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Health care systems around the world; what people in other countries think of their health care systems … you may be surprised.

2 Feb

The US seems to be in constant turmoil over health care.  For decades we have been arguing over the problem and how to fix it, in fact we aren’t even sure what the problem is.  Americans can’t seem to agree on what they want or how to pay for it. In the meantime most other developed countries have a system in place. They may have problems, but their citizens seem pleased with what they have.

Why do Americans have such a difficult time structuring a system for every citizen?  Is the rest of the world just smarter than we are or do Americans simply have unrealistic, we can have it all, expectations?

I have a strange hobby, I visit other countries and ask people how their health care works and if they like it.  In my most recent post on the Health Insurance Illuminated blog I report some of my findings

Take a look at what people in different countries have told me.

Related articles

Why tax-free health benefits may be in jeopardy; your 2012 W-2. It’s not only the wealthy who benefit from the tax code

31 Jan

2012 is the beginning of reporting the value of employer-provided health benefits on form W-2 and it may also be the beginning of the end of this tax benefit.  There is little logic to continue this massive revenue loss.

Read more on Health Insurance Illuminated.

FREE preventive health care services may end up costing you

26 Jan

A word of caution about those “free” preventive health care services mandated by the Affordable Care Act …they may quickly turn from preventive to diagnostic and that means your coinsurance, co-pays and possibly a deductible apply. This can happen for significant procedures but also for a simple office visit.

Read more about this in my post on Health Insurance Illuminated

Is Massachuetts headed toward a single payer system?

25 Jan

Is there is a solution to health care costs and quality? Apparently there is a simple solution, just have government – run the entire system, just like Medicare.

The following is from a newspaper in Massachusetts.  I guess what MA has already done is insufficient. A State representative has introduced legislation for a single-payer system. Throwing out a few platitudes about quality and affordability sounds good and gets some people excited, but it is hardly effective management of the health care system. There is no evidence that a single payer system makes health care affordable, improves quality or reduces costs (especially without numerous unintended consequences). With regard to Massachusetts, their current system has yet to prove itself beyond expanding coverage – much like the Affordable Care Act.

As I have said many times, when a politician makes outrageous promises, make sure you ask exactly how they will be met.

Last update Dec 31, 2011 @ 04:51 PM

Touting dramatic reductions in health care costs, improved access to health care for all residents and a boost to local businesses, state Sen. Jamie Eldridge, D-Acton, has filed a bill that would create a single-payer health care system for Massachusetts. The bill, heard by the Joint Committee on Health Care Finance, would establish a universal public insurance plan covering all medically necessary care. This plan would function for residents younger than 65 much the way Medicare does for residents 65 and older, but without premiums or co-payments, according to Eldridge’s office. “If Massachusetts is serious about reducing health care costs for families, businesses and state and local governments, we need to stop tinkering at the edges of a broken system and enact a single-payer healthcare system,” Eldridge said. “It’s the only reform that would truly reduce costs in a substantial way, eliminating medical debt and bankruptcies while guaranteeing access to quality, affordable health care as a right for all residents of the Commonwealth.”

“Unreasonable” premium increases denied-stand up and cheer?

23 Jan

If any insurance company, say your auto insurer or home owners insurer raised your premiums an unreasonable amount what would you do? I suspect you would switch insurance companies, perhaps give that little lizard a boot in the butt.  When it comes to health insurance it takes the federal government to tell you what is unreasonable. We all better hope that the denials being made by regulators are themselves reasonable. A small change in assumptions can make a big difference in outcomes and if premiums are too low, there will be a great deal of catching up to do. Remember, a premium set in 2011 is designed to cover claims incurred through 2012 which may not be reflective of experience in the past twelve months. Actuaries know this of course, but let us hope political pressure is not influencing the many variables that go into setting premiums.

If you look at the release below you will see a rate cut for Anthem Blue Cross in Connecticut. However, when you go to the HHS link in the press release you find this:

Connecticut Rate Review

The Rate Review program began September 1, 2011. No insurers in Connecticut have proposed rate increases of 10% or more since that time. Check back regularly for updates.

Then we have the following hype.  HHS is incapable of preparing a press release containing just facts, but rather must include more and more spin and unsubstantiated claims.

“The Affordable Care Act includes several policies, including rate review, to continue this slow growth.  By fighting fraud, better coordinating care, preventing disease and illness before they happen and creating a new state-based insurance marketplace, it helps keep health care cost growth low.”

In fact only rate review has been implemented, the efforts at coordinated care are focused on Medicare, preventive disease programs have been used by employers for many years with no measurable results and the state-based marketplace is two years away.

News Release

Affordable Care Act holding insurers accountable for premium hikes.  Health insurance premium increases in five states have been deemed “unreasonable” by the U.S. Department of Health and Human Services, HHS Secretary Kathleen Sebelius announced today.

After independent expert review, HHS determined that Trustmark Life Insurance Company has proposed unreasonable health insurance premium increases in five states—Alabama, Arizona, Pennsylvania, Virginia, and Wyoming.  The excessive rate hikes would affect nearly 10,000 residents across these five states.

To make these determinations, HHS used its “rate review” authority from the Affordable Care Act (the health care law of 2010) to determine whether premium increases of over 10 percent are reasonable.

“Before the Affordable Care Act, consumers were in the dark about their health insurance premiums because there was no nationwide transparency or accountability,” said Secretary Kathleen Sebelius.  ”Now, insurance companies are required to disclose rate increases over 10 percent and justify these increases.  It’s time for Trustmark to immediately rescind the rates, issue refunds to consumers or publicly explain their refusal to do so.”

In these five states, Trustmark has raised rates by 13 percent.  For small businesses in Alabama and Arizona, when combined with other rate hikes made over the last 12 months, rates have increased by 27.2 percent and 18.1 percent, respectively.  These increases were reviewed by independent experts to determine whether they are reasonable.  In this case, HHS determined that the rate increases were unreasonable because the insurer would be spending a low percent of premium dollars on actual medical care and quality improvements, and because the justifications were based on unreasonable assumptions.

In addition to the review of rate increases, many states have the authority to reject unreasonable premium increases.  Since the passage of the health care reform law, the number of states with this authority increased from 30 to 37, with several states extending existing “prior authority” to new markets.

Examples of how states have used this authority include:

In New Mexico, the state insurance division denied a request from Presbyterian Healthcare for a 9.7 percent rate hike, lowering it to 4.7 percent;In Connecticut, the state stopped Anthem Blue Cross Blue Shield, the state’s largest insurer, from hiking rates by a proposed 12.9 percent, instead limiting it to a 3.9 percent increase;In Oregon, the state denied a proposed 22.1 percent rate hike by Regence, limiting it to 12.8 percent.In New York, the state denied rate increases from Emblem, Oxford, and Aetna that averaged 12.7 percent, instead holding them to an 8.2 percent increase.In Rhode Island, the state denied rate hikes from United Healthcare of New England ranging from 18 to 20.1 percent, instead seeing them cut to 9.6 to 10.6 percent.In Pennsylvania, the state held Highmark to rate hikes ranging from 4.9 to 8.3 percent, down from 9.9 percent.

Today’s announcement comes the same week that a report showed that health care spending has grown at remarkably low rates.  According to an analysis done each year by the Centers for Medicare & Medicaid Services, U.S. health care spending experienced historically low rates of growth in 2009 and 2010.  A recent study released by Mercer Consulting also showed a slow-down in the average employee health benefit cost to businesses.

The Affordable Care Act includes several policies, including rate review, to continue this slow growth.  By fighting fraud, better coordinating care, preventing disease and illness before they happen and creating a new state-based insurance marketplace, it helps keep health care cost growth low.

For more information on the specific determinations made today, please visit http://companyprofiles.healthcare.gov/

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Health care spending moderated in 2010, but there is no joy in Mudville yet. Many employers are expecting 6-8% increases for 2012

22 Jan

According to a recent federal report, health care spending rose at only 3.9% in 2010, the lowest rate in several years. The experts say this is probably due to the weak economy. That may be part of it, but this cycle has happened in he past, mainly when there was a national focus on health care costs as when the federal government promoted HMOs as the final solution and during the Clinton health care initiative.

Some of this trend has to do with the turmoil and misinformation about where health care reform is going and whose ox is going to get gored. In times of uncertainty health care providers hunker down to keep a lower profile.

This time things may be much worse when the cycle changes again. Millions more Americans will have coverage under very comprehensive benefits, most will be heavily subsidized for their premium costs, the mentality of “free” services to consumers is stronger because of the Affordable Care Act. In addition, there is pent-up demand that will be released soon after the start of 2014 and perhaps before.

I'm still not optimistic

In some cases, especially with employer based coverage, more and more expenses will move to employees because of cost shifting. So while the employer premiums and costs are moderated, that is only part of the story. Keep in mind also that the new mandates within the Affordable Care Act have already added 3% + – to insurance costs. 

Finally, there are the hidden new costs imposed by the Affordable Care Act. New taxes and fees on medical equipment manufacturers, pharmaceutical companies, insurers and employers will eventually find their way into premiums and out of consumer’s pockets.  America may have slowed for the curve, but it has not hit the brakes.

There are some signs of serious efforts to fundamentally change the health care system and the way care is provided and paid for. However, how well patients will accept those changes is unknown, even if they are in their best interest.  Nevertheless, significant positive affects of such changes are years in the future. 

There is no joy in Mudville yet; mighty Casey is still looking for his bat.

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2012 is the start of new fees and taxes on health care organizations…what are the possible consequences? First up, a new excise tax on pharmaceutical companies

18 Jan
English: Novamoxin Prescription Drug - Amoxici...

First target

One of the criticisms of the Affordable Care Act has been that few people actually know what is contained in the Act.  Having spent untold hours reading the Act along with various independent assessments of the Act, I can testify to its immense complexity.   

For example, in order to pay for the expansion of subsidized health insurance to millions of Americans, the Affordable Care Act adds numerous new fees and taxes on individuals’, employers and the health insurance industry.  In 2010, there was a new tax on indoor tanning facilities (ok, so that is not a big deal, anyone who uses one of those deserves to be taxed). In 2014 there are new fees on employers and insurance companies, all of which have the potential of being passed along to consumers.  In 2012 pharmaceutical companies that sell to the federal government are assessed what is called an annual fee (excise tax). 

The various fees and taxes contained in the Act are among the few elements that are reasonably quantifiable.  Other elements of the Act that are to reduce costs rely on assumptions of long-term success for well-meaning, but untried programs generally related to Medicare.  To be successful, hospitals, physicians, other health care providers and Medicare beneficiaries must all work in a coordinated effort under new paradigms for providing health care.

Taking billions of dollars each year in new taxes impacts these organizations which then must find ways to mitigate this loss.  It is tempting to simply dismiss such taxes as justified on highly profitable organizations.  However, we should never forget that everything we do is connected to something else and every action has its consequences (think housing crisis).  Generating revenue for some means a loss for others, a savings here means less revenue there and in some cases that may mean a loss of jobs, less invested in research or simply passing costs along to another party. When additional costs are imposed on employers, especially related to health benefits, it generally means greater cost sharing for employees and a shift in compensation from cash to employee benefit programs.  Good benefits are valuable, but they don’t buy groceries or pay college tuition.

The following is excerpted from the IRS regulations with regard to the new fees on drug manufacturers (a very small sample of the hundreds of thousands, ultimately millions, of pages of regulations implementing the Affordable Care Act). 

The aggregate fee amount each year for all covered entities (referred to as the applicable amount) is $2.5 billion for fee year 2011; $2.8 billion for fee years 2012 and 2013; $3 billion for fee years 2014 through 2016; $4 billion for fee year 2017; $4.1 billion for fee year 2018; and $2.8 billion for fee year 2019 and thereafter. The applicable amount for each year is allocated, using a specified formula, among covered entities with aggregate branded prescription drug sales of over $5 million to specified government programs or pursuant to coverage under such programs.

The specified government programs are the Medicare Part B program, the Medicare Part D program, the Medicaid program, any program under which branded prescription drugs are procured by the Department of Veterans Affairs, any program under which branded prescription drugs are procured by the Department of Defense, and the TRICARE retail pharmacy program (collectively, the Programs).

The annual fee for each covered entity is calculated by determining the ratio of (i) the covered entity’s branded prescription drug sales taken into account during the preceding calendar year to (ii) the aggregate branded prescription drug sales taken into account for all covered entities during the same year, and applying this ratio to the applicable amount. Sales taken into account means branded prescription drug sales after the application of the percentage adjustment table.

Making health care affordable; now it’s your turn

17 Jan

The “experts” have their say every day, they all have the solution to controlling health care costs, it’s too bad they haven’t worked.

Soooooo, now it’s your turn. Visit Health Insurance Illuminated, read my latest post and add your ideas for controlling health care costs. Who better than patients and consumers to help solve this problem?

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I never file a health insurance claim, so what happens to my premiums?

16 Jan
Deutsch: Ein Straßenverkehrsunfall in Kopenhag...

The purpose of insurance

If you have homeowners insurance or auto insurance, I suspect you would be very happy never to have a claim and that goes double for health insurance.  However, that does not stop some people from thinking they may be entitled to a refund if they do not file a health insurance claim.

What does happen to your premiums?  Believe it or not, a relatively few people consume most of the health care and hence incur most of the health care expenses.  Read more about this issue in my blog post on Health Insurance Illuminated

Increased number of adult children covered by health insurance as a result of the Affordable Care Act

12 Jan
This image shows the income distribution of Am...

If there is one thing that the Affordable Care Act does well it is expanding health insurance coverage, much like what happened in Massachusetts. In the case of PPACA one goal was to expand coverage available to adult children. Some measure of additional coverage has been accomplished as reported below.  Keep in mind that these children do not have to be dependent on the parent (employee) in order to be covered, may be married and cannot be charged an extra premium for the coverage. In addition, beginning in 2014 these children can be employed and have other coverage available and will still be eligible for their parent’s plan.  Prior to that an employer may deny coverage to an employed adult child.

All this is a good thing if you are one of the families affected, but remember this additional cost is carried by employers and all other insured members of a group.

New Health Law Increased Insurance
Coverage of Adult Children

WASHINGTON—The new federal insurance law has increased the health insurance coverage of adult children between 2009 and 2011, according to a new report by the nonpartisan Employee Benefit Research Institute (EBRI).

The Patient Protection and Affordable Care Act (PPACA) enacted March 23, 2010, requires that group health plans and insurers make dependent coverage available for children until they attain the age of 26, regardless of tax or student status, or dependent status as it relates to financial support. The mandate to offer coverage to adult children ages 19‒25 took effect for policy years that began on or after Sept. 23, 2010, but since January is the beginning of the plan year for many employment-based health plans, many insurers adopted the requirements of the law before the effective date.

To determine whether the coverage mandate had an effect, EBRI examined data from two U.S. Census Bureau surveys (the Current Population Survey, CPS, and the Survey of Income and Program Participation, or SIPP), as well as from the National Health Interview Survey (NHIS) by the Centers for Disease Control. The data indicated:

  • The percentage of persons ages 19‒25 with employment-based coverage as a dependent increased from 24.7 percent in 2009 to 27.7 percent in 2010, according to the CPS. 
  • The percentage of individuals ages 19‒25 with employment-based health coverage as a dependent averaged 26.9 percent during January‒September 2010, and increased to an average 27.1 percent during October and November, per SIPP. 
  • The percentage with private insurance increased from 51 percent to 55.8 percent, and the percentage uninsured fell from 33.9 percent during 2010 to 28.8 percent during the first half of 2011 among those ages 19‒25, according to data from the NHIS. 

“Data from these three surveys show that PPACA has had a positive effect on the percentage of young adults with employment-based coverage as a dependent,” said Paul Fronstin, director of EBRI’s Health Research and Education Program and author of the report.

Full results of the report are published in the January 2012 EBRI Notes, “The Impact of PPACA on Employment-Based Health Coverage of Adult Children to Age 26,” online at www.ebri.org

The Employee Benefit Research Institute is a private, nonprofit research institute based in Washington, DC, that focuses on health, savings, retirement, and economic security issues. EBRI does not lobby and does not take policy positions.

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Does the public really care about health care costs? Survey: “Government shouldn’t interfere.” What would you do to control health care costs?

10 Jan
September 3, 2009 health care reform rally at ...

During the health care reform debate the President repeatedly said that no one (meaning insurance companies) should come between you and your doctor.  The US public seems to have taken the no interference philosophy to heart.  Most Americans do not believe in a cost benefit analysis as justification for denying payment for health care treatment.  Are we saying that cost does not matter?

This leads to a fundamental question; exactly how does the public expect health care costs to be controlled?  Or better still, does the public want health care costs managed at all as long as their share of premiums is limited?  If the public remains focused on premiums alone, we are headed for serious trouble far beyond our current state.  Remember, these are the same people who we expect to act like consumers when it comes to buying health care.

Survey: Government shouldn’t impose on health treatment decisions

Most Americans are frustrated by decisions that limit the use of high-cost prescriptions and treatments, according to a survey by the Harvard School of Public Health and the Alliance for Aging Research.

A majority say they oppose decisions by the government or health insurance plans where prescription drugs or medical or surgical treatments are not paid for because the payors determine the benefits and do not justify the cost. The exception is if there’s evidence that something else works equally well but costs less. Sixty-four percent believe the government or health insurance plans should not pay for a more expensive prescription drug or medical or surgical treatment if it has not been shown to work better than less expensive ones. Majorities in Italy and Germany share both of these beliefs with the U.S. public. In the United Kingdom, at least a plurality shares these beliefs.

 It is pretty clear what people do not like when it comes to controlling costs, so let’s hear from you.  What exactly would you do to control health care costs?

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Consumer driven health care is a myth and aiming at the wrong target

5 Jan

The CEO of Humana recently gave a talk on the health care system in which he correctly noted some of the fundamental problems in the system (unnecessary care being provided, little concern for cost (of care) by the consumer, lack of electronic medical records, variations among practice patterns and others). However, he incorrectly concludes as do many other “experts” in and out of government that consumerism by the patient is the key to solving our health care cost problem. In other words, if you shop for health care as you do for a new television, you will be more prudent and cost conscious when it comes to receiving an MRI or CT scan.

Let’s see what you actually know about that new television. You certainly know the price and you also know that if you go to a big box, no frills store you may save money. You may know something about the perceived quality, probably from word of mouth or perhaps a consumer report of some kind. And you also know something else; if you guess wrong in your purchase you may return it for a refund or replacement, or if all else fails you throw it out, learn your lesson, chalk up the loss of a few hundred dollars to a bad experience and start over.

Sure, buying a TV is exactly like that severe pain your child feels on her left side accompanied by a very high fever; start shopping!

 
Health care systems

Pick a system, any system

I have worked with thousands of people over the last fifty years as they navigate the health care system, deal with major illness, doctors, hospitals and their health insurance. Not one of those people knew the true cost of health care, not one could accurately assess the quality of care they received, not one knew if all the care received was necessary or appropriate. What they did know was that they or someone they loved were ill and wanted to get better, sometimes desperately so. On occasion (after the fact) there would be consternation over a high balance bill from a non participating physician, but more often than not the concern was that the insurer paid too little not that the doctor charged too much … “he saved my life.”

When it comes to health care we humans are not and can never be objective consumers motivated by cost (and sometimes even quality; witness the reaction to new guidelines for certain screenings that question popular wisdom).

All the well-known problems in the system must change, but it is the system that must change, not the consumer/patient. Why would we attempt to solve our problems by seeking to have 300 million people learn to question the next recommended MRI as opposed to changing the system so that we have confidence the next MRI is appropriate, necessary and cost efficient?  Let’s face it; if we believe that only external pressure from consumers can change the system, we are also saying the quality of health care in America is generally poor, overpriced, defensive and motivated largely by profit maximization.

Obamacare regulations and hidden costs

27 Dec
Senate Passes Insurance Industry Aid Bill

Money, money everywhere

By now we all know that the Affordable Care Act contains thousands of pages of new legislation mostly unread by those who enacted the law. It also contains about 1500 references to discretion to be exercised by the Secretary of Health and Human Services. Since enactment, various government departments have issued a flood of regulations, including in some cases changing provisions of the law (although for the better).

Medicare has initiated scores of pilot programs designed to change the way Medicare operates, pays for services and the way health care is practiced. Rules for employers are in process and of course, the biggy will be the rules operating the health insurance exchanges beginning in 2014. That’s a lot of rules and regulations for a lot of people to comply with.

On December 27, 2011 the Wall Street Journal published an editorial about regulations and this section caught my eye.

Then there’s the Affordable Care Act. Christopher Conover and Jerry Ellig of the Mercatus Center at George Mason University, in a trio of forthcoming papers, systematically examine every rule issued to date to create the new health-care entitlement. They conclude that “the federal government used a fast-track process of regulatory analysis that failed to comply with its own standards, and produced poorly substantiated claims about the ACA’s benefits and costs”—including an upward bias for benefits, a downward bias for costs, and numerous material omissions. Little wonder for a law that contains the phrase “the Secretary shall” 1,563 times. The Mercatus Center evaluates all major rules that cost over $100 million a year on a composite score of a dozen regulatory best practices. The Health and Human Services Department’s highest-scoring ObamaCare rules came in at 25 out of 60 points, the lowest at 13. These are not merely bad grades. They are relative Fs on the regulatory curve—about 35% to 40% lower than the averages for the other rules that the executive branch put out in 2008 and 2009. The ObamaCare rules score lower than other HHS rules in 2009.

You can think what you like about the ACA, but the fact remains it is a complex law and growing more so each day. It is not at all clear that the benefits outweigh the costs nor do we know the true costs, especially those hidden in employer and other entity compliance. The bottom line is that for good or bad the ACA is only the start of what must be done to manage health care costs in America.

We can only hope that first expanding coverage and enhancing benefits does not make the real task impossible to achieve.

Accountable Care Organizations (ACO) and the promise of savings without managed care or patient limitations.. I wish you all the best.

20 Dec

 Here is a text of an e-mail I received from HHS:

 Affordable Care Act helps 32 health systems improve care for patients, saving up to $1.1 billion

12/19/2011 12:01 AM EST

Thirty-two leading health care organizations from across the country will participate in a new Pioneer Accountable Care Organizations (ACOs) initiative made possible by the Affordable Care Act, HHS Secretary Kathleen Sebelius announced today.  The Pioneer ACO initiative will encourage primary care doctors, specialists, hospitals and other caregivers to provide better, more coordinated care for people with Medicare and could save up to $1.1 billion over five years

That headline really grabs you doesn’t it.  Seems like it’s a done deal and the savings are in the bank.  That’s far from the truth, of course. There is no new information here other than we know the names of some health care systems that will participate in this trial (“Pioneer”) effort for Accountable Care Organizations.  

Don’t get me wrong, this is a good idea because if there is one thing we need, it is more coordinated care, but we have a long way to go before we start patting ourselves on the back with a success under the Affordable Care Act.  We need it to work in terms of saving money and improving the care people receive.  That’s a tall order even for spin doctors.

I have one major reservation on the ability for this program to succeed and that is the limited involvement by the patient and the limited ability for the ACO to manage all of a patient’s care.  Working efficiently, the process should be virtually invisible to the patient, but that assumes the patient only uses health care providers within a given ACO.  Will the ACO that receives financial incentives to provide efficient care be reluctant to make outside referrals thereby losing some of the control over patient care?  In the long run there is no benefit to the ACO to do so, but this is one of the criticisms made of HMOs.  Here is what HHS says about patient rights.  I am concerned that we are again trying to have it both ways; efficient management of care and total freedom when seeking care.  I don’t think that can work, let’s hope I am wrong.

Beneficiary Participation

Under the Pioneer ACO Model, beneficiaries do not enroll in an ACO.    Primary care providers and other healthcare providers make the decision to participate in ACOs, meaning a beneficiary will not need to take proactive action to receive the benefits offered through an ACO.  ACOs are required to notify beneficiaries of their participation, ensuring the beneficiary is aware of the new arrangement, and his or her rights described in this document.  In addition, beneficiaries may affirmatively attest that their primary provider is in a Pioneer ACO, and can then be aligned with the ACO and benefit from the enhanced care coordination that it offers.

Beneficiary Rights and Protections

A beneficiary aligned to an ACO maintains complete freedom to visit any healthcare provider accepting Medicare, just as all Medicare beneficiaries participating in original, fee-for-service Medicare do.  These beneficiaries do not need a referral to see a specialist outside the ACO.   Unlike a managed care arrangement, like an HMO or a Medicare Advantage plan, a beneficiary aligned to an ACO is free to see any healthcare provider accepting Medicare at any time.  In addition, beneficiaries maintain all the benefits to which they are entitled in original, fee-for-service Medicare. 

Beneficiaries will have direct channels of communication to CMS to ask questions and relay concerns.  Through the initial notice of participation, beneficiaries will be informed that they can call 1-800 MEDICARE at any time to ask questions about the program,   alert CMS of any concerns they may have about the ACO.  Beneficiaries will also be surveyed each year to assess their experience with the new program.

 Here is a link to the list of the 32 organizations

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