House immigration negotiators have given themselves until the end of the week to hash out language on what kind of health benefits should be available to undocumented immigrants seeking U.S. citizenship, a crucial issue for the talks.

If they can’t resolve this issue, the four-year immigration negotiations could come to a crashing halt.

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Top Democrats said late Tuesday they do not think Republicans will walk away from the talks.

(Also on POLITICO: Senate Judiciary panel passes immigration bill)

It was only less than a week ago that the bipartisan House group announced it had reached a tentative agreement on a proposal “in principle” to be introduced in June.

The provision, in essence, said immigrants seeking citizenship must provide their own health care — and if any government entity provides them with services, they would be ineligible for permanent citizenship. The language was aimed at assuaging Republican concerns that the immigration bill would plunge the nation further into debt.

But as word spread, top Democrats — including House Minority Leader Nancy Pelosi (D-Calif.) and Minority Whip Steny Hoyer (D-Md.) — began to grow uncomfortable with the language their party drafted to prevent undocumented immigrants from taking advantage of government-subsidized health care.

Top Democrats are concerned that in emergency situations, for example, undocumented immigrants would be forced to undergo procedures that could bankrupt them, and eventually lead to deportation.

“They wrote it,” said Rep. John Carter (R-Texas), a member of the bipartisan group, referring to the initial language.

The situation is so tenuous that there have been constant Democratic leadership meetings with immigration negotiators — two in the past 24 hours. Just hours after a Tuesday afternoon gathering, Pelosi called a leadership meeting for Wednesday at 10 a.m.

At a meeting late Monday, Pelosi twice got into a “lively discussion” with Rep. Luis Gutierrez (D-Ill.) — a member of the immigration group — claiming that they went beyond their purview of negotiating an immigration compromise.

The situation illustrates how remote a bipartisan House agreement is, although it seemed close a few days ago.

House Republican and Democratic immigration negotiators are spending this week tripping over each other, trying to explain how the bipartisan accord they thought they had last week is close to falling apart at the seams.

It’s a big step back for the prospects of immigration reform. Without a bipartisan House bill, Speaker John Boehner’s chamber won’t have as much buy-in to the process.

Behind the scenes, the situation is getting messy.

Democrats and Republicans in the immigration group are increasingly frustrated with Rep. Xavier Becerra (D-Calif.), who was noncommital to the health care language before it was released, while most of the group agreed, according to several sources involved in the negotiation.

When asked whether Becerra and Democratic leadership were behind the holdup, Carter said, “I think so.”

So now, as the agreements come undone, a secret legislative process is unraveling in public view. The deal that canceled staff trips and kept aides busy during recesses is crumbling.

And as their Senate counterparts wrap up their bipartisan compromise in committee, Democrats and Republicans find themselves fighting on familiar ground — health care.

Article source: http://www.politico.com/story/2013/05/house-immigration-talks-hang-on-health-care-91709.html

Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of “The Redistribution Recession: How Labor Market Distortions Contracted the Economy.”

Massachusetts and a few neighboring states are likely to experience the Affordable Care Act a lot differently than the rest of America.

Today’s Economist

Perspectives from expert contributors.

Massachusetts is often held up as a window into America’s health insurance future, because it embarked on what came to be called the Romneycare reform six years ago. Like the Affordable Care Act provisions going into effect nationwide next year, Romneycare aimed to increase the fraction of the population with health insurance by imposing mandates on employers and employees and by subsidizing health insurance plans for middle-class families without employer plans.

Because the subsidized plans are available for only low- and middle-income families whose employers do not offer affordable health benefits, some analysts fear employers around the nation will drop their health benefits as the Affordable Care Act goes into full effect, resulting in millions of people losing the opportunity to get health insurance through an employer.

But some people say they believe this fear is likely to be unfounded, because the propensity of Massachusetts employees to receive employer-sponsored health insurance was hardly different after Romneycare went into effect than it was in the years before.

The details and dollar amounts in the Massachusetts health care law differ from the national Affordable Care Act, and for that reason alone I hesitate to infer too much from the Massachusetts experience. Even if the two laws were essentially the same, the effects in Massachusetts could be different than the national effects because Massachusetts has a different population and business environment than the rest of the nation.

Last week I explained how specific types of employers could be expected to drop their health benefits during the next couple of years: those employers that currently offer benefits but nonetheless pay much of their payroll to people living in households below 300 percent of the federal poverty line, who are eligible for the most generous federal subsidies as soon as their employer ceases to offer benefits.

Massachusetts has an extraordinary fraction (almost two-thirds) of its population above 300 percent of the federal poverty line, and as a result practically all Massachusetts employers will prefer to retain their health benefits over the next few years, even though a significant fraction of employers elsewhere will not.

One way to quantify the difference between Massachusetts employers and employers elsewhere is in the percentage of payroll going to employees from families below 300 percent of the poverty line. At a national level, the percentage varies from 4 percent in Internet publishing to about 50 percent in restaurants and private household employers. The national average is 20 percent, compared with 13 percent in Massachusetts.

Employers have a variety of factors to consider in their benefit offering decisions, but I have made some estimates that focus on the payroll-composition statistics noted above. By my estimates, employers with percentages of 26 to 35 percent of employees above 300 percent of the poverty level have a sufficiently high percentage that they are likely to have been offering health insurance benefits before the Affordable Care Act. Yet they have a low enough percentage that their employees gain on average if the employer health benefit is dropped and employees take the subsidies available through the Affordable Care Act’s health insurance exchanges.

About 10 percent of employees with health insurance live in a state and work in an industry with compensation percentages in the range where profits are to be gained by dropping employer health insurance. But none of them live in Massachusetts, and some states that border Massachusetts, including New Hampshire and Connecticut, are in a similar situation.

A number of states and industries – especially the industries I emphasized last week – have more than 35 percent of their payroll paid to people in families under 300 percent of the poverty line and are unlikely to be offering employee health benefits.

But those employers in Massachusetts who have 35 percent of their payroll paid to people in families under 300 percent of the poverty line are more likely to offer some kind of health benefit, in part because of Romneycare’s incentives to create “cafeteria plans” in which employees authorize pretax salary to be withheld from their paychecks for the payment of health insurance premiums.

Under the federal law, the Massachusetts cafeteria plans will lose some of their advantages to employers in terms of avoiding penalties for failure to offer health benefits.

Based on the combination of these two factors — that no Massachusetts industries have 26 percent to 35 percent of their employees under 300 percent of the poverty line, and that Massachusetts employers will lose the advantages of their cafeteria plans — I calculate that employers offering health insurance in Massachusetts are one-third as likely to drop their employee health plans over the next couple of years as are employers in the rest of the nation.

That’s because the percentage of the United States work force at risk of losing its employer insurance (because of the tendencies of their industry and states to have low- and middle income employees) is three times the percentage of the Massachusetts work force in the same situation.

Article source: http://economix.blogs.nytimes.com/2013/05/22/massachusetts-employees-will-keep-their-health-plans/

Zina Moukheiber said the New York Digital Health Accelerator Is a Model to Emulate at the beginning of the program. With the proliferation of accelerators, I thought I’d share an insider’s perspective on what it was like to be in the program now that it is complete. I’ll also share some ideas on how can take it to the next level building off of their already-strong foundation.

Zina described the program as follows:

One of the toughest hurdles for health IT start-ups is getting in front of customers. Doctors are reluctant to pay, and sales cycles at hospitals can take months. Entrepreneurs often inspired by a negative personal experience, and moved to fix the problem, find later that their product doesn’t fit the hospital’s “workflow,” or offers no incentive for doctors to adopt it.

The New York Digital Health Accelerator’s (NYDHA) program was unique in that over 50 CIOs and CMIOs from 23 leading providers were the selection committee — in other words, prospective customers, not investors, made the call. These same executives agreed to mentor the startups during the program. Consequently, despite announcing that 12 companies would be selected, the program only selected 8 out of the 250+ companies that applied. With the executives making that level of commitment, they were only able to find 8 companies that met their high bar.

A major focus of the program was to get us connected to providers. A key responsibility for the provider mentor was convening meetings with their organization’s leadership. Even though they didn’t all become customers, the feedback and perspective was invaluable for our focus going forward. A few of the companies (including mine), were able to close major opportunities that are game-changers. As these were extremely competitive bids, being a part of the NYDHA program was a big help. Why? It took a lot of the perceived risk out of the equation because the providers knew that we’d cleared a high bar (i.e,., 50+ senior executives and investors had agreed that the selected companies were worth investing their time and money).

With the support of investors such as Milestone Venture Partners, Janssen Healthcare Innovation (Johnson Johnson), United Health Group, Aetna and others, the investment was managed by the Partnership Fund for New York City (PFNYC) led by Maria Gotsch. The investors recognize Healthcare’s Trillion Dollar Disruption provides a great opportunity. The program was co-managed by the New York eHealth Collaborative (NYeC) led by ex Intel veteran Dave Whitlinger. Much of our day-to-day program interactions were conducted by Maria and Dave’s lieutenants — Jahan Ali at the PFNYC and Anuj Desai at NYeC. They teed up many opportunities such as being featured at the Digital Health Conference and getting access to federal healthcare leaders.

One of the distinguishing facets of the NYDHA is providing the most funding per company of any accelerator ($300,000 or more) — roughly 5-15x more than other accelerators while taking significantly less equity. This ensures that the NYDHA will be the most competitive program to enter as the value proposition is strongest for healthtech startups. New York leaders are striving to ensure that New York is the epicenter of healthcare’s reinvention. Increasingly, other communities are organizing themselves with similar ideas such as Tampa Bay. Like New York, they strive to be where healthcare gets revolutionized and understand what was written in Jim Clifton’s The Coming Jobs War – i.e., it’s not just about maximizing short-term equity returns. Todd Park, our nation’s Chief Technology Officer, has said that the NYDHA program is one that other locales should seek to emulate.

As Zina outlined at the outset, the NYDHA has specific focus areas:

The accelerator’s mission is very focused, answering the needs of the state and health care providers. Start-ups need to have a product that addresses care coordination, patient engagement, analytics, or message alerts. New York is moving away from a fee-for-service system for Medicaid patients suffering from chronic illnesses, to one based on patient outcome. That involves coordinating care among different health care providers to prevent the likelihood of hospitalization. NYEC also oversees the state’s health information exchange which allows hospitals and doctors to electronically transmit patient records; it is looking to build applications on top of its network.

At the kick-off of the NYDHA program, Dr. Nirav Shah, the New York State Commissioner of Health, explained how the NY Health Home program is a key plank of how they are shifting from a hospital-centric view of healthcare to one that extends beyond the hospital walls. A reason why providers need modern cloud-based vendors is captured in the needs of the Health Home. They require systems that can scale from a two-person clinic with no IT infrastructure (other than an Internet connection) to a large urban hospital and everything in between. Not only would it be cost-prohibitive to deploy a traditional client-server model, it’s a highly dynamic time when providers don’t want to be burdened with nightmarish version upgrades typical in a client-server model. It was refreshing during the program to find providers who fully understood this and how it was imperative to move to a cloud-based model. These smart providers recognize how other health systems are spending billions to prepare for the “last battle” rather than looking forward.

NYDHA Recognized for its Results

Since the launch of the program in September 2012, the inaugural class of companies made tremendous strides in a marketplace (healthcare) noted for its slow pace of change and long decision cycles. The following are some of the accomplishments of the program shared by the NYDHA:

• In aggregate, the companies raised approximately $5 million in funding in order to drive growth while significantly expanding their customer base.
• This growth has led to the creation of jobs in New York, with the companies hiring 40 new employees since the program’s inception, with plans to add 41 additional staff by the end of 2013.
• In addition to providing product feedback, the participating healthcare providers facilitated 17 pilots at their organizations. Mount Sinai has adopted Cureatr’s enterprise-grade mobile care-coordination mobile app. Mount Sinai has signed a multi-year contract to roll out the app to Mount Sinai clinicians. The Brooklyn Health Home (an organization of 50+ independent provider organizations) and Maimonides Medical Center (large hospital in Brooklyn) selected Avado as their enterprise-wide standard for a patient portal and engagement platform for multiple years. [Disclosure: Avado is the company where I'm the co-founder, CEO]  By the end of the summer, Aidan will be helping 30,000 patients choose their post-acute care.

The NYDHA has received broad national recognition including the following:

• The California Healthcare Foundation has called the NYDHA one of the most successful accelerator models in the country. In particular, the report noted the financial and strategic ties that have already been forged in the market. These strong market ties are critical because they will determine which accelerators survive and thrive in the long term.
• The Rotman School of Management has ranked the NYDHA the number one Health IT Accelerator in the world, compared to 21 similar accelerators. The ranking was based on 10 different criteria including access to customers, investors, government, and support for innovation.

Raising the Bar on HealthTech Accelerators

There are some terrific healthtech accelerators such as Blueprint Health, Healthbox and Rock Health. They continue to raise the bar as Rock Health has brought in significant new funding and I’ve heard great things about Blueprint’s latest class while Healthbox is expanding their footprint with an accelerator in Florida. The great thing for healthtech entrepreneurs is as each one raises the bar, it gets better for the entrepreneur. In turn, that helps the health ecosystem. The best accelerators will separate themselves from the pack. Until the new accelerators establish a track record, I’m dubious of their value given meager funding (e.g., $20,000 per company) and aggressive asks on the equity front (e.g., 6-8%). I have a hard time imagining how they will get high quality companies with unfriendly terms such as this.

As part of the exit from the NYDHA, they asked for feedback so they can continue to improve. The NYDHA is in the planning stages of the next class. Along with others, I suggested broadening to additional health organizations. I was pleased when the NYDHA indicated they are looking to bring on sponsors and additional mentors from payers, pharma, and tech companies. This is a smart move, particularly as the lines are blurring between various industry segments. Large multi-specialty groups, tech companies, pharma, etc. tend to make decisions faster than traditional hospitals. I’m certain the first class would welcome the opportunity to get in front of these organizations as well. It will be interesting, over time, to see which accelerator programs foster their “alumni” to ensure their long-term success. That would be logical given the equity interest as well as to promote the cache of their alumni companies.

I’ve personally seen payers and pharma, in particular, making major bets (largely behind the scenes today) versus most health systems that are just dipping their toe in the water. My most read piece on Forbes has been IBM’s Reinvention Should Inspire Flat Pharma Businesses which speaks to the imperative pharma has to avoid the fate of the railroad industry. Future NYDHA classes should benefit from the aggressive moves by pharma and payers. I would expect Anuj Desai (NYeC’s VP of Business Development) is going to be busy striking deals with these organizations.

Ultimately, the litmus test for accelerators is how well they fix the market inefficiency of innovative healthcare organizations not being aware of innovative technology companies that could accelerate their market success. With the longest program (9 months) and best funding, the NYDHA has grabbed the pole position. As nimble startups themselves, I’m certain that other accelerators are going to respond and try to leapfrog the NYDHA. Everyone, including the NYDHA, benefits by this healthy competition. It’s never been a better time to be a healthtech startup.

A Few Words from the Startup Entrepreneurs 

The video below includes perspectives from the accelerator companies. I encourage companies who have been in the NYDHA and other accelerators to weigh in below on their experiences and how the accelerators can continue to improve. We’ll all benefit if the health ecosystem is more friendly to startups. For a long time, I said healthcare is where tech startups go to die as the field has been extremely tilted in favor of companies with deep war chests that could wait out interminable decision processes. Fortunately, the NYDHA and other accelerators are dramatically changing that through their efforts.

Article source: http://www.forbes.com/sites/davechase/2013/05/21/ny-digital-health-accelerator-is-a-model-to-emulate-startups-perspective/