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From Japanese-American Internment Camp to Boys Town: Christmas and Other Bittersweet Memories During World War II

November 13, 2018 Leave a comment

From Japanese-American Internment Camp to Boys Town

Christmas and Other Bittersweet Memories During World War II

Story by Leo Adam Biga

Photography provided by Boys Town

Originally appeared in the Nov-Dec 2018 issue of Omaha Magazine 

(http://omahamagazine.com/articles/from-japanese-americaninternmentcamp)

 

Xenophobic fears ran wild after the Empire of Japan’s attack on Pearl Harbor. The U.S. promptly entered World War II, and nearly 120,000 Japanese-Americans were relocated or incarcerated in internment camps across the country.

The Rev. Edward Flanagan, the founder of Boys Town, strived to calm the hysteria in part—while alleviating the trauma falling upon his fellow Americans—by sponsoring approximately 200 Japanese-Americans from internment camps to stay at his rural Nebraska campus for wayward and abandoned youths.

Among them were James and Margaret Takahashi and their three children.

They joined the individuals and families escaping to Boys Town from prison-like internment camps. Flanagan offered dozens of families a place to live and work until the war’s conclusion. Some remained in Nebraska long after the war. Many used Boys Town as a stopover before World War II military service or moving to other American cities and towns, says Boys Town historian Tom Lynch.

Few outsiders knew Boys Town was a safe harbor for Nisei (the Japanese word for North Americans whose parents were immigrants from Japan) who lost their homes, livelihoods, and civil rights in the fear-driven, government-mandated evacuation of Japanese-Americans from the West Coast.

The oldest Takahashi child, Marilyn, was almost 6 when her family was uprooted from their Los Angeles home and way of life. Her gardener father lost his agricultural nursery.

“It was a very disruptive thing,” she recalls. “I was very upset by all of this. I can remember being confused and wondering what was going on and where are we going. I couldn’t understand all of it.”

She and her family joined hundreds of others in a makeshift holding camp at the Santa Anita Assembly Center, surrounded by barbed wire and armed guards. Stables at the converted race track doubled as spare barracks. Food riots erupted.

By contrast, at Boys Town, the Takahashis were treated humanely and fairly, as the full citizens they were, with all the comforts and privileges of home.

“We felt welcomed and did not have fears about our environment. The German farmers nearby were friendly and kind,” remembers Marilyn Takahashi Fordney.

 

The Takahashis were provided their own house and garden within the incorporated village of Boys Town’s boundaries. James, father of the family, worked as the grounds supervisor. The children attended school. The family celebrated major holidays—including unforgettable, bittersweet Christmases—in freedom, but still far from home.

None of it might have happened if Maryknoll priest Hugh Lavery, at a Japanese-American Catholic parish in L.A., hadn’t written Flanagan advocating on behalf of his congregation then being relocated in camps. Flanagan recognized the injustice. He also knew the internees included working-age men who could fill his war-depleted employee ranks. He had the heart, the need, the facilities, and the clout to broker their release from the Civil Exclusions Order signed into law by President Franklin

Delano Roosevelt.

Helping identify “good fits for Boys Town” was Patrick Okura, who ended up there himself, Lynch says. “It sort of started a pipeline to help bring people out,” and Flanagan “eventually took people of all different faiths,” not just internees from the Catholic parish that started the effort. “People from that parish went to the camps, and they met other Japanese-Americans, and they started communicating about this opportunity at Boys Town to get out of the camps.”

During her family’s four-month camp confinement, Marilyn’s parents heard that the famous Irish priest in Nebraska needed workers. James sent a letter making the case for himself and his family to come.

“People could leave if they had somewhere to go,” Marilyn says. “Permission didn’t come right away. It took writing back and forth for several months. Then, when we were all about to be moved to Amache [Granada War Relocation Center] in Colorado, the head of our camp sent a telegram to the War Relocation Authority. He received a telegram back with the necessary permission. We were released to Boys Town Sept. 5, 1942.”

Boys Town became legal sponsor for the new arrivals.

“It was very radical helping these people,” Lynch says. “Father thought it was his duty because they were good American citizens who should be treated well. But it wasn’t universally accepted. What made Boys Town unique is that we were way out in the country, so we were our own little bubble. Visitors really wouldn’t see the internees much. The men worked the farm or grounds. The women tended house. The kids were in school. But they were there all throughout the village.”

A similar effort unfolded at the University of Nebraska-Lincoln, where 100-plus Nisei students continued their college studies after the rude interruption caused by the “evacuation.”

During her Boys Town sojourn, Marilyn first attended a nearby one-room public school. She later attended a school on campus for workers’ children taught by a Polish Franciscan nun. Besides the standard subjects, the kids learned traditional Polish folk dances and crafts.

The Takahashis started their new life in an old farmhouse they later shared with other arrivals. Then Boys Town built a compound of brick houses for the workers and their families. “Single men lived in a dormitory on campus,” Lynch says. “Boys Town didn’t host many single women because Father would find jobs for them in Omaha, where they would stay with families they worked for as domestics.”

From Santa Anita, the Takahashi patriarch was allowed to go to L.A. to retrieve his truck and what stored family belongings he could transport. James drove to Nebraska to meet Margaret and the kids, who went ahead by train.

Marilyn’s initial impression of Flanagan was of Santa Claus with a cleric’s collar: “Father came to meet us at the station. He had this big brown bag of candy. I will always remember that candy. It was so thoughtful of him to give us that special treat.”

According to the Takahashi family’s file in the archives of the Boys Town Hall of History, Margaret said she was taken by Flanagan’s humanity, that she “could feel this warmth. I’ve never felt that from another human being. He was so full of love that it radiated out of him.”

According to Lynch, Flanagan considered the newcomers “part of the family of Boys Town.” They could access the entire campus or go into town freely.

Leaving altogether, though possible, was not a realistic option.

“They could leave at any time, if they really wanted to, but there was nowhere to go [without authorization]. They would have been detained and returned,” he says.

Marilyn’s experience of losing her home and living in a camp was dreadful. Going halfway across the country to live at Boys Town was an adventure. Her fondest memories there involve Christmas.

“Christmas and midnight Mass was very special at Boys Town,” she says. “It was something we looked forward to. I will always remember getting bundled up to face the blizzard-like winds. My father would carry each one of us to the truck. We would head off in the dead of night in that blasted cold to get to the church, which was dark except for the altar lights. The boys would be in a long line in their white and black cassocks, with red bows, each holding a big lit candle. They would begin to sing and come down the main aisle. It was an awesome sight and a special experience. The choir was exceptional. There was always one singer with a high-pitched voice who did a solo. It was amazing.”

Father Flanagan and children during Christmastime

 

Flanagan is part of her holiday memories, she says, as “he always made a point to come to our Christmas plays, and we would always take a photograph with him.” For the resident boy population, Flanagan “played” Santa by visiting their apartments and handing out gifts.

“We were happy at Christmas,” Marilyn says. “In the farmhouse, my father would cut a pine tree and bring it in, and the decorations were handmade and hand-painted cones with popcorn strung. He always did the final placement of things so that it looked perfect. We had wonderful Christmas days even though it was difficult to get toys because many things were not available due to the war.”

She continues: “We built an ice rink and would skate in front of the farmhouse or in front of the brick house. We even made an igloo one time. It got so tall the adults came out to help us close the top with the snow blocks because we were too little to reach it.”

Weather always factored in.

“The summers were extremely hot and the winters so severely cold,” she says. “We had never experienced snow. That was a tremendous adjustment for my parents. But, as children, we delighted in it. We’d run out and eat the snow with jam and build snowmen.”

Marilyn recalls visiting Santa at J.L. Brandeis & Sons department store in downtown Omaha with its fabulous Christmas window displays and North Pole Toy Land.

The Takahashis were content enough in their new life that they arranged for family and friends to join them there. Marilyn and family remained in Omaha for two years after the war (and anti-Japanese hysteria) ended.

“Eventually, my parents decided they couldn’t withstand that cold, and we headed back to California in 1947,” she says.

They endured tragedy at Boys Town when Marilyn’s younger brother contracted measles and encephalitis, falling into a coma that caused severe brain damage. His constant care was a burden for the poor family.

Another motivating factor for the family to leave was the father’s desire to work for himself again.

Leaving Boys Town just shy of age 12 was hard for Marilyn.

“I was heartbroken because I loved the snow and cold and all my friends there,” she says. “I did not want to go to California and live three families to a house and struggle. I knew what was coming. I also had a pet cat I was sad to leave. My pet dog Spunky that Boys Town gave me had passed on.”

Her parents had also bonded with some of the resident boys, and with some adult workers and their families.

“We went by Father Flanagan’s residence to say farewell, and he came out to bless us and to bless the truck we drove to the West Coast,” she says.

As an adult, Marilyn shared her story with archivists just as her parents did earlier.

“We considered ourselves fortunate,” Margaret told interviewer Evelyn Taylor with the California State University Japanese American Digitization Project in 2003. (This article for Omaha Magazine merged excerpts from that oral history with original interviews conducted over the telephone and

e-mail correspondence.)

There are occasions when Marilyn’s internment past comes up in casual conversation. “It is amazing how few people know about this,” she says. “It is now mentioned in history books in schools, but it wasn’t for a long time.”

When she brings up her Boys Town interlude, she says, “It is always a surprise and I am asked many questions.”

The retired medical assistant, educator, and author now runs family foundations supporting youth activities. She credits her many accomplishments to what the wartime years took away and bestowed.

“The internment made me an overachiever. Because I was the eldest and experienced so much, I have become actually the strongest of the siblings,” she says. “Nothing can stop me from reaching my goals.”

Her late parents also felt that the experience strengthened the family’s resilience. Margaret said, “I think from then on we were very strong. I don’t think anything could get us down.”

The kindness shown by Boys Town to relieve their plight made a deep impact.

“We are forever grateful Father Flanagan hired my father to take care of the grounds,” Marilyn says, “because it enabled us to get out of that internment situation.”

She came to view what Flanagan did for her family and others who had been interned as a humanitarian “rescue.”

Then there were the scholastic and life lessons learned.

“A Boys Town education gives you the tools needed to succeed in life,” she says.

Even though discrimination continued after the war, the lessons she learned during the internment and the Boys Town reprieve emboldened her.

“I am grateful that I went through the experience because it made me who I am today,” she adds.

Internees were granted reparations by the U.S. government under the Civil Liberties Act of 1988. Marilyn received $20,000, and she gave it all away.

She divided the reparations money into equal parts for four recipients: two younger siblings who also grew up in poverty (but did not experience the internment camps of World War II), to create the Fordney Foundation (for helping future generations of ballroom dancers), and Boys Town.

Forty-four years after the Takahashis left their safe haven in Nebraska, Marilyn returned to Boys Town in 1991. During the visit, she made her donation to the place that gave her family a temporary home and renewed faith in mankind.

Uchiyamada and Takahashi families with Father Flanagan in March 1944

 

James Takahashi’s Letter to Father Flanagan

Soon after arriving at Santa Anita Assembly Center, James Takahashi learned that Father Flanagan was hiring individuals with certain skills to work at Boys Town.

James hand-wrote an appeal to Flanagan asking to be considered. He provided references. The priest wrote Takahashi back requesting more information, including how many were in his family, and checked his references, all of whom spoke highly of “Jimmy,” as he was called, in letters they sent Flanagan.

Here is the text of the original letter James wrote (references excluded):

Dear Father Flanagan,

Today in camp I heard that you are asking for some Japanese gardeners. I am very interested as I have been a gardener and nurseryman in Los Angeles for the past five years.

Just before the evacuation, I was gardener at St. Mary’s Academy in Los Angeles. I re-landscaped the grounds and put in several lawns.

I am 30 years old of Japanese ancestry but was born and educated in this country. I was converted to the Catholic faith by my wife, who is half Irish and half Japanese.

I studied soil, plants, insect control, and landscape architecture at Los Angeles City College, and am confident that I would be able to handle any gardening problem.

I would be so grateful if you would consider me for this position.

Very sincerely,

James Takahashi

Visit csujad.com for more information about the California State University Japanese-American History Digitization Project.

Visit boystown.org for more information about Boys Town.

This article was printed in the November/December 2018 edition of 60Plus in Omaha Magazine. To receive the magazine, click here to subscribe.

 

Toshio “James” and Margaret Takahashi with their children at the Boys Town Farm, 1944

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The high price of juvenile justice Battle lines are drawn over cost, location of proposed youth detention center

November 13, 2018 Leave a comment

The high price of juvenile justice

Battle lines are drawn over cost, location of proposed youth detention center

 

©by Leo Adam Biga

Originally appeared in the Nov. 2018 issue of The Reader

 

The Reader - November 2018

 

As Douglas County pushes for construction of a $120 million justice complex downtown, conflict and controversy have emerged over greater good and expediency versus accountability to stakeholders.

The 10-story tower courthouse annex would house a combination of county adult and juvenile courtrooms, judges’ chambers, public defender and probation offices and related facilities. The juvenile justice element is getting the most attention because a four-story youth detention center containing 48 to 64 beds would connect to the annex. Services and programs for juveniles and families would be onsite. A parking garage would also be built.

The Douglas County Board of Commissioners is charged with approving or denying the project. A majority of the seven-member board supports it. The project’s two vocal opponents, commissioners Jim Cavanaugh and Mike Boyle, take issue with its scale and location as well as the mechanism to pay for it and the private nonprofit created to oversee it. They’ve called for a reset to halt the project to review alternatives, including scaling it back.

Meanwhile, the county seeks to acquire a nearly century-old brick building at 420 South 18th Street, raze it and then build the complex. When owner Bob Perrin refused to sell last summer, the county began eminent domain proceedings, only to have a court order the county to back off pending further hearings.

“There are obstacles we’re going to have to overcome now and we’re working through those,” said commissioner Mary Ann Borgeson, who champions the project. “I hope in the end we’ll be able to come to a resolution. It (eminent domain) isn’t a popular thing to do or use, but we can’t go forth really without that (building).”

Cavanaugh sees things differently.

“With the court having stopped eminent domain for now it allows us that chance to step back and take a deep breath and look at alternatives that exist and that will work,” he said. “We have been proposing specific alternatives, which include construction of a juvenile justice center courthouse on land we own adjacent to the (current) courthouse and refurbishment of the (existing) youth center on 42nd Street. We would add a courtroom facility to the youth center to allow proximity.

“Kids will have access to outdoor activities on a campus that looks more like a school than a correctional center with numbers significantly lower than those proposed for the $120 million project.”

There’s broad agreement the current courthouse is past capacity and long overdue for expansion.

“We have been trying to jerry-rig judges into cubbyholes and all kinds of things to try and make this thing work   without having to do what we know we needed to do 20 years ago, which was to build an annex facility,” said Ben Gray. an Omaha City Council member who served on the city-county building commission driving the project and now chairs the nonprofit overseeing it. “So this was not fast-tracked or anything like that.”

“It’s nothing new,” Borgeson said. “What is new is that we actually have a conceptual plan that puts the center across the street from the existing courthouse-civic center.”

She said other locations, including the old Civic Auditorium site and MUD property, were considered.

There’s less agreement on the need for a new detention center and how many youth it should serve.

Proponents tout the efficiencies of a one-stop shop. The current center near 42nd and Woolworth would be replaced by the new one, thereby putting detainees in close proximity to the justice system and to services supporting their transition back into society.

“Hopefully, this one-stop shop being imagined will be built based on the input of what kids, families and community providers who work with them say they need,” said LaVon Stennis-Williams, a county Operation Youth Success initiative committee member. Her ReConnect Inc. serves families of current and former incarcerated. “Programs that can keep kids from being detained are underutilized. That has to be factored in.”

She said a proposed partnership among the county, University of Nebraska Medical Center and Creighton University to bring more psychologists and psychiatrists onsite “is going to be a game-changer in terms of getting the assessments done on children quicker.”

“Then we can look for services that will keep kids at home,” she said. “On any given day, most of the kids detained are there awaiting placement and professional assessment, not for their underlying offense. You’ll remove maybe two-thirds of your population with the right professionals engaged and looking for alternatives to detention. There are opportunities in the community to put those things in place.”

Gray, who has a long history working with at-risk youth, said the new center will utilize “best practice policies for getting kids in and out and served quickly and assessing what their real needs are.”

“We want to change the trajectory of how we’re doing things by enhancing service at the county level for our kids and families,” Borgeson said. “A lot of details are being worked out in terms of the internal guts of the buildings and how they’re going to look and operate.”

Some observers express concern the new detention center will house fewer youth (68 max) than the current average detainee population of 70 to 80 and less than half the existing capacity (144).

“It doesn’t make sense why we’re reducing capacity when the average daily population has been steady for years and the county has not produced any projections on how they will reduce the number of kids in detention,” community activist Brian Smith said.

“That is a valid concern,” Stennis-Williams said. “But if we’re moving towards juvenile justice reform we should applaud reducing the number of beds – just so long as we do not have any notion of shipping kids to other jurisdictions when we run out of bed space. We need to address why we’re detaining the number of kids we are and what we’re detaining them for.”

Opponents question another number – the price tag. It would be the largest capital construction project in Douglas County government history. Funding would come through bonds issued by the Omaha-Douglas Public Building Commission and likely require a county property tax rate increase. Mayor Jean Stothert said she wants no city taxpayer money used for its construction.

The 501C3 formed to develop and manage the project – Douglas County Unified Justice Center Development Corp. – is based on a model UNMC used to construct its Buffett Cancer Center. The nonprofit would have the ability to solicit private philanthropy to fund the project.

“We have some ideas, but we have to have a more concrete plan before private donors will jump on board,” Borgeson said, “and that’s what we’re trying to get at.”

Critics assert a lack of transparency and due diligence in the process that created the nonprofit, whose board is comprised of various elected and appointed officials.

 

Jim Cavanaugh

 

“We don’t need a private corporation to head up construction. We’re perfectly capable doing it ourselves,” Cavanaugh said. “There’s a better, cheaper, smarter way to go, and we’re doing that right now with the 2016 public safety bond $45 million construction project voters overwhelmingly approved after months of public hearings and discussions. It’s refurbishing a large county office building to consolidate some county services, including a new state-of-the-art 9/11 center, a satellite office for the Douglas County Treasurer to serve western Douglas County and West Omaha, headquarters for our emergency services and environmental services, plus the crime lab and sheriff’s department spaces.

“We are also refurbishing the county correction center downtown. We’re installing in all fire stations in the city new alert systems. All this new construction and equipment is administered by the public property division – on time, on budget and no tax increase.”

He dislikes the apparatus behind the juvenile justice project because, he said, “It’s not accountable to the people.”

“Handing to a private corporation concocted behind closed doors by private entities control over the expenditure of $120 million of tax dollars without any vote of the people, without public access, hearings or discussions, and without any public bidding process, is wrong. It’s a top-down, cart-before-the-horse approach to what should be a well-thought-out, strategic, decision-making plan in public,” Cavanaugh said.

“I’m calling for the process to result in a bond issue that would be voted on by the public.”

He suspects the slated downtown location is more about accommodating lawyers and judges than serving kids.

 

juvenile justice

 

County officials selected a troika of Omaha power players – Burlington Capital, Kiewit Construction Corp. and HDR – to manage and build the project without apparently other potential players considered or asked to submit bids. It strikes some as back-room, sweetheart deal-making and incestuous political maneuvering. The Nebraska Accountability and Disclosure Commission is investigating a conflict-of-interest complaint brought against some officials sitting on multiple boards involved in the project’s governance.

“It seems like HDR, Kiewit and Burlington Capital have been preselected for this program with no competitive bids,” said watchdog Smith, whose Omaha Public Meetings has convened forums on the topic. “There’s no explanation of where that $120 million number came from and why this 501c3 is going to manage it using the Double A bond borrowing status versus the county’s Triple A bond status.

“There are a lot of unanswered questions.”

Smith and others point out that HDR has pitched doing a mega-justice complex for more than a decade.

Cavanaugh sees “real estate development, sales and construction” interests as “the driving forces behind a lot of the private discussions by a lot of private players in the way the thing has been designed and put forward.”

“When they (the building commission) originally brought it to us in private,” Cavanaugh said, “I said we immediately should go public and have some discussion on this. But for months there was no public discussion. Finally, I started holding hearings in the Administrative Services Committee simply because it was clear something of this magnitude needed to be discussed in public. You can’t do a $120 million project like this without public discussion and a public vote really.”

 

By Ben Gray
By Ben Gray
By R Justice Braimah
By Elizabeth Lynn Welch

Project advocates concede it could have been a more open process.
By R Justice Braimah
By Elizabeth Lynn Welch

“I think some things could have easily been done in a public session,” Gray said, “but there were some concerns about prices going up and other things like that which made it more or less a better proposition to do it in executive session so as to try and preserve and not create any additional burden for taxpayers.

“So it was necessary in the beginning to start this effort in a sort of quiet way to get things started and get people on board and get things moving in the right direction. Now you can argue back and forth whether we should have done it sooner or not. We debate that among ourselves even. But at the end of the day it is what it is and we’re here now and we are telling the story that needs to be told.”

 

Said Borgeson, “We should have done a better job of coming out sooner with the conceptual plans, and what our thoughts are on that I can’t go back and change that, but what I can change going forward is what we’re doing and that is a monthly update at the board meeting of where we are – good and open conversation about the programs and gaps we have in the programs.”

 

Mary Ann Borgeson

 

She said she’s heard from constituents who support and oppose the plan, but she adds, “Once people really listen to what the end result is they may continue to disagree with how we got there but they’re supportive of what we’re trying to do because it’s such a need.”

ReConnect’s Stennis-Williams thinks what should be the main focus has been obscured by the conflict.

“I believe some of the arguments are mere distractions when what’s lacking are quality services for our kids.

The county needs to separate the issue of having a new courthouse, which is badly needed, from the issue of renovating, redesigning, reimagining youth detention,” she said.

“When you’re talking about formulating even the design of this detention center, parents’ voices need to be first, not secondary. I don’t care where it’s built, if we get it, how much it costs. My concern is what’s ultimately going to go inside the building. What is disturbing to me is that most of the people advocating for or against it have not sat down and talked with parents to see what they really do need. Most people on either side of the issue do not serve kids or represent that parent voice of having a system-involved child. Instead of reducing the argument to sticking points, talking points, we need to throw down deep enough to see how we keep kids from even getting system-involved. That is what needs to be upfront.”

 

 

The historic building owned by Bob Perrin that stands in the way of the proposed justice cener project

 

For Omaha architect Perrin, who owns the four-story, 40,000-square-foot, industrial-style building at 18th and Howard impeding the project, his property is no side issue. He rejected the county’s $900,000 offer for it, declaring it’s not for sale because he has plans to convert it into offices or condominiums.

His attorney, David Domina, filed suit against the county’s eminent domain attempt, and a judge enacted a temporary restraining order. The suit maintains the county lacks jurisdiction alone to obtain the property and contends the City Council and county building commission must also OK seizing the building.

Perrin has led various Omaha preservation efforts. He’s also previously challenged efforts to seize his holdings. He won a nearly $2 million settlement over land he owned coveted by the University of Nebraska Board of Regents for a University of Nebraska Medical Center expansion.

Gray openly suspects Perrin’s motives in bucking community progress interests. “He wants a better price for his property. That’s what this whole thing is about.” Perrin flatly refutes the assertion and says he simply wants the right to retain his property for what he deems a better public use. He added that he only broke even in his lawsuit against the university.

Gray questions the current structure’s historical integrity. “Because the building is old doesn’t make it historic.”

 

The area designated for the justice center.

 

The Omaha Planning Board has unanimously approved the 1920 building for local landmark status, on which the Council must vote. Landmark status would not guarantee the building from being taken by the county.

Several individuals and groups have expressed support for saving the building and criticized the city’s poor preservation track record.

Gray counters that two historic buildings – the courthouse and former downtown public library – are being preserved rather than razed for the project.

The county’s aggressive pursuit of the building became the public flashpoint for the project.

“The project had been behind the scenes with Cavanaugh the only one yelling and getting no attention at all until they started to take my building and I resisted,” Perrin said. “I feel like all the commissioners were in a dark room with their clothes off and I walked in and turned the lights on.”

He believes the industrial building, which housed early auto dealerships and more recently U.S. Corps of Engineers testing labs, is a diamond in the rough that should not be sacrificed for a project that could be built elsewhere.

“They’re disrespecting the history of our city. They’re wanting to demolish something that’s really important that we didn’t even know we had.”

He and other project detractors question placing a juvenile detention facility and justice center so close to the county’s adult prison.

Cavanaugh, who calls the planned center “a cellblock,” said, “It’s the wrong place to put children. Putting them   downtown within close proximity of the adult jail is exactly the wrong message we want to send these children.”

Critics say the project would impose a chilling effect on the area’s redevelopment.

“They’re wanting to do the wrong thing with the site by putting in things with uses that would degrade the value of neighboring properties,” Perrin said.

“It doesn’t make any sense why we would put a detention center in an already very fragile part of downtown,” Smith said.

Backers claim the project will revitalize the Flatiron District, though they don’t say how.

Lost in all of this, some assert, is what youth and parents say they want and need. Project advocates contend their actions are in the best interests of kids and families. Others call for more input from parents with youth in the system.

“It’s disturbing that the people most affected by this have the least voice,” Smith said.

 

ReConnect Inc.

Lavon Stennis-Williams

 

“We have gotten so comfortable excluding the voice of parents that we proceed as a matter of course now without getting them involved,” Stennis-Williams said. “There needs to be a direct effort to reach out to parents. We have to meet them where they’re at to intentionally get them involved in this conversation.

“We have not done a good job of getting them engaged. We’ve become comfortable speaking for parents using all these different surrogates. I’d like to have it come from a closer experience than from people looking at it from a policy standpoint. These families and kids are suffering. There are things we can do, that we can fix that we’re not putting proper attention on because we’re still arguing on issues that have nothing to do with what’s best.”

She wishes Perrin’s building fight never entered the fray.

“I think the effort to locate the center downtown and the fight to preserve the building standing in its way has become a polarizing situation keeping the parties from talking to each other. Instead, they’re talking at each other,” she said. “When you get engaged in that argument you lose sight of the kids and they need to be our foremost purpose.”

Smith is alternately a realist and idealist when projecting the outcome of this fight.

“The pessimist in me says the county is going to bulldoze their way through this first part of their plan, which is a real estate acquisition, and then maybe involve people in a meaningful way in the conversation about the actual design and programming of the facility. So the first part may be a loss. But the second part may highlight the fact people want engagement and explanation in the process.

“The optimist in me holds out hope the city, the mayor, the planning department, the city council will step in early enough in this process to prevent the demolition of the Perrin building and force some meaningful change in the way this process is planned out.”

Cavanaugh believes all is not lost.

“I think you’ve seen movement by some of my colleagues. Commissioner Boyle is now on board with stop eminent domain, right-size the project and put it on the ballot. I think others on the board are taking another look at this to maybe open it up to the robust public discussion that it needs.

“This is going to be a big issue going forward obviously because there’s so much money involved, and it’s now gotten people’s interest.”

Meanwhile, Borgeson, Gray and Co. are confident their plan will prevail in the end, with or without a vote of confidence or approval from the public.

Read more of Leo Adam Biga’s work at leoadambiga.com

The healthcare war: Round and round it goes again, and where it stops, nobody knows

August 18, 2018 Leave a comment

The healthcare war:

Round and round it goes again, and where it stops, nobody knows

©by Leo Adam Biga

Originally appeared in the August 2017 issue of The Reader (www.thereader.com)

 

As we go to press with this issue, the Republican-led attempt to repeal and replace Obamacare struggles on..

One of the most controversial things the GOP plan broached was severely cutting Medicaid, the nation’s largest health care program. Critics see it as an entitlement grown far beyond its original scope. Most recipients are children, mothers, the disabled and the elderly. The proposed $770 billion cut – spread out over several years – would have impacted millions, particularly the working poor in rural regions, who account for many of those added to the rolls through the ACA’s Medicaid expansion.

One World Community Health Centers CEO Andrea Skolkin said far from an automatic hand-out, qualifying for Medicaid is actually “very difficult.” She added, “There’s a lot of myths about Medicaid and who’s eligible to be enrolled. If you’re an able-bodied adult, you’re not really eligible. You really have to be an advocate for yourself in getting enrolled with all the paperwork because you have to prove your income. It’s an arduous process.”

The program, said Skolkin, places severe limits on not only eligibility, but coverage for certain things. Any tightening of eligibility and reduction of spending, she said, would result in even less access to care.

“As Medicaid ratchets down what it pays to providers, providers are less likely to want to accept Medicaid and so this vulnerable population doesn’t have as much choice of provider of where to get care, and that’s a problem.”

Currently, one in five Americans is enrolled in the program. In Nebraska, which refused Medicaid expansion, one in eight or some 230,000 people are enrolled. Skolkin estimates about 70,000 Nebraskans fall in the gaps – either not eligible for the marketplace or not covered by a private plan or by Medicaid.

Nebraska Methodist Health System vice president and CFO Jeff Francis was most troubled that “draconian cuts” to Medicaid were even on the table for so long.

“The thing that still looms out there that bothers me is that there wasn’t much budge on that,” Francis said. “I  understand the partisan divisions on that, but at the end of the day that degree of cut to Medicaid is going to really impact individuals and individuals’ coverage. In Nebraska we get a bit of a double whammy, no matter what happens with the cuts because, one, we weren’t a Medicaid expansion state, so we’ve not benefited at all from some of the expanded coverage in federal dollars that went along with that. And, two, historically we’ve been lower on the Medicaid spending spectrum, and so as that translates into cuts and block grants for the states, Nebraska’s going to get hit pretty hard.”

Medicaid is crucial for millions getting treatment for maladies, and Skolkin said, “It also has an impact on long-term care in a tremendous way.”

Low weight new babies, infant mortality, STD and teen pregnancy rates are at crisis levels. The opioid epidemic got highlighted in the recent care plan debates. Mental illness is increasingly recognized as an acute public health problem. In the proposed Medicaid cut, some public schools would have lost funding for screenings and other care that students from low income families rely on.

In this high needs scenario, cutting access to care means some people will delay or defer treatment, and those with conditions that could be prevented or controlled will get sicker, while others will seek care in emergency rooms, all of which puts more pressure on providers. The system’s closely interwoven nature is such that pulling hard on one strand, like public health, will fray or undo other strands in this fragile crazy quilt.

“The tapestry doesn’t work without all the threads,” said One World pediatric nursing practitioner Sara Miller.

Nebraska Medicine CEO Dr. Daniel DeBehnke appreciates how those outside the industry often fail to see just what a tightly-knit fabric it is.

“I don’t know if it’s a disconnect or just a reflection of the complexity of it,” DeBehnke said.

In the event of cuts, he said, “low income individuals are going to need to make really tough choices about how to pay for a roof over their head and feed their family and pay for healthcare, and some may put off healthcare, and that has several domino effects. People become less healthy and when they do access healthcare, they require more services. Once they do require services, a lot of that financial burden gets shifted to the facilities caring for them, be it a local clinic, provider or large health system.”

Sara Miller envisions “life expectancy decreasing because you don’t have the opportunity to intervene in the early years, especially for kids to have healthy habits, and to do preventive medicine, so that folks don’t have diabetes or high cholesterol by the time they’re in their mid-20s.” She added, “My fear most is for the families that it affects and their deciding between food and electricity and healthcare. That’s a decision nobody should ever have to make.”

Exacerbating it all, DeBehnke said, is the “skyrocketing” cost of care.

“We should be focusing on that as well and not just in cutting the dollars that go for healthcare – but how can we decrease the cost of healthcare, the cost of prescription drugs driving a lot of the cost. How can we drive healthcare systems like ours and others to be more efficient and cost-conscious. We’re working on that every single day because we know that’s how we’re going to be paid in the future,” DeBehnke said. “But there are all those other things we should be working on as well so that we pay less for healthcare as opposed to just giving less money for healthcare.”

No matter where this all lands, he said, “When we talk about Nebraska Medicine and our mission, we’ll take care of anybody that walks in our door. That’s who we are and that’s what we do and we’re big enough to be able to do that.”

As a Federally Qualified Health Center, One World takes anyone, too, but it doesn’t have as deep of pockets as Nebraska Medicine.

“When we have increases in numbers like we have seen – we cared for over 18,000 patients last year who were uninsured, which is more than half of all of our patients – that’s an increasing burden as an organization in trying to leverage other funds so we can take care of all people,” Skolkin said. “If Medicaid reduces what it reimburses for certain services, again that’s a reduction to every provider, including us. So, whether you need an x-ray or some lab work. as things get reduced we get less payment for that and then it just has a ripple effect.

“So, cuts do impact us and at some point we won’t be able to provide the extent of care we provide. I would hate to see that happen, but at some point you have to be able to make your budget.”

DeBehnke said no matter what happens, “there’s going to be people left behind,” adding, “The idea that I hope legislators are thinking about is how do we leave the least amount behind.”

Jeff Francis said this is no time to be complacent even as Nebraska Methodist Health System is “operating well under the Affordable Care Act.” He added, “It took some time for us to be able to understand it. We’re now into the fourth year of the federal exchanges and the insurance aspects of it. Other parts of it we’ve been operating under for about six years. And so it’s going on. We’re seeing better outcomes because the focus is on quality and outcomes as opposed to just the fee for service or being paid for services.”

But just as the ACA was never meant to be a panacea for all the system’s faults, Francis said major cuts to public health would have negative consequences.

“To the extent there are less insured and so people are doing less preventive, that would be a step backwards from a public health standpoint. We still have the vulnerable populations – those with chronic conditions, in some cases multiple chronic conditions, those with mental health challenges, the working poor.”

Methodist Health and others are working to fill the gaps where they can.

“We’re reaching out to try and address that,” Francis said “by opening up a community health center in downtown Omaha to work with other entities-services to reach vulnerable populations. That center is going to have Lutheran Family Services associated with it to try to deal with that behavioral health component.”

The center is part of the Kountze Commons project on the former KETV site at 26th and Douglas. It’s an expansion of existing Kountze Memorial Lutheran Church health and food services.

Andy Hale, Vice President of Advocacy for the Nebraska Hospital Association, said his organization has been lobbying the state’s congressional delegation to “ensure all Americans can access the compassionate, patient-centered and affordable healthcare they deserve.”

“Nebraska’s hospitals serve as the safety net in each of their communities,” Hale said.

Hospital programs benefit the state, he said, by “providing free care to individuals unable to pay, absorbing the unpaid costs of public programs such as Medicare and Medicaid,” as well as “subsidizing health services reimbursed at amounts below the cost of providing the care … and incurring bad debt from individuals that choose not to pay their bills,” according to Hale.

Hale said hospitals serving more rural regions typically to treat “older, poorer, sicker populations” who tend to be on Medicare or Medicaid.

“Medicaid plays a critical role for Americans who live in small towns and rural areas,” Hale said. “Almost half of all children living in small towns and rural areas receive their health coverage through Medicaid. Research shows Medicaid provides families with access to necessary health services.”

He said any drastic cuts will be felt most in rural areas.

“Many hospital margins are already thin, but when you begin cutting reimbursement rates, it hits their bottom lines and drives those hospitals to significant losses.”

One World’s Andrea Skolkin said even in this repeal and replace mania, vital aspects of public care should not be lost in the shuffle.

“The expansion of Medicaid funding for children through CHIP (Children’s Health Insurance Program) expires on September 30. All of these things are tied together.”

DeBehnke would like whatever process follows this latest effort to undo the ACA to be deliberate.

“President Trump said at the beginning of all this, ‘Who would have thought this was so complex?’ Well, we’ve all known it’s this complex and we’ve been trying to warn it’s this complex all along,” DeBehnke said. “As opposed to rushing to try to get something done because it was a campaign promise lawmakers made to their constituents, let’s take our time and try to figure it out and get it right. Obamacare wasn’t perfect either. There are good things we can pull from there that are in the right direction.”

Behind-the-scenes, executives like DeBehnke and Francis are bending elected officials’ ears.

“We’re wanting to make sure legislators and policymakers keep that longer view perspective. I think that’s coming out in some of the town halls the senators and congressman are hearing,” Francis said.

Meanwhile, the leadership of Nebraska Medicaid is in transition. Longtime director Calder Lynch left for a federal job in May. Former deputy director Rocky Thompson is serving as interim head until a permanent replacement is found.

Andrea Skolkin is unsettled, too, by the unknown but feels something like universal care will emerge and retain a public health haven.

“We are having those conversations – trying to make our representatives aware of the patient base we care for and what the impacts of cuts would be. Many of our patients, almost all of them, fall into this vulnerable bracket. If you cut too hard, then that social compact becomes less available for the people that need it most.

“I do believe there will be something for everyone. I think Medicaid is still going to be there. There’s a lot of argument-dialogue going around right now. It hasn’t been as productive as it could be. But I am hopeful it will end in the right place. Whether the Affordable Care Act is repealed or not, there has to be a safety net in place for people who are more vulnerable.”

Read more of Leo Adam Biga’s work at leoadambiga.com.

Who’s Going to Pay? Before and After the Affordable Care Act

March 16, 2017 Leave a comment

There’s nothing like getting current, though it’s hard to do when you write for a monthly. Still, in this cover story I wrote for the March 2017 issue of The Reader (http://www.thereader.com) I think I mostly managed to stay relevant to the topic of health care coverage in America, the forces pushing and pulling for and against the Affordable Care Act and what the ACA has meant in terms of gains and what its repeal and replacement would mean in losses. For the piece I spoke to local professionals on the provider and insurer sides of the equation for their take on how we got here and where we might be heading. The story went to press with us knowing Congress was working to repeal and replace Obamacare, though no one knew what that entailed, and then just about the time our story got published that plan was unveiled. As you know by now, the proposed new plan was met with disdain from all quarters, especially consumer rights groups and elected officials, even conservative Republicans, who heard loud and clear from constituents that they they oppose the called for cuts that would cause many people to lose insurance. As the push back continues, town halls and debates ensue, and presumably negotiations, revisions and compromises will get made. Meanwhile, America still can’t get its health care system to work equitably and efficiently.

 

Who’s Going to Pay? Before & After the Affordable Care Act

©by Leo Adam Biga

Appeared in the March 2017 issue of The Reader ((http://www.thereader.com)

One accident, one illness could be catastrophic. Not just medically, but also financially.

Families stood to lose almost everything in medical bankruptcies when health insurance companies rejected those with pre-existing conditions and capped their policies with lifetime limits.

Uncovered costs helped health care expenditures soar, more than tripling in the last 20 years according to the federal National Health Spending Report. In 2015, the federal government was the largest payer of health care, covering 37% of the total cost through its two programs Medicaid and Medicare.

The curve was starting to bend.

According to the Kaiser Family Foundation, health insurance costs increased 63% from 2001 to 2006 and 31% from 2006 to 2011. That number dropped to 20% from 2011 to 2016.

Part of the reason was the Affordable Care Act and a landmark shift in how health care was being offered. Through a series of tax increases targeting high-income earners, the ACA was able to fund experiments in in- novation while subsidizing the cost of bringing almost 30 million Americans into the health insurance system.

With the end of Obamacare at the top of the national conversation, The Reader talked to the major stakeholders about life before and potentially after the Affordable Care Act.

It’s not just the $2 billion in federal revenues Nebraska passed up for health insurance, or the 275,000 Nebraskans with pre-existing conditions that could be denied health insurance, according to the Kaiser Family Foundation. It’s not even the estimated 165,000 Nebraskans that would lose health insurance, an increase of 111% of the uninsured, according to the Economic Policy Institute, leading to almost 3,000 jobs lost and $400 million in federal health care dollars gone that we subsidize.

It’s also about the way we take care of each other.

Quality of Health Care Over Quantity

America treating healthcare as a commodity helps explain its high delivery and coverage expense. Characterized by historic lack of incentives to drive prices down, providers and insurers dictate terms to consumers. Subsidies to assist low income patients who can’t pay out of pocket get passed along to other consumers. But affording care and its coverage is a burden even for the middle classes.

Amid runaway costs and coverage gaps, America’s clunkily moving from a volume to a value-based system as part of long overdue healthcare reform. The Affordable Care Act was passed in 2010 after contentious bipartisan debate. The statute’s full roll-out began in 2014.

Nebraska Medicine CEO Daniel DeBehnke said, “The tipping point that brought the ACA forward is really the unsustainable growth in our country’s healthcare costs.”

The calculus of people not being able to afford care translates into real life implications. Untreated chronic diseases worsen without treatment. Early diagnoses are missed absent annual physicals or wellness checks.

Championed by President Barack Obama, who promised reform in his campaign, the ACA’s enacted consumer protections and mea- sures holding providers account- able for delivering value.

Nebraska Methodist Health System CFO Jeff Francis said organizations like his have “con- tracts and monies at risk for hit- ting certain quality items, not just with Medicare, but with some of our commercial insurers as well, Five or ten years from now,” he added, “we’ll probably have more at risk financially from a quality and outcome standpoint. Recent federal legislation changed the way physicians get paid by CMS (Centers for Medicare and Medicaid Services). Starting in 2019 they’re having potential penalties depending on whether they’re hitting certain quality metrics or not.”

He said the stick of such punitive measures works.

A new Standard in American Health Care

Aspects of Obamacare, such as the individual mandate and public health exchanges, have detractors. Federal lawsuits challenging it have failed. But its intact survival is in jeopardy today. A chief critic is President Donald Trump, who with the Republican controlled Congress vowed to repeal and replace, though that’s proving more daunting in reality than rhetoric. On February 16, GOP leaders shared a replacement plan with tax credits for buy- ing insurance and incentives for opening healthcare savings accounts, but no details for funding the plan or its projected impact on the insured and uninsured.

Debehnke said, “I don’t think there’s any question, regardless of where you land politically, there are components of the current ACA that require tweaking. Even Democrats will tell you it wasn’t exactly perfect – nobody said it was going to be perfect. It was understood there were going to need to be changes as things move along.”

There’s widespread consensus about the benefits accruing from the ACA. New subsidies allowed millions more people nationwide and tens of thousands more in Nebraska to be insured, in some cases getting care they deferred or delayed. Insurers cannot deny coverage for pre- existing conditions or cancel coverage when someone gets sick. Plans must cover essential care and wellness visits. Adult children can remain on their parents’ insurance until age 26.

Francis said, “A lot of good things have come out of this. We’re focusing on well- ness, we have fewer uninsured, we’re having better outcomes for patients. I think there’s satisfaction with the improvements. I just think there’s disagreement with how it’s occurring or being done.”

“You can’t believe the difference it’s made by setting minimum standards for health insurance,” said One World Community Health Chief Medical Officer Kristine McVea, “so that things like child immunizations and mammograms are covered.”

Since the ACA’s adoption, uninsured 18-to 24-year-olds in Nebraska dropped from 25.5 percent in 2009 to 12.4 percent in 2015, according to the Kids Count in Nebraska Report.

McVea said, “At One World people get assistance in enrolling for health insurance. Counselors guide them through the market- place. People are really becoming more savvy shoppers. Improved health literacy has been a result of this process, you can really compare for the very first time apples to apples in terms of different plans. That has been a tremendous boon to clients.”

Not everyone included – Nebraska drops the Kick- back

Healthcare disparities still exist though. In Omaha 24% of adults living below the poverty line

lack health coverage while 3% of adults with medium to high in- come are uninsured. Some 36% of Hispanic adults, 15% of black adults and 5% of white adults are uninsured in the metro, ac- cording to numbers reported by The landscape, a project of the Omaha Community Foundation.

McVea said, “The poorest of the poor are not eligible for the marketplace at all because that part of the Affordable Care Act carved them out thinking states would cover them with Medicaid. Well, Nebraska’s elected not to expand Medicaid, so there’s this whole gap of people not insured. Then there’s prob- ably another tier who do get assistance through the marketplace, but considering the economic pressures they’re under, even with the assistance, it still falls outside their reach to get good healthcare.”

The Kids Count Report found 64 percent of uninsured Nebraska children are low-in- come — likely eligible for but not enrolled in Medicaid or Children’s Health Insurance program (CHIP).

Past Nebraska Medical Association president Rowen Zettermen said, “In Nebraska we have somewhere in the neighborhood of 60,000 to 90,000 uninsured people that would have otherwise been eligible for Medicaid expansion. you find the highest percentage uninsured rates in rural counties. We still have 20 some million uninsured in this country. A number may have insurance but they’re underinsured for their various conditions. Ideally, everybody should be able to establish a healthcare proposition with their physician, nurse practitioner or physician’s assistant to access care whenever they need it.”

Then there are federal DSH monies to fund Medicaid expansion the state foregoes because the legislature’s voted against expansion. Gov. Pete Ricketts opposes it

as well. Disproportionate Share Hospital payments are subsidies paid by the federal government to hospitals serving a high percentage of uninsured patients. Nebraska hospitals write off uncompensated care cost while getting no money back for it.

Zetterman said, “We could expand Medic- aid and take advantage of the roughly $2 to $2.5 billion that’s failed to come into the state. It would have paid salaries for more people in physicians offices and a variety of things that would be taxed and bring in more revenue.”

DeBehnke of Nebraska Medicine said, “Being a large hospital health system that takes all comers, we have a Medicaid percentage of our business. We would be better off in a Medicaid expanded state. We would like to see more coverage for the working poor. That’s what Medicaid expansion is – providing coverage to the working poor. Those who don’t currently qualify for it would under an expansion.”

Proposed federal community block grants could expand coverage. DeBehnke cautioned, “We just have to be sure there’s good control around how those dollars are used and they actually go for healthcare coverage. Expanding coverage to all people is really the key.”

Nebraska State Senator Adam Morfield is the sponsor of lB 441, which would expand Medicaid in Nebraska. The bill is scheduled for a March 8 Health and Human Services Committee hearing.

The care-coverage-income gap may be more widespread than thought. Kids Count Report findings estimate 18.5 percent of Nebraskans are one emergency away from financial crisis.

Preventative Care is Long-Term Savings

Having coverage when you need it is a relief. Insurance also motivates people to get check-ups that can catch things before they turn crisis.

“A woman having symptoms for some time didn’t have any insurance and she waited

before she sought care,” McVea said. “By the time she came to us for diagnosis she already had a fairly advanced stage of colon cancer. She’s undergone chemo- therapy and surgery and is now living with a colostomy. That didn’t have to happen. We see things like that every day – people who’ve let their diabetes and other things go to where they have coronary artery dis- ease, and that’s not reversible. We’re trying to get them back to the path of health with treatments, but they’ve lost that opportunity to maintain a high quality of health.”

Zetterman said, “There’s good data to show patients with cancer who don’t have insurance tend to arrive with more advanced disease at the time of initial discovery because they come late to seek care.”

That pent-up need is expressed more often, McVea said, as “people have insurance for the first time or for the first time in a long time.”

“We’ve seen a lot of people come in as new patients saying, ‘I know I should have come in a long time ago, and I’ve just been putting it off.’ Many are middle-aged. They’ve been putting off chronic health conditions or screening tests or other things for years. We see people come in with diabetes or high blood pressure that’s out of control and within three months we get them to a point where everything’s in control, they’re feeling better, they have more energy, they’re feeling good about their health. We’ve maybe given them advice about diet and exercise and ways they can keep themselves healthy.”

More positive outcomes are prevalent across the healthcare spectrum.

“I would say overall the average patient is having a better experience and outcome now than they were five years ago,” Nebraska Methodist’s Jeff Francis said.

One World’s CEO, Andrea Skolkin, said, “We’ve been able to reach more people living on limited income so our services have been able to expand both in terms

of numbers of patients we care for as well as types of services and locations.” One World opened two new satellite clinics with help from ACA generated monies. “As we’ve opened new clinics we’ve seen a number of people that had never been seen or delayed being seen with very complex

medical and sometimes mental health issues – and it’s more costly. We grew from about nine or ten percent of patients with insurance to close to 15 per- cent. For newly insured patients it’s meant some peace of mind.”

Fewer insured people, Higher Costs

She and her community health center peers favor more afford- able coverage to increase the numbers of those insured.

Zetterman said high premiums and co-pays present obstacles that would be lessened if everybody got covered. “The financial burden on the individual patient and family for health- care right now is too high.”

DeBehnke said, “A lot of the

burdens of those premiums in terms of high deductibles and other things have been shifted to families. There has to be some degree of subsidization if we’re going to make this all work. Regardless of where we land with this, the financial burden on the individual patient and family for health- care right now is too high.”

For the poor, the last resort for care continues to be the ER.

“If you’re uninsured the one place you can go in this country is to the emergency room of a hospital because the laws say you cannot turn anyone away from there,” said Zetterman. “As a consequence the uninsured make use of the ER because it guarantees they’ll get cared for – at least at that moment. The ER is the most expensive place to go for things that could otherwise be handled in a healthcare office.”

Zetterman said America’s handling of its social contract and safety net means “we cost shift in the healthcare environment to pay for things.” “In Nebraska, where we didn’t expand Medicaid,” he said, “we cost shift from private insurance and healthcare providers to people who have private insurance. They help pay for the uninsured-underinsured. We’ve estimated that to be well over a billion dollars. We can’t control costs reliably until everybody is in the system with some kind of a paid healthcare benefit. That can include all the current federal and state programs as well as commercial insurance that’s out there.

“Once we no longer cost shift to pay for healthcare we can begin to address the questions where are we spending our money and why are we spending it in those areas. Then we have a chance to control the growth of healthcare costs.”

Skolkin said, “A lot of hands in the pot helps add to the cost. There’s a lot of system inefficiencies, particularly in billing and credentialing, that could be made a lot of easier. That would save resources.”

DeBhenke said, “As the healthcare industry, we have not been engaged to the degree we need to be to actually decrease overall cost of care because frankly from a pure financial standpoint it’s not been in our best interest. The health systems, providers and other organizations have to really get be- hind this whole idea of providing value, of decreasing overall total cost of care while improving outcomes for patients. That’s got to work in parallel with legislative and subsidization levels at the federal level.”

He said until there’s more buy-in from “young invincibles” – 20-somethings in good health – to broaden or balance the risk pool and thus reduce payouts, costs will be a problem.

“Certainly the pricing needs to be attractive to those individuals to broaden the pool. And frankly the benefits associated with products on the exchange need to be attractive so those individuals feel comfort- able and actually want to have coverage. Those least likely to go to the marketplace and buy individual health insurance plans are exactly the people we want to do that to broaden the pool. Healthy individuals that don’t utilize healthcare much soften the financial blow.”

Repeal Without replace is A mess, Why not repair?

The ACA’s meant adjustments from all healthcare stakeholders. Opponents have resisted it from the start and that fight continues. In early January the Republican-led Senate began reviewing ACA to try and garner enough votes to repeal it through the budgetary reconciliation legislative process.

“Unfortunately President Trump has focused on what he’s going to take away without have a plan in place,” said Kristine McVea, “I think that’s been harmful. There’s a lot of fear and uncertainty among our patients. These are people who struggled without health insurance who finally got a chance at taking care of their health and are now very afraid of the possibility that’s all going to be taken away. We hear this every day from people coming into the marketplace and coming into see us for care, I think the capricious statements made by this administration have fueled that.”

More recently, talk of flat-out repeal has given way to amend or modify in acknowledgment of the gains made under ACA and the difficulty of dismantling its far-reaching, interrelated tentacles, absent a ready-to-implement replacement. The political fallout of taking away or weaken- ing protection people have come to rely on would be severe.

“Once leadership has really started to

dig into what it would mean to repeal this outright and try to replace it they’re finding it is not a simple thing to do and the health and coverage of millions of people are at stake,” said James Goddard, an attorney with the public advocacy group Nebraska Appleseed. “So things are slowing down with the recognition they need to be careful with this, and of course they do.

“I think the change in the way it’s being discussed is a reflection of the reality that this is a dramatic thing you’re discussing altering and they need to do it the right way. Much of the ACA hangs together and one thing relies on another and if you start pulling pieces of it apart, you have the potential for the whole thing to fall down.”

Zetterman said he and fellow physicians favor a cautionary approach.

“Most of us would say the Affordable Care Act should be maintained and improved. There are dangers in taking it away and replacing it because it’s now in so many different places.”

Nebraska Appleseed attorney Molly McCleery said total repeal would affect many. “Initial Congressional Budget Office projections show 18 million people would lose coverage, and then in the out years, 32 million would lose coverage – both private and public. The Urban Institute’s state-by- state impact study found 200,000-plus Nebraskans with a pre-existing condition would be impacted if that consumer protection would be taken away.”

Jeff Francis said, “The new ‘r’ word I’m hearing is repair. The consensus seems to be to keep what’s popular and working and change what’s not.”

EDITOR’S NOTE: Details of the recently proposed GOP replacement had not been released as of this printing.

Daniel DeBehnke said of the current climate, “I think it’s extremely confusing because it’s complicated. It’s like a balloon – you poke in one area and something bulges out in another. I think people are frustrated, and rightly so, they pay a lot for healthcare. It’s not just as simple as I-pay- a-lot-for-my-healthcare, ACA is bad, let’s get rid of it.’ There are layers of complexity. We may not like exactly how things are funded or how some components are dealt with. We may not agree totally with all the tactics to get there, but at the end of the day we’ve got more people covered.

I don’t think anybody has the appetite to change that back.

“We just have to figure out how to incrementally lessen the financial burden while maintaining the real goal – more people covered and providing value for the money being spent.”

He said the best course of action now for providers is to “just take really good care of patents and decrease unnecessary utilization and duplication of services,” add- ing, “It’s what everybody wants anyway.”

Fixing the marketplace

Meanwhile, on the insurers’ side, some carriers have left public health exchanges after incurring major losses. This state’s largest healthcare insurer, Blue Cross Blue Shield, opted out of the volatile marketplace.

“Since we started selling on the ACA marketplace we’ve lost approximately $140 million,” executive vice president Steve Grandfield said. “We have a responsibility to all our members to remain stable and secure, and that responsibility was at risk

if we had continued to sustain losses. The public marketplace is unstable, which has driven increased costs and decreased com- petition and consumer choice. The higher premiums go, the more likely people, especially healthy people, drop their coverage. That means the majority of people remain- ing on ACA plans are sick, with increasingly higher claims, which drives premiums up even further.”

He cited instances of people gaming the system by buying plans when they need care, then dropping them when they longer need it.

Granfield said Blue Cross supports a well modulated ACA overhaul.

“It’s important to put in place a smooth transition. We would like to see regula- tory authority for insurance returned to the states, including rate review and benefit design and closing the coverage loopholes that lead to higher consumer costs.”

He has a long wish-list of other changes he wants made.

The leaders of two major Nebraska health provider systems say they haven’t seen any impact from the BCBS defection because there are many other insurers and products on the market. The executives were not surprised by the move given the fluid healthcare field.

Nebraska Methodist’s Jeff Francis said, “There were a lot of unknowns. I think it takes several years through the insurance cycle to be able to correct those kinds of unknowns, especially the way the federal government handles the bidding and setting of rates That’s why you won’t see craziness or changes in the rates in the years to come because they now have several years of experience with this new population and they’re then able to price accordingly.”

Daniel DeBehnke of Nebraska Medicine said, “Regardless of what happens in Washington, if the exchanges are kept in place there will be some changes made either in the pricing or pool that will help organizations like Blue Cross perhaps get back in that business.”

Quality Health Care Starts with Collaboration

Collaboration is key for containing costs in a system of competing interests. More U.S. healthcare decisions are happening outside silos.

Francis said, “A big change in the last 10 years is opportunities to work more collaboratively. In the past it would have been much more stand-alone. Now the hospitals and physicians are working more closely. Nebraska Methodist is part of an account- able care organization – Nebraska Health Network, along with Nebraska Medicine and Fremont Health. We recognize the importance of learning better practices from each other so we can pass that along to make healthcare better for the community and for employers paying for their employees insurance.”

One result, he said, is “less antibiotics pre- scribed by our family doctors at Nebraska Medicine and Methodist Physicians Clinic.”

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