Information from the U.S. Department of Justice on how to file an Americans with Disabilities Act (ADA) complaint. Includes answers to questions about how to file an ADA complaint by email, regular mail or other delivery service, what to do if you cannot prepare your own complaint due to a disability, how to find out the status of your complaint and what happens if your complaint is referred for possible mediation.

The Affordable Care Act is the most fundamental legislative transformation of the US health care system in forty years. This analysis estimates that the act will provide health insurance for an additional 3.4 million people in California in 2016. This will mean that nearly 96 percent of documented residents of California under age sixty-five will be insured. Enrollment in Medi-Cal, the state’s Medicaid program, is expected to increase by 1.7 million people, while 4.0 million people are expected to enroll in the state’s planned new health insurance exchange. Employer-sponsored insurance and spending on health insurance will decline slightly. Low-income households will experience substantial financial benefits, but families at the highest income levels will pay more.

The fifty states will play a critical role in implementing the Affordable Care Act, and California is one of the states at the forefront of reform. The act can provide coverage to millions of currently uninsured Californians and offers important benefits in terms of more-affordable coverage, improved access to services, and better health outcomes. As the paper by Peter Long and Jonathan Gruber in this issue of Health Affairs notes, the ultimate effects of health reform in California will be influenced by the policy and program decisions that state lawmakers and administrators make during the next three years. Key issues include revamping cumbersome eligibility determination and enrollment processes that could prevent rapid enrollment in expanded public health insurance—but also affording that expansion in the face of large state budget deficits. California policy makers need to move thoughtfully and strategically to ensure that the potential of federal health reform becomes a reality for state residents.

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States’ budget woes continue, and one way many newly elected Republicans would like to address them is to pare back Medicaid. Several different options are already on the table.

In 2009, US health care spending grew 4.0 percent—a historically low rate of annual increase—to $2.5 trillion, or $8,086 per person. Despite the slower growth, the share of the gross domestic product devoted to health spending increased to 17.6 percent in 2009 from 16.6 percent in 2008. The growth rate of health spending continued to outpace the growth of the overall economy, which experienced its largest drop since 1938. The recession contributed to slower growth in private health insurance spending and out-of-pocket spending by consumers, as well as a reduction in capital investments by health care providers. The recession also placed increased burdens on households, businesses, and governments, which meant that fewer financial resources were available to pay for health care. Declining federal revenues and strong growth in federal health spending increased the health spending share of total federal revenue from 37.6 percent in 2008 to 54.2 percent in 2009.

The Affordable Care Act created accountable care organizations (ACOs), which will be a new part of Medicare as of January 2012, together with a “shared savings program” that will modify how these organizations will be paid to care for patients. Accountable care organizations have the potential to lower costs, improve the quality of care, facilitate delivery system reform, and promote innovation in health care. The federal government is set to create rules to regulate these organizations and has broad discretion to allow them to pursue a variety of approaches. Drawing on experience from some ACO pilot programs and the Medicare Part D prescription drug coverage program, we argue that regulations governing accountable care organizations should be flexible, encouraging of diversity and innovation and allowing for changes over time based on lessons learned. We recommend using regulations as a general framework, while relying on notices and other guidance below the regulatory level to spell out specific requirements.

Under the Affordable Care Act, the new Center for Medicare and Medicaid Innovation will guide a number of experimental programs in health care payment and delivery. Among the most ambitious of the reform models is the accountable care organization (ACO), which will offer providers economic rewards if they can reduce Medicare’s cost growth in their communities. However, the dismal history of provider-led attempts to manage costs suggests that this program is unlikely to accomplish its objectives. What’s more, if ACOs foster more market concentration among providers, they have the potential to shift costs onto private insurers. This paper proposes a more flexible payment model for providers and private insurers that would divide health care services into three categories: long-term, low-intensity primary care; unscheduled care, including unscheduled emergency services; and major clinical interventions that usually involve hospitalization or organized outpatient care. Each category of care would be paid for differently, with each containing different elements of financial risk for the providers. Health plans would then be encouraged to provide logistical and analytic support to providers in managing health costs in these categories.

Banks don’t like it when the Federal Deposit Insurance Corporation takes them over, but the FDIC doesn’t like it either — particularly when they must absorb all the failed institution’s losses. In order to recoup some of this money, the FDIC may sue up to 109 former executives of failed banks, reports Christine Ricciardi of Housing Wire. The agency has named 109 executives subject to investigation and a possible personal liability lawsuit. The parameters of a possible lawsuit are broad: FDIC needs to prove “gross or simple negligence” on the part of former bank officers, directors, accountants, appraisers or brokers.

FDIC has already sued two lenders, including Glenwood, Illinois-based Heritage Bank. The lawsuit, filed in the U.S. District Court of Chicago, contends that Heritage made irresponsible commercial real estate loans and that executives gave themselves bonuses as the bank imploded. (Sounds like almost every single bank in the country during the housing boom.) These sweeping investigations are good news for FDIC, but trouble for former executives of the 17 Illinois banks that failed in 2010.

E. J. Dionne makes a great point today in the Washington Post about the potential collision between the rhetoric and labels politicians use to get elected and the hard facts and hard work of actually governing.  It’s one thing to talk about government waste, another to figure out what programs to cut.   It’s a fair assumption that federal agencies are often inefficient and wasteful (a lot of private corporations are too), but harder to get in and figure out how agencies that deal with the public health, welfare, education, agriculture, food safety and the economy can do their work better.

By looking at what programs work and which ones don’t, the new majority in the House of Representatives can accomplish a lot.  It can begin to change the tone in Washington and show the public that congressional hearings are focused on things that really matter.  But if the conversation is limited to stereotypes, generalities, and potshots against government, the new Republican majority won’t help change anything for the better (including public opinion about the effectiveness of Congress).  And then 2012 could seem like 2010, except, you know, the other way around.

A scant 19 years after the plan was first proposed by California regulators, the US Environmental Protection Agency announced it has approved a comprehensive approach to restoring water quality and fish habitat in the storied, but now officially “impaired,” Klamath River.  As Bettina Boxall writes in the Los Angeles Times and Peter Fimrite writes in the San Francisco Chronicle, farmers, ranchers, loggers and a utility will all have to make concessions for decimated salmon populations. Over the past century, once-teeming Chinook salmon populations have declined by 90 percent, Coho salmon by 98 percent.

Under terms of the regulations, farmers will have to sharply reduce the amounts of phosphorous and nitrogen in the agricultural runoff reaching the river, as these chemicals deplete oxygen levels.  Ranchers will have to prevent wandering cattle from trampling riverbanks, which adds murky silt.  Logging operations will have to alter erosion-causing practices.  And finally, an Oregon utility owned by Warren Buffet’s Berkshire Hathaway will have to operate its hydro-electric dams to prevent river water from reaching temperatures damaging to the salmon.

Despite the pronouncements of the EPA implying that the lengthy dispute — between fishermen, native tribes and the California Water Quality Control Board on one side and ranchers, farmers, logging companies, the US Forest Service and PacifiCorp on the other is over, a spokesman for the utility said the company is considering legal action to protect its ratepayers and investors.

A separate agreement with the utility calls for the removal, starting nine years from now, of various dams along the Klamath that prevent salmon from reaching their historic spawning beds.

Hopefully, the dwindling salmon can hang on long enough for these protections to take effect.

Here is the most powerful evidence yet that Asian carp will invade the Great Lakes unless the Army Corps of Engineers takes action.  Dan Egan of the Journal Sentinel reports that scientists who found carp DNA in the Chicago canal system, a few miles off of Lake Michigan, had their work approvingly peer-reviewed by the journal Conservation Letters.  Despite our commitment to intricate policy pieces, Understanding Government typically doesn’t blog about findings in Conservation Letters. However: the substantive argument by businesses and Illinois elected officials who didn’t want the Army Corp of Engineers to close a lock that connects Lake Michigan to Chicago waterways was that carp DNA evidence wasn’t peer-reviewed. The scientific doubt about the carp threat was partly behind the ruling of a Chicago federal judge to keep the locks open after five Great Lakes states sued to get them closed.

The review by recognized authorities in the scientific world bolsters the contention of states like Michigan that the Army Corps of Engineers needs to act soon before the Great Lake’s fishing industry and overall ecology are ruined. The Army Corps of Engineers, though, is not even planning to release a report on the carp problem until 2015. Barack Obama has named a “carp czar” to deal with the issue — but the czar, John Goss, says he has no Congressional authority to act. Hopefully these scientific findings will make the carp problem more apparent and urgent for the federal government.

Barack Obama named William Daley his new Chief of Staff yesterday. While Daley has held many titles — like Commerce Secretary for Bill Clinton — he is arguably best known, at least in Chicago, as brother and son of Richard M. Daley and Richard J. Daley, who have combined to serve as Chicago’s Mayor for 42 of the 55 years. No chief of staff pick says Chicago more than a Daley, and that includes departed Chief of Staff Rahm Emanuel who will almost certainly be Chicago’s next mayor. So it’s not surprising that conservatives like Grover Norquist have attacked the choice. “If everybody sitting in the White House is from a 10-mile radius of Chicago, it gives you a skewed view of how the country works,” Norquist told the Chicago Tribune’s Katherine Skiba and John Byrne. “And then they sit there and wonder why the country doesn’t agree with what they’re doing and what they’re saying.”

I think Norquist is partly right — Daley’s views are borne out of his Chicago experience. But which Chicago is Daley coming from? Eric Lipton of the New York Times reports that the Chicago Daley knows is the home of the city’s biggest corporations — he’s been Midwest head for J.P. Morgan Chase, a lobbyist for Boeing, and a board member for global drug company Abbot Laboratories. In contrast to Barack Obama, the Democratic Party, and most Chicago residents, these companies have fought against financial regulatory reform, cutting Pentagon waste, and health care reform.

Daley’s Chicago is not that of, for example, a potential chief of staff like Luis Gutierrez who could give the perspective of urban Latino residents of modest incomes. It’s not the Chicago of Jesse Jackson, Jr. who could tell the White House how a policy plays in poor, deeply segregated black neighborhoods. It’s the Chicago of corporate movers-and-shakers in downtown glass and steel skyscrapers who worry that change in government will stifle their annual profits. Daley is widely praised as a great manager — probably the most important attribute in a chief of staff. But he is not likely to lend special insight into what most Chicago residents (or many other Americans) want out of the Obama administration.

John Mecklin of Miller-McCune was inspired (in part by a vexing visit to his local Social Security office) to zero in on ways the federal government could become more efficient.  He highlights a plan by which government could save $1 trillion or more by using high-tech infrastructure solutions that have already saved billions in the private sector.  The recommendations come from an October 2010 report by the Technology CEO Council that mentions seven areas in which the federal government could consolidate services among agencies, offer more services online, improve supply chains, and standardize computer software, all steps that would save major money.

As Congress, including the new GOP majority in the House, looks for ways to cut budgets and reduce the deficit, Mecklin says, it should

go beyond these specific recommendations to investigate and then institute programs that bring the full innovative power of the digital technology revolution directly to bear across the government.  It’s a revolution that has remade the private sector . . . but has only been fitfully adopted by slow-moving federal agencies that fear its power . . .

Federal agencies and employees are likely to resist consolidations, sensible cost-cutting, and innovations not because they are inherently evil, but because “their supervisors have lived their professional lives in a culture that views itself as self-contained and immune from oversight or fundamental change.”  It’s a fair criticism.  And it shows how tough the battle to make government more efficient will be.  People don’t like to lose their jobs, and the kind of reforms Mecklin analyzes mean tens and even hundreds of thousands of government employees could lose their jobs.  Imagine if the government — across the board — embraced “just-in-time” inventory management or aggressively looked at selling off “underperforming assets” in its massive real estate holdings.  It would be a real shakeup, and not fun for anyone — public employees and legislators alike.

Mecklin compares the effects of a high-tech revolution in government to the changes in the world of media in the last generation, which he calls “often frightening and cruel,” adding that “as they’re happening, layoffs never feel particularly creative.”  This is one area where an understanding government (pardon the pun) could help government employees.  If part of the projected savings could be devoted to early retirement packages and retraining initiatives, the new revolution in government could be seen as a sacrifice in the country’s interest while also acknowledging the real contribution that so many government employees have made over the years.

California customers of health insurer Blue Shield should brace themselves for more sticker shock — the independent non-profit licensee of the national Blue Cross/Blue Shield association is planning to raise premiums by nearly 60 percent for some customers effective March 1. According to Duke Hefland of the Los Angeles Times, the company said 193,000 customers would see increases of 30 to 35 percent, but Hefland quotes one San Diego man saying his monthly premium is set to leap 59 percent — from $271 to $431.

Almost 25 percent of customers will see increases of over 50 percent over a four-month period.

The news comes a year after for-profit Anthem Blue Cross attempted to hike premiums for its 700,000 customers with individual plans by an average 39 percent just as the health care reform bill seemed heading for certain defeat. After flaws were found in Anthem’s rate increase petition by state regulators, the company settled for increases of about 20 percent.

A Blue Shield of California spokesman said the rate hikes are necessary to cover fast-rising health care costs and to absorb expenses required under the health reform law.

Newly elected state Insurance Commissioner Dave Jones, a Democrat who replaced Republican Steve Poizner, said his only point of leverage is if Blue Shield does not meet the state’s requirements that not less than 70 percent of the insurers’ revenue from premiums be used to pay actual medical claims. If Blue Shield meets that threshold, Jones’ hands are tied.

Jones said it would take legislative action to grant him the kind of regulatory authority to oversee health insurers that his office already has over automobile insurers (another area where insurers in California have tried to introduce substantial increases with little warning).

Meanwhile, Anthem Blue Cross has applied for a 9.8 percent increase effective April 1^st on top of a 14 percent jump that it imposed in October.

Monique Garcia of the Chicago Tribune reports that the Illinois Senate voted 58-0 to enact a series of reforms to the state Medicaid system. As the vote indicates, the reforms are hard to argue with. Unfortunately, as I’ve reported, they do very little to resolve the state’s Medicaid financing crisis — a crisis that can only be solved through some combination of drastic cuts in Medicaid, major state tax increases, and greater federal assistance to Illinois, which unlike the federal government, must balance its budget.

Most of the reforms boil down to good-government and anti-fraud measures such as ensuring that people who receive Medicaid are actually who they say they are and qualify for the program. The state does plan to reduce eligibility for the AllKids health care program from literally all kids in Illinois to those at no more than 300 percent above the poverty level, which means a $66,000 annual income for a family of four. But these changes will, at most, subract a few hundred million dollars from a Medicaid budget that will cost the state $6.8 billion in fiscal-year 2011.

The fate of the state’s Medicaid program between now and 2014, when national health care reform will dramatically increase federal financial support, is tied to much bigger political choices:  Namely, whether any additional federal assistance is forthcoming and whether Gov. Pat Quinn and the state legislature can work out a solution to the state’s $15 billion budget deficit. Quinn’s most recent proposal is a $15-billion bond to pay off the deficit plus a tax increase to pay off the interest on the bond. Wise or not, Quinn’s proposal is suitably dramatic for an unprecedented state fiscal crisis — one where Illinois will probably continue to fail to pay health care service providers.