Inside ACL Injuries
ACL injuries are an ever-present threat to the health of professional athletes who participate in high demand sports like football, basketball, and soccer. The latest victim being the Houston Texans rookie quarterback Deshaun Watson, who suffered a torn ACL during practice this weekend.
However, this type of injury does not only target pro athletes, anyone can suffer an ACL injury regardless of age or gender, from kids playing sports at school to weekend warriors who want to have a little fun outdoors, and yes even us couch potatoes can sustain an ACL injury.
What is an ACL Injury?
The knee joint is comprised of three bones, the femur (thighbone), the tibia (shinbone) and the patella (kneecap). These three bones connect to each other via ligaments that hold the bones together and provide stability to the knee.
There are two kinds of primary ligaments in the knee:
Collateral Ligaments: Found on either side of the knee, these ligaments are responsible for controlling the sideways movement of the knee.
Cruciate Ligaments: These are inside the knee, there are two of them the anterior cruciate ligament (ACL) which is in front and the posterior cruciate ligament located in the back. These ligaments cross each other to form an X and are responsible for controlling the back and forth motion of the knee. The ACL prevents the tibia from sliding out in front of the femur and provides rotational stability to the joint.
An ACL injury occurs when there is a tear in the ligament, more than half of ACL injuries cause damage to other structures in the knee such as cartilage, meniscus, and other ligaments.
Injured ligaments are considered sprains, but, depending on the severity they can be:
Grade 1 Sprains: Ligaments are slightly stretched but are still able to keep the knee stable.
Grade 2 Sprains: In this type of sprain the ligament has stretched to the point where it becomes loose, this is considered a partial tear of the ACL. This type of injury is rare.
Grade 3 Sprains: Known as a complete tear of the ligament. In these cases, the ligament is so severely stretched it splits into two pieces, causing the knee to become unstable.
Causes and Symptoms of ACL Injuries
The most common causes of an ACL injury include:
Being hit hard on the side of the knee, as is the case in a football tackle.
Overextension of the knee joint.
Changing direction rapidly.
Slowing down while running.
Landing from a jump incorrectly.
Pivoting with your foot firmly planted.
Symptoms of an ACL injury include:
Feeling or even hearing a pop in the knee at the time the injury occurs.
Pain on the outside and back of the knee.
Swelling within the first few hours of the injury, sudden swelling is usually a sign of a serious knee injury.
Loss of full range of motion.
Instability of the knee joint, feeling as if your knee is “giving way” or buckling with weight bearing.
Preventing ACL Injuries
Proper training and exercise is the best way to prevent ACL injuries, the ER Trained Physicians at Altus Emergency Centers recommend:
Doing exercises to strengthen your leg muscles, particularly the hamstring to ensure overall balance in leg muscle strength.
Exercises to strengthen your core which includes your hips, pelvis, and lower abdomen.
Use proper techniques and knee position when jumping and landing.
Improve pivoting techniques.
Wear footwear and padding that is appropriate for the type of activity you are engaging in.


Anthropomorphism is the attribution of human qualities to anything other than a human being – in literature it is typically done with animals or natural events. Aesop’s fables are a good place to start if you want to see anthropomorphism in action.
The reason that it is immoral is that animals aren’t humans and can’t talk. As such, it’s a deception. Think for a moment, on what life would be like if your pets really could talk. There is no reason to believe they would be kind or even helpful. Your cat for example, is probably a jerk, potty-mouthed, and likely a bit of a passive-aggressive racist.
You would be sitting there on your end of the couch, Mr. Tiddles on his and you’d be watching the news while he licked his anus with that raspy pink tongue of his, buffing that ruddy pink spider-bite to a new-car shine. Something would come on and you’d only be half paying attention when he’d stop his counter-clockwise lingual rotation and say “I just don’t trust those people!”
You would look over and say “Did you actually just say that? Did I actually just hear that?” and he’d go back to licking himself, very slowly, clockwise this time – for two complete rotations – and without ever breaking eye-contact with you (a challenge to your authority!) he’d stop and say “Why don’t you take a f*cking picture, Fatty. It’ll last longer.”
And that kind sirs and good madams, is your cat.
Don’t even get me started on your dog. If your dog was an actual person he’d repeat everything you said right back to you as a question, be obsessed with poop, and be like that kid in class the teacher shuts in a closet because he’d immediately stick his hand down his pants anytime he heard his name called, even if it was just to go into the closet for having his hand down his pants.
The above illustrate why we should not anthropomorphisize. I don’t even think anthropomorphisize is a real word. It didn’t pass spellcheck here. So don’t do it.
Now go take Mr. Tiddles to the vet and have him put down. He deserves it.
Keep the faith brothers and sisters, and I’ll be back after Watership Down is over. LOVE that movie.


But the electron affinity refers to an isolated gaseous atom while the E. An electronegativity table of the elements has the elements arranged exactly like in a periodic table, except that each atom is labeled with its electronegativity. NaBr exhibits the classic of ionic substances whereas is a gas a room temperature. You can then assess the quality of a bond between 2 atoms by looking up their electronegativities on the table and subtracting the smaller one from the larger one. If we take closed shelled elements also in to account, it is neon. Answer: Fluorine Which element has the lowest E.
In other words, the shared pair of electrons do not lie in the middle of the molecules but shift towards the atom having greater electron affinity. The O is more electronegative than the two Hs, so it holds the electrons more tightly and makes the entire molecule partially negative at the O end and partially positive at the H ends. This changes because as you move from left to right on the periodic table each additional electron added is not dignificantly farther away … from the nucleus but the charge in the nucleus increases so it attracts that electon with a greater force. This pattern will help when you are asked to put several bonds in order from most to least ionic without using the values themselves. If the difference is between 1. N difference between the two atoms by the Hannary and Smith relationship.
Since Pauling's formula only calculates differences, it is crucial that we are given the electronegativity of the one of the atoms in a compound before being able to perform our calculations. You can not talk about how strongly electrons attract when they join, if they do not join. A value between zero and two represents a polar covalent bond. This bond does not contain atoms at all, it consists of two ions. If only nonmetals are involved, the bond is considered polar covalent.
Provide details and share your research! If you're asking because you need homework help its a completely different process than what you're used to. In between the two exist the polar covalent bonds. I would say that depending on the compound. It can also be used to predict if the resulting molecule will be polar or nonpolar. Electronegativity changes from atom to atom because the force between the protons in the nucleus and the electrons in the outer shell changes from atom to atom. We can't talk about the electronegativity of one atom in a vacuum. Obviously there is a wide range in bond polarity, with the difference in a C-Cl bond being 0.
A bond in which the electron pair is equally shared is called a nonpolar covalent bond. N as the electrostatic force exerted by the nucleus on the valence electrons. Have you ever noticed how some people attract others to them? Electronegativity may be expressed on the following three scales. Find the first ionization energy of your atom. Typically this exchange is between a metal and a nonmetal. Electronegativity is the ability of an atom to attract electrons or electron density to itself.
To calculate electronegativy, find the electronegative values of each element involved in the bond. Inert gases have zero E. It has been found that the difference in electronegativity chart varies with the environment of the element. The larger the difference in the electronegativities, the more negative and positive the atoms become. Electronegativities give information about what will happen to the bonding pair of electrons when two atoms bond.
N difference between the two atoms and then by assigning arbitrary values to few elements e. Electronegativity is not measured in energy units, but is rather a relative scale. Mulliken Scale In this Mulliken scale, E. The atom that more strongly attracts the bonding electron pair is slightly more negative, while the other atom is slightly more positive. This is because their nuclei does not have a strong attractive force on electrons.
The results of the M. Pauling did not assign electronegativities to the noble gasses because they typically do not form covalent bonds. With a few exceptions, the electronegativities increase, from left to right, in a period, and decrease, from top to bottom, in a family. However, this effect is reduced in longer molecules. For this, it definitely depends on the two atoms you're looking at, and will not be constant throughout - however, it will also notsimply be the difference you'd calculate from an electronegativity table because of the effects mentioned above. Use an electronegativity table as a reference. That isn't to say we can't speak in averages, and for all intents and purposes Though not technically , the effective electronegativity of an oxygen atom bound to a carbon atom will be more or less the same.


Room 20 at the National Portrait Gallery
The Road to Reform
This largest room on the top floor has two large group portraits dealing with reform dominating the display. On the end wall is the House of Commons, 1833, commemorating the passing of the Great Reform Act in 1832, whilst the Anti-Slavery Convention, 1840 dominates another wall, with a portrait of Wilberforce closeby. On the wall opposite there is a full-length portrait of the parliamentary reformer Sir Frances Burdett, one of a number of portraits in the room by Sir Thomas Lawrence. There is also a striking two-tier plinth of white marble busts at the entrance to the room.
33 portraits on display in Room 20 at the National Portrait Gallery


lactone lac·tone (lāk'tōn')
An anhydride formed by the removal of a water molecule from the hydroxyl and carboxyl radicals of hydroxy acids.
Any of various organic esters derived from organic acids by removal of water. Lactones are formed when the carboxyl (COOH) group of the acid reacts with a hydroxyl (OH) group in the same acid, releasing water and causing the carbon atom to join to the hydroxyl's remaining oxygen atom, forming a ring. Vitamin C, the antibiotic erythromycin, and many commercially important substances are lactones.


Hawksbill Sea Turtle
Hawksbill Sea Turtle (Eretmochelys imbricata) Spanish Name: Tortuga carey
The hawksbill prefers shallow coastal waters and is frequently found around underwater rocks and coral reefs. Sometimes they are seen in estuaries.
This turtle lives in the warm tropical and subtropical waters of the Pacific, Atlantic, and Indian oceans as well as the Caribbean Sea.
The hawksbill is distinct among the sea turtles. It has a beaklike mouth that is curved and sharp, helping the turtle protect itself and eat. This is the only turtle with overlapping scutes (plates) on its shell. The shell is heart-shaped or shield-shaped; the edge becomes serrated toward the rear of the body. The hawksbill also has two pairs of large scales on its head between the eyes. Finally, and importantly, this turtle has an iridescent brown and cream pattern on its back popularly known as "tortoiseshell."?
Both sexes of this species have brown to reddish-brown scales on their skin that are bordered with yellow. The plastron, or underside, is yellow. The female's plastron is flat, but the male has a plastron that curves inward. This helps the male hold onto the female better when they mate, because her shell curves out. The male also has a long tail that can help him hold on.
Biology and Natural History
Dangerous as it is delicate, the hawksbill can and does defend itself with its large, hooked upper jaw. This is one of the most aggressive sea turtles.
Males and females meet in the shallow waters offshore of nesting beaches between April and November, with the highest activity in June or July. But these turtles mate when the female is returning to sea after laying her eggs, so their coupling is for a future season. Unlike the green turtle and olive ridley, the hawksbill is an individual nester. A female comes to nest once every three years, and she lays multiple clutches of eggs. At night, she crawls ashore, digs a chamber in the sand with her hind flippers, and releases between 50 and 200 eggs. She then pushes sand back over the eggs and heads back to the surf. Her eggs will hatch after 8 or 9 weeks, and the young turtles will begin racing to the water.
This turtle's diet makes it poisonous to humans (see below), but the hawksbill has still been overhunted for a long time. The hawksbill's shell, uniquely patterned and considered fashionable in some places, made the turtle a target for hunters. The shells were used for combs, jewelry, and other trinkets at the cost of heavily endangering the irreplaceable hawksbill. Now tortoiseshell patterns are manufactured so there should not be demand for the turtle's body. Still, poachers kill these turtles for their shells, meat, and eggs.
The hawksbill is a critically endangered species. It is protected by international policies and illegal to hunt. Read about Sea Turtles: Promises and Threats to learn more about the challenges facing this animal.
As a younger turtle, the hawksbill eats both plants and prey, but as it matures it eats more meat, including fish, mollusks, and sponges. It is able to eat jellyfish, and even eats the dangerously poisonous Portuguese man-of-war. Toxins from the jellyfish and sponges that the turtle eats make it a dangerous meal for humans, even though some still sell it as food. As long as people keep buying turtle eggs, meat, or shells, the fate of these delicate creatures is at great risk.
At its largest, the hawksbill can reach almost 100 cm in length.
Leenders, Twan. A Guide to Amphibians and Reptiles of Costa Rica. Zona Tropical, S.A, Miami, FL, 2001.
-Amy Strieter, Wildlife Writer


posted on Jun, 20 2004 @ 12:39 AM
A warning: This is mostly a brain storming / rough rough draft of a paper that I might attempt to flesh out.
Question 1: Does science necessarily find truth?
Answer 1: No. Science is inherently self correcting. The ideas that are given to us by the scientific method change all the time -- that is,
science tends to be in a more historical method of finding truth: "What is true depends on the time." New discoveries overthrow old explanations
of events, and as a result, what is thought to be true (With respect to science) is always negotiable.
Why is this? The scientific method has a horrible draw back that is not very well known about outside of philosophy circles: the problem of
induction. As most know, the heart of the scientific method is the experimentation and the observation thereof. Let me give a mathematical example
of the problem, then apply it to the typical science experiment ...
Let a function, say f(x) exist. Now, we notice that every time we insert an even number into the function f(2), f(4), f(6) .. and so on, the output
Can we then conclude for all even numbers of x that f(x) = 1? The answer is no; it could be the case that the number just after the last one we tried
would give a different value. That is, supposing we went up to f(100000),
f(1000002) could output 2 (we wouldn't know -- we didn't try it). The point being, we can never be with a certainty about f(x) until we tried all
possible even numbers (an infinite amount!).
Some would say this is obvious, but how does it apply to science? When science tests a variable within an experiment, it only does so a finite amount
of times. That is, there could exist an experiment where the same observation isn't made. This is the heart of why science must be self correcting;
it is always possible for a future observation to be different.
Question 2: If science doesn't find truth, then why do things built with scientific principles work?!
Answer 2: It is simple, really. Just because something works at doing a task doesn't mean the ideas behind its mechanism is true. For a quick
analogy, consider a possible scenario where every time a person leans on a specific wall a light turns on. This occurs with all people on this
particular wall. Is it true that leaning on a wall will turn on this light? Not exactly; for all you know, the light turns on because of a specific
motion (say a human leaning motion) that is programmed to turn on the light.
Bringing this all together: Consider the Newtonian concept of gravity. While it might be a phenomenon related to the distance and masses of objects,
for all we know there could be little faeries pulling us down that happen to correlation with masses and distance. The truth is not known, even
though the equations work!
Question 3: Okay, so science doesn't give truth. It only "works." Do you have any other problems with it? In short, science is silly in some
regards. Most sciences can be considered a specialized part of physics; i.e. what is biology but particles in motion? What is chemistry but
particles in motion? etc. The fundamental idea behind physics is "force."
What is a "force?" Existentially, a force is a "push or pull." However, having spoken with a couple of physics professors, I have been
corrected. More precisely, a "force" is more of an abstract concept. Why is this? All things in the physical universe (according to the physics
professors) are matter and energy (not to mention matter and energy are related). The common thing both matter and energy have is mass (even an
electron has mass), and if they have mass, then they have weight. (weight = mass * accel. of gravity).
A "force" does not have mass. It can not be weighed. It can not therefore be matter or energy. It can not therefore be in the universe. The
contradiction is apparent: Physicists talk about forces in the universe when it can not exist in the universe. Silly? I think so.
Question 4: It may be silly, but it still works. What's your problem?
Answer 4: By "works" I assume we all mean technology that uses the scientific method's conclusion work. Let me point out something odd:
Technology (and the science behind it) comes to maturity the quickest in warfare research.
The every day technology that we use now have some interesting backgrounds: The wrist watch was first developed to time cannon fire, for example.
What does this mean? What "works" may not necessarily be the best for mankind. Considering human nature, (especially at the point we are at right
now), do we really want an atomic bomb to work? Do we want machine guns to work? Do we want steel to become harder for better sabres?
For any reader of Gulliver's Travels, it is here one might focus their attention to the philosopher king that would not allow gun powder in to his
kingdom. The same point is reached: technology is not necessary for happiness (as the horses point out), nor should humans necessarily be trusted
Question 5: What about medicine?
Answer 5: Medicine never necessarily needed the scientific method. The scientific method was first really brought up by Descartes ("Discourse on
the Method"), and there existed medicine before then. Not to mention, before then (and even now!) people were claimed to be healed from methods
outside of current scientific research.
My conclusions on science follow as a consequence:
1. Science does not necessarily give us truth.
2. Technology that results from science is not necessarily good for us.
3. The value of science depends on how much value one places on truth, and how much value one places on "what works."


Although evidence of cognitive impairment in MSA is admittedly more limited than in Parkinson disease, it is now substantial enough to address modification of diagnostic criteria to include the potential for cognitive impairment at any stage of the disease.
Evaluating the risk factors of neurocognitive decline in HIV.
Findings from animal studies indicate that anesthetics may be neurotoxic and could result in long-term central nervous system alterations and cognitive dysfunction.
Physicians should provide counseling to adolescents on the effects of marijuana.
Mechanisms including silent cerebral infarct, microemboli, microbleedings, and cerebral hypoperfusion may be responsible for the link between atrial fibrillation and cognitive decline.
Individuals with prevalent dementia and any nursing home use had especially high 1-year mortality.
Cognitive dysfunction may be the result of lower intracerebral vasomotor reactivity which is linked to PHPT.
Previous reports have suggested that statins or the low levels of LDL cholesterol they promote may have an adverse impact on cognition.
Findings from this trial challenge current recommended systolic blood pressure targets for older adults.
Visual dysfunction is associated with poor cognitive function in older adults.
Cognitive deficits can be caused by sleep-disordered breathing.
Effective cognitive screening instruments are needed in order to assess and manage milder forms of HIV-associated neurocognitive disorders.
Most patients undergoing skull base irradiation for cancer do not have detectable cognitive impairment.
Reduced intelligence may be linked with developmental exposures to polybrominated diphenyl ethers.
A set of biomarkers is associated with cognition in male professional fighters.
Many residents in nursing homes with cognitive impairments may be taking potentially inappropriate medications.
Light therapy has a moderate effect on behavioral disturbances and depression for people with cognitive impairment.
The researchers found that postoperative delirium occurred in 24% of participants and that 12% had 2 or more delirium days.
Improved cognitive function in older adults is being linked to the Mediterranean diet.
Cognitive dysfunction is 3 times higher in patients with systemic lupus erythematosus.
An intensive lifestyle intervention including diet and exercise resulted in no improvements in cognitive impairment.
Significant benefits were seen with aerobic exercise, resistance training, multicomponent training, and tai chi.
Chronic use of low-dose aspirin was not associated with onset of dementia or cognitive impairment, but was also not associated with significantly better global cognition.
The researchers found that higher baseline HOMA-IR and fasting insulin levels were independent predictors of poorer verbal fluency performance.
Patients with subclinical hypothyroidism scored worse on tests of processing speed than patients with normal thyroid function.
Previous research has suggested that statins and PCSK9 inhibitors may adversely affect cognition.
Middle-aged adults with orthostatic hypotension were found 40% more likely to develop dementia over time.
The study results suggest that patients with non-NPSLE have impaired memory function indicative of working memory-related neural dysfunction.
Engaging in mentally stimulating activities like games, crafting, and computers may help slow cognitive decline in the elderly.
Specific differences were found in the brains of those who attempted suicide and those who did not.
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The Revolution That Led to the Iran We Know Today
The 1979 Iranian Revolution set the stage for today’s tough negotiations over Iran’s alleged nuclear ambitions. WSJ’s Jason Bellini has The Short History of Iran’s revolutionary ideals.
This transcript has been automatically generated and may not be 100% accurate.
... in today's Iran ... conservative and reformist forces are battling for supremacy ... Thames performers present son wanting to liberalize drones political system ... relaxed strict Islamic code ... are met with stiff resistance in Ayr on ... your credit dictatorship ... the present power is limited by the Supreme leader ... Ayatollah ... he or she ever wants court Islamic government and its antagonistic relationship with the West ... can be traced to the nineteen seventy nine Islamic revolution ... here's the short history it's the nineteen seventies ... your arms economy faltering ... it still played a key to the shop grows increasingly unpopular ... among it was intellectual class the scene is beholden to the US and Israel ... a secular Muslim his social reforms ... including giving women the right to vote ... for him at odds with the bronze religious leaders ... day help spread the writings and speeches of Ayatollah Khomeini ... who shot pushed into exile nineteen sixties ... abroad I've told me you'll street protests calling the overthrow shop ... shop supporters non violent counter protests ... Iran is on the brink of civil war ... then you're left as the meantime the child is drawn in what was officially described as a vacation ... open the way for the Ayatollah to return from exile to popular acclaim ... ten days later the Shah's appointed prime minister goes into hiding ... and Khomeini and his hardline Islamic supporters sees now ... death toll declares Iran Islamic Republic and himself ... as creamy ... as anti Western sentiment bills ... many of the country's western educated the lead the country ... later that year a group of Iranian protesters demand the extradition of the shop back to Rome ... so we can face trial and execution ... at this time he was in the US for cancer free ... the protesters stormed the US embassy ... seeking sixty six people hostage ... held hostage rescue attempts results in the depths of the U S servicemembers hostages are finding that these ... four hundred and forty four days later just minutes after the new American President Ronald Reagan takes the oath of office ... succeeding Jamie quarter ... since then the hardliners with an iron hand ... trading today's ongoing conflict between the former Sri locked country strict Islamic social code ... and what federal issues with the West ... and country entrenched conservative establishment ... to find those ideas at odds with their revolutionary right to its ... that's the short history of the Iranian revolution ...


Juan Mendoza, a seventh grader at Fair Haven Middle School, used to be fat. Like most overweight kids in middle school, he endured his share of taunting. But as much as it bothered him, he didn?t know how to change his situation. ?I used to just eat and not really care. I didn?t know why I was eating what I was eating,? he remembered. At the end of the school day, having skipped lunch and breakfast, Juan would hit the vending machines and stuff himself with unhealthy treats. On the way home local convenience stores lured him in with the promise of his favorite snack: Doritos. At home Juan?s family served him fried food; until last spring he had never even tried broccoli or cauliflower.
But in the fall of 2001, all of that changed. For 16 weeks Juan and 20 of his peers participated in an after-school program designed by Dr.
Margaret Grey, Assistant Dean of Research Affairs at Yale School of Nursing, and a team of colleagues. To Dr. Grey and her team, Juan is
representative of a national ?epidemic of obesity? that has hit low-income and minority populations disproportionately hard. Though all
of America is getting heavier as a result of reduced physical activity and poorer nutritional habits, socio-economic factors often determine
who is most affected. It is a fact that the poorest people in this country are also the most overweight.
In this regard, New Haven is a prototypical American city. Statistics highlight the gaping health discrepancies that exist nation-wide between upper- and middle-class citizens and inner-city dwellers. While approximately 16 percent of American youth are obese, in New Haven, where 85 percent of students in public schools are either African American or Hispanic, and the majority eat state-subsidized free lunches, the numbers hover between 45 and 50 percent. 41 students participated in the 16-week program at Fair Haven and Sheridan middle schools. All of them were considered clinically obese and all but one of them were either African American or Hispanic.
Yale psychology professor and obesity expert Kelly Brownell likens the weight crisis to the early days of the hiv/aids epidemic. ?Obesity is somewhat like hiv/aids was in that it is a stigmatized problem and so despite its dire consequences the public is slower to respond,? he explained. For the most part, poor people in America do not have access
to healthy food, cannot afford physically active lifestyles, and live in communities where obesity is commonplace. More troublesome, however, is the fact that obesity is the number one cause of Type 2 diabetes, one of the fastest growing diseases in America. In a statement issued last winter calling for changes in school lunch policies and the fast-food industry, Surgeon General David Satcher lamented, ?The nation?s obesity epidemic has gotten so bad it soon may overtake tobacco as the leading cause of preventable deaths.?
For Juan, the program presented an opportunity to improve his health, to stop being teased about his size, and to become an exception to the
rule. A lot was at stake for Dr. Grey and her research team as well: If the program, one of the first of its kind, could reverse trends towards
obesity and, more importantly, Type 2 diabetes in Juan and his peers, despite their home and school environments, then it could be a viable answer to a national problem. But success will depend on the program?s ability to counter problems deeply engrained in American society.
Statistically, Latino males between the ages of six and twelve like Juan have the highest incidence of childhood obesity?clinically defined
by a ratio of height to weight above the 85th percentile. Childhood obesity has been linked to low self-esteem, altered body image,
decreased preferences for physical activity, and depression. The most alarming problem, however, and the one that Dr. Grey is most worried
about, is the direct connection to the early onset of Type 2 diabetes, a condition that impairs the body?s ability to use insulin. As a
result, fats and sugars are less effectively digested, causing high blood sugar levels. This can lead to reduced energy, high blood
pressure, heart disease, and kidney disease. In 1980, only 2 percent of Type 2 diabetes cases occurred in children between the ages of nine and 19. Now that figure has jumped to between 40 and 50 percent. The sharp rise in Type 2 diabetes in children is a troubling indicator of what is to come. ?The problem here isn?t only health related,? explained Grey. ?This health epidemic has huge societal implications. These kids will be suffering from complications in their 20s that we haven?t generally seen until much later in life?and this doesn?t have to be the case.? But if the over-arching goals of Grey?s course are of national significance, its classroom goals are surprisingly basic: nutrition, exercise, and coping skills.
Juan remembers the beginning of the class as being extremely challenging. ?Almost everything I learned was new and it was hard to
change the kind of food I ate.? At the second session of the class, students were asked to talk about the kinds of foods they consume and
think of why they might choose those foods. While choosing foods based on taste, cost, and convenience was familiar to the students, thinking
about nutrition was not. High-sugar and high-fat foods are ubiquitous, regularly appearing in advertisements and promotions, while messages
about nutrition are more obscure. According to Brownell, ?the economics of food are the reverse of what they should be. Unhealthy food is easy, cheap, everywhere, and tastes good.? The students? diets at the beginning of the course reflected this. ?Their diets were high-fat,
high-carb and low-protein. They were drinking close to a liter of soda a day and didn?t know that it was a problem,? said Diane Berry, one of the primary researchers.
During the first few weeks, the nutritionist for the course, Pamela Galasso, tried to give the students tools and information that they
could use when making choices about food. ?I had to present them with a new way of talking to get them thinking about and actively participating in more meals,? said Galasso. The approach Galasso used was holistic. Rather than focus on diet and weight-loss, she tried to emphasize small changes that students could make. She presented them with ?culturally competent? food guide pyramids that included foods that the students typically ate, such as rice and beans, and taught them some mnemonic devices to help them make decisions about food.
Among the devices were phrases like ?diet: Deprived Individuals Eat Too much??a reminder not to skip meals?and ?soda: Stop Options Decide Act??encouraging careful decision making when choosing a beverage. Though these strategies may seem simple, for students who didn?t know that ?four tennis balls? of rice was too much, they were welcome tools. Each week Juan made goals for the next week?s class based on what he had learned: ?Sometimes it was to add more vegetables or to eat some breakfast. I would try to eat less high fat food.? The course gave Juan clear messages about food and nutrition?messages that were not often reinforced at home or at school.
Unfortunately, processed, high-fat, and high-calorie food is just as prevalent in schools as it is in homes and stores. Students on subsidized school lunch programs do not have many options when choosing what to eat. School lunches, though financed by the government and required to meet certain standards, are often high in fat and light on fruits and vegetables. ?The government policies are confused,? explained Grey. ?There are rules and regulations regarding school lunches. But in places like New Haven, where many of the meals are subsidized, the stuff they get free or cheap are the high fat choices.? In a recent study only 20 percent of schools met all the government?s nutritional requirements. ?Lots of times I didn?t like the school lunch,? Juan said, ?and so I would buy a soda or a candy bar or maybe both.? Juan?s decision to skip school meals and buy food from the vending machines was not unusual. ?Lots of these kids are eating two meals a day at school. If the school lunch doesn?t appeal to them, they turn to the vending machines. They have very limited healthy options,? said Berry. Schools across the country have lined their hallways with candy-stocked vending machines and filled their cafeterias with


Traumatic losses such as the death of a loved one by suicide are far outside of what we normally expect in life. The reactions of suicide survivors often include and go beyond normal grief reactions in severity and duration.
Common reactions include:
• Distressing recollections of the death
• Distressing dreams about the event
• A feeling of reliving the experience
• Feeling numb
• Feeling emotionally detached from other people
• Always feeling “on guard”
• Difficulty working
• Difficulty in social situations
• Difficulty falling or staying asleep
• Irritability or outbursts of anger
• Difficulty concentrating
Some survivors have a more difficult time healing. They develop more severe and lasting symptoms which are diagnosed as “Post Traumatic Stress Disorder.” (PTSD) There are many positive ways to cope with symptoms of trauma. A trained professional, experienced in suicide loss or treatment of traumatic grief, can be very helpful.
Post Traumatic Stress Disorder
Post Traumatic Stress Disorder is defined in DSM-IV, the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual. For a doctor or medical professional to be able to make a diagnosis, the condition must be defined in DSM-IV or its international equivalent, the World Health Organization’s ICD-10.
The diagnostic criteria for Post Traumatic Stress Disorder are defined in DSM-IV as follows:
A. The person experiences a traumatic event in which both of the following were present:
- the person experienced or witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others;
- the person’s response involved intense fear, helplessness, or horror.
B. The traumatic event is persistently re-experienced in any of the following ways:
- recurrent and intrusive distressing recollections of the event, including images, thoughts or perception
- recurrent distressing dreams of the event
- acting or feeling as if the traumatic event were recurring (e.g. reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those on wakening or when intoxicated)
- intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
- physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma) as indicated by at least three of:
- efforts to avoid thoughts, feelings or conversations associated with the trauma;
- efforts to avoid activities, places or people that arouse recollections of this trauma;
- inability to recall an important aspect of the trauma;
- markedly dimished interest or participation in significant activities;
- feeling of detachment or estrangement from others;
- restricted range of affect (eg unable to have loving feelings);
- sense of foreshortened future (eg does not expect to have a career, marriage, children or a normal life span.
D. Persistent symptoms of increased arousal (not present before the trauma) as indicated by at least two of the following:
- difficulty falling or staying asleep;
- irritability or outbursts of anger
- difficulty concentrating;
- exaggerated startle response
E. They symptoms on Criteria B, C and D last for more than one month.
F. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.


Exaptation, aka Co-Option: Still a Favorite Darwinian Excuse for Complex Adaptations in Nature
Birds fly because parts (like feathers) popped into existence for no reason, but later were found useful (for flight). Is that any way to explain the complex adaptations in life?
How evolutionary adaptations and innovations originate is one of the most profound questions in evolutionary biology. Previous work emphasizes the importance of exaptations, also sometimes called pre-adaptations, for this origination. These are traits whose benefits to an organism are unrelated to the reasons for their origination; they are features that originally serve one (or no) function, and become later co-opted for a different purpose. (Emphasis added.)
So we see that exaptation, pre-adaptation and co-option are essentially synonymous, supporting the counter-intuitive idea that purposelessness leads to purpose. (For a general answer to co-option, see Unlocking the Mystery of Life, the section about the bacterial flagellum.)
Barve and Wagner set out to determine whether evolution builds eyes, wings and other wonderful things primarily by natural selection or by exaptation. They also wanted to know how exaptations originate.
Exactly how new traits emerge in evolution is a question that has long puzzled evolutionary biologists. While some adaptations develop to address a specific need, others (called "exaptations") develop as a by-product of another feature with minor or no function, and may acquire more or greater uses later. Feathers, for example, did not originate for flight but may have helped insulate or waterproof dinosaurs before helping birds fly
Their short answer is, Yes -- exaptation outcompetes natural selection as evolution's mechanism of choice.
The findings underscore the idea that traits we see now -- even complex ones, like color vision -- may have had neutral origins that sat latent for generations before spreading through populations, Wagner says.
"Our work shows that exaptations exceed adaptations several-fold," he says. (Emphasis added.)
The Empirical Data
To support their claim, Barve and Wagner tinkered with the metabolism of E. coli bacteria. By altering steps in their metabolic networks in computational models, they found that some of the hypothetical bacteria were able to use other sources of carbon for energy:
Starting with the metabolism of an E. coli that can survive on glucose as its sole carbon source, they subjected the complex metabolic chemical process to a "random walk" through the set of all possible metabolisms, adding one reaction and deleting another from it with each step. They kept constant the total number of reactions and the bacterium's ability to survive on glucose alone, but allowed everything else to change. Every few thousand steps they analyzed the altered metabolism's reactions.
They found that most metabolisms were viable on about five other carbon sources -- sugars, building blocks of DNA or RNA, or proteins -- that are naturally common but chemically distinct compounds. To be certain that viability on these other carbon sources wasn't a natural consequence of viability on glucose, they tested metabolisms starting with viability on 49 other carbon sources, and each time found that exaptations emerged allowing the metabolism to survive on any one of several other carbon sources alone.
They reasoned that neutral mutations pre-adapted them to use those energy sources, even though in the wild they fed exclusively on glucose. Since exaptation appeared to work here, it must be a universal mechanism available to evolution.
But does their limited experimentation justify the claim that all of life generates complex adaptations by exaptations?
There are a number of problems with their conclusions, not exhausted by the following list:
1. Assume a toolkit: They assumed that all necessary nutrient transporters were present. "If this is not the case, the incidence of exaptation may be reduced," they confessed. They felt justified, though, since "84% of E. coli transporters can transport multiple molecules, and their substrate specificity can change rapidly, thus ameliorating this constraint." What other parts did they assume, or provide by intelligent design?
2. Search space: If lucky exaptations just "emerge" randomly, they have an excessively large search space to find a function. Stephen Meyer discussed this problem in Chapters 9-12 of Darwin's Doubt in relation to protein folds, but the same reasoning applies here: "combinatorial inflation" guarantees that no random process will have the time to search the available functional space. Barve and Wagner admit their method relies on chance:
Briefly, this procedure involves random walks in the space of all possible networks. During any one such random walk, a metabolic network can change through the addition and deletion of reactions. Although this process resembles the biological evolution of metabolic networks through horizontal gene transfer and (recombination-driven) gene deletions, we here use it for the sole purpose of creating random samples of metabolic networks from the space of all such networks.
3. Investigator interference: To avoid combinatorial inflation, which would have guaranteed failure on grounds of probability, they applied their own intelligent design to drastically reduce their test-tube "universe" of reactions:
As we described earlier, we specifically used the REACTION and COMPOUND databases to construct our universe of reactions while excluding all reactions involving polymer metabolites of unspecified numbers of monomers, or general polymerization reactions with uncertain stoichiometry; reactions involving glycans, owing to their complex structure; reactions with unbalanced stoichiometry; and reactions involving complex metabolites without chemical information. The published E.?coli metabolic model (iAF1260) consists of 1,397 non-transport reactions. We merged all reactions in the E.?coli model with the reactions in the LIGAND database, and retained only the non-duplicate reactions. After these procedures of pruning and merging, our universe of reactions consisted of 5,906 non-transport reactions and 5,030 metabolites.
4. Wild type: They did not test the efficiency of alternate carbon sources in living bacteria, nor did they release any in the wild to see if they continued thriving on other carbon sources in real-world conditions. The whole setup was contrived in models.
5. Coding: They did not test whether the alternative lifestyles would recode the genes to preserve the change, so that it could be inherited; they just assumed standard mutation and selection would take care of it.
6. Pre-design: Living E. coli can and do use multiple carbon sources for metabolism, but Barve and Wagner cannot assume that their lab-derived hypothetical exaptations would arise without purpose in a random or neutral manner. Metabolic systems in living cells could be pre-designed to adapt. There are many examples in living cells of "backup plans" if environmental conditions present starvation of resources.
7. Designed variability: Life also uses targeted variation. Our immune system, for instance, randomly generates and varies antibodies in the thymus gland when presented with an unknown pathogen. Once a suitable fit is obtained, it is put to use -- a form of "artificial selection" by a system designed to use randomness for a purpose. The researchers did not consider whether the bacteria were prepared -- by design -- to respond to an imposed "random walk."
8. Extrapolation: Barve and Wagner acted recklessly in their extrapolation, taking results from an artificially small "universe" of reactions in one species of bacteria and assuming it could speak to a universal principle. From their highly contrived results, they presumed to pontificate about bird flight and eye design.
9. Bye-bye Darwin: If Barve and Wagner are right, it means 154 years of faith in natural selection to produce complex adaptations has been misguided. They appear worried about that, saying in their conclusion, "If confirmed in systematic analyses like ours, the pervasiveness of non-adaptive traits may require a rethinking of the early origins of beneficial traits." The Santa Fe Institute puts it this way: "If exaptations are pervasive in evolution ... it becomes difficult to distinguish adaptation from exaptation, and it could change the way evolutionary biologists think about selective advantage as the primary driver of natural selection."
For these and other reasons, this paper and its accompanying news release amount to little but bluff and bluster. Their conclusions do not follow from their contrived setup. Maybe we should just ask Barve and Wagner if their own scientific work was an exaptation from hunting for meat or howling at the moon. If so, why would it have any validity? (See The Magician's Twin, Chapters 8-9).
It's hard to take seriously the beliefs of those who see dinosaurs finding feathers "emerging" on their arms for no purpose, or to keep warm or attract mates, then imagine that birds found them useful for flying. Time to watch Flight: The Genius of Birds again.


Taking care of your teeth should be a part of your daily routine. Neglecting a consistent oral health routine can lead to tooth decay and a variety of dental issues, most commonly cavities.
Tooth decay can be caused by many factors such as dry mouth, frequent sugary snacks and improper hygiene. However, the best way to combat tooth decay is to prevent it. Below we have listed five of our top tips to help you prevent tooth decay.
Brush With Toothpaste Containing Fluoride
Fluoride helps protect the enamel on your teeth so that it can resist the acid produced by bacteria in your mouth. Toothpastes that contain fluoride are extremely useful and effective in helping to prevent cavities.
Maintain A Daily Routine
Brushing and flossing twice a day assists in keeping your teeth and gums healthy. Flossing removes plaque and cleans areas that your toothbrush can’t reach. It is important to clean your teeth before going to sleep so that bacteria doesn’t have a chance to damage your teeth. Make sure when doing so, you brush and floss with proper technique, otherwise your efforts will not have the same desired result.
Limit Sugary Foods
A well-balanced, healthy diet helps to improve your overall oral health. By limiting sugary foods and drinks not only will you improve your overall diet, but you will help reduce your chances of developing cavities. If you do indulge, make sure to brush your teeth to remove any remnants that can lead to tooth decay.
Dental sealants cover up deep grooves in teeth in individuals that have a high risk for decay. This minimizes chances of decay in the future by converting grooves that catch food to a shallow smooth surface that will not hold bacteria.
Routine Dental Visits
Regular hygiene visits and dental exams are essential to maintaining your oral health. Regular cleanings allow your dentist to assess the health of your gums and teeth. It is recommended you attend regular appointments once every six months, or more depending on the recommendations of your dentist.
Looking To Book Your Next Dental Appointment?
If you have any questions on how you can modify your dental routine to help prevent tooth decay, or if you would like to book your next check-up, contact us today.


Types of tones in essaysAspasia Aurstad December 24, 2016
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Pronunciation: (un-kon'shus), [key]
1. not conscious; without awareness, sensation, or cognition.
2. temporarily devoid of consciousness.
3. not perceived at the level of awareness; occurring below the level of conscious thought: an unconscious impulse.
4. not consciously realized, planned, or done; without conscious volition or intent: an unconscious social slight.
5. not endowed with mental faculties: the unconscious stones.
the unconscious, Psychoanal.the part of the mind containing psychic material that is only rarely accessible to awareness but that has a pronounced influence on behavior.
Random House Unabridged Dictionary, Copyright © 1997, by Random House, Inc., on Infoplease.


1911 Encyclopædia Britannica/Priene
|←Priego de Cordoba||1911 Encyclopædia Britannica, Volume 22
|See also Priene on Wikipedia; and our 1911 Encyclopædia Britannica disclaimer.|
PRIENE (mod. Samsun kale), an ancient city of Ionia on the foot-hills of Mycale, about 6 m. N. of the Maeander. It was formerly on the sea coast, but now lies some miles inland. It is said to have been founded by Ionians under Aegyptus, a son of Neleus. Sacked by Ardys of Lydia, it revived and attained great prosperity under its “sage,” Bias, in the middle of the 6th century. Cyrus captured it in 545; but it was able to send twelve ships to join the Ionian revolt (500-494). Disputes with Samos, and the troubles after Alexander's death, brought Priene low, and Rome had to save it from the kings of Pergamum and Cappadocia in 155. Orophernes, the rebellious brother of the Cappadocian king, who had deposited a treasure there and recovered it by Roman intervention, restored the temple of Athena as a thankoffering. Under Roman and Byzantine dominion Priene had a prosperous history. It passed into Moslem hands late in the 13th century. The ruins, which lie on successive terraces, were the object of missions sent out by the English Society of Dilettanti in 1765 and 1868, and have been thoroughly laid open by Dr Th. Wiegand (1895-1899) for the Berlin Museum. The city, as rebuilt in the 4th and 3rd centuries, was laid out on a rectangular scheme. It faced south, its acropolis rising nearly 700 ft. behind it. The whole area was enclosed by a wall 7 ft. thick with towers at intervals and three principal gates. On the lower slopes of the acropolis was a shrine of Demeter. The town had six main streets, about 20 ft. wide, running east and west and fifteen streets about 10 ft. wide crossing at right angles, all being evenly spaced; and it was thus divided into about 80 insulae. Private houses were apportioned four to an insula. The systems of water-supply and drainage can easily be discerned. The houses present many analogies with the earliest Pompeian. In the western half of the city, on a high terrace north of the main street and approached by a fine stairway, was the temple of Athena Polias, a hexastyle peripterial Ionic structure built by Pythias, the architect of the Mausoleum. Under the basis of the statue of Athena were found in 1870 silver tetradrachms of Orophernes, and some jewelry, probably deposited at the time of the Cappadocian restoration. Fronting the main street is a series of halls, and on the other side is the fine market place. The municipal buildings, Roman gymnasium, and well preserved theatre lie to the north, but, like all the other public structures, in the centre of the plan. Temples of Isis and Asclepius have been laid bare. At the lowest point on the south, within the walls, was the large stadium, connected with a gymnasium of Hellenistic times.
See Society of Dilettanti, Ionian Antiquities (1821), vol. ii.; Th. Wiegand and H. Schrader, Priene (1904); on inscriptions (360) see Hiller von Gärtringen, Inschriften von Priene (Berlin, 1907), with collection of ancient references to the city. (D. G. H.)


The Florida Health Care Landscape
On January 1, 2014, the Affordable Care Act (ACA) goes into full effect and ushers in health insurance reforms and new health coverage options that will impact Americans across the country. Florida, like other states, will experience changes to its health care delivery system. This fact sheet provides an overview of the health, health coverage, and health care in Florida today, as well as health reform efforts and opportunities looking forward to 2014.
Florida has a large and diverse population. Home to over 18 million residents, Florida is the fourth most populated state in the U.S. In 2011, 59% of Floridians identified as White, 22% identified as Hispanic, and 15% identified as Black (Figure 1).1,2 Florida has a higher share of individuals ages 65 and older than any other state, reaching 18% of the state’s population, or over 3 million people.3 Over 19% of Florida’s population was foreign-born in 2011, although 91% of Floridians are U.S. citizens.4 Over ¼ of the population (28%) speaks a language other than English at home.5 Aligned with the national average, 20% of the state’s population, or nearly 4 million people, were living in poverty in 2011 (Figure 2). However, like in other states, poverty in Florida is not equally distributed by race or age. Thirteen percent of those living in poverty identified as White, while 29% identified as Hispanic and 36% identified as Black. In addition, 28% of those living in poverty were children 18 or under, while 20% were adults 19-64 and 14% were 65 or older.6
The total population health of Floridians is ranked below the national average. Florida ranked 34 among the 50 states for total population health in the United Health Care Foundation’s report, America’s Health Rankings 2012.7 Florida’s rates of infant mortality, obesity, and diabetes are slightly higher than the national average,8 while the state’s smoking rates are lower.9 Average life expectancy in Florida is above the national average.10 While the prevalence of asthma among Floridians is lower than the national average, the prevalence of asthma among Hispanics in Florida is well above the national average and ranked the 12th highest in the U.S.11
Disparities in health and health care access are faced by Florida residents. In 2012, 21% of White nonelderly adults had no health care provider, compared to 25% of Blacks and 43% of Hispanics.12 In addition, White adults, including the elderly population, reported being in good health more frequently than Black and Hispanic adults.13 Population health also varies across Florida’s 67 counties, with many rural counties, such as those in the panhandle, faring worse than urban ones. Disparities exist among measures of health outcomes, such as morbidity and mortality, and across health behaviors and health care access and utilization.14
State and local initiatives are aimed at addressing existing health disparities and improving the health of the state’s population. Florida’s Office of Minority Health within the Department of Health has a “Closing the Gap” grant program to reduce racial and ethnic health disparities and promote disease prevention across the state.15 The Department of Health has also developed a Statewide Health Improvement Plan (SHIP) to improve the health of Floridians through improvement of key health and health access indicators.16 Population health is being addressed on a local level through the development of Community Health Improvement Plans across several Florida counties, such as the Alachua, Charlotte, and Gulf Counties.17 Community-based partnerships, such as Healthy Central Florida (HCF), are also working to promote healthier behaviors throughout their communities.18
Over 3.8 million people, or 20% of Florida’s population, were uninsured in 2011. This is the fourth highest uninsured rate of any state and it exceeds the U.S. average of 16% (Figure 3). Eight percent of the nation’s uninsured live in Florida. As shown in Figure 11 (Appendix), the nonelderly uninsured in Florida are not equally distributed across the state’s counties. As in other states across the U.S., the majority of nonelderly uninsured have at least one full-time worker in their households, have incomes below 250% of the Federal Poverty Level (FPL), and are under age 55 (Figure 4).19
Among the 80% of Floridians with health insurance, the largest share were insured through employer-sponsored coverage (53%), followed by Medicare (21%), Medicaid (18%), and individual insurance (6%).20
Florida’s Medicaid program covers nearly 2.7 million low-income individuals, for whom the state spent about 16% of its general revenue funds during the 2011 state fiscal year (Figure 5).21 Of those enrolled in 2010, 51% were children, who accounted for 20% of expenditures (Figure 6). Meanwhile, 28% were elderly or disabled, who accounted for 66% of total costs.22 The combined federal and state costs for Florida Medicaid were $18.3 billion in FY 2011.23 Average state and federal spending per beneficiary was $4,434, which was lower than the national average of $5,563 (Figure 7).24 This fiscal year, the federal government will pay 58.o8% of the cost of Medicaid in Florida; therefore, for every $1.00 that Florida spends on Medicaid, the federal government will send $1.39 to the state in matching funds.25 Florida also provides coverage for certain groups of children up to 200% FPL through three separate CHIP-funded programs: Healthy Kids, MediKids, and the Children’s Medical Service Network.26
Almost half (47%) of Florida’s Medicaid beneficiaries are enrolled in managed care arrangements.27 However, managed care penetration varies by region, from 28% to 66%.28 In October 2005, the Centers for Medicare & Medicaid Services (CMS) approved a Section 1115 Medicaid demonstration waiver, entitled Medicaid Reform, that piloted a new managed care program in 5 Florida counties.29 The program was designed to promote consumer choice and market competition among private health plans, while reducing the rate of spending growth.30,31 Participating health plans were allowed to offer customized benefits and reduced cost sharing and a cap was placed on annual benefits for beneficiaries. The waiver also established Enhanced Benefits Accounts, through which beneficiaries accrue credits for healthy behavior, and a Low Income Pool (LIP) that distributed $1 billion annually to support the state’s safety net providers. Concerns were raised two years after the waiver’s implementation about the effect it was having on beneficiary access to services and continued provider participation due to increased administrative burdens, in addition to questions about whether the waiver is cost-saving.32 Caps on annual benefits and limits on children’s benefits have been eliminated and the waiver was renewed for three years on December 15, 2011.
Florida has received approval to expand Medicaid managed care statewide. In June 2013, CMS approved an amendment to Florida’s Medicaid Reform waiver, now re-named the Managed Medical Assistance Program, for a statewide expansion of managed care for nearly all Medicaid beneficiaries, including dual eligible beneficiaries or those eligible for both Medicaid and Medicare.33 Along with approving the amendment, CMS included some unprecedented consumer protections, including a medical-loss ratio (MLR) requirement of 85% for participating plans (this is the first time CMS has required a MLR as part of a waiver agreement).34 The waiver agreement also requires that participating health plans commit to participating in the program for five years; the state must create annual consumer health plan report cards for plans on quality-of-care metrics (with a target of the 75th percentile among Medicaid plans nationally; this is a unique requirement of this waiver); and there are more stringent requirements for consumer input through the Medicaid Medical Care Advisory Committee (MCAC). The managed care transition is scheduled to be phased in throughout Florida’s 11 regions. By October 31, 2013, Florida must submit an implementation plan to the federal government that includes the state’s plans for assessing plan readiness and network adequacy, among other things. Enrollment is scheduled to begin in early 2014.35,36 Although it was just approved this past June, the waiver is scheduled to expire at the end of June 2014, three years from when it was originally submitted to CMS. Florida, therefore, must start seeking an extension of the amendment prior to the completion of the managed care transition.
Florida will transition many elderly and disabled Medicaid beneficiaries to managed care. Florida received approval from CMS in February 2013 for a three-year combined Section 1915(b)/(c) waiver to transition Medicaid beneficiaries using long-term services and supports (LTSS) to managed care.37 The Florida Long-Term Care Managed Care program will require mandatory managed care enrollment for most Medicaid beneficiaries ages 65 and older and ages 18 to 64 with physical disabilities. Through a phased implementation by geographic region, nearly 100,000 beneficiaries will be notified and transitioned to managed care from April 1, 2013 through March 1, 2014. Florida’s dual eligible beneficiaries, in addition to other high-need beneficiaries, will be impacted by both of these waiver managed care transitions. Florida is not one of the 9 states participating in CMS’ demonstration project to integrate Medicaid and Medicare for dual eligible beneficiaries.38
Florida’s safety net delivery system plays an important role in delivering health care to the state’s vulnerable populations. Florida’s community health centers and safety-net hospitals provide access to needed primary, preventive, and acute care services for low income and underserved residents. The state is home to 48 federally qualified health centers (FQHCs), which each have between one to 25 access sites around the state.39 During 2011, these health centers provided more than 4.1 million patient visits.40 Florida is also home to 14 safety net hospital systems that operate 23 hospitals throughout the state. Although safety net hospitals account for only 10% of the state’s hospitals, they see a quarter of all hospital admissions, including 100% of all Level I Trauma Center and Pediatric Trauma Care admissions. Forty percent of all Medicaid hospital days are spent in safety-net hospitals and they provide over 40% of the uncompensated care in the state.41 Despite the existing care capacity of Florida’s health care safety net, there are still high levels of unmet health care needs, in part due to provider shortages. Florida has 253 primary care health professional shortage areas (HPSAs), 218 dental HPSAs, and 140 mental health care HPSAs. Across each of these measures, less than 60% of the need for care is currently being met.42
Florida has been a leading opponent of the Affordable Care Act (ACA). On March 23, 2010, the day that President Obama signed the ACA, the state of Florida filed a lawsuit in federal district court challenging the constitutionality of the individual mandate and the Medicaid expansion.43 Florida was joined by 25 other states. The case was considered by the Supreme Court, combined with the case by another group of plaintiffs, including the National Federation of Independent Businesses (NFIB). On June 28, 2012, the Supreme Court ruled that the individual mandate was constitutional, but that the Medicaid expansion was unduly coercive, effectively making it a state option.
Florida is not expanding Medicaid coverage at this time. The Medicaid expansion is one of the major vehicles for expanding health insurance coverage under the ACA, expanding coverage to nearly all adults with incomes at or below 138% of the federal poverty level (FPL)($15,856 for an individual in 2013). The state of Florida estimated that just over 1 million Floridians would be eligible to enroll in Medicaid under the Medicaid expansion, primarily parents and other low-income adults (Figure 8).44 If Florida took up the Medicaid expansion, the federal government would pay 100% of the cost of coverage for 2014 through 2016, and then phase down to 90% in 2020 and beyond.
Despite prior opposition, Florida Governor Rick Scott announced on February 20, 2013 that he supports a three-year Medicaid expansion, with legislative approval.45,46 State Senator Joe Negron introduced SB 1816 this past legislative session to expand Medicaid through a privately administered managed care plan.47 This proposal, which was supported by Governor Rick Scott, projects state budgetary savings over the first 10 years of the expansion.48,49 In addition, some state estimates show that the influx of new federal funds would positively impact the state economy, by increasing general revenues, premium taxes, and provider taxes and fees.50 Ultimately, the Florida Legislature passed a limited health care bill that did not include the Medicaid expansion before adjourning the legislative session, which was signed into law in June 2013.51,52 As of September 30, 2013, Florida is one of 25 states not moving forward with the Medicaid expansion at this time.53 Regardless of a state’s Medicaid expansion decisions, all states must implement new eligibility and enrollment processes under the ACA, including a transition to determining income eligibility for most groups using Modified Adjusted Gross Income (MAGI)(Figure 9).54,55 Under the new MAGI eligibility rules, the eligibility level will be 210% FPL for children, 191% FPL for pregnant women, and 35% FPL for parents.56
Nearly 764,000 poor uninsured Floridians could be left without access to new health coverage options (Figure 10).57 Beginning in January 2014, citizens with incomes between 100% – 400% FPL will be eligible for tax subsidies to purchase health insurance in the Health Insurance Marketplace (undocumented immigrants are ineligible to receive subsidies to purchase coverage in the Marketplace, regardless of income). In Florida, nearly 1.6 million individuals will be eligible for premium tax credits.58 However adults with some of the lowest incomes (parents between 35% and 100% FPL and all childless adults < 100% FPL), will not have access to new coverage options. This will leave nearly 764,000, or 27% of the state’s nonelderly uninsured adults, including 91% of the nonelderly uninsured adults with incomes up to 100% FPL, without affordable health coverage options. Further, safety net clinics and hospitals that have traditionally served the uninsured population will continue to be stretched in Florida, especially safety net hospitals as their uncompensated care funding is likely to drop, while many remain uninsured.
Florida has defaulted to a federally-facilitated Health Insurance Marketplace. In December 2012, Governor Scott announced that Florida will not pursue a state-based Marketplace and, instead, will default to a federally-facilitated Marketplace. Florida is one of 27 states in which the federal government has set up and will run their Health Insurance Marketplace.59 Eleven insurance providers are participating in Florida’s Marketplace, although only Blue Shield of Florida is offering plans throughout the state.60 Floridians will have an average of 102 Qualified Health Plans (QHPs) per region, although the number of available QHPs is much lower in many of the state’s rural counties. The Marketplace will offer Bronze to Platinum level plans, all of which cover the Essential Health Benefits.61 Individuals can sign up for coverage by visiting www.healthcare.gov and those who have incomes between 100% and 400% FPL may qualify for sliding-scale premium tax credits to lower the cost of coverage.
Florida is pursuing its own marketplace for small businesses, called Florida Health Choices.62 The initiative, which began in 2008 with the enactment of SB 2534, will include a web portal where employers with 50 or fewer employees and some individuals, such as state retirees, can shop for health plans offered in their county.63 Florida Health Choices is a separate state initiative and does not comply with ACA requirements for the marketplace, such as providing subsidies to assist eligible low-income individuals with purchasing insurance or mandating that all health plans sold through the marketplace cover the Essential Health Benefits. The state provided $1.5 million for start-up funding in 2008 and an additional $900,000 in 2013. Florida Health Choices is intended to be self-sustaining with ongoing support provided through a fee of 2.5% of the premium for every policy sold through the marketplace paid by participating health plans and a $300 annual payment from agents who sell policies through the marketplace. Florida Health Choices has appointed a Board of Directors, hired staff, and appointed two steering committees to advise the Board – one for vendors and another for agents. In May of 2012, Florida Health Choices identified a third party administrator to provide a web portal, online plan selection tools, and a statewide customer contact center and, in September 2012, the state began beta testing the web portal.64,65 Thus far, Florida Blue, and its affiliate Florida Health Care Plans, has agreed to offer health plans, and Liberty Dental and Argus Dental have agreed to offer dental plans.66 Florida Health Choices is scheduled to become operational in early 2014 and it is unclear whether it will be amended to comply with the ACA.67
Florida has returned ACA grant funding, accepting less per capita than other states. Florida is one of two states (along with Alaska) that have not accepted any federal grant money for their Health Insurance Marketplaces.68 In 2010, Governor Rick Scott returned the state’s $1 million Exchange Planning Grant and, together with Louisiana and New Hampshire, is one of three states that have returned all or part of their Exchange Planning Grant funds.69 Although Florida has been awarded over $82 million in federal ACA grant funding, including a $2.3 million Consumer Assistance Program Grant to the Department of Elder Affairs in 2012, Florida has accepted less money per capita than other states.70 As of 2012, Florida had accepted $15.24 per capita in grant funds, the least amount of any state across the country and much lower than the national average of $40 per capita.71
The state is imposing barriers to ACA outreach and enrollment efforts. Outreach and enrollment efforts will be important to educating individuals about their new coverage options and assisting them with successfully enrolling in coverage. The federal government has provided $7.9 million in grant funding to eight organizations in Florida that will serve as Navigators who will facilitate enrollment in QHPs in the state’s federally-facilitated Marketplace.72 On May 31, 2013, Florida passed legislation to establish certifications and registration requirements for Navigators that go beyond the federal requirements.73 In mid-August, Florida raised concerns over the ability of Navigators to protect sensitive consumer information by joining 12 other states in an August 14, 2013 letter sent to HHS Secretary Kathleen Sebelius.74 A month later, Florida’s Deputy Health Secretary issued guidance for county health departments, stating that Navigators will not be able to inform individuals of the coming health care changes in county health departments.75
There is much to watch in Florida over the upcoming months, as the state’s waivers continue to be implemented and the ACA goes into full effect in January 2014. Opportunities exist to improve coverage and care for low-income and uninsured Floridians; however, without expanding Medicaid, many of Florida’s low-income adults will remain without affordable health coverage options.
Urban Institute (UI) and Kaiser Commission on Medicaid and the Uninsured (KCMU) estimates based on the Census Bureau's March 2011 and 2012 Current Population Survey (CPS: Annual Social and Economic Supplements).
UI and KCMU estimates based on Census Bureau's March 2011 and 2012 Annual Social and Economic Supplements to the CPS.
UI and KCMU estimates based on Census Bureau's March 2011 and 2012 Annual Social and Economic Supplements to the CPS.
Migration Policy Institute. “Florida Social & Demographic Characteristics” (2013), http://www.migrationinformation.org/datahub/state.cfm?ID=FL#3 and UI and KCMU estimates based on Census Bureau's March 2011 and 2012 Annual Social and Economic Supplements to the CPS.
U.S. Census Bureau. 2012 American Community Survey 1-Year Estimates: Characteristics of people by language spoken at home, http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_12_1YR_S1603&prodType=table.
UI and KCMU estimates based on Census Bureau's March 2011 and 2012 Annual Social and Economic Supplements to the CPS.
United Health Care Foundation. America’s Health Rankings: State Ranking Overview (2012), http://americashealthrankings.com/FL/2012. Full report available at: http://reportgenerator.americashealthrankings.org/Report/Create/Print/RankingsPreview/ALL/2012/false
Between 2007 and 2009, the infant mortality rate in Florida was 7.10% compared to the national average of 6.6%; in 2011, the percent of adults who had ever been told by their doctor that they have diabetes in Florida was 10.4% compared to the national average of 9.5%; in 2011, the percent of adults who are overweight or obese in Florida was 63.4% compared to the national average of 63.3%. All data is available on Florida’s page at www.statehealthfacts.org.
In 2011, the percent of adults who smoked in Florida was 19.1% compared to the national average of 20.1%. Data is available on Florida’s page at www.statehealthfacts.org.
In 2010, the life expectancy of a Floridian was 79.4 years compared to the national average of 78.9 years. Data is available on Florida’s page at www.statehealthfacts.org.
In 2010, the prevalence rate of adult self-report current asthma in Florida was 8.3% compared to the national average of 8.6%; in 2010, the prevalence rate of adult self-report current asthma among Hispanic Floridians was 9.9% compared to the national average of 7.2%. All data is available on Florida’s page at www.statehealthfacts.org.
This data is from a 2 year merge (2011-2012) but is referred to by the second year, 2012. Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data, 2011-2012.
In 2012, 83.4% of adult Whites claimed that they had good or better health compared to 76% among Black adults and 75.2% among Hispanic adults. This data is from a 2 year merge (2011-2012) but is referred to by the second year, 2012. Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data, 2011-2012.
Roderick King. County Health Rankings & Roadmaps: Florida (University of Wisconsin Population Health Institute, 2013), http://www.countyhealthrankings.org/app/florida/2013/rankings/outcomes/overall/by-rank.
Florida Department of Health, Office of Minority Health. “Closing the Gap” (August 5, 2013), http://www.doh.state.fl.us/minority/CTG/.
Florida Department of Health. Florida State Health Improvement Plan 2012 -2015 (Tallahassee, Florida: Florida Department of Health, April 2012), http://www.doh.state.fl.us/planning_eval/strategic_planning/SHIP/FloridaSHIP2012-2015.pdf.
Alachua County Health Department. Alachua County Community Health Improvement Plan (November 212), http://www.doh.state.fl.us/chdalachua/docs/alachuaCHIP.pdf; Charlotte County Health Department. Charlotte County, Florida Community Health Improvement Plan (August 2012), http://www.doh.state.fl.us/chdcharlotte/Resources/CCHD_CHIP-web.pdf; Gulf County Department of Health. Gulf County 2013 Community Health Improvement Plan Report (September 2013), http://www.gulfchd.com/forms/GULF_CHIP_Report.pdf.
Healthy Central Florida website: http://www.healthycentralflorida.org/.
National Association of State Budget Officers. State Expenditure Report: Examining Fiscal 2010-2012 State Spending (Washington, D.C.: 2012), http://www.nasbo.org/sites/default/files/State%20Expenditure%20Report_1.pdf.
UI and KCMU estimates based on data from FY 2010 MSIS.
Urban Institute Estimates based on data from 2011 CMS, Form 64 (August 2012).
Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY 2010 MSIS and CMS-64 reports.
Federal Register, November 30, 2011 (Vol 76, No. 230), pp 74061-74063, at http://www.gpo.gov/fdsys/pkg/FR-2011-11-30/pdf/2011-30860.pdf.
Martha Heberlein, Tricia Brooks, Joan Alker, Samantha Artiga, and Jessica Stephens. Getting into Gear for 2014: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2012-2013 (January 2013), http://www.kff.org/medicaid/report/getting-into-gear-for-2014-findings-from-a-50-state-survey-of-eligibility-enrollment-renewal-and-cost-sharing-policies-in-medicaid-and-chip-2012-2013/.
Florida Agency for Health Care Administration. Medicaid Managed Care Enrollment Reports. (August 2013), http://ahca.myflorida.com/mchq/managed_health_care/MHMO/med_data.shtml.
Florida Agency for Health Care Administration. (August 2012).
The pilot began in Broward and Duval Counties on July 1, 2006 and expanded to Baker, Clay, and Nassau Counties on July 1, 2007.
“Florida Medicaid Reform Pilot,” Florida Department of Health, http://ahca.myflorida.com/medicaid/medicaid_reform/index.shtml, 2011.
Samantha Artiga. Florida Medicaid Reform Waiver: Early Findings and and Current Status (Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation, October 2008), http://www.kff.org/health-reform/issue-brief/florida-medicaid-reform-waiver-early-findings-and/.
Georgetown University Health Policy Institute. Florida’s Experience with Medicaid Reform: What has been learned in the first two years? (October 2008), http://hpi.georgetown.edu/floridamedicaid/pdfs/briefing7.pdf.
Florida’s Managed Medical Assistance Program approval documents, http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/fl/fl-medicaid-reform-ca.pdf.
Medical Loss Ratio (MLR) quantifies the percentage of health care funds that must be spent on medical care, as opposed to overhead, executive salaries, or marketing. Starting in 2012, the ACA requires insurance companies to spend at least 80% to 85% of premium dollars on medical care and to provide rebates to consumers if they do not meet those standards.
Joan Alker. Florida’s Medicaid Managed Care Waiver Receives Final Approval: Some Strong Consumer Protections Included, Oversight Will Be Critical (Georgetown University Center for Children and Families, June 14, 2013), http://ccf.georgetown.edu/all/floridas-medicaid-managed-care-waiver-receives-final-approval-some-strong-consumer-protections-included-oversight-will-be-critical/.
Joan Alker and Jack Hoadley. Medicaid Managed Care in Florida: Federal Waiver Approval and Implementation (Georgetown University Health Policy Institute, October 2013), http://hpi.georgetown.edu/floridamedicaid/.
CMS. Approval letter for “Florida Long-Term Care Managed Care” 1915(b)/(c) waiver (February 1, 2013), http://ahca.myflorida.com/medicaid/statewide_mc/pdf/Signed_approval_FL0962_new_1915c_02-01-2013.pdf.
Nine states currently have MOUs signed with CMS, but this number keeps changing as CMS approves demonstrations on a rolling basis. For more information about the Demonstration projects, please see CMS. “Financial Alignment Initiative” (updated September 26, 2013), http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialModelstoSupportStatesEffortsinCareCoordination.html.
Florida Association of Community Health Centers. “Florida’s Federally Qualified Health Centers”, http://www.fachc.org/about-member-centers.php.
State Health Facts. “Federally-Funded Federally Qualified Health Centers Patient Encounters or Visits, 2011” (Kaiser Family Foundation, March 2013), http://www.kff.org/other/state-indicator/total-fqhc-encounters-or-visits/.
Safety Net Hospital Alliance of Florida website: http://safetynetsflorida.org/.
Bureau of Clinician Recruitment and Service. “HRSA Data Warehouse: Designated Health Professional Shortage Areas Statistics, as of July 29, 2013” (Health Resources and Services Administration, July 2013), http://ersrs.hrsa.gov/reportserver/Pages/ReportViewer.aspx?/HGDW_Reports/BCD_HPSA/BCD_HPSA_SCR50_Smry_HTML&rs:Format=HTML4.0.
MaryBeth Musumeci. A Guide to the Supreme Court’s Affordable Care Act Decision (Kaiser Family Foundation, July 2012), http://www.kff.org/health-reform/issue-brief/a-guide-to-the-supreme-courts-affordable/.
Florida Office of Economic and Demographic Research. Social Services Estimating Conference. Estimates Related to Federal Affordable Care Act: Title XIX (Medicaid) & Title XXI (CHIP) Programs (March 7, 2013), http://edr.state.fl.us/Content/conferences/medicaid/FederalAffordableHealthCareActEstimates.pdf.
Office of Governor Rick Scott. “Florida Won’t Implement Option Portions of Obamacare” (July 1, 2012), http://www.flgov.com/florida-wont-implement-optional-portions-of-obamacare/.
Office of Governor Rick Scott. “Governor Rick Scott: We Must Protect the Uninsured and Florida Taxpayers with Limited Medicaid Expansion” (February 20, 2013), http://www.flgov.com/governor-rick-scott-we-must-protect-the-uninsured-and-florida-taxpayers-with-limited-medicaid-expansion/.
Legislative actions for SB 1816, http://www.flsenate.gov/Session/Bill/2013/1816.
Fiscal analysis of Negron’s Healthy Florida proposal, http://ahca.myflorida.com/Executive/Communications/Press_Releases/archive/docs/2013/ProposalComparison.pdf.
There have been many economic impact analyses of the Medicaid expansion on Florida. The state’s Social Services Estimating Conference has released a series of such analyses. The latest, released on March 7, 2013, projects that the Medicaid expansion would draw down $51.5 billion in federal funds over from 2014 – 2023, costing the state $3.5 billion over the same time period (Florida Office of Economic and Demographic Research. Social Services Estimating Conference. Estimates Related to Federal Affordable Care Act: Title XIX (Medicaid) & Title XXI (CHIP) Programs (March 7, 2013), http://edr.state.fl.us/Content/conferences/medicaid/FederalAffordableHealthCareActEstimates.pdf).
Stan Dorn, John Holahan, Caitlin Carroll, and Megan McGrath. Medicaid Expansion Under the ACA: How States Analyze the Fiscal and Economic Trade-Offs (Urban Institute, June 2013), http://www.urban.org/UploadedPDF/412840-Medicaid-Expansion-Under-the-ACA.pdf.
Florida Chapter Number 2013-110 (June 6, 2013), http://laws.flrules.org/2013/110.
The Florida House of Representatives did introduce a bill on April 11, 2013 for a program called “Florida Health Choices Plus+”, that would be an alternative to the Medicaid expansion. If this program is adopted, the state would give each participant $2,000 per year to help them purchase coverage and enrollees would pay a $25 monthly premium. Nondisabled enrollees would be required to work at least 20 hours per week. Florida House Majority Office. Florida Health Choices Plus+ (April 2013), http://www.myfloridahouse.gov/Handlers/LeagisDocumentRetriever.ashx?Leaf=housecontent/HouseMajorityOffice/Lists/Other%20Items/Attachments/6/Florida_Heath_Choices_Plus.pdf&Area=House.
State Health Facts. “Status of State Action on the Medicaid Expansion as of October 22, 2013” (Kaiser Family Foundation, October 22, 2013), http://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/.
Medicaid.gov. “Medicaid and CHIP Eligibility Levels” (September 30, 2013), http://medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/Medicaid-and-CHIP-Eligibility-Levels/medicaid-chip-eligibility-levels.html.
Kaiser Commission on Medicaid and the Uninsured. Medicaid Eligibility for Adults as of January 1, 2014 (Kaiser Family Foundation, October 2013), http://www.kff.org/medicaid/fact-sheet/medicaid-eligibility-for-adults-as-of-january-1-2014/.
For current child and adult Medicaid eligibility levels, please see: Martha Heberlein, Tricia Brooks, Joan Alker, Samantha Artiga, and Jessica Stephens. Getting into Gear for 2014: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2012-2013 (Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation, January 2013), http://www.kff.org/medicaid/report/getting-into-gear-for-2014-findings-from-a-50-state-survey-of-eligibility-enrollment-renewal-and-cost-sharing-policies-in-medicaid-and-chip-2012-2013/.
Kaiser Commission on Medicaid and the Uninsured. The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid (Kaiser Family Foundation, October 2013), http://www.kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/.
Gary Claxton, et al. State-by-State Estimates of the Number of People Eligible for Premium Tax Credits Under the Affordable Care Act (Kaiser Family Foundation, November 2013), http://kff.org/health-reform/issue-brief/state-by-state-estimates-of-the-number-of-people-eligible-for-premium-tax-credits-under-the-affordable-care-act/.
State Health Facts. “State Decisions for Creating Health Insurance Marketplaces” (Kaiser Family Foundation, May 28, 2013), http://www.kff.org/health-reform/state-indicator/health-insurance-exchanges/.
For a list of participating health insurers, see: Florida Office of Insurance Regulation chart, http://www.floir.com/siteDocuments/Avg_Costs_PPACA.pdf.
Center for Consumer Information and Insurance Oversight (CCIIO). Additional Information on Proposed Essential Health Benefits Benchmark Plans, http://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.html.
Florida Health Choices website: http://myfloridachoices.org/.
SB 2534 (Chapter 2008-32). Florida act related to health insurance and Cover Florida Health Care Access Program. 2008, http://laws.flrules.org/files/Ch_2008-032.pdf.
Health Choices Florida. “Florida Health Choices Names Xerox as Program Administrator” (May 2012), http://myfloridachoices.org/florida-health-choices-names-xerox-as-program-administrator/
See Florida Health Choices: https://www.floridahealthchoices.com/.
Lily Rockwell. “Florida’s Health Care Insurance exchange” (Florida Trend, September 3, 2013), http://www.floridatrend.com/article/16056/floridas-health-care-insurance-exchange.
Carla Anderson. “Florida’s Ongoing Battle Against the Affordable Care Act” (HealthInsurance.org, October 14, 2013), http://www.healthinsurance.org/florida-state-health-insurance-exchange/ (accessed October 20, 2013).
State Health Facts. “Total Health Insurance Exchange Grants” (Kaiser Family Foundation, 2013), http://www.kff.org/health-reform/state-indicator/total-exchange-grants/.
Annie Mach and C. Stephen Redhead. Status of Federal Funding for State Implementation of Health Insurance Exchanges (Congressional Research Service, June 19, 2013), http://www.fas.org/sgp/crs/misc/R43066.pdf.
Data pulled on September 9, 2012 from Tracking Accountability in Government Grants System (TAGGS), http://taggs.hhs.gov/.
Kaiser Family Foundation Analysis of ACA Funding, May 1, 2012. Per Capita calculations were completed using US Residents per State, KCMU/Urban Institute estimates based on the Census Bureau's March 2010 and 2011 Current Population Survey (Annual Social and Economic Supplements).
For more information on consumer assistance programs, see: Kaiser Commission on Medicaid and the Uninsured. Helping Hands: A Look at State Consumer Assistance Programs under the Affordable Care Act (Kaiser Family Foundation, September 2013), http://www.kff.org/health-reform/issue-brief/helping-hands-a-look-at-state-consumer-assistance-programs-under-the-affordable-care-act/.
Florida Statute § 625.25
Patrick Morrisey, Attorney General, State of West Virginia, A communication from the States of West Virginia, Alabama, Florida, Georgia, Kansas, Louisiana, Michigan, Montana, Nebraska, North Dakota, Oklahoma, South Carolina, and Texas regarding data privacy risks posed by programs assisting consumers with enrollment in health insurance through the new exchanges, August 14, 2013, https://www.oag.state.tx.us/newspubs/releases/2013/Letter_to_HHS_re_Data_Privacy__final_8_14_13_.pdf, last accessed on October 17, 2013.
“Florida bans insurance ‘navigators’ in counties,” Herald-Tribune, September 12, 2013, accessed October 17, 2013, http://www.heraldtribune.com/article/20130912/ARTICLE/130919851.