Trauma Centers and Access to Health Care

  • Poor, uninsured hit hardest by closing of trauma centers nationwide, By Ellen Kleinerman, October 5, 2011, Cleveland Plain Dealer: “The shuttering of trauma centers across the country since 2001 has had a greater impact on communities with black, Hispanic, elderly, uninsured and poor people, according to a study released Wednesday. Researcher Dr. Renee Yuen-Jan Hsia said the closings — mostly in urban areas — were due to the high cost of trauma care, rising numbers of uninsured patients and cuts in Medicare payments…”
  • Study finds nearest trauma center is now farther away for 1 in 4 Americans, Associated Press, October 5, 2011, Washington Post: “One hour can spell the difference between life and death for victims of severe injury, but about a quarter of Americans now have to travel farther to reach the nearest hospital trauma center, a study published Wednesday concludes. The reason: Hundreds of trauma centers have closed over the past two decades. Sixty-nine million people had to travel farther to reach a trauma center in 2007 than in 2001, according a study in the journal Health Affairs…”

Young Adults and Health Insurance Coverage

  • Young adults gain health insurance under new law, By N.C. Aizenman, September 21, 2011, Washington Post: “Nearly 1 million more young adults have obtained health insurance since the 2010 health-care law began requiring insurers to let adult children stay on their parents’ plans until age 26, according to government data released Wednesday. The jump in enrollment caused the share of young adults who are uninsured to drop from 34 percent at the start of 2010 to 30 percent – or 9.1 million people – by March of this year, according to a national interview survey by the Centers for Disease Control and Prevention…”
  • Young adults make gains in health insurance coverage, By Kevin Sack, September 21, 2011, New York Times: “Young adults, long the group most likely to be uninsured, are gaining health coverage faster than expected since the 2010 health law began allowing parents to cover them as dependents on family policies. Three new surveys, including two released on Wednesday, show that adults under 26 made significant and unique gains in insurance coverage in 2010 and the first half of 2011. One of them, by the Centers for Disease Control and Prevention, estimates that in the first quarter of 2011 there were 900,000 fewer uninsured adults in the 19-to-25 age bracket than in 2010. This was despite deep hardship imposed by the recession, which has left young adults unemployed at nearly double the rate of older Americans, with incomes sliding far faster than the national average…”

States and Health Insurance Programs

  • States, unhappy with health-care overhaul, look to form compact, By Guy Gugliotta, September 19, 2011, Boston Globe: “State governors and legislators opposed to the federal health-care law are considering a novel approach to escape its provisions: joining an ‘interstate compact’ that would replace federal programs – including Medicare and Medicaid – with block grants to the states. To date, legislation has been drafted or introduced in 14 states and brought to the floor by lawmakers in at least nine. Three Republican governors – in Georgia, Oklahoma, and Texas – have signed the compact into law, while Governor Jay Nixon of Missouri, a Democrat, let the compact become law without signing it. Supporters say they hope to get 40 states to put it on the legislative calendar in 2012. If a significant number of states pass the compact, supporters plan to submit it to Congress for approval in the same way that the body approves interstate compacts regulating commerce, transportation, and resource conservation and development…”
  • Study looks at who remains uninsured in Mass., By Chelsea Conaboy, September 19, 2011, Boston Globe: “Much of the discussion around the 2006 Massachusetts health law has focused on how far the state has come in providing coverage for the uninsured. Dr. Rachel Nardin, a neurologist at Cambridge Health Alliance and chair of the Massachusetts chapter of Physicians for a National Health Program, said sometimes it is important to take a different look — to look at the glass as half empty and ask, why? She and others at the Harvard-affiliated health system published a study online with the Journal of General Internal Medicine last week looking at why people remain uninsured in Massachusetts despite a law mandating that most residents have health insurance…”
  • Pa. considering shift in Medicaid payments to help cut rising expenses, September 21, 2011, By Phil Galewitz, Philadelphia Inquirer: “Pennsylvania is considering paying Medicaid recipients as much as $200 as an incentive to visit higher-quality and lower-cost hospitals and doctors. Experts say the strategy has never been tried by other states. Gary Alexander, the state’s secretary of public welfare, said his agency hoped to launch the plan by early next year to help control rising expenses in the $30 billion Medicaid program…”

Health Insurance Coverage in the US

Healthcare costs rose while insurance coverage fell, studies show, By Noam N. Levey, September 8, 2011, Los Angeles Times: “U.S. workers whose wages stagnated over the last decade also saw their health insurance degrade, even as medical costs gobbled up a growing share of their income, two new studies show. An estimated 29 million adults who had health insurance lacked adequate coverage in 2010, leaving them exposed to medical expenses such as high deductibles that they couldn’t afford, according to a survey by the nonprofit Commonwealth Fund. That is up from 16 million underinsured people in 2003, the survey found, underscoring the rising burden that insurance plans are placing on consumers as the industry raises required co-pays and deductibles…”

Benefits of Medical Insurance to the Poor

  • First study of its kind shows benefits of providing medical insurance to poor, By Gina Kolata, July 7, 2011, New York Times: “When poor people are given medical insurance, they not only find regular doctors and see doctors more often but they also feel better, are less depressed and are better able to maintain financial stability, according to a new, large-scale study that provides the first rigorously controlled assessment of the impact of Medicaid. While the findings may seem obvious, health economists and policy makers have long questioned whether it would make any difference to provide health insurance to poor people. It has become part of the debate on Medicaid, at a time when states are cutting back on this insurance program for the poor. In fact, the only reason the study could be done was that Oregon was running out of money and had to choose some people to get insurance and exclude others, providing groups for comparison…”
  • Medicaid makes ‘big difference’ in lives, study finds, By Julie Rovner, July 7, 2011, National Public Radio: “As high-level budget talks drag on in Washington, the Medicaid program for the poor remains a prime candidate for cuts. In recent months, Republicans have criticized Medicaid for badly serving its target population. But a new study – the first of its kind in nearly four decades – finds that Medicaid is making a bigger impact than even some of its supporters may have realized. The study, being published as a working paper by the National Bureau of Economic Research, has a distinctly bipartisan flavor. Among its authors are Katherine Baicker of Harvard, who was an economic adviser to President George W. Bush, and MIT economist Jonathan Gruber, who has advised the Obama administration…”

Workplace Health Insurance Coverage – Minnesota

Fewer families get health coverage from workplace, By Jackie Crosby, June 28, 2011, Minneapolis-St. Paul Star Tribune: “The number of Minnesotans who get health insurance through employers has dropped 10 percentage points in the past decade, outpacing the decline nationwide, according to a study released Tuesday by the University of Minnesota. A decade ago, about 8 in 10 workers and their families received health benefits from a company-offered plan. By 2009, the most recent year available, 71 percent of Minnesotans were covered through the workplace. The shift parallels a trend in which growing numbers of Minnesotans earn lower wages and the ranks of those living in poverty swells…”

State Medicaid Programs – New Jersey, Massachusetts

  • Christie proposal to slash Medicaid by $540 million puts NJ at center of national debate, By Josh Lederman (AP), June 11, 2011, Washington Post: “As states across the country look for ways to trim billions off their spending on Medicaid, New Jersey is garnering particular attention for a proposal that opponents characterize as an unprecedented and draconian attempt to balance the state’s precarious budget on the backs of society’s most vulnerable populations. The debates taking place in statehouses, clinics and living rooms crystalize the unfortunate truth about economic recessions: Citizens rely most on public services just when the government has the least money to spend on those services. In New Jersey’s case, changes would mean a parent of two earning more than $103 per week would be ineligible…”
  • Human Services officials release details on N.J. Medicaid program cuts, changes, By Susan K. Livio, June 10, 2011, Star-Ledger: “The Christie administration released a long-anticipated outline today of how the state proposes to drastically restructure New Jersey’s Medicaid program and cut more than $300 million to help close a deficit. In the most controversial element of the proposal, the Department of Human Services expects to save as much as $32.5 million by sharply limiting who is eligible for coverage. It was the first time that the state disclosed estimates of what each change would save. For instance, parents in a family of three earning more than $422 a month, or $5,000 a year, would be disqualified for earning too much money, according to a document summarizing the proposal. Currently the income cut-off is $24,600 for a family of three…”
  • Advocates: ‘glitches’ keep Mass. kids uninsured, By Johanna Kaiser (AP), June 11, 2011, Boston Globe: “Forgotten paperwork, returned mail, and a lack of information are keeping thousands of Massachusetts children from receiving stable health care coverage in a state known for its far-reaching health care initiative. Although Massachusetts has the highest rate of insured children in the county — more than 99 percent — health care advocates and lawmakers say thousands of eligible children still go on and off the state’s Medicaid program, known as MassHealth, during the year because of administrative issues and other paperwork problems…”

Safety Net Hospitals and Charity Care

2 Illinois hospitals on brink of closure illustrate pressures on US health care safety net, By Carla K. Johnson (AP), May 9, 2011, Washington Post: “Two charity hospitals in Illinois are facing a life-or-death decision. There’s not much left of either of them – one in Chicago’s south suburbs, the other in impoverished East St. Louis – aside from emergency rooms crowded with patients seeking free care. Now they would like the state’s permission to shut down. The institutions, which have served low-income people in the state for more than 100 years, represent a significant development that’s gone largely unnoticed as the nation climbs out of the recession. Many charity hospitals, already struggling with rising costs, are on the brink of failure because of looming budget cuts, increasing numbers of uninsured patients and a slow economic recovery…”

Unemployment and Health Insurance Coverage

  • Report: Unemployment adds 9 million uninsured in U.S., By Steven Reinberg, March 16, 2011, US News and World Report: “The millions of Americans who lost their jobs and their health benefits during the recession often had no way to regain affordable health coverage, leaving them and their families at risk of financial ruin, according to a new report from The Commonwealth Fund. The spate of layoffs during the recession catapulted 9 million more Americans — or 57 percent of those who had had health insurance in a job that evaporated over the last two years — into the ranks of the millions already uninsured. In addition, 19 million people anxiously seeking private coverage over the last three years were either turned down or could not find a plan that was affordable and met their needs, the report found. The Biennial Health Insurance Survey also found a whopping 60 percent increase in skipped care due to cost in the past decade. The survey reported that medical debt problems and out-of-pocket spending costs were on the rise as well, with 29 million Americans using up their entire life savings to pay for medical bills and millions more unable to afford food, heat and rent due to medical payments…”
  • Job loss, health costs pushed uninsured to 52 million in U.S., March 16, 2011, San Francisco Chronicle: “Unemployment and rising expenses caused 9 million Americans to lose health insurance during the past two years, according to researchers backed by a group advocating access to health care. Losses of coverage helped swell the ranks of uninsured adults in the U.S. to 52 million in 2010, according to a study released today by the Commonwealth Fund, a New York-based foundation that says it backs research aimed at expanding and improving care. An additional 73 million adults had difficulties paying for health care and 75 million deferred treatment because they couldn’t afford it, researchers said. President Barack Obama’s health overhaul will provide access to insurance to almost all of the currently uninsured through expansion of the Medicaid program for the poor and through private health plans, said Sara Collins, a study author. Federal subsidies and rules on affordability and mandated benefits will allow many to buy coverage by 2014 when the law is due to take full effect, she said. The law is being challenged in court cases questioning its constitutionality…”

Ohio Family Health Survey

1.5 million Ohioans among the uninsured, By Suzanne Hoholik, March 8, 2011, Columbus Dispatch: “More Ohioans are uninsured, fewer businesses offer health benefits to workers and almost 250,000 people joined the state Medicaid rolls from 2008 to 2010, according to a survey released yesterday. The 2010 Ohio Family Health Survey found that the number of uninsured grew by almost 160,000 – including 15,283 children – during the two-year period. In all, there are about 1.5 million uninsured Ohioans. ‘These are preliminary numbers. They raise more questions than they answer at this point,’ said William Hayes, an adjunct assistant professor at Ohio State University’s College of Public Health. The survey also found that being uninsured is the second-largest category of health-coverage status, behind employer-sponsored health plans, for working adults 18 to 64 years old…”

Health Insurance Coverage in the US

  • Number of uninsured U.S. adults hits record high, By Steven Reinberg, November 10, 2010, USA Today: “Nearly 50 million Americans have gone without health insurance for at least part of the past year – up from 46 million people in 2008, federal health officials reported Tuesday. Those people included not only those Americans living in poverty, but an increasing number of middle-income people, according to a report from the U.S. Centers for Disease Control and Prevention. ‘The bottom line is that uninsurance of young and middle-class adults increased by 4 million people from 2008 to the first quarter of 2010,’ CDC Director Dr. Thomas R. Frieden said during a news conference Tuesday. What’s more, the number of people without insurance for a year or more increased from 27.5 million in 2008 to 30.4 million in the first quarter of 2010, Frieden said. ‘That’s an increase of 3 million of chronically uninsured adults…'”
  • Report: 59 million Americans lack health care, By Joshua Norman, November 10, 2010, CBS News: “More than 59 million Americans had no health insurance for at least part of 2010, an increase of 4 million from the previous year, the U.S. Centers for Disease Control reported Tuesday. While the worsening economic conditions did have a direct impact on the number of Americans with coverage, the situation also meant that a far greater number of Americans are forgoing needed medical care because of costs…”

Employment and Health Insurance Coverage

  • Health care becomes optional for people who are underemployed, By Aziza Jackson, October 11, 2010, Anniston Star: “It is no surprise that uninsured and underinsured Americans cannot afford to get sick nowadays. Obtaining affordable health care has indeed become a growing problem for many Americans, and, for the residents of Calhoun County, the problem hits even harder. According to a study headed by Dr. Samuel Addy, director and associate research economist at the Center for Business & Economic Research at the University of Alabama, Calhoun County has the highest number of underemployed workers out of all the other counties that make up the region known as ‘Region 5.’ Underemployed Calhoun County residents are considered employed because they do hold jobs. However, their jobs do not equal stability and do not provide them or their families with healthcare coverage. The underemployed are finding it difficult to make ends meet and afford medication and preventative care. Simply put: They can’t afford to get sick…”
  • High-risk insurance pool accepts patients with pre-existing conditions, By Patricia Anstett, October 11, 2010, Detroit Free Press: “Deri Mick is left to wonder whether the health insurance he just got through Michigan’s new program for the hard-to-insure came in time to help. Mick, 46, of Swartz Creek was set to have kidney cancer surgery last week at the University of Michigan. But tests found more cancer than expected. He awaits further tests and possibly chemotherapy. Through Michigan’s new high-risk insurance pool, Mick, who hasn’t had insurance for nine years, was able to get coverage that will cost him $350 a month. The program, which began offering coverage Oct. 1, is open to any adult 19-64 who has been rejected for insurance in Michigan. It will accept the first 3,500 applicants. Mick was turned down earlier in September by Blue Cross Blue Shield of Michigan, which can legally refuse to offer insurance to people with a pre-existing condition for a period of six months from the time of the request. But the company referred Mick to the new pool. ‘I’m going to be high risk all my life,’ said Mick, a divorced father of two who earns $38,000 a year. He hopes he will qualify for some financial help in 2014, when broader health reforms begin, including subsidies for lower-income people, particularly those earning less than $40,000 a year…”

Health Care Reform and Children’s Coverage

  • For many, health care relief begins today, By Kevin Sack, September 22, 2010, New York Times: “Sometimes lost in the partisan clamor about the new health care law is the profound relief it is expected to bring to hundreds of thousands of Americans who have been stricken first by disease and then by a Darwinian insurance system. On Thursday, the six-month anniversary of the signing of the Patient Protection and Affordable Care Act, a number of its most central consumer protections take effect, just in time for the midterm elections. Starting now, insurance companies will no longer be permitted to exclude children because of pre-existing health conditions, which the White House said could enable 72,000 uninsured to gain coverage. Insurers also will be prohibited from imposing lifetime limits on benefits…”
  • Some insurers to halt new child-only policies, By N. C. Aizenman, September 21, 2010, Washington Post: “Some of the country’s most prominent health insurance companies have decided to stop offering new child-only plans, rather than comply with rules in the new health-care law that will require such plans to start accepting children with preexisting medical conditions after Sept. 23. The companies will continue to cover children who already have child-only policies. They will also accept children with preexisting conditions in new family policies. Nonetheless, supporters of the new health-care law complain that the change amounts to an end run around one of the most prized consumer protections…”
  • New healthcare law kicks in today, By Todd Ackerman, September 23, 2010, Houston Chronicle: “Tens of thousands of Texas children will be directly affected by the 11th-hour decision of a number of major health insurance companies to stop selling child-only policies rather than comply with the new federal law that requires they cover youngsters with pre-existing conditions. All insurance companies starting today will accept children in family plans regardless of medical history, but Texas insurers United Healthcare, Aetna Inc. and Cigna Inc. are among the ones that will no longer offer policies just for individuals under 19. Such plans have grown in popularity in recent years as employee-based policies have cut coverage of dependents…”

Children’s Health Insurance Coverage

  • Health care program aims to cover uninsured children, By Patricia Anstett, September 3, 2010, Detroit Free Press: “As millions of children return to school, health leaders today launched an unprecedented national campaign to enroll 5 million uninsured children nationwide – including 172,000 in Michigan – in free or low-cost health insurance programs. Kathleen Sebelius, secretary of the U.S. Department of Health and Human Services, said the Connecting Kids to Coverage Challenge was timed to coincide with the opening of schools because ‘no child should be unable to read a book because their vision was not checked’ or be unable to participate in school sports because he or she didn’t have affordable coverage to pay for a sports physical. The federal Centers for Medicare and Medicaid is giving grants to states to help enroll more children in insurance programs…”
  • Participation in Children’s Health Insurance Program varies widely across country, By Phil Galewitz, September 3, 2010, Kaiser Health News: “The hunt for the nearly 5 million uninsured U.S. children who are eligible for free or low-cost coverage through Medicaid or the Children’s Health Insurance Program just got a road map. A new study published today in Health Affairs shows that 39 percent of the uninsured but eligible kids live in three states: California, Texas and Florida. Another 22 percent live in Georgia, New York, Arizona, Illinois, Ohio, Pennsylvania and North Carolina. That’s not a big surprise, because those states have more than half of all children in the country, according to the researchers at the Urban Institute, a non-partisan think tank in Washington. The study’s real value was showing that the states with the lowest participation rates in Medicaid and CHIP were largely in the Rocky Mountain region and Florida. While the national participation rate in Medicaid/CHIP was 82 percent, five states had participation rates below 70 percent: Nevada (55.4 percent), Utah (66.2 percent), Colorado (68.9 percent), Montana (69.3 percent) and Florida (69.8 percent). In contrast, the study showed the states with highest participation rates are Massachusetts (95 percent), Vermont (94 percent) and Maine (92 percent)…”

Free Health Clinics – Wisconsin

At these clinics, income no object, By David Wahlberg, August 29, 2010, Wisconsin State Journal: “They assembled in a parking lot on a hot afternoon: diabetics, men with toothaches and chest pain, a woman with torn cartilage, workers whose low wages or job losses left them uninsured. Mary Lyons waited for the free clinic to open so she could refill her nine medications. A diabetic with heart disease and a persistent cough, she works nights cleaning meat processing machines, making enough to get by but not enough to buy insurance, she said. She relies on the clinic for medical care. ‘I don’t know what I’d do without it,’ said Lyons, 61. Free clinics have become a prominent safety net in rural Wisconsin, especially in the southwest part of the state, where clinics have opened in the past four years in Boscobel, Dodgeville and Richland Center. Another, in Prairie du Sac, has been around for more than a decade. Volunteer doctors at the clinics care for the uninsured without charge and offer drugs at deep discounts. The need for free care around the state and the country could drop once the new federal health care reform law fully kicks in by 2014, some say. But Robin Transo, who opened Boscobel’s free clinic in the walk-out basement of a hearing clinic run by her husband, isn’t so sure…”

Recession and Rural Hospitals – Georgia

Rural hospitals face challenges across the state, By Charles Oliver, August 22, 2010, Dalton Daily Citizen: “The economic downturn, cuts in state and federal health care programs, and attempts by private businesses to rein in their own health care costs have combined to create a ‘perfect storm’ that threatens small rural hospitals across the state, according to Jimmy Lewis, CEO of HomeTown Health, which represents 55 rural hospitals in Georgia including Murray Medical Center. ‘We could wake up tomorrow and have 10 hospitals about to close,’ said Lewis. Forty-one Georgia hospitals have closed since 1980, according to the Georgia Hospital Association, many of them small rural hospitals. The problem that rural hospitals face is that their ‘payer mix’ is typically heavy in patients on Medicare and Medicaid and those without insurance…”

Recession and Health Insurance Coverage

  • Economy led to cuts in use of health care, By Robert Pear, August 16, 2010, New York Times: “The economic crisis in the United States has reduced the use of routine medical care, and the cutbacks here are much deeper than in countries with universal health care systems, researchers say in a new report. The study, published by the National Bureau of Economic Research, finds that ‘Americans, who face higher out-of-pocket health care costs, have reduced their routine medical care’ much more than people in Britain, Canada, France and Germany. Individuals and families in all five countries lost income because of unemployment and lost wealth because of steep declines in stock prices…”
  • 8.4 million Californians lack health coverage as the ranks of the uninsured swell, study finds, By Molly Hennessy-Fiske, August 23, 2010, Los Angeles Times: “The number of Californians who lost jobs and health insurance probably increased in every county last year, according to a study released Monday by the UCLA Center for Health Policy Research. The new analysis found that 37 counties — including Imperial, Kern and Shasta — had uninsured rates above the statewide average of 24.3%. ‘Different parts of the state were more adversely impacted than others, but really it is spread across the state,’ said one of the study’s authors, Shana Alex Lavarreda, the center’s director of health insurance studies. ‘You have counties from Kern to Shasta that were hit very hard with averages over what we saw in Los Angeles,’ she added. The report backs up the findings of a previous study the center released in March that showed nearly one in four Californians lack health insurance. According to the latest estimates, the state’s uninsured population has reached 24.3%, or about 8.4 million, up from 6.4 million in 2007…”
  • 85,000 lost health insurance in Sacramento area, UCLA study finds, By Bobby Caina Calvan, August 24, 2010, Sacramento Bee: “Researchers issued yet another grim statistic Monday on the toll of the recession: 2 million additional Californians – 85,000 of them in the capital region – lost their health care coverage during the recent economic slide. As a result, difficult decisions are playing out in living rooms and across kitchen tables as families struggle with joblessness and tighter finances, according to the authors of a new UCLA study that gives a county-by-county account of the state’s swelling numbers of uninsured, now estimated at 8 million. In Sacramento County, 17.6 percent of the non-elderly population went uninsured at some point last year, compared with 13.1 percent in 2007. In two years, the ranks of the county’s uninsured climbed by 63,000 people – bringing the total to more than 224,000, according to the study by the University of California, Los Angeles, Center for Health Policy Research…”

The Homeless and Access to Health Care

For the homeless, federal changes promise better access to health care, By Mary Agnes Carey and Andrew Villegas, August 20, 2010, Washington Post: “Homeless and unemployed, Tianne Hill said she dreads getting mail at the city shelter on Guilford Avenue where she lives because it often includes medical bills she can’t pay. The 40-year-old former waitress and short-order cook owes about $6,000 for abdominal surgery. She’s expecting another bill soon for emergency treatment of a seizure. And she has other conditions that require expensive care: asthma, arthritis, anxiety and depression. Like many other homeless people, Hill is uninsured and ineligible for Medicaid, the state-federal program that covers millions of other poor Americans. But beginning in 2014, Medicaid greatly expands under the new health-care law to include adults without children, who generally have been excluded. The Medicaid expansion also will enable agencies that serve the homeless to divert resources now spent on medical care to other services such as finding housing and jobs. The new law provides another boost through a five-year, $11 billion expansion of the community health center system that treats many in this population…”

Funding for Health Centers

Health centers to get $250 million in grants to build clinics, boost services, By Darryl Fears, August 18, 2010, Washington Post: “Health centers across the country are lining up for a shot in the arm from the Obama administration: $250 million in federal grants to build clinics and bolster services at existing clinics for low-income patients such as public housing residents, the homeless, seasonal farmworkers and others who struggle to pay for care. The administration announced last week that the nation’s 1,100 health centers, which operate nearly 8,000 clinics in medically underserved areas, can apply for the grants through the Health Resources and Services Administration (HRSA)…”

Emergency Room Use in the US

UCSF study finds big jump in ER visits, By Victoria Colliver, August 11, 2010, San Francisco Chronicle: “Emergency room visits to U.S. hospitals increased more than 23 percent from 1997 to 2007 – double what researchers expected the rise would be based on population growth, according to a UCSF study released today. Total annual visits to the country’s emergency departments rose from 94.9 million in 1997 to an estimated 116.8 million over the next decade, the study found. Visit rates for adults on Medicaid accounted for the jump, while rates for adults with private insurance and those on Medicare showed no significant change. Relatively low reimbursements to physicians who care for patients on Medicaid, the federal-state health program for the poor who meet certain criteria, were believed to be a key factor behind the increase…”