text:
OPEN LETTER TO PRESIDENTIAL CANDIDATES
Dear Presidential Candidates:
We, the undersigned organizations, representing millions from the Puerto Rican Diaspora and allies, strongly urge you to publicly support a comprehensive platform addressing the fiscal and economic crises facing the Commonwealth of Puerto Rico.
The people of Puerto Rico, U.S. citizens and residents alike, are still recovering from devastating firsts —including the worst natural disaster and largest bankruptcy proceeding in U.S. history— a depressed economy, and imminent fiscal cliffs in public health, schooling and higher education, public pensions, and nutritional assistance. Many of these challenges are the result of artificial, arbitrary, and often discriminatory decisions made by the federal government in how it treats Puerto Rico. Only bold action spurred by presidential leadership – together with detailed policy prescriptions – can move the needle on these complex issues.
As a presidential candidate, we strongly urge you to publicly support the following policy priorities. Though action is needed on many more fronts, Puerto Rico needs:
A Marshall Plan-type mobilization to fully rebuild and recover after Hurricanes Irma and Maria
Full participation of Island residents in critical federal anti-poverty programs such as:
– Medicaid
– Child Tax Credit (CTC)
– Earned Income Tax Credit (EITC)
– SNAP
Economic tools such as:
– Jones Act exemption
– Fix how federal tax reform law treats the Island and provide tax incentives for job creation, along with improved labor standards
– Significant public debt relief
Recognition of the right to self-determination of the Puerto Rican people along with a permanent and self-sustained, inclusive, fair and transparent process to end 121 years of U.S. colonialism in Puerto Rico
We stand ready to assist you and your team to answer any questions or provide more in-depth analysis of Puerto Rico issues and look forward to your prompt response as we prepare to periodically report back to the public on the policy positions taken by all presidential candidates.
Alianza for Progress/Florida
Asociación de Puertorriqueños en Marcha (APM), PA
Americas for Conservation and the Arts
Bay Area Alliance for a Sustainable Puerto Rico, Leadership Committee
Bay Area Boricuas
BoricuActívatEd
Boricua Vota
Boricuas de Corazón, Inc
Boricuas Unidos en la Diáspora
Catalino Productions
Diáspora en Resistencia
Faith in Florida
Fort Washington Collegiate Church
Green Latinos
Iniciativa Acción Puertorriqueña
Juan Antonio Corretjer Puerto Rican Cultural Center
La Tertulia Boricua of San Francisco Bay Area
Jangueo Boricua
Misión Boricua
National Boricua Human Rights Network
National Conference of Puerto Rican Women
National Puerto Rican Agenda
Organize Florida
Our Revolution Puerto Rico
Parranda Puerto Rico
Puerto Ricans in Action (Los Angeles)
Puerto Rican Arts Alliance
Puerto Rican Alliance of Florida
Puerto Rican Women in Action
Puerto Rico Advocacy Group
Puerto Rico Connect
The Puerto Rican Agenda of Chicago
Women's March – FL
Signatories as of June 7th, 2019
CASA Maryland
Corazones Unidos Siempre Chi Upsilon Sigma National Latin Sorority, Inc.
El Centro de Servicios Sociales/Ohio
El Puente Puerto Rico: Enlace Latino de Acción Climática
Florida Immigration Coalition
G-8, Grupo de las Ocho Comunidades Aledañas al Caño Martín Peña, Inc.
Hispanic Roundtable/Ohio
Latinos for Healthcare Equity
MoveOn Political Action
Puerto Rican Leadership Council of South Florida
Vieques en Acci?n
Young Latino Network/Ohio
Edgardo Miranda, creator of La Borinqueña
Nilda Medina, Executive Director, Incubadora Microempresa, Bieke, Inc.
Roberto Rabin, Director, Vieques Historic Archives & General Manager of Radio Vieques
Topics: Uncategorized | No Comments »
2019 Medicaid funding cliff could cause mass migration from Puerto Rico
By admin | April 3, 2019
"Chronicle of a "disaster" foretold" — an ominous phrase coined by author Gabriel Garcia Marquez that no longer characterizes a fictional novel, but a very real and terrible occurrence that may happen in Puerto Rico at the end of this year.
Puerto Rico is still recovering from the historic destruction caused by Hurricanes Irma and Maria and now, to add insult to injury, close to one million residents are in peril of losing their Medicaid coverage in 2019. A man-made, perfect storm that could impact not just Puerto Rico, but also states like Florida and other states where residents could potentially relocate to maintain their Medicaid coverage.
Citizens of the United States since 1917, the island's residents are among the poorest in the nation, with 43.5 percent living below the federal poverty line, compared to 14 percent nationally. Those living under the poverty line are most reliant on public services like Medicaid.
Puerto Rico, with a total population of 3.4 million, covers 1.3 million residents under Medicaid at a total cost of $2.62 billion a year. If it were a state, the federal Medicaid reimbursement rate would cover most of the cost. But because Puerto Rico is a U.S. territory, it is ruled by discriminatory, archaic and unacceptable Medicaid rules that limit the federal funding the island receives to cover these U.S. citizens.
Unlike in the states, where federal Medicaid funding is not capped and the federal share varies based on states' per capita income, federal funding for Medicaid in the territories is subject to a statutory cap and a fixed federal matching rate. Because of this, Puerto Rico's Federal Medical Assistance Percentage (FMAP) is capped at 55 percent when it would be closer to 83 percent if it was calculated similarly to rates set for U.S. states.
Under these unequal, discriminatory regulations, Puerto Rico experiences a significant burden to cover its medically indigent. This steep fiscal burden has contributed significantly to Puerto Rico's troubled fiscal situation, which helped lead to the government declaring bankruptcy. It also helps explain why health outcomes on the island are generally worse than in the states, with residents having higher rates of heart disease, diabetes and infant mortality.
Now these problems may become even worse. In February 2018, Congress approved additional funding for Puerto Rico through the Bipartisan Budget Act (BBA), which provided $4.8 billion for Puerto Rico. These relief funds expire at the end of September 2019, which means that just a few months from now, 900,000 Puerto Rican residents could lose their Medicaid coverage.
Not only would this be disastrous for those already struggling on the island, but it could also financially burden southern states like Florida and northeast states like Massachusetts, Connecticut, New York and Pennsylvania, where residents of Puerto Rico most commonly migrate. If health conditions continue to worsen on the island, residents will have no choice but to move to where they have historically sought better health services on the mainland.
This health-driven migration could cost about $9.7 billion for the federal government and $6.1 billion divided among various states. By comparison, the cost of providing these services in Puerto Rico would total less than $4 billion.
This potential mass migration is 100 percent preventable. Congress can act to immediately end the unequal funding of Medicaid for Puerto Rico and achieve stability in the island's health care system.
Through legislative fixes, Congress can change the formula of how the cap is calculated by covering the cost of all residents at or under 100 percent of federal poverty level, as is currently applied to the 48 contiguous states and Washington DC. This is one of multiple solutions that could help stabilize Puerto Rico's health care system, getting rid of the cap would go a long way towards increasing the island's financial assistance and getting its residents back on their feet.
One way or the other, Congress will have to help Puerto Rico's residents and provide them with the health services they need to thrive as part of our country's essential fabric. If Congress does not act soon, the probable disaster of Puerto Rico's Medicaid funding cliff will not be just for the island to bear alone.
Dr. Jaime R. Torres is the president of Latinos for Healthcare Equity and the former regional director of the U.S. Department of Health & Human Services, Region II, serving New York, New Jersey, Puerto Rico and the U.S. Virgin Islands.
https://thehill.com/opinion/healthcare/436556-2019-medicaid-funding-cliff-could-cause-mass-migration-from-puerto-rico
Plaskett's Bill Calls for Eliminating Health Care Inequities in U.S. Territories
Delegate to Congress Stacey Plaskett on Wednesday again called for equitable treatment of United States territories when it comes to healthcare funding, announcing that she is reintroducing the Territories Equitable Health Act that seeks to lift the cap on the federal Medicaid match that exists only for U.S. territories.
"This has been an issue for decades. It has become an even more significant issue in the aftermath of the natural disasters that the territories have all experienced in the past two years," Plaskett told reporters at a press conference in Washington.
In the Virgin Islands, even though residents pay the same taxes for Medicaid, Medicare and Social Security as employees anywhere in the country, federal law has set a cap on the federal match for Medicaid payments at 55 percent. Federal Medicaid match in the 50 states and Washington D.C., however, are open-ended; these jurisdictions enjoy a federal match from 50 percent up to 81 percent for the poorest states.
"That is not fair. It is not within parity, and it is not equitable," Plaskett said. "This is a fundamental underlying problem that the territories have: a limited federal medical assistance percentage, in addition to a cap on overall funding."
The Medicaid funding cap for the territories means once the cap is reached, the territories must bear the full cost of Medicaid services.
"The caps are antithetical to the purpose of the program, to be able to expand and contract based on local need," Plaskett said.
Rep. Jenniffer Gonzalez-Colon (R-PR), who stood beside Plaskett at the press conference, said Puerto Rico is suffering from the same restrictions, with Medicaid federal match capped at 55 percent even though 45 percent of Puerto Rico's population falls below the poverty threshold, compared with Mississippi's 21 percent.
The situation was worse before the Obama-era Affordable Care Act. In 2005, the U.S. General Accounting Office found that the territories only received about $50 per capita in Medicaid funding, while states received $800 per capita. The Affordable Care Act provided supplemental funding for the territories starting July 2011, according to Plaskett, which also allowed for the increase of funding from 55 percent to 100 percent in the aftermath of Hurricanes Irma and Maria. That support, which is crucial, according to Plaskett, expires in September 2019.
In the case of Puerto Rico, the territory received a direct allocation of $3.8 billion dollars that resulted in 100 percent of federal cost share for Medicaid and Medicare services, but that also ends in September 2019.
"If we are not addressing [that] in this kind of bill, we're going to have, in the 2020 budget, a lot of federal funding [that] will revert statutorily to the cap of 55 percent," said Gonzalez. "That's the reason we need to fix, in the long term solution, this situation with federal medical assistance percentage."
The low rate of federal matching funds is arbitrary, according to Plaskett, and has forced the government of the Virgin Islands to spend more local Medicaid dollars than a state would. The 55 percent local match also meant keeping the Medicaid eligibility rolls down, setting unrealistic income requirements that exclude individuals who would have qualified for Medicaid in states. This results in residents of territories moving to states that can provide better for their healthcare needs.
"Before the 2017 hurricane season, a state-like FMAP alone, if we had been treated in the similar manner as the states, it would have provided the government hospitals in the Virgin Islands approximately $22 million per year in local matching funds and would have reduced the uncompensated care costs, and subsidized the local treasury," Plaskett said.
Plaskett said the effects of the low federal match were seen after the 2017 hurricanes, when hospitals were destroyed because "hospital administrators have to make the decision between putting a new roof on, supplementing, or paying doctors and nurses and healthcare individuals."
In addition, Plaskett said, even before the storm, the territory's two hospitals — Schneider Regional Medical Center on St. Thomas and Juan Luis Hospital on St. Croix — were excluded from the Medicaid Disproportionate Share for Hospitals program, or DSH, in spite of the significant amount of uncompensated care.
Plaskett's legislation, HR 1354 or "The Territories Health Equity Act of 2019," with support from representatives from other territories, aims to lift the Medicaid caps and provide for fair inclusion of the territories in Medicaid, Plaskett said.
The Territories Health Equity legislation would also address low hospital payments under Part A. Hospitals in the Virgin Islands receive Medicare compensation under Part A through a system using what Plaskett calls out-of-date reimbursement formulas. Payments to the two hospitals are based on 1982 and 1996 costs, annually adjusted for inflation, but due to the large permanent changes in services, Plaskett said, the cost of care at both hospitals is not comparable to the inflation-adjusted expenses of their base year.
The legislation would also include small territories in the Medicaid DSH program, Plaskett said, improve the treatment of territories under Medicare Part D, or its low-income subsidy programs.
"We must confront the difficult reality that these territories and citizens and residents have [been] neglected and allowed to fall behind. This bill attempts to bring parity of Medicaid services," Plaskett.
Rep. Darren Soto (D-FL), who arrived later in the press conference to show support for the bill, has been "a champion and huge supporter" of U.S. territories, according to Plaskett, particularly of Puerto Rico and the USVI. After the 2017 hurricanes, Soto was one of the first people to step forward and offer support to the two Caribbean territories, she said.
"We cannot overlook health care equality in our nations' territories as well," said Soto, pointing to the cultural and economic connections his state has with Puerto Rico and the Virgin Islands.
"We take no enjoyment in knowing that there has been an exodus of doctors from Puerto Rico to Florida. We want Puerto Rico, we want the Virgin Islands to succeed and that means we have to have a well-funded system that has topnotch hospitals, that has access to healthcare, that creates a system where doctors want to continue to practice in the Virgin Islands…in Puerto Rico," Soto said.
As for bipartisan support and the bill's prospects for passage, Plaskett said many members of Congress from both sides of the aisle support the bill, including members of Congress representing districts in New York, Florida and Texas that have many constituents from the U.S. territories. Soto is a member of the committee of primary jurisdiction for the bill, the Committee of Energy and Commerce. Plaskett said she has also had conversations with Committee Chairman Rep. Frank Pallone (D-NJ) and Rep. Diana Degette (D-CO), who chairs the Subcommittee on Oversight and Investigation under the Committee on Energy and Commerce.
https://stjohnsource.com/2019/03/07/plasketts-bill-calls-for-eliminating-health-care-inequities-in-u-s-territories/
Life and Limb–Inside the Rio Grande Valley's Amputation Crisis
By admin | March 9, 2019
Daniel Zamora still remembers the smell. At first he didn't realize anything was wrong. A small blister appeared on his left pinky toe where his sneaker rubbed against his skin. He had developed blisters before, but this one wouldn't go away. First the tip of the toe darkened, slowly turning the jet-black color of his hair. Then the color spread toward the rest of his foot.
He was used to ignoring such things. It was 2016, and Zamora, now 55, had gone his whole life without health insurance. Born in Matamoros, Mexico, he moved across the border with his family to Brownsville when he was about 6 years old. For decades, Zamora, a legal permanent resident, worked maintenance jobs for low pay and no benefits. He couldn't afford to take time off or see a doctor. Sometimes, when he wasn't feeling well, he'd brew an herbal tea from the leaves of the moringa tree just outside his front door. He often tried curing his cuts and blisters with ointment or rubbing alcohol. Occasionally, if things got really bad, he reluctantly went to the emergency room, where, he says, doctors made snide remarks about his inability to pay. So he waited. Maybe it would pass.
Finally, the smell got unbearable. Like road kill in the hot South Texas sun. A couple of months after the blister appeared, Zamora drove 2 miles to Valley Baptist Medical Center, where doctors quickly diagnosed him: His diabetes, uncontrolled for years, had blocked blood flow to his toe, preventing it from healing. What began as a minor blister was now a life-threatening emergency. Zamora says the doctors sent him home with medication to treat the wound, but a few weeks later he went back to the ER, where he had two toes on his left foot amputated to prevent gangrene from spreading up his leg.
When Zamora found out he had diabetes, about 10 years ago, it didn't come as much of a surprise. In the Rio Grande Valley, nearly one in three people has the disease, triple the national rate. The Valley is among the poorest and least-insured regions in the country. It's also overwhelmingly Hispanic, a population that has a higher risk of developing type 2 diabetes.
Perhaps the most visceral indication of the Valley's diabetes crisis is the shocking number of people living with amputations. The rate of diabetic amputations in the Valley was about 50 percent higher than the state rate in 2015, according to data from the state health agency. In Cameron County alone, where Zamora lives, hospitals recorded 281 diabetic amputations that year. That's more than 50 percent higher than the national rate, according to the Centers for Disease Control and Prevention. The estimated amputation rate in smaller Willacy County, just north of Cameron, was more than four times the national rate. "Good gracious," said Ed Gregg, a CDC epidemiologist, when looking at the data. "What's going on with Willacy?"
When he first found out he was diabetic, Zamora says, he "didn't pay too much attention to it." Both of Zamora's parents died from diabetes, which is the seventh-leading cause of death in the United States. His father used a wheelchair for the last years of his life, after a diabetic amputation above the knee. In the Valley, there's a fatalism associated with the disease, often considered an inevitable inheritance.
What Zamora didn't realize is how big an impact a small blister would have on his life. For months after the surgery, he couldn't walk. Nor could he afford professional wound care, so his son came by each day to change the bandage. Zamora had to quit his job cleaning a nearby gym because it required him to be on his feet and lift heavy weights. Along the way, he racked up about $100,000 in medical bills, which he'll never be able to pay. When he developed an ulcer on his other foot, he went to see a doctor in Matamoros, because it would be cheaper. Finally, last summer, Zamora's disability qualified him for Medicaid and Medicare.
When I ask how he's doing, Zamora's typical response is: "surviving." He's frustrated that he had to wait until he was very sick and couldn't work to get health coverage from the government.
"Being diabetic is real bad…" Zamora's voice trails off. "A lot of people die from it."
He's adjusting to life as an amputee, but he still loses his balance, wobbling "like an egg" when he walks. That, along with vision problems due to the diabetes, makes manual labor difficult. But without a high school diploma, he has few job options. For now, Zamora is surviving on a disability check that's even less than the $1,300 a month he made at the gym.
It's a story told over and over again in the Valley: You don't know you have diabetes until it's severe, because you rarely see a doctor. You get a cut or blister but ignore it, because diabetes-related nerve damage means you can't feel it, or you're too busy working or taking care of your family to go to the doctor. The wound gets infected. By the time you get help, the infection is so bad that amputation is necessary. You can't afford proper care, so sometimes the wound gets infected again. You get another amputation.
In the Valley, there's a fatalism associated with the disease, often considered an inevitable inheritance. Diabetic amputations have a domino effect on the lives of patients and families. It begins with the patient exiting the workforce, sometimes decades early, "which creates every complication we can think of," said Belinda Reininger, regional dean at the UTHealth School of Public Health in Brownsville. "The family's economic situation is negatively impacted; children may have to start working and supporting their parents, slowing or putting aside their educational attainment goals. … We're already an area known for living $20,000, $25,000 below the median income of the state — to lose your wage earner is just tremendous. That's at the family level; you magnify that to the society level and it continues to ripple."
Each diabetic amputation represents not just a personal tragedy, but a failure of the U.S. health-care system. The epidemic also suggests a possible future for the rest of the country, as life expectancy increases, the Latino population booms and health officials grapple with how to get diabetes under control. The number of adults diagnosed with diabetes in the United States quadrupled between 1980 and 2014. CDC researchers now project that the number will nearly triple by 2060.
A new study published in Diabetes Care in November found that following a two-decade decline, the rate of diabetic amputations nationwide increased in recent years, especially among young and middle-aged adults. Gregg, who worked on the study, told the Observer that though diabetes care overall has improved, the "alarming" findings are a "wake-up call." He says amputations are important indicators that something went wrong with diabetes management, because they're generally preventable in patients who can access diabetes education and primary care.
Lisa Mitchell-Bennett, a project manager at UTHealth, put it more bluntly: "We're literally cutting people's limbs off, when they could just be taking medication. It's kind of crazy in a developed country."
When patients at risk of amputation resist Noel Oliveira's instructions to stay home from work and off their feet, he has a simple response: Enjoy life one-legged! That tends to make them listen.
A family physician who's originally from Brownsville, Oliveira opened the first wound care center in the Rio Grande Valley in the early '90s. At his Edinburg clinic, tucked into a complex of buildings at Doctors Hospital at Renaissance, most of his patients are diabetic, with stubborn wounds that refuse to heal. He tries to prevent amputations by treating severe cases like Zamora's. Before, diabetics had to travel hours to get this kind of care, said Oliveira, who co-founded the Rio Grande Valley Diabetes Association in 2007.
"In every corner of the United States, and the globe, diabetes and obesity has become a problem. In our area, it's just magnified," he said when I visited him at his office in December. The clinic was cheerfully appointed with Christmas decorations; a shiny banner reading NOEL hung across Oliveira's door.
He shows me the mementos in his office: a black T-shirt reading "Renaissance Rockers," the name of the band he plays guitar in with other doctors at the hospital. There's a photo with FBI agents he treated, and another from when he served as a WWE team doctor. ("They don't mess around, man.") On his desk is a Selena-themed thermos next to a DVD of Dr. No — his nickname around the clinic.
Nearly bald and sparsely mustached, Oliveira is blunt yet warm with his patients. Over the course of his career, he's seen more wound care practices like his crop up across the Valley; coupled with medical advances, that means there are more opportunities to prevent the loss of limbs, he says. But Oliveira and other doctors describe persistent obstacles.
"The lifestyle in the Valley is high-work, low-income," said Oscar Corral, a podiatrist in McAllen. Dealing with devastating wounds is routine, because caring for oneself often takes a backseat to looking after family and putting food on the table.
Corral recently stopped doing amputations because it was too upsetting. He focuses now on preventive foot care. "Everybody's big on the amputations, but not big on the preventive care part. They're so busy doing hospital consults on patients that already need an amputation. … They don't have time to do the preventive care."
When I visit Oliveira's clinic, he's seeing an elderly man named Israel Guerra who's had uncontrolled diabetes for years. Like Zamora, he didn't have health insurance until late in life, when he qualified for Medicaid and Medicare through disability. A couple of years ago, a doctor amputated half of Guerra's left foot after blisters on his toes refused to heal. In November, he lost his right leg just above the knee. "That one was his good leg, one he could rely on, walk better on," Guerra's daughter Esmeralda says, pointing to his right leg. She holds up his left shoe, which is half-filled with foam. "But now, now this one is the good one."
Guerra is at the clinic because of a small wound near his groin. He lies on the bed staring at the ceiling, pulsing his right thigh up and down. At first he didn't want to tell the doctors he could still feel the leg — a common "phantom limb" sensation — because they'd think he was crazy. Sometimes his missing leg still itches; he tries to soothe it by scratching the air where it used to be.
It'll be months before Guerra can get a prosthetic leg. In the meantime, Esmeralda, who has a family of her own, says she left her waitressing job at Denny's to help with his care. She tears up when I ask how it's going. "He's very motivated. He's actually being stronger for us than we're doing for him."
McAllen podiatrist Joseph Caporusso, who Guerra says did his first foot amputation, told me that he performs at least one toe or partial foot amputation each week, often on repeat patients. The hope is to prevent repeat amputations through proper wound care. "Once you have an amputation, it's kind of like falling down a mountain," he said. "My job is to stop it at hopefully the top of the mountain, before you fall more."
Oliveira leaves Guerra and his daughter with a set of instructions: Don't pack the wound too tightly. Keep it clean. Move the leg so the muscles don't atrophy. And later, when you're back on the dance floor, no fast songs. Oliveira raises his arms to an imaginary partner and sways slowly. "Solo canciones románticas." Only romantic songs.
The message Oliveira gives patients is one of empowerment, to take control of their own health. He recounts a recent visit with a patient who ignored his instruction not to work while his foot healed. The man returned to the clinic weeks later with an infection that threatened to consume his foot. After Oliveira removed the gangrene, the man followed the doctor's orders by staying home, wearing appropriate shoes and lowering his blood sugar. It looks like he will save his foot. "It's dang hard, bro, but you've got to do it," Oliveira recalls telling him. "If you want to stay two-legged, 10-toed, that's what you've got to do."
A few buildings over from Oliveira's clinic, a support group meets at the hospital each month to help each other in the difficult process of recovering from and living with an amputation. Most of the participants have diabetes, including the group's founder, Elizabeth Reynoso, whose leg was amputated in 2015 after a small cut from clipping her toenail got infected. She started the group to find people who understood and shared her experience. "When you lose your leg, it's like losing a loved one," she said after a presentation about depression and mental illness in the November meeting. "There's anger, there's depression, there's sadness, there's what-ifs, why me. You question it a lot. You need the help in dealing with that."
Diabetes is sometimes called the "silent killer" because so many people don't realize they have it until it's too late. Both type 1 and type 2 diabetes can be managed with proper medication and care, but the American Diabetes Association estimates that of the 30 million people living with diabetes in the United States, nearly a quarter don't know.
"Everybody's big on the amputations, but not big on the preventive care part. They're so busy doing hospital consults on patients that already need an amputation. … They don't have time to do the preventive care."
In the Rio Grande Valley, the numbers are more stark. Researchers at UTHealth estimate that nearly 30 percent of adults in the Rio Grande Valley are diabetic, and more than one-third of Valley diabetics don't know they have the disease. Another 32 percent of Valley residents have prediabetes.
By the time people seek treatment, the complications can be devastating. "When you see people going blind, missing part of their body, down here the first thing you ask is, 'Are they diabetic?' The majority of the time the answer is 'yes,'" said David Ceron, 42, a former teacher in McAllen. He recently published an e-book called The Adventures of Exo and Cy to teach kids how to prevent diabetes through healthy diet and exercise. In his family, the disease is rampant. Ceron, his mother and all seven of his siblings have had diabetes. Three siblings had amputations; two of them died from diabetes. The third, Carmen Zuniga, 61, lost her sight, developed heart problems and last year began dialysis for 12 hours every week.
"What's been really shocking and disturbing is oftentimes the age these patients will present with such horrific conditions," said Christopher Romero, a doctor at Valley Baptist Medical Center in Harlingen. "They're often younger than one might expect to have developed such severe complications. So it's probably a result not only of it being poorly managed, but also being late in diagnosis." Even for patients who are diagnosed early in life, "making it to the doctor is just the tip of the iceberg when it comes to the challenges in dealing with diabetes," said Romero.
On an unseasonably hot and sticky November afternoon, Daniel Zamora steps onto a scale in the cramped kitchen of his one-bedroom home near downtown Brownsville. "Pobrecito," he mutters. Poor scale.
Zulema Medrano, a community health worker, or promotora, and diabetes educator at the local nonprofit Proyecto Juan Diego, laughs and scribbles Zamora's weight in her notebook: 251 pounds. It's gone down since their last check-in a few months earlier; that's good news. The bad: Zamora's blood sugar level is dangerously high, putting him at risk for more complications. Does he know why it might have spiked?
Zamora shakes his head. "La comida," he guesses. Colorful fruit-and-vegetable-shaped magnets pepper the outside of his mostly empty refrigerator. On his kitchen table, next to his pile of pill bottles and blood-sugar tests, is a bag of limes, which he squeezes into water in place of soda. He's trying to eat better, but it's hard. Zamora's favorite foods are ones he has eaten his whole life: menudo, enchiladas, tamales. He lists them slowly, as though dreaming up his next meal. Plus, healthy food is expensive, he says. At the corner store, he can get a plate of taquitos for just a few dollars.
Sometimes, for a bit of exercise and fresh air, Zamora takes a slow walk around his public housing complex, looping down a couple of blocks and back to his own, where, he says, he pays just over $150 in rent each month. An old bench press sits just inside the front door, stacked with papers, gathering dust.
A community health worker, Zulema Medrano, measures Daniel Zamora's waist at his home. SOPHIE NOVACK
Zamora is enrolled in the Salud y Vida diabetes program, a partnership of local nonprofits, hospitals and universities. Funded in large part through a Medicaid Section 1115 waiver from the federal government, the program serves as a bridge between individuals and the health-care system, providing home visits and blood-sugar tests every three months, and seven classes on managing the disease.
Medrano and I leave Zamora and drive north on the highway back to her office, past towering fast-food signs and strip malls that connect Brownsville's residential neighborhoods. She sighs, "Daniel's not doing good right now." Medrano decided to help diabetic patients like Zamora because her mom has had the disease for 30 years. Medrano, who has hypertension, used to be on that path too, previously weighing 200 pounds. Then she started eating better and taking Zumba classes through Proyecto Juan Diego, where she heard about the promotorajob. But she no longer attends the exercise classes. "I'm too busy!"
Medrano shares a frustration I've heard from doctors across the Valley: People too often follow the advice of friends, family and neighbors instead of medical professionals. "If they don't help us, how can we help them?" she says of patients skipping their meds or using unprescribed remedies. Part of it is cultural, Medrano explains: "That's a typical thing with us, the Mexican people," she laughs. "Normally with the people we work with, they believe other people and not their doctor. … They say that doctors only want their money."
"When you lose your leg, it's like losing a loved one. There's anger, there's depression, there's sadness, there's what-ifs, why me. You question it a lot."
But it's hard to separate cultural explanations from systemic ones. In the Valley, health care access is often sporadic and inconsistent, and community health centers are overburdened and underfunded; many people never form lasting relationships with health professionals. Zamora has spent his life without insurance, without a consistent doctor, forgoing necessary medicine or stretching doses because of cost. And he's survived. So why should he take two different kinds of insulin now, he wonders — is that really necessary?
Another community program aims to reach people at risk of diabetes before it gets too bad. At a makeshift clinic in the pulga, or flea market, in Alamo, nestled among booths hawking tropical fruits, used clothing and Mexican candy, health workers offer free diabetes testing and consultation. Posters about nutrition and exercise cover the turquoise walls of the clinic, which resembles an elementary school classroom. So far, the grant-funded project has screened a few thousand Valley residents. Anyone who tests positive is referred to an appointment at a low-cost community health clinic.
When I ask doctors and advocates across the Valley how the diabetes epidemic can be reversed and amputations reduced, they point to two broad and interconnected priorities: access to preventive health care and education. Funding community programs like Salud y Vida and the pulga clinic is an important first step. But in the long term, a patchwork of grant-dependent programs and cash-strapped clinics can only do so much.
The biggest leap forward would be for Texas to expand Medicaid under the Affordable Care Act. Yet Republican lawmakers, opposed to Obama's signature law, have repeatedly declined billions in federal funds that would extend health care coverage to about 1 million poor Texans. In the Rio Grande Valley, about 100,000 people would be newly eligible for coverage, according to a December study from the Urban Institute, a Washington, D.C., think tank.
There's a strong economic case for better access to preventive care, too. In Texas alone, there were just over 31,500 hospital discharges due to diabetic lower extremity amputations from 2014 to 2016, costing more than $3.4 billion, according to state data. That's an average cost of about $108,700 per amputation. Just over half the amputations were covered by Medicare. About 15 percent of the cases were uninsured patients like Zamora, where the hospitals were likely on the hook for much of that cost.
"Anywhere we can keep people from having their first entrance into the medical system be in the emergency room, we're saving money," said Reininger, the UTHealth dean, who pointed to health coverage and "incentivizing prevention" as important steps. "If we build trails and people are more physically active, does that help? I think it does. When we do school-based interventions and we prevent kids from becoming diabetic at 14, do we save money in the long run? Absolutely."
There's been slow progress. Communities in the Valley have started farmer's markets, organized races and built hiking paths in recent years. But a broader shift is needed, Reininger said, in how the country prioritizes health, and how it invests now for the sake of long-term savings — of taxpayer dollars, lives and limbs.
"We are not going to solve this issue one foot at a time, one toe at a time," she said. "That is only putting a little Band-Aid on a very big issue."
Top caption: Elizabeth Reynoso, whose leg was amputated in 2015, is the founder of a support group for amputees in the Rio Grande Valley.
Life and Limb
How Much Will Americans Sacrifice for Good Health Care?
By admin | February 18, 2019
A battle is looming over universal health care. Politicians and voters will have to decide whether the trade-offs are worth it.
It's been nearly 10 years since the passage of the Affordable Care Act — one of the most sweeping health care overhauls in the nation's history. The law has brought the number of uninsured people in America to an all-time low, secured protections for people with pre-existing conditions and advanced the notion that health care is a human right.
But the system was never perfect, and its fractures and stress points have become too great to ignore. The number of people who are uninsured or underinsured is rising again, after two years of sabotage to the current law by the Trump administration. A Republican-led lawsuit that once seemed like a lark is threatening Obamacare's protections for pre-existing conditions. And high out-of-pocket costs, absurd hospital billing practices and ever-rising prescription drug prices have forced too many people to skip crucial treatments, avoid emergency rooms and ration life-sustaining medications.
America may be a country rich in medical innovation — a place where robots perform surgery — but it's also one where tens of thousands of people die every year because they can't afford basic care.
Both parties seem certain to make health care a significant election issue over the next two years. There are no fewer than six Democratic bills floating through Congress that would address these problems. And "Medicare for all" — a concept that describes only some of those proposals — has become both a rallying cry and a test of progressive credentials.
Voters, however, appear more ambivalent. Though health care has long topped the electorate's list of concerns, including in the 2018 midterms, surveys suggest that most Democrats want their party to focus on fixing the Affordable Care Act rather than on starting a long-shot bid for a single-payer health care system. In a recent Kaiser Family Foundation poll, some 56 percent of Americans, including nearly a quarter of Republicans, supported the idea of a new federal program; but when trade-offs like higher taxes or the loss of private insurance options were factored in, that support evaporated.
As the 2020 race heats up, here's a primer to help citizens sort out where they stand.
What are the options?
The plans currently in play differ in their particulars: Senator Bernie Sanders's Medicare for All Act would scrap private insurance and create a new federal system to cover everyone; a plan from the Center for American Progress, a think tank, would create an optional public program that anyone could buy into; and a plan from Senator Debbie Stabenow would give all Americans the option to buy into Medicare when they turn 50. But these plans would extend coverage to more people and would increase the federal government's role in providing and policing health insurance.
The proposals fall into two broad categories: universal and incremental. On the universal side, Medicare for all would largely eliminate the need for private insurance and for other public programs like Medicaid and the Children's Health Insurance Program. Its coverage would also be more expansive than current Medicare: It would include eye and dental care as well as prescription drugs, and it would eliminate premiums, deductibles, copays and surprise medical bills.
A single federal payer — as such proposals envision — may well eliminate the waste, inefficiency and corruption that make the current system so expensive and inaccessible; the experience of countries like Canada and Britain that rely heavily on one government payer suggests as much. But such a system would require dramatic changes from the status quo and would be a tough political sell. What's more, single-payer is not the only way to achieve universal coverage.
On the incremental side, several different proposals would allow certain people to buy into existing public plans. Some would enable older Americans who are not yet eligible for Medicare to buy into that program — at age 50 or 55 or 60. One would let people who don't have other insurance coverage buy into Medicaid (as long as their state opted into the program).
Because these programs don't rely on a single payer, they would not do as much to clean up the existing system. But they have a better chance of being adopted by Congress, and some could bring the country very close to achieving universal coverage.
What would happen to private insurance?
A recent Kaiser poll found that the potential loss of private insurance was what turned most people off the concept of Medicare for all. That's not surprising. About half of all Americans — some 156 million people — get their health insurance through employer-based plans, and another 30 million rely on other forms of private coverage, including the A.C.A. marketplace and Medicare Advantage plans. The vast majority of those people say that they like their coverage. And so far, the majority of Americans seem loath to give up what they have, no matter how good the alternative is made to sound.
That's too bad. The idea of forcing more than half the country off existing programs might sound scary, but the majority of those people are at constant risk of losing their health coverage — for instance, if they lose or leave their jobs, if their employers change plans or if their insurers change their terms in ways that increase out-of-pocket costs.
Still, the choice between universal health care and private insurance will very likely prove to be a false one. Most of the six plans leave ample room for private options to play a role, and the ones that don't — the true Medicare for all proposals — will almost certainly change as they are negotiated. As Vox points out, no other country has managed to achieve universal health care without including some form of private insurance.
Proponents of Medicare for all say that total health care spending would remain roughly the same, but that more of that spending would be shouldered by the federal government and less of it would be wasted.
A single-payer system would mean fewer administrative costs. Eliminating other government programs would free up billions of dollars for the new plan. And eliminating private insurers would bring billions more dollars worth of profits and employer taxes back into the health care system. (Businesses currently enjoy a tax break on the money they spend covering their employees.)
But there would also be new taxes. Proponents say that, to the extent those taxes fell on consumers, they would be offset by the elimination of premiums, deductibles and copays. But that may not be enough to assuage voters. In Vermont and Colorado, legislators dropped bids for a state-run single-payer system when it became clear that people would not support the tax increases needed to sustain such a program.
Taxes are not the only trade-off. Increased efficiency and less profiteering should mean that more people would be covered and could afford the care they needed. But a single-payer system could also mean the elimination of many thousands of health care jobs and lower pay for providers, both of which could impede access to, and the quality of, care. Those impediments could be small — slightly longer wait times, for example. Or they could be substantial — much longer wait times and far fewer doctors.
What would be covered?
There are two basic ways for insurance programs to curb costs. One is to cover fewer things; the other is to negotiate on prices.
Medicare for all would forgo the first option, meaning that it would cover everything. But it would use the massive bargaining power of so many users — the entire United States population — to negotiate far better deals on prescription drugs, hospital stays and more. The different incremental programs would use both levers: Most would not cover vision or dental, for example. But all of them would also direct the secretary of health and human services to negotiate costs with providers.
Most other countries use negotiating power to control health care costs; that's why prescription drugs cost so much less elsewhere than they do in the United States. But those countries accept a trade-off, inherent in this approach, that the United States has so far resisted: They forgo access to certain innovations, like pricey new drugs and medical devices whose benefits are found to be minimal.
A plan that results in higher taxes but skimps on cutting-edge medicine may seem unfair — and may well be unpopular. But many Americans are already being denied essential services every day. It may make sense to forgo innovations that a growing number of people can't benefit from anyway in exchange for a program that sets fair prices at the outset and doesn't leave people rationing low-tech essentials or begging for donations to cover basic costs.
The fight to once again remake American health care will almost certainly be brutal. Before voters can decide if they want to have that fight, candidates will need to clarify what they are selling. Only then can the nation have an honest dialogue about the risks, benefits and trade-offs ahead.
https://www.nytimes.com/2019/02/16/opinion/sunday/medicare-for-all-universal-health-care.html
Medicaid in the Territories: Program Features, Challenges, and Changes
Individuals born in the U.S. territories are U.S. citizens or nationals, but the territories differ from the states on key demographic, economic, and health status indicators. Most of the territories have a larger share of people living in poverty and longstanding fiscal challenges. Recent hurricanes, typhoons, and the North Korean missile crisis exacerbated pre-existing fiscal issues by damaging infrastructure and limiting tourism. In addition, a larger share of residents in the territories report that they are in fair or poor health than in the states. However, Medicaid, the program that serves low-income and vulnerable individuals, operates differently in the territories. The most fundamental difference is that federal funding for Medicaid in the territories is subject to a statutory cap and a fixed federal matching rate, unlike in the states, where federal Medicaid funding is not capped, and the federal share varies based on states' per capita income. This brief draws on a survey of and interviews with territory Medicaid officials, as well as other research, to examine key issues and trends in their Medicaid programs.1 Key findings include the following:
The expiration in September 2019 of temporary federal Medicaid funds provided through the Affordable Care Act (ACA) and for Puerto Rico and the U.S. Virgin Islands after the hurricanes is expected to result in what some territory officials describe as a "devastating fiscal cliff." All of the territories have increasingly relied on the ACA funds to finance their Medicaid programs.
Medicaid enrollment trends have been relatively stable in the territories, except in Puerto Rico and the U.S. Virgin Islands, where enrollment increases followed recent hurricanes, although future trends are somewhat uncertain.
Medicaid benefits and delivery systems vary in the territories. Only Guam offers long-term services, and Guam, American Samoa, and the Northern Mariana Islands provide nearly all Medicaid services through one public hospital. Puerto Rico is the only territory to operate a managed care delivery system, with new reforms implemented in November 2018.
Most of the territories have struggled with provider shortages, which are often tied to persistent outmigration and poor infrastructure and are most prominent for specialty care and mental health services.
Looking ahead, long-term Medicaid financing reforms such as increased federal matching rates, increased spending caps, or elimination of the caps could help the territories meet the health care needs of their Medicaid populations. Conversely, the expiration of temporary Medicaid funds without new resources to address the resulting fiscal cliff could have negative consequences for Medicaid coverage and services.
https://bit.ly/2WrQ8kU
Survey of New York physicians shows support for aid in dying
By NICK NIEDZWIADEK — POLITICO
ALBANY — Nearly 3 in 5 physicians in New York state support measures that would allow doctors to prescribe lethal medications for terminally ill patients who wish to end their lives, according to an online survey conducted on behalf of an advocacy group.
Of the 601 doctors sampled, 56 percent supported medical aid in dying — alternatively referred to as physician-assisted suicide among detractors. The findings were released Monday by Compassion & Choices New York, which supports legislation authorizing the practice.
"We were only surprised at the results in so far it showed how strongly doctors supported having this option," Corinne Carey, the group's campaign director, told POLITICO. "The doctors' support has been among the top concerns of lawmakers that we've talked to."
Support from doctors increased to 67 percent in favor and 19 percent opposed, according to the survey, when they were informed of the provisions of the Medical Aid in Dying Act, NY A2694 (19R), which requires two physicians to determine that an adult patient has fewer than six months to live. But physicians were less likely to say they'd be willing to write such a prescription, with 42 percent saying they would and 35 percent saying they would not.
The report was intended as a counterweight to a similar survey undertaken by the Medical Society of the State of New York, which has roughly 30,000 members and has long opposed aid in dying.
That effort was undermined by a low response rate and design flaws that made it susceptible to being gamed by some of the most-ardent voices on the issue, who were able to easily forward it to like-minded colleagues and distort the results. The ensuing fallout has sown dissent among MSSNY's members.
A presentation of the survey's results to the Legislature by the society's president, Thomas Madejski, last year rankled bill sponsor Assemblywoman Amy Paulin (D-Scarsdale) and other supporters, who felt it was misleading and downplayed the methodological concerns.
"We wanted to try to get an accurate picture of how doctors in our state feel about this," Carey said. "The Legislature deserves to know the truth."
Compassion & Choices' survey was conducted by a sampling of New York physicians listed in a database maintained by Medscape, which is owned by WebMD. A handful of specialties like dermatology and plastic surgery, in which the issue is largely outside their practice, were excluded, and primary care providers made up nearly half of those surveyed.
Last year, Hawaii became the seventh state to legalize the practice, though Vermont is the only state east of the Mountain Time Zone to have done so.
Opposition to the practice does not fall neatly along partisan lines, but comes most vocally from disability rights advocates — who fear vulnerable people would be subject to coercion — and religious groups, who object on moral grounds.
A Quinnipiac University poll released last May found that voters in New York supported medical aid in dying 63 percent to 29 percent, but that was nearly flipped — 61 percent opposed to 34 in favor — for those who attend religious services weekly.
Has single-payer health care's time finally come?
By admin | December 10, 2018
Democrats are coming out of the woodwork to back the New York Health Act.
By REBECCA C. LEWIS
With their new majority in the state Senate, Democrats are finally preparing to pass long-stalled progressive legislation. Perhaps the most expansive and expensive item on the agenda – and among the most controversial – is the New York Health Act, which would establish a single-payer health care system in the state, and one study estimated it would cost $139 billion in 2022. Many incoming lawmakers campaigned on the promise that they would get it done, but even if it does pass, it likely won't be implemented right away.
The Democratic-controlled Assembly has passed the legislation every year since 2015, but in that time it never came up for a vote in the state Senate thanks to the Republican majority. Now that the chamber will be in Democratic hands, the legislation seems far more likely to pass.
A single-payer health care system means that a single entity covers the cost of all health care, which is still delivered by private or nonprofit providers. Everyone pays into a single plan run by the government, which in turn is the only provider of coverage paying claims. Assemblyman Richard Gottfried's single-payer bill has proposed one public option and a ban on the sale of private insurance unless it offers additional coverage not included in the state plan.
One major obstacle the New York Health Act must overcome is a less than enthusiastic governor. Although Gov. Andrew Cuomo has expressed support for single-payer health care as a concept, he has repeatedly said that it would be better implemented at the national level. In a recent interview on WCNY, he expressed doubt that the state would be able to finance the $150 billion program, since that would nearly double the state's budget. "There will be rhetorical desire to do things," Cuomo said. "Governmentally there will have to be a reality test to get all things to fit in the budget."
Although this sounds like it could put a serious damper on the future of the legislation, Gottfried called the governor's stance "a perfectly reasonable position for a governor," noting that Cuomo is already far more progressive than other governors by simply supporting the concept of single-payer health care. Gottfried said he has been in talks with the administration and expects those conversations to accelerate now that passage is more realistic.
Gottfried said that stakeholders who have remained quiet in the past are coming forward to voice their concerns. Most recently, Gottfried and state Sen. Gustavo Rivera, the bill's Senate sponsor, have been negotiating with New York City public unions over concerns that union members would pay more or have fewer benefits. "What we're talking about is modifications just to accommodate concerns that people are raising now that it looks like it can easily pass both chambers this session," Gottfried told City & State. "People who we haven't heard from are starting to come forward and say, 'Gee, could you add this nuts and bolts?' or 'Tighten it up here.''"
Gottfried said making tweaks to the bill will continue at least a couple weeks into the session, which begins in early January. However, Gottfried said that he and Rivera will not make any major structural changes to the bill and said the Assembly is "well positioned" to pass the bill this upcoming session.
Rivera expressed more caution, telling City & State that he feels confident that the chamber will engage in meaningful conversations about the bill, which it has never done before, but did not want to make any promises about a timeline for passage. "This is not a simple thing that we're trying to do," Rivera said. "We want to make sure that we don't put anything up for a vote, to be signed by the governor, unless it's ready to go."
Bill Hammond, a health policy expert at the right-leaning Empire Center for Public Policy, argued that no amount of change to the New York Health Act would actually make the legislation viable. "I think (Gottfried and Rivera's) posture right now is not to acknowledge the sacrifice, it's to make it even more attractive to whatever interest group thinks they're going to lose," Hammond told City & State. He added that any changes would likely add to the already astronomical cost of the bill.
But Gottfried maintained that a single-payer system will lead to lower overall health care spending despite the introduction of a new payroll tax because the average New Yorker would no longer pay insurance premiums and copays. He cited the Rand Corp. study, commissioned by the New York State Health Foundation, which found total health care spending could be lower under the New York Health Act than under the status quo. "To me, the issue is not about where your check goes," Gottfried said. "What people really care about is how much are they going to have to spend, and how much they will be able to keep under the New York Health Act."
However, Hammond pointed out that since there is no precedent for the system in the country, the details of the new tax plan have not been worked out yet and it is hard to accurately predict the cost of the program, so the Rand study could be wrong. He added that it also hinges on the federal government providing waivers to in order to divert Affordable Care Act, Medicare and Medicaid funding into the single-payer system, an unlikely prospect with the current administration. "There's all kind of doubt and uncertainty about who's going to pay more and who's going to pay less," Hammond said.
Rivera dismissed the idea that the New York Health Act depends on receiving those federal waivers, saying they would be helpful, but not necessary. "We believe, both my colleague and myself, believe that there are ways within the system that we could actually extend the New York Health Act as a wraparound service that would ultimately not require waivers," Rivera said. He added that since the single-payer system would take years to put into place, he remained hopeful that a different, more sympathetic administration would be in the White House by then.
Another sticking point in evaluating and passing the New York Health Act is the fact that the previous legislation contained no specific language on tax rates for the proposed payroll tax, forcing Rand to use a hypothetical tax schedule. Gottfried said no language about tax brackets will be added to the legislation that he and Rivera will introduce and that it will be worked out after the bill's passage since the program will take years to implement. He added the absence of this information will not pose an impediment to passage and that it could be easily added in if it becomes necessary.
Despite the many obstacles the legislation appears to face, Gottfried said that he and Rivera have learned from their previous mistakes, such as not including a revenue stream, and they remain confident New York will lead the country in single-payer health care. "Anything has to start with somebody," Gottfried said. "And New York is ideally suited to be the state that begins single-payer coverage."
Upstate NYers medical debt mysteriously paid off
For nearly 150 people around the NY Capital Region who've been hounded for years by debt collectors, the mail should have recently brought some good news. News that seemed too good to be true.
If it came in a yellow envelope with a return address of Rye, New York from a group called "RIP Medical Debt," it wasn't. Too good to be true, that is. Your years-old medical debt has been forgiven. Paid off. No strings attached.
"A lot of people get our letters and think they're too good to be true and throw them out," said Daniel Lempert, a spokesman for RIP Medical Debt. "That's why we try to get the word out.
Thanks to a fundraising campaign by a group out of the Finger Lakes, the medical debt of some 1,284 people around upstate New York totaling $1.5 million has been forgiven. In the Capital Region, 146 people had $298,507 worth of old debt wiped out — all because Judith Jones and Carolyn Kenyon, of Ithaca, got the idea to raise money for a good cause.
The women are members of the Finger Lakes chapter of the Campaign for New York Health, which advocates for universal health coverage through passage of the New York Health Act. The pair were looking to do some good, and maybe make a political statement at the same time. So when they came across RIP Medical Debt, a nonprofit that buys bundled portfolios of medical debt for pennies on the dollar and forgives it, they were intrigued.
"The further we got into it, the more we realized what a serious issue medical debt is," said Jones, a retired chemist. "When you start to learn how bad the problem is, it makes you want to do more."
RIP Medical Debt was founded in 2014 by two former debt collection industry executives, Craig Antico and Jerry Ashton. Dissatisfied with the way they saw debtors being treated, the pair teamed up to create a nonprofit that would buy up medical debt incurred by people who are hard-up financially, for the sole purpose of forgiving it.
Working with third-party credit data providers, the nonprofit searches bundled debt portfolios to locate accounts meeting its criteria for financial relief. It then negotiates to buy portfolios at a steep discount — on average, a penny on the dollar — so it can forgive the debt.
The return on investment is what made the group so appealing, Jones said. It took her and Kenyon four months to raise $12,500, which RIP then used to purchase $1.5 million worth of debt.
Prior to these purchases, the medical bills have passed through several collection agencies and months or years of collection pursuit. It's this type of debt that really damages a person's credit, impacting their ability to buy or rent a home, buy a vehicle, secure a loan, or even get a job.
"As medical costs rise to unspeakable levels, so does un-payable medical debt," RIP says on its website. "Medical debt has destroyed the financial stability of large segments of America's most vulnerable communities: the sick, the elderly, the poor, and veterans. It also particularly targets the middle class, driving many families who are barely getting along into poverty."
The statistics are sobering.
More than 1 in 3 Americans say they struggle to afford the cost of medical care, with 43 million now owing $75 billion in past-due medical debt. It's not for lack of health insurance, either. Three out of every four people who end up in medical bankruptcy had insurance.
While many have taken on extra jobs or worked more hours to cover these bills, some are turning to charity for help. One in every three GoFundMe fundraisers, for example, are for medical bills, according to CEO Rob Solomon.
"One thing that really struck me in my research was the medical debt incurred by women who had metastatic breast cancer," Jones said.
A number of recent studies and surveys have documented the negative financial toll that treatment takes on cancer patients. Several studies, meanwhile, have found this toll is even associated with a higher risk of death.
More than 11 million Americans took on added credit card debt in 2013 to cover medical expenses. The same year, 15 million depleted their savings to pay for medical bills. Another 10 million were unable to pay for basic necessities, including rent, food and utilities, because of medical bills.
"We really just want people to be aware of what a terrible problem medical debt is," Lempert said. "And we want recipients of these letters to know this debt is finally off their credit report."
In-Depth Analysis by Team of UMass Amherst Economists Shows Viability of Medicare For All
Comprehensive plan is estimated to reduce U.S. health consumption expenditures by nearly 10 percent, while providing decent health care coverage to all Americans
Contact: Robert Pollin
AMHERST, Mass. – A team of economists from the University of Massachusetts Political Economy Research Institute (PERI) has found that the Medicare for All Act of 2017, introduced to the United States Senate by Senator Bernie Sanders, is not only economically viable, but could actually reduce health consumption expenditures by about 9.6 percent while also providing decent health care coverage for all Americans.
In a nearly 200-page report released at the Sanders Institute Gathering, the first major event hosted by the think tank founded by Jane O'Meara Sanders and David Driscoll, the senator's wife and son, the economists outline seven major aspects of transforming the U.S. health care system, detailing step-by-step the actions needed to be taken to achieve truly universal health care and its potential impacts on individuals, families, businesses and government. The analysis, which was in development for 18 months, has received praise from 11 distinguished experts in the fields of economics and health care studies who have rigorously reviewed the researchers' findings.
"The most fundamental goals of Medicare for All are to significantly improve health care outcomes for everyone living in the United States while also establishing effective cost controls throughout the health care system. These two purposes are both achievable," says lead author Robert Pollin, Distinguished Professor in economics at UMass Amherst and co-director of PERI. "As of 2017, the U.S. was spending about $3.24 trillion on personal health care—about 17 percent of total GDP. Meanwhile, 9 percent of U.S. residents have no insurance and 26 percent are underinsured—they are unable to access needed care because of prohibitively high costs. Other high-income countries spend an average of about 40 percent less per person and produce better health outcomes. Medicare for All could reduce total health care spending in the U.S. by nearly 10 percent, to $2.93 trillion, while creating stable access to good care for all U.S. residents."
The PERI research team of Pollin, James Heintz, Peter Arno, Jeannette Wicks-Lim and Michael Ash, found that Medicare for All would reduce annual health care spending to $2.93 trillion from the current level of $3.24 trillion. Public health care revenue sources that presently provide about 60 percent of all U.S. health care financing, including funding for Medicare and Medicaid, would provide $1.88 trillion of financing for the new system. Removing the other costs attributed with the current system would leave a gap of $1.05 trillion, which the economists suggest could be raised with a set of four proposals that will generate enough revenue to create a surplus of 1 percent for the system.
The researchers propose:
Continuing business health care premiums, but with a cut of 8 percent relative to existing spending per worker. Businesses that have been providing coverage for their employees would thereby see their health care costs fall by between about 8-13 percent. ($623 billion)
A 3.75 percent sales tax on non-necessities, which includes exemptions for spending on necessities such as food and beverages consumed at home, housing and utilities, education and non-profits. The researchers include a 3.75 percent income tax credit for families currently insured by Medicaid. ($196 billion)
A net worth tax of 0.38 percent, with an exemption for the first $1 million in net worth. The researchers state that this tax would therefore apply to only the wealthiest 12 percent of U.S. households. ($193 billion)
Taxing long-term capital gains as ordinary income. ($69 billion)
Under these recommendations, the researchers find that the net costs of health care for middle-income families would fall by between 2.6 and 14 percent of income. For high-income families health care costs will rise, but only to an average of 3.7 percent of income for those in the top 20 percent income group, and to 4.7 percent of income for the top 5 percent.
The researchers also find that based on 2017 U.S. health care expenditure figures, the cumulative savings for the first decade operating under Medicare for All would be $5.1 trillion, equal to 2.1 percent of cumulative GDP, without accounting for broader macroeconomic benefits such as increased productivity, greater income equality and net job creation through lower operating costs for small- and medium-sized businesses.
"Medicare for All will produce large cost savings for both businesses and households," says co-author Jeannette Wicks-Lim, associate research professor at PERI. "Under our proposal, all businesses that now provide health care coverage for their employees will receive an across-the-board 8 percent cut in premiums. For families, our results show that Medicare for All will promote both lower average costs and greater equity. For example, middle-income families who now purchase private insurance on the individual market would see their health care costs fall by an average of 14 percent under Medicare for All."
"This study is the most comprehensive, detailed, authoritative study ever undertaken of Medicare for All, and it points powerfully and unassailably in support of MFA," said economist and public policy expert Jeffrey Sachs, University Professor at Columbia University, in reviewing the researchers' analysis. "Medicare for All promises a system that is fairer, more efficient, and vastly less expensive than America's bloated, monopolized, over-priced and under-performing private health insurance system. America spends far more on health care and gets far less for its money than any other high-income country. This study explains why, and shows how Medicare for All offers a proven and wholly workable way forward."
In his review of the report, William Hsiao, K.T. Li Professor of Economics at the Harvard University T.H. Chan School of Public Health, said the study "presents an objective, unbiased, comprehensive and thorough economic analysis of Medicare for All. Professor Pollin and his co-authors have set a new high standard for transparency and clarity in presenting their analyses, estimations, and conclusions. The research methods they used to estimate both the cost increases and savings are sound. The assumptions they used to generate cost estimations are based on the latest empirical evidence. Consequently, the conclusions of this study on the overall costs and savings of Medicare for All are reasonable and scientifically sound."
"This stellar economic analysis of a single-payer, universal health care system for the U.S. is the first to sufficiently document each step of the calculations, enabling reproducibility of the findings. It is also the first study that thoroughly addresses the transition to and financing of a universal health care system for the U.S.," said Alison Galvani, director of the Center for Infectious Disease Modeling and Analysis and Burnett and Stender Families' Professor of Epidemiology at Yale University, in her review of the report. "Underlying the analysis is an interdisciplinary evidence base that has been compiled from literature spanning economics, health policy and clinical care both within the US and internationally. The methodology is sound and the assumptions are conservative with regard to their conclusions. Specifically, lower-end figures from the expert literature are used in the calculation of savings, whereas anticipated expenditures are based on the higher end of empirical distributions. Despite stacking the deck against Medicare for All, this analysis convincingly demonstrates the substantial improvements in cost efficiency that could be achieved by Medicare for All. I am confident that the Pollin et al. study will become recognized as the seminal analysis of a single-payer universal health care system for the U.S."
Pollin and Wicks-Lim were joined in crafting the analysis by UMass Amherst colleagues James Heintz, associate director and Andrew Glyn Professor of Economics, Peter Arno, senior fellow and director of health policy research, and Michael Ash, senior research fellow and professor of economics and public policy.
The complete report, "Economic Analysis of Medicare for All," can be found online here.
The full set of reviews of the report by economics and health care studies experts can be found here.
« Previous Entries	Next Entries »


text:
iPad mini 5 Teardown Reveals Same Size Battery, 3GB RAM, More
By Oliver Haslam | April 3rd, 2019
The 2019 iPad mini, or the iPad mini 5, if you prefer, isn't a huge departure from the previous model from the outside. Inside, the inclusion of the iPhone XS' A12 CPU makes a world of difference, but beyond that, Apple hasn't really said what has changed internally. The folks at iFixit are usually a great source for information like that and, as per usual, they've torn down a new iPad mini to give us the lowdown on what's inside.
As we already knew, externally, the new iPad mini looks identical to the old one, and inside, iFixit says that the newly refreshed iPad mini does just look like an updated version of the older iPad mini rather than a smaller version of the new iPad Air. That means the battery is no different to the old one, although there are new ambient light sensors for use with the equally new True Tone display. An updated 7-megapixel front-facing camera is also present.
Other tidbits are the inclusion of Bluetooth 5 support and 3GB of RAM, and just as was probably expected, the folks at iFixit aren't keen on the lack of repairability that the new iPad mini offers. In fact, the amount of adhesive that is used renders all repairs "unnecessarily difficult," which is about as bad as it gets.
After a number of conflicting experiences ultimately leading up to this Mini's glued-in battery, we're officially not optimistic anymore about seeing adhesive pull tabs for iPad batteries.
Regardless, this new iPad mini is a great update for those who like the small 7.9-inch display rather than any of the larger options. We don't expect the issues with repairing these things to put many people off buying one, but still, it's a factor worth considering.
The new iPad mini is available now and can be picked up from Apple and its retail partners.
(Source: iFixit)
Download iOS 12.2 Final IPSW Links And OTA Update For iPhone And iPad
Download: iOS 12.3 Beta 1 IPSW Links, OTA Update Released
iOS 12 / 12.1.2 iPhone XS Max Jailbreak Update Provided By Unc0ver Lead Developer
iOS 12.2 Jailbreak Status: Here's What You Need To Know
How To Downgrade iOS 12.2 To iOS 12.1.4 On iPhone Or iPad
You can follow us on Twitter, or Instagram, and even like our Facebook page to keep yourself updated on all the latest from Microsoft, Google, Apple, and the Web.

redpajama_set_name: RedPajamaCommonCrawl


text:
(function() {

    'use strict';
    var isIonic = !!window.ionic;

    function TrailappAdminUserEditFormController(TrailappAuthService, ApiService) {
        var self = this;
        self.user = _.clone(TrailappAuthService.getUser());
        self.state = 'none';

        self.submit = function(form) {
            if (form.$invalid)
                return;
            else {
                self.state = 'in-progress';
                ApiService.postJsonWithToken('/api/users/edit', {
                    Email: self.user.Email,
                    Name: self.user.Name,
                    Biography: self.user.Biography,
                    Summary: self.user.Summary,
                    NewPassword: self.user.NewPassword,
                    CurrentPassword: self.user.CurrentPassword
                }).$promise.then(function(data) {
                    self.state = 'success';
                }, function(err) {
                    self.state = 'error';
                    switch(err.data.Error) {
                        case 'wrong_password':
                            self.error = 'The Current Password field is incorrect';
                            break;
                        case 'bad_email':
                            self.error = 'The new email address you have chosen is invalid';
                            break;
                        case 'bad_password':
                            self.error = 'The new password you have chosen is invalid';
                            break;
                        case 'bad_name':
                            self.error = 'The new name you have chosen is invalid';
                            break;
                        case 'bad_biography':
                            self.error = 'The new biography you have chosen is invalid';
                            break;
                        case 'bad_summary':
                            self.error = 'The new summary you have chosen is invalid';
                            break;
                        case 'email_exists':
                            self.error = 'The email address you have chosen already exists';
                            break;
                    }
                });
            }
        };
    }

    TrailappAdminUserEditFormController.$inject = ['TrailappAuthService', 'ApiService'];

    function TrailappAdminController(TrailappAuthService, ApiService) {
        var self = this;
        self.user = TrailappAuthService.getUser();
        self.locked = undefined;

        ApiService.getWithToken('/api/system/islocked').$promise.then(function(data) {
            self.locked = false;
        }, function(err) {
            if(err.status === 423)
                self.locked = true;
        });

        self.lock = function() {
            if(self.user.Role.indexOf('admin') === -1)
                return;
            else if(self.locked === true) {
                var cont1 = confirm("Unlocking the system will allow non-admin contributors to create, " +
                    "edit and delete their events and venues again. Continue?");
                if(cont1) {
                    self.locked = undefined;
                    ApiService.postJsonWithToken('/api/system/unlock').$promise.then(
                        function(data) {
                            self.locked = false;
                            alert('The system was successfully unlocked');
                        }, function(err) {
                            self.locked = true;
                            alert('There was an error unlocking the system');
                        }
                    );
                }
            }
            else if(self.locked === false) {
                var cont2 = confirm("PLEASE READ: Locking the system will prevent non-admin users from creating, " +
                    "editing and deleting their events and venues. Are you sure you want to do this?");
                if(cont2) {
                    self.locked = undefined;
                    ApiService.postJsonWithToken('/api/system/lock').$promise.then(
                        function(data) {
                            self.locked = true;
                            alert('The system was successfully locked');
                        }, function(err) {
                            self.locked = false;
                            alert('There was an error locking the system');
                        }
                    );
                }
            }
        };
    }

    TrailappAdminController.$inject = ['TrailappAuthService', 'ApiService'];

    function TrailappAdminConfig($stateProvider, $urlRouterProvider) {
        $stateProvider
            .state('admin', {
                url: '/admin',
                templateUrl: 'components/admin/admin.html',
                controller: 'TrailappAdminController as AdminCtrl'
            });
    }

    TrailappAdminConfig.$inject = ['$stateProvider', '$urlRouterProvider'];

    angular
        .module('trailapp.admin', ['trailapp.admin.events', 'trailapp.admin.venues', 'trailapp.admin.analytics'])
        .controller('TrailappAdminController', TrailappAdminController)
        .controller('TrailappAdminUserEditFormController', TrailappAdminUserEditFormController)
        .config(TrailappAdminConfig);

})();

redpajama_set_name: RedPajamaGithub


Today's #StyleSteals is our Tortoise Jewelry Collection in 11 different styles! Most come with matching stud earrings.
Style Steals - 3/4/15 - All Tortoise Jewelry - 50% OFF ($2.97-$14.97) & FREE SHIPPING - Use code **TORTOISE**.


The lack of transparency in the operation of the city of Tower's harbor committee came home to roost on Monday as members of the city council, who have been left out of the loop, expressed frustration with the lack of information they've received about the project. Inaccurate and inflammatory statements, particularly by council member Kevin Fitton at Monday's city council meeting, highlighted the lack of understanding that too many councilors have about the project, which needlessly puts the development at risk.
Fitton's misunderstandings about the reasons behind delays in the project, as well as its finances, reflect the problems inherent in the secrecy that has shrouded the functioning of the harbor committee for at least the past two years. Most councilors clearly have only a limited understanding of the agreements that have been reached between the harbor committee and the project developers and of the factors behind ongoing delays.
It's no surprise that councilors have questions, since the three official members of the harbor committee, Mayor Josh Carlson, City Clerk-Treasurer Linda Keith, and Steve Altenburg, have plainly failed to keep fellow council members apprised of the project's twists and turns. Virtually no documentation of the committee's activities is available since the committee takes no minutes and rarely provides any kind of written report of their activities to the council. And councilors can't always rely on news reports in the Timberjay since the committee has repeatedly held unscheduled meetings without informing the newspaper, in violation of the state's Open Meeting Law.
Some council members, particularly Fitton, seemed to harbor serious misunderstandings of the town home project and how it has evolved since Orlyn Kringstad and his development team first responded to a city Request for Qualifications in late 2015. At that time, the city was seeking only architectural, planning, marketing, and construction services for a town home project in which the city's economic development authority would serve as developer. It was only after Kringstad's group was brought to the table that the harbor committee changed the deal, insisting that his company, Tower Vision 2025, assume the developer role for the project. Under that new arrangement, the city agreed that it would finance all the public infrastructure, such as water, sewer, roads, and other utilities. While initially reluctant to take on the new role, because of the added financial risk for his company, Kringstad and his partners did agree to the city's request.
At Monday's meeting, Fitton falsely accused Kringstad of coming with his hand out seeking the city's help in paying for the public infrastructure. Fitton had it exactly backwards. In fact, it was the city that strained the relationship with Tower Vision 2025 this spring by changing the deal yet again, insisting that Tower Vision take on even more risk by backstopping the city's costs for public infrastructure through a letter of credit or similar bond. This, after Kringstad's group had already spent hundreds of thousands of dollars on architectural designs, floor plans, marketing, legal work, and much more under the terms of the original development agreement, which included the city bearing the costs for related infrastructure.
Kringstad, to his credit, has tried to find a mutually-satisfactory resolution of the dispute. Most other developers would have simply walked away, or got the lawyers involved by this point.
Indeed, other developers have chosen to walk away. In early 2016, Bob and Diane Bremer, who have significant experience in urban redevelopment in small cities, also approached the harbor committee with plans for renovation and new construction on Main Street. The Bremers eventually gave up, however, after requests for information from the city went unanswered for months. There are other examples as well.
It's understandable that councilors are frustrated with the slow pace of progress at the harbor since the groundbreaking 11 years ago. But lashing out at Mr. Kringstad, who has worked long hours in good faith to try to advance the city's goals for the harbor is hardly a sensible response. Members of the council can't blame Mr. Kringstad for their lack of understanding of the project. It's their duty to inform themselves or find out why their own harbor committee has failed to provide them the information they need to make sensible decisions. This project is too important for the council to blow it up now.


text:
<?php

?>
<?php
if(!defined("gb.class.php")) {
	define("gb.class.php",1);

require_once("crmysqli.class.php");
require_once("captcha.class.php");

class GB {
	var $databaseConnection;
	var $errorMessage;

	/**
	 *
	 * @param $db
	 */
	function __construct($db) {
		$this->databaseConnection = $db;
		$errorMessage = null;
	}

	/**
	 * Verifies the input of the user.
	 * @param $data Assoc array of the input.
	 * @return true if every input is valid and cause no impact to business logic, otherwise false.
	 */
	function verify($data) {
		global $_SESSION;

		$this->errorMessage = "";

		$p = $data;
		$s = $_SESSION;

		if(	$s['captchares'] != $p['captchares'] ||
			empty($p['captchares'])
		   ) {
			$this->errorMessage .= " - Check the captcha entry.
";
		}
		if(empty($p['username']) || strlen($p['username'])<5) {
			$this->errorMessage .= " - Add a username or more than 5 letter.
";
		}
		$m = $p['mail'];
		if(empty($m) || !isValidEmail($m)) {
			$this->errorMessage .= " - Add a mail address.
";
		}
		if(empty($p['subject']) || strlen($p['subject'])<10) {
			$this->errorMessage .= " - Add a subject or more than 10 letter.
";
		}
		if(empty($p['message']) || strlen($p['message'])<10) {
			$this->errorMessage .= " - Add a message text or more than 10 letter.
";
		}

		if(!empty($this->errorMessage)) {
			$_SESSION['frm']['username'] = $p['username'];
			$_SESSION['frm']['mail'] = $p['mail'];
			$_SESSION['frm']['subject'] = $p['subject'];
			$_SESSION['frm']['message'] = $p['message'];

			$captcha = new Captcha();
			$captcha->init();

			return false;
		}
		return true;
	}

	/**
	 *
	 * @param $data
	 * 	['username']
	 *  ['mail']
	 *  ['subject']
	 *  ['message']
	 * return Increment id of the new row.
	 */
	function add($data) {
		$onlyFields = array("username"=>"", "mail"=>"", "subject"=>"", "message"=>"");

		$f = "";	// fields
		$v = "";	// values
		foreach($data as $key => $value) {
			if(array_key_exists($key,$onlyFields)) {
				$f .= $key.",";
				if(is_string($value)) {
					$v .= "'".strip_tags($value)."',";
				} else {
					$v .= $value.",";
				}
			}
		}

		$f = substr($f,0,strlen($f)-1);
		$v = substr($v,0,strlen($v)-1);

		$sql = "INSERT INTO gb(".$f.") VALUES (".$v.")";

		$captcha = new Captcha();
		$captcha->init();

		return $this->databaseConnection->q($sql);
	}

	/**
	 *
	 * @param $id
	 * @return true if deleted, otherwise false.
	 */
	function delete($id) {
		return $this->databaseConnection->q("DELETE FROM gb WHERE id=" . $id . " LIMIT 1");
	}

	/**
	 * Returns a list of all entries of one page.
	 * @param $pagenumber
	 * @param $entries
	 * @return Array
	 */
	function get($pagenumber, $entries) {
		$sql = "SELECT * FROM gb ORDER BY ts DESC LIMIT "
			.(($pagenumber-1)*$entries).", ".$entries;

		$list = array();
		if($this->databaseConnection->q($sql)) {
			while($r=$this->databaseConnection->assoc()) {
				$list[] = $r;
			}
		}
		return $list;
	}

	/**
	 *
	 * @return string of error
	 */
	function getErrorMessage() {
		return $this->errorMessage;
	}
}

} // gb.class.php
?>


text:
Bride Wars - La mia migliore nemica (Bride Wars) è un film commedia romantica del 2009 diretto da Gary Winick, con protagoniste Anne Hathaway e Kate Hudson.

Il film è uscito negli Stati Uniti il 9 gennaio 2009 e in Italia il 20 febbraio successivo.

Trama
Liv ed Emma sono amiche da sempre, entrambe sono fidanzate e per organizzare il matrimonio dei loro sogni si rivolgono alla wedding planner più prestigiosa di New York. Entrambe vogliono sposarsi al Plaza, ma per errore i loro matrimoni vengono prenotati nella stessa data: non essendoci altre date disponibili prima di tre anni, si crea uno scompiglio perché ognuna desidera che l'altra sia la sua damigella d'onore.

Iniziano così a discutere su chi delle due debba sposarsi al Plaza a giugno, il sogno di una vita per entrambe, ma dopo che Emma, la più timida, si stanca di essere sempre messa da parte da Liv, comincia una vera e propria guerra fatta di dispetti. Tutto questo rende le due ragazze molto diverse da come sono di solito: Liv diventa più emotiva, in particolare dopo aver perso un importante contratto di lavoro, Emma invece più decisa a furia di arrabbiarsi per i dispetti di Liv. Continuano a rovinarsi i preparativi del matrimonio a vicenda, ma nessuna delle due rinuncia alla data.

Il giorno del matrimonio entrambe si presentano al Plaza. Prima di entrare nelle rispettive sale preparate per le cerimonie si incontrano e vedendosi in abito da sposa si sorridono, ma quando Emma fa il suo ingresso in sala viene proiettato un suo vecchio video imbarazzante: il video viene visto da tutti gli invitati, incluso lo sposo. Emma si infuria ed entra nella sala di Liv: inizia una lotta tra le due amiche sotto gli occhi increduli di tutti. Le ragazze, sfinite, si ritrovano sdraiate sul pavimento e stremate arrivano ad una tregua. Subito dopo, però, Emma capisce di non amare più il suo fidanzato e di non essere più la ragazza di cui lui si era innamorato dieci anni prima. Infine Liv ed Emma fanno pace, e così Emma accompagna Liv all'altare come sua damigella d'onore.

Un anno dopo le due amiche si ritrovano in un bar. Emma è tornata dal viaggio di nozze con Nate, fratello di Liv che ha sempre amato la ragazza. Le due brindano al loro legame, ma nessuna delle due può bere perché entrambe sono in dolce attesa.

Riconoscimenti
2009 - MTV Movie Awards
Candidatura Miglior performance femminile a Anne Hathaway
Candidatura Miglior combattimento a Anne Hathaway e Kate Hudson
2009 - Razzie Awards
Candidatura Peggior attrice non protagonista a Candice Bergen
2010 - People's Choice Awards
Candidatura Miglior commedia
2009 - Teen Choice Award
Miglior attrice in un film commedia a Anne Hathaway
Candidatura Miglior attrice in un film commedia a Kate Hudson
Candidatura Miglior fischio a Kate Hudson
Candidatura Miglior brontolio a Anne Hathaway e Kate Hudson
Candidatura Miglior momento da rockstar a Anne Hathaway

Altri progetti

Collegamenti esterni

Film commedia romantica
Film ambientati a New York

redpajama_set_name: RedPajamaWikipedia


text:
A Thousand Moons
by Barry, Sebastian
Winona Cole, an orphaned child of the Lakota Indians, finds herself growing up in an unconventional household on a farm in west Tennessee. Raised by her adoptive parents John Cole and Thomas McNulty, whose story Barry told in his acclaimed previous novel Days Without End, she forges a life for herself beyond the violence and dispossession of her past.
Tennessee is a state still riven by the bitter legacy of the Civil War, and the fragile harmony of her family is soon threatened by a further traumatic event, one which Winona struggles to confront, let alone understand. Exquisitely written, A Thousand Moons is a stirring, poignant story of love and redemption, of one woman's journey and her determination to write her own future.


text:
package com.github.dynamicextensionsalfresco.actions.annotations;

import java.lang.annotation.ElementType;
import java.lang.annotation.Retention;
import java.lang.annotation.RetentionPolicy;
import java.lang.annotation.Target;

import org.alfresco.service.cmr.dictionary.DataTypeDefinition;

/**
 * Indicates an {@link ActionMethod} method parameter.
 *
 * @author Laurens Fridael
 *
 */
@Target({ ElementType.PARAMETER })
@Retention(RetentionPolicy.RUNTIME)
public @interface ActionParam {
	/**
	 * The parameter name.
	 *

	 * As with {@link ActionMethod}s, it is recommended to specify the name explicitly, preferably using a static String
	 * constant visible to code that invokes the action.
	 *

	 * If the parameter name is not specified, the parameter's Java variable name will be used instead. (The variable
	 * name is only available if classes are compiled with debug info.)
	 *
	 * @return
	 */
	String value() default "";

	/**
	 * The qualified name of the parameter type. If not specified, the Java parameter type is used to determine a
	 * matching {@link DataTypeDefinition}. For ambiguous cases, you need to specify the type explicitly.
	 *
	 * @return
	 */
	String type() default "";

	boolean mandatory() default true;

	String displayLabel() default "";

	String constraintName() default "";
}