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How Nebraska's two-tier Medicaid expansion plan compares with other states' approaches

LINCOLN — The two-tier Medicaid system that officials are proposing as a way to cover more low-income Nebraskans would be unique to the state.

The Heritage Health Adult system would include work, wellness and personal responsibility requirements, many of which have been tried by other states. However, the combination of requirements and the penalties for failing to meet requirements would be new.

As outlined by state officials, people would not get dental, vision and over-the-counter medication coverage if they fall short on any of the requirements. But they could still keep physical, medical and prescription drug coverage. Reviews would be done every six months to determine compliance.

“This is a very Nebraska-specific program that we have put forth,” Matthew Van Patton, the state Medicaid director, told lawmakers recently. “Nobody under this model loses benefits.”

The Nebraska Department of Health and Human Services put forth Heritage Health Adult in response to voter approval of a state law expanding Medicaid to about 94,000 more low-income people.

To implement the proposed system, Nebraska will have to get federal approval to waive traditional Medicaid rules.

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Robin Rudowitz, vice president of the Kaiser Family Foundation, which tracks such waivers, said the Nebraska approach would be different from waivers that have been implemented around the country. But it would share some features with waiver programs tried in other states, including Indiana and Iowa.

The most-common shared feature would be Nebraska’s plan to end retroactive eligibility for most Medicaid patients. The change would mean coverage starts in the month a person applies for Medicaid. Under current regulations, coverage goes back three months before the application date.

Here are some lessons that can be drawn from other states’ experiences:

No state has work requirements in effect for Medicaid recipients. Nearly 20 states are in various stages of trying to establish work requirements for Medicaid recipients, with encouragement from the Trump administration. Nine states are in the process of trying to get federal approval.

In three states, the requirements were blocked by courts, which have ruled that they undermine Medicaid’s mission of providing health care for the needy.

Six states have federal approval but have not implemented the requirements. Two of the six, Arizona and Indiana, voluntarily suspended implementation efforts. Arizona officials cited the court decisions in other state. Indiana’s requirements are facing a legal challenge.

Other states would suspend benefits or cut eligibility for falling short on work requirements. All other states seeking to implement work requirements have proposed suspending benefits or dropping people from Medicaid if they fail to comply with the requirements. The states vary in how long the suspension or loss of eligibility would last and how people could regain benefits.

Nebraska is proposing to limit, not suspend, benefits. State officials have touted that difference. Van Patton called it a “mark of distinction” among other states.

But the requirements look similar otherwise. All states, including Nebraska, would accept a variety of activities as meeting the work requirement, such as education, internships, substance abuse treatment, job searches and volunteer work.

All would exempt certain groups from the requirements. Commonly exempt are pregnant women, people with serious mental illnesses and family caregivers.

Wellness incentives have had limited success in other states. A handful of other states, including Iowa, have incorporated some wellness incentives and penalties into their Medicaid waivers, as Nebraska is proposing to do.

Nebraska would provide additional benefits to people who meet all of the wellness requirements — taking a health risk screening and an assessment of social determinants of health, filling prescriptions, having lab work done, going in for an annual doctor visit and choosing a primary care provider.

But only limited numbers of people have completed wellness activities in other states.

Michigan offers a $50 gift card to Medicaid patients below the poverty line or a reduction in future premiums to those above poverty who complete a health risk assessment. A 2017 Kaiser study found that just 16% had done the assessment.

In Iowa, Medicaid patients can avoid paying small monthly premiums by getting a yearly exam and doing a health risk assessment. But state reports show that fewer than one in four complete both requirements.

Ending retroactive eligibility would increase costs for patients and providers. Eight states, including Iowa, have won federal approval to end retroactive eligibility, according to the Kaiser waiver tracker. The courts have put the change on hold in three of those states.

Von Patton said Nebraska is proposing the change to make Medicaid more like commercial insurance and to encourage people to sign up before they get sick. The change would affect people newly eligible for Medicaid because of expansion and people previously eligible for Medicaid, with some exemptions.

Critics said that ending retroactive eligibility hurts health care providers as well as patients. Retroactive eligibility means that doctors and hospitals get paid for care provided to people who qualify for Medicaid but have not yet enrolled, while patients are not faced with medical debt.

The change can save money for state Medicaid programs. When Iowa launched its change, officials estimated a savings of more than $36 million a year from ending retroactive eligibility for up to 40,000 people.

Company gives back $44.7 million after profiting too much on Nebraska Medicaid contract

Nebraska's Medicaid director said the state's share of that money will be used for six initiatives aimed at strengthening the health care system by making better use of health data across the state. Two state lawmakers questioned why a decision on the use of taxpayer funds was made with no opportunity for legislative oversight or involvement from consumers and taxpayers.

No other state has the same system of six-month benefit reviews. Nebraska appears to be alone in proposing reviews every six months to determine whether patients will get the basic tier of benefits or qualify for the premium tier, which includes dental, vision and over-the-counter medications.

Rudowitz said she doesn’t know of another state with such a requirement.

Nebraska officials originally wanted to determine eligibility for Medicaid every six months, not just review a patient’s benefit tier. But federal law requires annual determinations. The state backed away from the more frequent eligibility determinations after talking with federal officials.

Now, Van Patton said, the state will stick with annual eligibility determinations, with periodic checks to verify that people still qualify for Medicaid. In addition, there will be reviews every six months to see whether patients are meeting the requirements for the premium benefits.

He told lawmakers that Nebraska’s approach would lead to better and more cost-effective outcomes, while avoiding potential penalties for enrolling people who do not qualify for Medicaid.

“This is our best hope for bending the cost curve to build a sustainable program,” he said.

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Neighbors say $6 million high-end condo proposal is too modern for Gold Coast

A plan to erect an almost $6 million condo project amid a cluster of historic midtown mansions has received a brick wall reception from the neighborhood’s resident group.

Members of the Blackstone Neighborhood Association went as far as to pen a resolution laying out multiple reasons why they think the project by high-profile developer Noddle Cos. is “inappropriate.”

They say the 15-condo structure proposed for 501 S. 38th St. is too bulky, too tall and not far enough from the sidewalk.

The overriding gripe, said Mark Maser, who lives across the street: “It’s a super-modern design nestled among historic mansions ... so different than everything else.”

Noddle’s Todd Swirczek, on the other hand, said the development is an answer to what city officials have said growing urban neighborhoods need. Such dense housing options, he said, help meet the demand of expanding area employers and will supply riders for the city’s rapid bus transit investment.

“The few remaining single family residences in that area were built at a specific time for a specific reason in our city’s history,” Swirczek said. “We are building this project to address today’s issues and concerns regarding economic development, transportation and land use.”


A rendering of the building proposed for 38th Street and Dewey Avenue, just south of Harney Street. It would have 15 condos that would sell for about $400,000 each.

On Wednesday, the Planning Board will hear more pros and cons of the 3½-story condo project proposed for the southeast corner of 38th Street and Dewey Avenue. The board’s recommendation will then go on to the City Council, which must approve code waivers requested in the plan.

As proposed, the yet-unnamed condo building would rise on the site of an existing 1,900-square-foot residence built in 1950. That structure is not a landmark and therefore not protected from demolition.

The project — which is part of Noddle’s relatively recent entry into the residential housing market — is rare in that it would bring newly constructed, for-sale condominiums to the midtown market, Swirczek said. He said that up until now, for-sale options have been largely town house-style housing with stairs to climb.

This building, he said, would be attractive to homeowners interested in living on a single level. There would be underground parking with a stall for each bedroom.

Residences would go for about $400,000 apiece, with sizes ranging from 1,100 square feet to 1,800 square feet, he said.

Within walking distance of the Blackstone District and the expanding University of Nebraska Medical Center, the condo project responds to the demands of a forward-looking city, Swirczek said.

“We have to be more walkable,” he said. “We have to be more accepting of other building” types.

The Blackstone Neighborhood Association, in its multiple meetings with the developer, has said that it is not against development and additional housing, said Maser, who has lived in the neighborhood for 30 years, 10 of those across the street from the project site.

Maser said he is excited about new and remodeled retail and housing buildings along the nearby Blackstone District corridor.


A stone marker in front of Mark Maser’s home. Maser said the condo project would result in “a super-modern design nestled among historic mansions ... so different than everything else.” The Gold Coast, including numerous stately homes on 38th Street, stretches roughly from Jones to Cuming Streets.

He contended that the developer has not responded to suggestions by the neighborhood group to make the condo project more compatible with the existing Gold Coast Historic District.

“When proposed projects do not improve the historic quality of the existing neighborhood ... but detract from it, the Blackstone Neighborhood Association will stand to oppose such efforts,” the group’s resolution says.

Since the project’s original design, Swirczek said, the Noddle team has added more brick to the building’s exterior, as well as more landscaping and old-style lighting, and has discussed having a neighborhood representative join a committee to talk about public art.

Before the project was revealed to the neighborhood, he said, the development team planned for underground parking, as parking has been a concern in past projects.

He said the Noddle team believed that for-sale units would be welcomed by the neighborhood.

Noddle Homes, a subsidiary of Noddle Cos., is currently working on its first residential housing project, town houses, in the Aksarben area. Those seven residences should be done next year, Swirczek said, and several have already been claimed by owners.

Changing Omaha: More than 50 stories of local development projects in the works

Moving further from 2015 nuke deal, Iran spins more centrifuges

TEHRAN, Iran (AP) — Iran on Monday broke further away from its collapsing 2015 nuclear deal with world powers by doubling the number of advanced centrifuges it operates, linking the decision to U.S. President Donald Trump's withdrawal from the agreement over a year ago.

The announcement — which also included Iran saying it now has a prototype centrifuge that works 50 times faster than those allowed under the deal — came as demonstrators across the country marked the 40th anniversary of the 1979 U.S. Embassy takeover that started a 444-day hostage crisis.

By starting up these advanced centrifuges, Iran further cut into the one year that experts estimate Tehran would need to have enough material for building a nuclear weapon — if it chose to pursue one. Iran long has insisted that its program is for peaceful purposes, though Western fears about its work led to the 2015 agreement that saw Tehran limit its enrichment of uranium in exchange for the lifting of economic sanctions.

Tehran has gone from producing about 1 pound of low-enriched uranium a day to 11 pounds, said Ali Akbar Salehi, the head of the Atomic Energy Organization of Iran. Iran now holds over 1,102 pounds of low-enriched uranium, Salehi said. The deal had limited Iran to 661 pounds.

Visiting Iran's underground Natanz enrichment facility, Salehi dramatically pushed a button on a keyboard to start a chain of 30 IR-6 centrifuges as state television cameras filmed, increasing the number of working centrifuges to 60.

"With the grace of God, I start the gas injection," the U.S.-trained scientist said.

The deal had limited Iran to using only 5,060 first-generation IR-1 centrifuges to enrich uranium by rapidly spinning uranium hexafluoride gas. An IR-6 centrifuge can produce enriched uranium 10 times faster than an IR-1, Iranian officials say.

Salehi also announced that scientists were working on a prototype he called the IR-9, which would work 50 times faster than the IR-1.

As of now, Iran is enriching uranium up to 4.5%, inviolation of the accord's limit of 3.67%. Enriched uranium at the 3.67% level is enough for peaceful pursuits but is far below weapons-grade levels of 90%. At the 4.5% level, it is enough to help power Iran's Bushehr reactor, the country's only nuclear power plant. Prior to the atomic deal, Iran reached only up to 20%.

Iranian President Hassan Rouhani will announce further steps away from the accord sometime soon, government spokesman Ali Rabiei said separately Monday, suggesting that Salehi's comments could be followed by additional violations of the nuclear deal. An announcement had been expected this week.

Iran has threatened in the past to push enrichment back up to 20%. That would worry nuclear nonproliferation experts because 20% is a short technical step away from reaching weapons-grade levels of 90%. It also has said it could ban inspectors from the United Nations' nuclear watchdog, the International Atomic Energy Agency.

The Vienna-based IAEA declined to comment on Iran's announcement. The IAEA previously said Iran planned to build two cascades, one with 164 IR-2M centrifuges and another with 164 IR-5 centrifuges. A cascade is a group of centrifuges working together to more quickly enrich uranium.

Iran broke through its stockpile and enrichment limitations to try to pressure Europe to offer it a new deal, more than a year since Trump unilaterally withdrew the United States from the accord. But so far, European nations have been unable to offer Iran a way to help it sell its oil abroad as it faces strict U.S. sanctions. Salehi again expressed Iran's ability to step back if a deal is made.

"If they return to their commitments, we also will go back to our commitments," he said.

Maja Kocijancic, a spokeswoman for the European Commission, urged Iran "to reverse such steps without delay and to refrain from any further measures that would undermine the nuclear deal."

The White House, in a statement noting the 40th anniversary of the hostage crisis, said the U.S. "will continue to impose crippling sanctions" until Iran changes its behavior. The U.S. also imposed new sanctions Monday on members of Supreme Leader Ayatollah Ali Khamenei's inner circle.

The collapse of the nuclear deal coincided with a tense summer of mysterious attacks on oil tankers and Saudi oil facilities that the U.S. blamed on Iran. Tehran denied the allegation, though it did seize oil tankers and shoot down a U.S. military surveillance drone.

The U.S. has increased its military presence across the Mideast, including basing troops in Saudi Arabia for the first time since the aftermath of the Sept. 11, 2001, terrorist attacks. Both Saudi Arabia and the neighboring United Arab Emirates are believed to be talking to Tehran through back channels to ease tensions. Rouhani recently sent a letter to both Bahraini and Saudi leaders on regional peace and security, said Rabiei, the Iranian government spokesman.

White Housemakes it official: U.S. will leave Paris climate accord

WASHINGTON — The Trump administration notified the international community Monday that it plans to officially withdraw from the Paris climate accord next fall, a move that will leave the world's second-largest emitter of greenhouse gases as the only nation to abandon the global effort to combat climate change.

President Donald Trump has long criticized the 2015 accord and insisted that the United States would exit it as soon as possible. As recently as last month, Trump called the agreement "a total disaster" and argued that the Obama administration's pledges to cut carbon emissions under the deal would have "hurt the competitiveness" of the United States.

In a statement Monday, Secretary of State Mike Pompeo said the administration had sent official notification to the U.N. of its plans.

"In international climate discussions, we will continue to offer a realistic and pragmatic model — backed by a record of real world results — showing innovation and open markets lead to greater prosperity, fewer emissions, and more secure sources of energy," Pompeo said. "We will continue to work with our global partners to enhance resilience to the impacts of climate change and prepare for and respond to natural disasters."

But environmental and public health activists quickly condemned the decision, even as it came as no surprise.

"Abandoning the Paris Agreement is cruel to future generations, leaving the world less safe and productive," said Andrew Steer, president of the World Resources Institute. "It also fails people in the United States, who will lose out on clean energy jobs as other nations grab the competitive and technological advantages that the low-carbon future offers."

The Paris climate agreement legally entered into force Nov. 4, 2016, after the United States and other countries formally joined the landmark deal. But under rules set out by the United Nations, no country could leave the accord for three years, after which there is a one-year waiting period for the withdrawal to fully take effect.

Monday marked the first day that the Trump administration could give that one-year notice, and it wasted no time. That means the U.S. can officially leave the Paris accord on Nov. 4, 2020 — the day after the presidential election.

Should a Democrat win the White House, the nation could reenter the accord after a short absence. But if Trump prevails, his reelection would probably cement the longterm withdrawal of the United States, which was a key force in helping forge the global effort under President Barack Obama.

Monday's move comes at a time when scientists say that the world must take unprecedented action to cut its carbon emissions over the next decade, slashing them in half by 2030 to avoid irreversible and potentially catastrophic effects of climate change.

The world already has warmed more than 1.8 degrees Fahrenheit above preindustrial levels. The Paris accord laid out ambitious goals to keep the planet's warming "well below" a rise of 3.6 degrees and, if possible, not above 2.7 degrees.

A Washington Post analysis has found, however, that roughly one-tenth of the globe has already warmed by more than 3.6 degrees, when the past five years are compared with the mid-1800s.