional problem if we adopt your argument.” Kennedy reasoned that the states are being unconstitutionally “coerced” if, as the challengers argue, the law requires them either to establish their own exchanges or see their residents disqualified from the subsidies.
The only way to avoid constitutional problems, suggested Kennedy, may be to resolve any ambiguities in Obama’s favor. This seemed inconsistent with the suggestions by Scalia, Alito and the challengers that the relevant language is free of ambiguity and without constitutional problems.
Roberts was sphinxlike during the argument in King v. Burwell. The case puts him in an unenviable position.
When Roberts stunned court-watchers by joining the four liberal justices and upholding the individual mandate in the 2012 decision, National Federation of Independent Business v. Sebelius, he was bitterly assailed by his usual allies — Kennedy, Scalia, Thomas and Alito — and was called a traitor by many other conservatives.
This barrage was intensified by a well-sourced news report that Roberts had initially voted to strike down the individual mandate and changed his mind — provoking a huge battle inside the court — after liberals led by Obama had preemptively denounced any decision to strike down the law as politically motivated, conservative “judicial activism.”
The conservative denunciations of Roberts will be even more bitter if he sides with Obama this time, too. On the other hand, if Roberts votes with the other four Republican appointees to gut the Democratic president’s signature accomplishment, it will feed the kind of attacks that the chief justice dreads on the Roberts court’s conservative majority as a bunch of robed politicians.
Looking to the future, a ruling against Obama could be extremely awkward politically for Republican members of Congress, presidential candidates and officials in the mostly red, affected states, even though it might be cheered (at least initially) by Republican voters.
In this scenario, the president and other Democrats would immediately demand that Republicans help them save the subsidies of millions of people at risk of losing their health insurance, by adopting new legislation.
Some Republicans say this would be an opportunity to extract compromises from Obama such as more choices for consumers – especially less expensive, less comprehensive health insurance options; the elimination of the mandate to buy insurance; or restrictions on medical malpractice lawsuits.
Others predict a humiliating and internally divisive Republican cave-in to avoid being blamed for the “disastrous consequences” that Justice Scalia hypothesized.
Whatever the outcome, the chief justice, in his tenth year on the Court, is in for a long, hot summer.