Highlights

• SNFs Can Again Ask Families to Sign Arbitration Agreements
• Immigration Policy Updates
• Family Fun Day Cruise
• Spaulding Adaptive Sports
• List of Poorly Performing SNFs
• Public Comment re: Healthcare Civil Rights
• SNF Financing Crisis
• Proposed SNAP Restrictions

Sections

• Program Highlights
• Policy & Social Issues

Questions, comments about the newsletter? Contact Ellen Forman, 617-726-5807.

Emergency Assistance (Family Shelter) Requirement to Stay in a Place Not Meant for Human Habitation Repealed

Hot off the presses: Massachusetts has repealed a rule advocates say led to many homeless families spending a night in a car or emergency room before becoming eligible for shelter.
The Legislature’s fiscal 2020 state budget included language to repeal the rule. Governor Baker signed the state budget today (July 31, 2019) and did not veto this provision.

Families with children today can enter shelter in Massachusetts if they were a victim of domestic violence, were evicted or suffered a natural disaster. Or, for a family to qualify under a rule meant to prevent children from living in unsafe situations, they must have spent a night in a place "not meant for human habitation."

Advocates for homeless people have been trying for years to repeal this rule, which was put in place under former Gov. Deval Patrick in 2012 and kept by Gov. Charlie Baker. The provision was implemented by Patrick in order to control shelter costs and ensure that families who enter shelter actually need it.

 “Government should not be in a place where you’re actively putting families in harm’s way,” said Rep. Marjorie Decker, D-Cambridge, who introduced legislation to repeal the rule. “That was what that rule did.”

Advocates for repealing the rule said it resulted in children sleeping for a night in cars, bus stations, campgrounds, emergency rooms or other places not meant for families to live. The rule also dissuaded some families from seeking emergency shelter, even if they were at imminent risk of homelessness.

“Its purpose was to have a chilling effect, and I think it worked,” Decker said.

The coalition estimates that around 1,000 more families annually would become eligible for shelter immediately under the rule change.

Turley called the move “a really important step forward” to making Massachusetts live up to its claim that is “a right to shelter” state, where all homeless families with children are eligible for emergency shelter. “In practice, it hasn’t been, because of the barriers such as this provision that have been in effect,” Turley said.

The change should become effective immediately, though there is likely to be an implementation lag to update policies and procedures and educate DHCD staff.  

-See the full Mass Live article.

-Additional material (budget signed without veto of this provision) from Kelly Turley, Associate Director, Mass Coalition for the Homeless, July 31, 2019.

The Massachusetts legislature belatedly sent their FY20 (the fiscal year that started July 1) budget recommendations to Governor Baker. The Governor signed the budget today (July 31, 2019) without significant vetoes to housing and shelter provisions noted below.

Housing and Shelter Highlights from the Conference Committee's budget

• Emergency Assistance (family shelter)
• Repeal of requirement to stay in a place not meant for human habitation- the budget proposal includes language to ensure that children and families do not have to stay in places not meant for human habitation before accessing shelter. After nearly seven years, this policy has been repealed! (See accompanying story.)
• Allows families to retain shelter benefits while increasing their incomes up to 200% of the federal poverty guidelines (before the existing grace period would begin).

• Unaccompanied youth and young adults- includes funding of $5 million for housing and wraparound services for unaccompanied youth and young adults experiencing homelessness which is $1.7 million more than the FY'19 appropriation.

• Residential Assistance for Families in Transition homelessness prevention program (RAFT) funding at $1 million more than the FY'19 appropriation.

• While it is not spelled out in the budget language, the Department of Housing and Community Development (DHCD) has agreed to pilot an upstream rent arrearage program through the RAFT line item. $4.7 million has been set aside this year to help households who have fallen behind on their rent, but have not yet gone to court for eviction. See page 4 of DHCD's new RAFT administrative plan for FY'20 (PDF).

• Massachusetts Rental Voucher Program (MRVP) includes language that would update the allowable monthly rent levels to match current fair market rents for mobile subsidies issued or renewed on or after August 1st and that would carry over up to $6,000,000 in unspent FY'19 funds.

- From Kelly Turley, MA Coalition for the Homeless, July 22, 2019.

Medicaid to Negotiate Drug Prices

As part of the compromise budget agreement, legislators have passed steps designed to reduce spending on the most costly drugs covered by MassHealth, the state Medicaid program.
Gov. Charlie Baker is reviewing the plan, a spokesman for his office said. It included much of what the Republican governor initially proposed in January to curb drug costs that he says have nearly doubled since 2012.

The plan would establish direct negotiations with drug companies for high-priced drugs. If the governor isn’t satisfied with the results, his office could propose a price, hold public hearings or refer the drug price in question to the state’s Health Policy Commission (HPC).

Lawmakers softened the impact of the drug pricing policy at the request of the state’s powerful biotech industry.

In the final version, drug manufacturers can’t be required to negotiate, they don’t have to attend any public hearings, and companies accused of charging excessive prices will not be referred to the state's attorney general.

A spokeswoman for AG Maura Healey said that doesn’t necessarily mean the AG’s office won’t investigate. “It is never necessary to get a referral from another agency to use our authority under the consumer protection law,” she said.

House Ways and Means Committee Chair Rep. Aaron Michlewitz said the goal of the compromise was to create a cooperative working relationship between all parties.

Health Care for All, a leading consumer advocacy group, said it was pleased that the public will soon have more information about drug prices and how those prices are set. HCFA director Amy Rosenthal said it’s time for the state’s biotech industry to help address rising health care costs.

There’s no timeline for the start of negotiations under the new plan. The Baker administration can request negotiations if drug prices meet one of two criteria: those that cost more than $25,000 for each patient annually after rebates, or those for which the state spends more than $10 million a year after rebates.

At least two drugs that cure Hepatitis C are expected to trigger both. MassHealth spent $116.8 million on a medication called Harvoni, before rebates, in 2018 and $80.5 million on another drug, Epclusa. Both are produced by Gilead Sciences. A spokeswoman said the company “is committed to helping make our medicines accessible to those who need them.”

-See the full WBUR story.

The Centers for Medicare and Medicaid Services (CMS) has issued a final rule that will once again allow nursing facilities to force residents to settle their disputes through arbitration and deny access to the courts. Taking away the ban on pre-dispute arbitration agreements deprives nursing facility residents of important rights and opens the door to the routine use and enforcement of arbitration agreements that a resident signs before knowing what the dispute is or what is at stake. 

In 2016, CMS issued new nursing facility regulations that strengthened consumer protections for residents by prohibiting nursing homes from forcing residents to arbitrate disputes. This new final rule takes away most of these protections, and will once again allow nursing facilities to ask residents to sign pre-dispute arbitration agreements at the time of admission. Although facilities will not be able to require residents to sign such agreements as a condition of admission under the final rule, the circumstances surrounding the admissions process combined with the enormous disparity of bargaining power means that most prospective residents are unaware of the content of what they are signing or the significance of the decision to enter into a pre-dispute arbitration agreement. In short, allowing facilities to ask residents to sign pre-dispute arbitration agreements is unfair to residents and their families and will harm their rights, safety, and quality of care.

-From Justice in Aging, July 17, 2019.

Saying there is a lot going on in immigration policy is an understatement. Here is a brief update:

A court has temporarily blocked the Trump administration’s attempt to deny asylum to anyone who crossed another country prior to arriving.

At the same time, a drastic expansion of “expedited removal” could deny due process to thousands of people who can’t prove they’ve been here for over two years – and lead to rampant racial profiling.

And at a time when a record 70.8 million people are forcibly displaced around the world, there’s talk of zeroing out refugee admissions for the coming year.

On the good-news front, the U.S. House of Representatives has approved Temporary Protected Status (TPS) for citizens of Venezuela. It now heads to the Senate and, if passed, then on to President Trump for his signature.

And, of course, the citizenship question is off the 2020 Census.

-From MIRA Coalition, July 26, 2019

The Kelly Anne Dolan Memorial Fund has been offering help and hope to families with seriously ill children since 1976. Based in the Philadelphia area, they have been offering a luncheon cruise to these families for many years, and recently began offering cruises in DC and New York City. Now they are extending the offer to Boston. Through a partnership with Entertainment Cruises, they are inviting approximately 425 parents, patients and siblings to a luncheon cruise on the Spirit of Boston on September 14, 2019.

There will be music, dancing, clowns and a healthy, kid-friendly lunch! The middle deck is handicap accessible and will allow seating for about 30 families with children who use wheelchairs.

Children with all kinds of diseases including rare genetic disorders, disabilities (cognitive and physical) and injuries are eligible to attend.

Registration must be made by the social worker, case manager or medical professional working with the families by completing the following application: https://www.surveymonkey.com/r/spiritbos2019

Schedule: Saturday September 14, 2019, boarding at 10:00 am; sailing at 11:00 am, docking at 1:00 pm. The Spirit of Boston is docked at the Seaport World Trade Center at Commonwealth Pier, 200 Seaport Blvd. #75, Boston, Massachusetts 02210.

-See the flyer.  

MassHealth, through its contracted provider, UMass Medical School, provides an onsite worker at the major medical centers throughout the state to ensure that residents access the most complete health insurance coverage and services available to them. Anna Giunta is the Health Benefit Coordinator with the Enhanced Coordination of Benefits (ECOB) program who is based at MGH.

ECOB Enables People to Enroll in Private Health Insurance
ECOB ensures that MassHealth members (or those eligible) who are under 65 and have access to private insurance coverage enroll and maintain coverage. Many people don’t take the health insurance coverage offered through their employer because they can’t afford the premiums. For those who are MassHealth eligible, ECOB can help them apply for MassHealth’s Premium Assistance program, which would cover the premium. They would retain MassHealth as a secondary insurance that would cover services not covered by the private plan, deductibles and co-pays (patients would still be responsible for the a small MassHealth Prescription Drug dispensing fee).

ECOB also will cover COBRA premiums which are typically 102% of the cost of a former employer’s group health insurance premium.
ECOB can in some cases enroll people outside of open enrollment periods.

Eligibility
Patients must

• Be under 65 and not eligible for Medicare
• Be a MassHealth member or pending MassHealth (MassHealth Standard or CommonHealth only)
• Have access directly or through a family member to private health insurance

ECOB works with those who have catastrophic illness, chronic disease, complex medical needs and long or repeated hospitalizations. Typical diagnoses include cancer, extreme prematurity (NICU babies), cardiac diagnoses, organ transplants, accident/trauma, and high cost disability. Through a related program they also serve those with HIV, Cystic Fibrosis, and Cerebral Palsy. They also are particularly interested in reaching those with hemophilia.

ECOB Helps Family Members Not Otherwise MassHealth Eligible
Many families have “mixed MassHealth status”- some members are eligible and some are not. This may be for financial reasons, such as a family with an income level where the children qualify, but the parents do not, or it could be for reasons related to immigration status. The Premium Assistance Program can pay for the private insurance’s family premium- enabling those who are not MassHealth eligible on their own to get full insurance coverage (note: these members would not get MassHealth wrap-around services such as coverage of co-pays).

How Does Premium Assistance Work?
Patients are issued a check in advance that they use to pay the private insurance premium or compensate for the insurance premium deductions from their paycheck. It is known as “reimbursement”, but the patient/family have the money in advance of the payment due date and so do not need to cover the payment with their own funds.

Note: Premium Assistance should not be confused with the similar sounding Family Assistance coverage type that may also pay for insurance premiums. Family Assistance is for Massachusetts residents not otherwise eligible for MassHealth Standard, typically these members have “PRUCOL” immigration status. Family Assistance members that have, or have access to, other health insurance, may have MassHealth pay all or part of their household's health insurance premiums provided certain rules are met. Those with Family Assistance do not receive MassHealth wrap-around services (MassHealth as a second insurance). Since these families do not receive MassHealth wrap services, they are not eligible for the enhanced coordination of benefits offered by the ECOB program.

How do Patients Benefit?
In addition to more complete insurance coverage, ECOB coordinators help members to understand and use benefits to which they are entitled. They can answer questions, explain MassHealth notices and what the member needs to do to comply, and offer information and referrals to community agencies. If one is applying for disability, they even may be able to expedite the disability review process because Disability Determination Services is also housed at UMass Medical School.
How does MGH Benefit?
The MGH, and other health institutions, benefit from this program because it helps people access private insurance which generally offers more generous reimbursement than MassHealth. It also may offer private insurance coverage to family members who were not MassHealth eligible; so those members would have private coverage when otherwise they would be Health Safety Net (HSN) cases. If you recall how HSN is funded- by contributions from health insurers and health care institutions, you can see the benefit to these parties. Referring to ECOB early in the admission helps increase the likelihood of adequate coverage for discharge planning purposes.

What Happens When Someone Becomes Medicare Eligible?
When a member becomes Medicare eligible either due to length of disability or age, the Premium Assistance program helps transition them to Medicare. If they qualify financially, MassHealth covers the cost of the Medicare Part B and Medicare Part D (drug coverage) premiums.

Scenarios

Here are some examples of scenarios in which ECOB might assist.

• Inpatient with complex medical diagnosis, has employer sponsored insurance coverage, on FMLA with or without pay who will be unable to return to work. The patient could be assisted to apply for MassHealth and referred to ECOB. Anna would work with family through the enrollment/eligibility process and expedite Disability if needed. She might outreach to the employer to educate about the laws and rules applicable for retention of employer sponsored plan/ work with COBRA if needed. She might support hospital staff with questions and concerns regarding the case and follow up with review of primary payments for proper billing and reimbursement as a MassHealth secondary payor to the hospital.
• A child born prematurely who is now in NICU, family with employer insurance which requires adding children within 30 days of birth.  Medically complex case, baby will be discharged home with trach or g-tube or might need block nursing. Baby applies for MassHealth with disability and possible Kaileigh Mulligan program allowing for block nursing. If the MassHealth application was timely, the family will benefit from MassHealth wrap for deductible for the inpatient stay and further apply for Premium Assistance with reimbursements of their out-of-pocket insurance premium cost. ECOB/Anna would again assist the family with the MassHealth process, education about MassHealth as a secondary payor, coordinate with all parties for a smooth transition, and support the family on discharge.

For more information contact Anna Giunta, at 617-886-8037, or anna.giunta@umassmed.edu

-Thanks to Sarah Taddei for reminding us about this program and Anna Giunta for her patience and detailed review and contributions to this article.

Spaulding Adaptive Sports Centers

The Spaulding Adaptive Sports Centers recently hosted The MGH Council on Disabilities Awareness for an information session and facility tour.

Spaulding Adaptive Sports Centers (SASC) support individuals of all abilities in leading active and healthy lives through participation in adaptive sports and recreational activities.

The programs are delivered under the supervision of Spaulding clinicians and adaptive sports professionals, and are open to children and adults. Staff members help each participant find the most appropriate activities to meet their abilities. Programming is year-round in sites in Boston, the North Shore and the Cape.

Programs include a wide variety of recreational as well as competitive events for all levels.

Programs include:  

*Backyard games includes recreational-level games like cornhole, ladder ball and bocce. See the current summer events brochure for more information and additional opportunities- including fishing, pickleball, adaptive dance for Parkinson’s and specialized programs for veterans.

Due to generous donations they are able to keep participant costs low and can provide some need-based sliding-scale and even no-cost participation.

Additional Services

SASC also consults to schools and fitness facilities to help understand accessibility and adapt their programs and equipment. They also can provide information and referral to other area adaptive sports programs and services.

-See the full presentation. Includes photos of equipment and adaptive technology.

-See the summer events brochure.

-Thanks to Alison Riley for the information and tour and for her assist with this article. Thanks also to Amy Sam, Zary Amirhosseini, Lenny Debenedictis, and Tracey Ritucci for arranging the tour.

On December 19, 2019, the Stephen Beck, Jr. Achieving a Better Life Experience Act (ABLE) will be five years old. The ABLE Act allows an estimated eight million Americans with disabilities to save money for qualified disability expenses for their short-term needs and long-term future. ABLE account holders can use the funds for qualified disability-related expenses including housing and maintenance, as well as costs related to employment, transportation, health, technology and financial and benefits planning.

Forty-two states and the District of Columbia have ABLE programs (including Massachusetts, Rhode Island, New Hampshire and Vermont). Even if your state, hasn’t established an ABLE program (e.g., Maine), you can enroll in any state’s program, if they accept out-of-state residents, which many do. State ABLE programs are managing more than $220 million in savings and investment accounts.

These ABLE savings accounts will largely not affect your eligibility for Supplemental Security Insurance (SSI), Medicaid and other public benefits. ABLE account owners, who are SSI beneficiaries, are no longer stuck in a life of poverty or have to face the $2,000 asset limit and be disqualified from receiving SSI benefits.

Beginning last year, the ABLE National Resource Center (ABLE NRC) established its national ABLE Ambassadors to help millions of ABLE-eligible individuals and families learn that there are ABLE account holders very similar to them. And ABLE accounts grew by almost 17 percent in the fourth quarter last year, while assets under management grew by 19 percent for the same period.

To learn about ABLE accounts and state ABLE programs, please visit the ABLE NRC at www.ablenrc.org, which is managed by the National Disability Institute. The website has information on how to become ABLE ready, a state ABLE program comparison tool and guidance on setting short- and long-term financial goals. To receive updates on the #ABLEtoSave campaign in August, sign up for the ABLE NRC listserv.

This is a guest blog post created by the National Disability Institute to promote the use of ABLE accounts.

-See the full SSA blog post.

Members of Congress recently released a report on nursing facility quality Families’ and Residents’ Right to Know: Uncovering Poor Care in America’s Nursing Homes that included a list of 400 facilities that the Centers for Medicare & Medicaid Services had cited for persistent substandard care, but whose names had previously not been made public on the nursing home compare site or elsewhere. Despite ongoing quality of care concerns in facilities, enforcement of federal laws governing nursing facilities has been lax under the Trump Administration.

“In such facilities, some residents have experienced outright neglect, such as going without proper nutrition or languishing in filthy conditions,” the report says. “Some older adults and people with disabilities have even experienced physical abuse, sexual assault and premature death.”

Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, an advocacy group, said it shouldn’t have taken congressional action for the names of questionable nursing homes to be revealed. “The fact that this information wasn’t reported before is concerning,” she said. “Consumers need the full range of information available to make the best decisions.”

Only a few months after President Trump took office in 2017, his administration announced it was acceding to requests from the nursing home industry and changing how fines are levied for regulatory violations.

Rather than fining a nursing home for each day it was out of compliance, which was typically how things worked under a tightening of rules under the Obama administration, Trump’s White House said a single fine would be imposed for any infractions. This softened the blow of regulatory crackdowns and minimized a key incentive for nursing homes to quickly remedy troubles.

While CMS discloses the names of about 80 nursing homes with documented problems — the agency’s so-called Special Focus Facility program — it has for years kept under wraps hundreds of other facilities considered “candidates” for closer scrutiny.

Casey’s and Toomey’s report names the nearly 400 candidate nursing homes and says they were “indistinguishable” in terms of quality of care from identified “special focus” homes as of April.

An appendix to the report cites a number of instances of nursing home residents being endangered in candidate facilities.

Again, the identities of these nursing homes were kept secret from the public, meaning that families seeking care for elderly loved ones wouldn’t have known of the incidents regardless of how much due diligence they performed.
In response to the report, CMS said it would start releasing the names of candidate nursing homes along with special focus facilities. It said the greater transparency would begin “soon.”

Other resources to keep in mind:

• Start your search for a qualified nursing home with CMS’ Nursing Home Compare, which provides information and ratings for all Medicare- and Medicaid-certified facilities. Presumably this will incorporate the agency’s newfound openness.
• Check out other online rankings, such as listings offered by U.S. News and World Report and Yelp.
• Don’t be shy about seeking advice from your doctor or friends. Contact social workers in your area and ask what they’ve heard about various facilities.
• Schedule visits to homes you’re interested in and meet with senior staff. Ask to speak with residents and to see any recent citations. Reputable facilities won’t hesitate to share such information.

Report excerpts:

Many documented cases of abuse and neglect occur infacilities affiliated with the federal Special Focus Facility (SFF) program. The SFF program is designed to increase oversight of facilities that persistently underperform in required inspections conducted by state survey agencies. As stipulated by federal law, the SFF program targets those facilities that “substantially fail” to meet the required care standards and resident protections afforded by the Medicare and Medicaid programs.

A nursing home’s participation in the SFF program is not readily transparent or easily understood among would-be residents and their families.

Aside from recent actions by CMS to update Nursing Home Compare so that the website more clearly displays nursing homes that are SFF participants, it lacks detailed information or context on the SFF program. There is no information on Nursing Home Compare explaining the reason for a facility’s participation in the program, the length of time it has been in the program or whether it has improved. Further, CMS does not include information on facilities that routinely cycle in and out of the SFF program.

Additionally, the Senators’ review of Nursing Home Compare suggests that the online tool is not consistently updated to reflect changes in the SFF program. For example, in March2019, the small icon used to indicate that a facility is a SFF participant was not on the webpage of five of the 17 newly-added SFF participants.

“Candidates” for the SFF program are not disclosed to the public and these facilities do not receive any additional oversight.

information on SFF candidates is absent on the Nursing Home Compare website. Star ratings continue to be displayed on the Nursing Home Compare webpages for SFF candidates and there is no designating icon to indicate a nursing home is a SFF candidate. Several candidate facilities possess star ratings that may be misleading. Based upon a review of Nursing Home Compare conducted after the Senators’ receipt of the April 2019 candidate list, 27%of candidate facilities had a two stars out of five overall. The quality and staffing ratings (subcategories of the overall ratings) for these facilities may prove more misleading. Approximately 48% of SFF candidates had a quality rating of three stars or higher. Similarly, 49%of SFF candidates possessed a staffing rating of three stars or greater. Nine SFF candidates boasted perfect staffing and quality scores.

Finally, SFF candidates are not subject to additional oversight. SFF candidates are not surveyed more frequently (aside from surveys following a complaint, which are required) nor are they subject to more rigorous enforcement actions, additional disclosure or reporting requirements. Moreover, CMS does not have a way to add a candidate facility to the SFF program if a particularly egregious incident occurs, including any event substantiated by a state investigation or complaint survey.

See the report for a list of SFF and SFF Candidate facilities.

Sources

• See the full Los Angeles Times column
• Additional material from Justice in Aging, July 10, 2019
  

The Trump-Pence administration has released a notice of proposed rulemaking (NPRM) that would roll back the Health Care Rights Law (also known as section 1557 of the ACA). The Health Care Rights Law protects patients from discrimination in health care and is the first broad prohibition of sex discrimination in health care in federal law. This roll back impacts LGBTQ+ people, people who have sought or may in the future seek abortions and other reproductive health services, people whose first language is not English, immigrants, people of color, and people with disabilities.

The public comment period for this rule ends on August 13.

The National Women’s Law Center has a comment portal as does a coalition of advocacy groups including Justice in Aging: Take Action.

-Adapted from email from Co-Chairs of the Protecting Immigrant Families Campaign, July 15, 2019.

Massachusetts lawmakers are extending a financial lifeline to the state's nursing home industry, which has seen a string of providers shutter in recent months. Both houses of the state Legislature passed a budget with $415.4 million in Medicaid funding for nursing homes — a $50 million increase from the previous year's budget.

But there's a problem: The difference between what the state's Medicaid program, MassHealth, pays nursing home operators, and what nursing homes actually spend on care is around $362 million, according to the Massachusetts Senior Care Association (MSCA), an industry group which represents hundreds of nursing homes, rehabilitation centers and other facilities.

Tara Gregorio, president of the MSCA estimates that 70% of nursing facility residents have their care paid for by MassHealth, and chronic underfunding has been "a major driver of more than 30 nursing facility closures in the last 18 months," she said. "Additionally, the underfunding has contributed to an inability to make needed investments in resident care and meaningful wage increases for front-line staff."

The new state budget includes a provision calling for the formation of a "nursing home sustainability task force" with three primary goals: to ensure the financial stability of skilled nursing facilities; consider the role of skilled nursing facilities within the continuum of elder care services; and address current workforce challenges.

MSCA estimates that over half of the state's roughly 400 nursing facilities are operating at a loss. And because reimbursements are based on 2007 costs, the group says Medicaid reimbursements to nursing homes currently fall about $38 short of the average daily cost of care.
There are currently 150,000 elderly Massachusetts residents living in nursing homes, according to MSCA estimates, and about 77,000 workers who help care for them.

The need for nursing home services will likely continue to increase: 15% of commonwealth residents are age 65 or older, according to a 2018 analysis of federal government data by the Gerontology Institute at UMass Boston. That demographic is expected to balloon to about 21% of residents by the year 2030.

This past March, Health and Human Services Secretary Marylou Sudders told a group of state lawmakers that more nursing homes were likely to close because senior citizens in Massachusetts are increasingly turning to assisted living services or services that allow them to remain at home. As a result, Sudder said, a quarter of nursing facilities have an occupancy rate of 80% or less.

The situation for nursing homes is "not sustainable," Sudders said.

-See the full WBUR story.

The Trump Administration rule designed to support health workers who opt out of providing care that violates their moral or religious beliefs will not go into effect in July as scheduled. The effective date has been delayed by four months, according to court orders.

The "Protecting Statutory Conscience Rights in Health Care" rule was originally issued in May by the Department of Health and Human Services' Office for Civil Rights. It aligns with that office's religious freedom priorities and would put new emphasis on existing laws that give health care workers the ability to file a complaint with that office if they are forced to participate in medical care that violates their conscience — such as abortion, gender confirmation surgery, and assisted suicide.

As NPR has reported, the rule also expands the type of workers who are able to file this kind of complaint to billing staff and receptionists and anyone else who in any way "assist[s] in the performance" of a procedure.

Complaints of "conscience rights" violations are relatively rare — for a decade, the office would receive an average of one complaint like this each year. Last year, that number jumped to 343. That number is dwarfed by the number of complaints the Office for Civil Rights receives over issues like health privacy or race, sex and age discrimination, which typically number in the thousands.

Several groups sued the federal government over the rule immediately after it was issued. New York state led a coalition of 23 cities and states in one suit, and three jurisdictions in California also sued, including California state and San Francisco. Yet another plaintiff, Santa Clara County in California's Bay Area, made the case that the rule put patient safety at risk, since it gave health workers the right to opt out of providing care without prior notice — potentially even in an emergency.

"If the rule goes through as it's written, patients will die," Santa Clara's county executive, Dr. Jeff Smith, told NPR last month. "We will have a guaranteed situation where a woman has had a complication of an abortion, where she's bleeding out and needs to have the services of some employee who has moral objections. That patient will die because the employee is not providing the services that are needed."

That new effective date is Nov. 22.

All parties are hopeful that the judges will make their decisions in these cases before the new effective date in November.

-See the full NPR article.

New Hampshire announced this month that it would delay further implementation of its Medicaid work reporting requirements, citing both new legislation that changes what qualifies as work and who is exempt from the requirements, as well as the fact that the state’s outreach to affected enrollees has been largely unsuccessful. In other words, the state recognized that about 20,000 low-income Medicaid enrollees would lose coverage if the onerous requirements were enforced. The legislation also directs the state to amend its waiver of three months retroactive coverage to allow for coverage 45 days prior to an eligibility determination. 

New Hampshire’s waiver is also being challenged in court and Justice in Aging filed an amicus brief.

Learn more about the harms to older adults and family caregivers of these restrictions in Justice in Aging’s state-by-state analysis. 

- From Justice in Aging, July 12, 2019.

The Trump administration has announced it will set up a system to allow Americans to legally import lower-cost prescription drugs from Canada, weakening a longstanding ban that had stood as a top priority for the politically powerful pharmaceutical industry.

Health and Human Services Secretary Alex Azar made the announcement Wednesday morning. Previous administrations had sided with the industry on importation, echoing its concerns that it could expose patients to risks from counterfeit or substandard medications.

Azar, a former drug industry executive, said U.S. patients will be able to import medications safely and effectively, with oversight from the Food and Drug Administration. The administration’s proposal would allow states, wholesalers and pharmacists to get FDA approval to import certain medications that are also available here.

It’s unclear how soon consumers will see results.

Most patients take affordable generic drugs to manage conditions such as high blood pressure or elevated blood sugars. But polls show concern about the prices of breakthrough medications for intractable illnesses like cancer or hepatitis C infection, whose costs can run to $100,000 or more. And long-available drugs like insulin have also seen price increases that have forced some people with diabetes to ration their own doses.

The administration’s move comes as the industry is facing a crescendo of consumer complaints over prices, as well as legislation from both parties in Congress to rein in costs.

Eyeing his reelection campaign, Trump has made lowering prescription drug prices one of his top goals. As a candidate, he called for allowing Americans to import prescription drugs, and recently he’s backed a Florida law allowing state residents to gain access to medications from Canada

Drug prices are lower in other economically advanced countries because governments take a leading role in setting prices. But in the U.S., Medicare is not permitted to negotiate with drug companies.

Some experts have been skeptical of allowing imports from Canada, partly from concerns about whether Canadian suppliers have the capacity to meet the demands of the much larger U.S. market.

But consumer groups have strongly backed the idea, arguing that it will pressure U.S. drugmakers to reduce their prices. They also point out that the pharmaceutical industry is a global business and many of the ingredients in medications sold in the U.S. are manufactured abroad.

The drug industry lobby, Pharmaceutical Research and Manufacturers of America, has successfully blocked past efforts in Washington to allow importation. It argues that patients would be at risk of receiving counterfeit or adulterated medications.

-See the full Boston Globe article.

This month the Massachusetts Senate unanimously voted to support An Act to increase consumer transparency about insurance provider networks, legislation to eliminate “ghost networks” among Massachusetts health insurers and increase access to mental health care for patients who need it.

Out-of-date and inaccurate health insurance provider directories appear to have a large number of in-network providers. In reality, the number is often much smaller, as providers may have moved, closed their practices, no longer accept new patients, or no longer participate in particular health insurance plans. These “ghost networks” are especially challenging for people seeking care for behavioral health conditions: in 2018, the Division of Insurance reported provider directories for behavioral health services listed only 29% to 64% completely accurate information.

“Many families and individuals seeking health care, particularly mental health care, are unable to find a provider that meets their needs because of outdated and unclear provider directories,” said Senator Jason Lewis, the lead sponsor of the legislation. “Accurate provider directories are critical to improving access to timely and appropriate care to reduce disparities, to improve health outcomes, and to decrease unnecessary utilization of emergency room and inpatient care. I’m very pleased that the Senate took this important step forward.”

For many families and individuals, provider directories are the “front door” to accessing services for behavioral health conditions. Struggling through outdated information and refusals by multiple unavailable providers is exhausting and frightening, leaving patients at risk for clinical deterioration and harm, often ending up with a visit to the emergency room, rather than getting appropriate care when it was needed.

An Act to increase consumer transparency about insurance provider networks would require insurers’ provider directories include the most up-to-date list of participating doctors and specialists and their services. The bill also creates a task force to study and recommend further improvements to provider directories, particularly information about behavioral health providers and the specific services they offer. This legislation was the result of months of collaboration between the Senate, insurers, providers and other stakeholders.

The legislation now awaits action in the House of Representatives (vote expected today – 7/31/19)  before it can be considered by the Governor to become law.

-See the full press release.

A new University of Michigan business school study reveals that Medicaid expansion has reduced deaths in states where it has been adopted. By contrast, in states that have refused to expand their Medicaid coverage, approximately 15,600 people have died as a result. This study is the first large-scale assessment of the effect of Medicaid expansion on mortality.

Created by the Affordable Care Act (ACA), Medicaid expansion offers states the option to establish a pathway for Medicaid coverage for able-bodied low-income adults aged 19-64. Prior to the ACA, these individuals were not generally eligible for Medicaid. In the first year of the expansion’s availability, 29 states plus the District of Columbia leapt at this opportunity, and seven other states have since chosen to extend coverage.

The study, which focused on individuals who were between 55 and 64, found a large reduction in deaths in states that expanded Medicaid. Before Medicaid expansion was available, members of this group had similar mortality trends no matter where they lived. After the expansion, however, those in non-expansion states began dying at a higher rate. This trend started in the first year of the expansion and has increased every year that a state continues to offer the coverage. The authors calculate that approximately 15,600 deaths could have been averted if all states had adopted the Medicaid expansion. They also note that because of the nature of these health gains, the difference between expansion and non-expansion states is likely to continue to increase.

Michael Hiltzik writes in an LA Times column “Adversaries of Medicaid expansion have always pointed to the lack of evidence that enrollment in Medicaid improves health and saves lives, and therefore the expansion is a waste....(the) new study should put that argument to rest, permanently.”  In other words, he continues, “the 22 mostly red states that refused to accept expansion starting in 2014 caused 15,600 unnecessary deaths among their residents”.

The Medicare Rights Center supports Medicaid expansion both because of its positive effects on the individuals who are eligible for coverage and for the benefits to the Medicare program of having people receive regular health care before they reach Medicare eligibility. This study should spur non-expansion states to take another look at the benefits of expanding coverage and the devastating costs a failure to expand may be inflicting on vulnerable residents.

• Read the study.
• Read more about the results of the study.
• Learn which states have and have not expanded Medicaid.

-See the Medicare Rights Center blog post.

The Trump Administration is proposing changes to the rules that govern who is eligible for the Supplemental Nutrition Assistance Program, SNAP, commonly known as food stamps. Under the proposed rule changes, the U.S. Department of Agriculture estimates three million people would lose benefits, which includes an estimated 90,000 people in Massachusetts, according to the state's Department of Transitional Assistance (DTA).

The proposed changes would prohibit the states from expanding who is eligible for the program beyond the federal baseline, which is $33,475 for a family of four — or 130 percent of the federal poverty level. Right now, 39 states, including Massachusetts, offer federally-funded SNAP benefits to people who make more than that. Massachusetts uses a standard of 200 percent of the federal poverty level, which corresponds to $51,500 for a family of four if they can demonstrate they have trouble paying for food.

Federal law also says households must have less than $3,500 in assets to receive the benefits, a standard that Massachusetts waives for households with seniors or people with disabilities. These state-level rules that expand coverage are called “broad-based eligibility” and would be overturned under Trump’s proposed changes.

Currently, about 265,000 children in the U.S. automatically qualify for free school lunches through SNAP, and the proposed rule changes could affect who is eligible, threatening a program that thousands of Massachusetts children rely on.

Currently, 43 U.S. states allow residents to automatically become eligible for food stamps through the Supplemental Nutrition Assistance Program, or SNAP, if they receive benefits from another federal program known as Temporary Assistance for Needy Families, or TANF (called TAFDC in MA), according to the USDA.

The administration wants to change that by requiring people who receive TANF benefits to pass a review of their income and assets to determine whether they are also eligible for free food from SNAP, officials said.

In a statement, U.S. Secretary of Agriculture Sonny Perdue said the rule changes will “close a loophole” and would save the federal government an estimated $2.5 billion a year.

If 90,000 people lose benefits, Drew expects many will rely on the dozens of food banks and pantries in the state, which may not be adequate for some people, such as seniors, and people with disabilities who have limited mobility.

The public has until mid September to comment on the proposal before the Agriculture Department can move forward with its implementation. The proposal is expected to face harsh opposition and legal challenges.

Massachusetts state officials are now working to understand the full impact of the rule changes on residents.

 “Trump’s proposal would wallop working families in Massachusetts, where the cost of living is high and the flexibility of categorical eligibility is crucial,” central Massachusetts Rep. Jim McGovern, who serves on the House Agriculture Subcommittee on Nutrition, Oversight and Department Operations, which oversees SNAP program policies said in a statement. “This proposal is rotten, it’s wrong, and we’re going to fight it tooth and nail.”

-See the full WGBH story
-See the full Reuters article.

Anti-poverty advocates are making a major push to expand state welfare benefits as part of a campaign to lift tens of thousands of children out of "deep poverty."

One proposal, backed by more than 80 mostly Democratic lawmakers, would increase welfare benefits through the state’s primary cash assistance program, known as Transitional Aid to Families with Dependent Children (TAFDC), by 10% every year until the payments reach 50% of the federal poverty level. That would raise the benefits for an average family of three to $889 a month.

Supporters of the measure say benefits haven't increased in nearly two decades, while the cost of living has skyrocketed.

Lawmakers behind the proposal say $50 million more in state aid over a four-year period will only bring families up to what is considered "deep poverty," or half the federal poverty level. For a family of four, "deep poverty" is considered $10,665 or less.

Overall, the number of families on the state’s primary cash assistance program has declined by half since the 1990s, to about 30,000 per month, according to the state Department of Transitional Assistance.

Combined the state spends roughly $16 million a month on the programs.

Under current law, a recipient is limited to receiving welfare for two years in any five-year period. The family of three in the program collects a maximum of $593 per month.

Last year, lawmakers pushed through a repeal of state rules that denied additional benefits for children born into families already receiving assistance from the state.

Repealing the so-called "cap on kids" means that a parent receiving benefits now gets an additional $100 in monthly benefits for each child, regardless of whether the child is born before or after the parent became eligible for benefits. Families also receive an additional $300 yearly clothing allowance per child.

Anti-poverty advocates say overall the state's welfare programs have failed to keep pace with the rising cost of living, forcing families to scrimp on basic necessities.

"Thirty years ago these grants at least lifted families out of poverty," said Deborah Harris, a staff attorney at the Massachusetts Law Reform Institute, one of several anti-poverty groups backing the proposal. "But now families can't afford to meet their basic needs. That includes buying food, when food stamps run out, and paying for things like laundry and diapers."

Lawmakers are weighing a separate proposal, also heard by the committee this month, to create a pilot project extending benefits for families that reach a "cliff" when they hit the two-year limit on receiving benefits.

Medical professionals say families scraping by on the federal poverty line experience negative health and educational impacts that affect not just the children but their parents as well.

"Lifting families out of deep poverty not only makes it possible for parents to meet the basic needs of food, shelter and education, it also reduces parents' anxiety and depression that also harms children," Dr. Ann Easterbooks, a child psychologist and professor at Tufts University, told the panel. "Even a small increase in funds ... makes a difference in the life of a family."

-See the full Gloucester Times article.

Bills sponsored by Rep. Mindy Domb, D-Amherst,  Rep. William “Smitty” Pignatelli, D-Lenox, and Sen. Joan Lovely, D-Salem, H.107/S.65, would create a new fund to give grants to organizations that distribute free diapers. They envision an initial one-year pilot program that provides money to up to 12 organizations, distributed throughout the state. The size of the fund would be determined by the Legislature.

The lawmakers say the program is needed because of the necessity and cost of diapers. According to the National Diaper Bank Network, children typically require around 10 diapers a day, and the average family with a baby will spend $75 a month on disposable diapers — or $900 a year. While cloth diapers are an option, most laundromats do not allow cloth diapers to be washed in their machines.

Diapers aren’t covered by federal food stamps, known as the Supplemental Nutrition Assistance Program. Nor are they provided by the Women, Infants and Children nutrition program, which classifies them with cigarettes and alcohol as invalid items.

Ellen Jawitz, family resource coordinator for the Jewish Family and Children’s Service’s Center for Early Relationship Support, said there are only a few diaper pantries available, generally in the Greater Boston area, and most are only open to residents of specific towns. The supplies they provide are limited. Jawitz said some low-income families cannot get to big box stores that sell diapers cheaply. Many cannot use cloth diapers because they do not own a washer and dryer.

“Without enough diapers, parents may try to stretch the time between diaper changes, but this causes tremendous discomfort, and puts the baby at risk of serious infection,” Jawitz said in written testimony to the Joint Committee on Children, Families and Persons with Disabilities. She said many families buy diapers but then fall behind on utility and rent bills.

Because daycares require parents to provide diapers for their children, a parent without money for diapers must keep their child home, which means they cannot work.

If the plan takes shape and is approved, Massachusetts would be the first state to provide diaper subsidies to welfare beneficiaries.

-See the full Mass Live article.
-With additional material from the Gloucester Times.

Recently Disability Issues (DI) interviewed former Massachusetts Rehabilitation Commission (MRC) Commissioner Charlie Carr about Electronic Visit Verification (EVV), his leadership of opposition to it, and other matters pertaining to the PCA Program.  Mr. Carr is currently Legislative Liaison at the Disability Policy Consortium and volunteers as Chair of the National Council of Independent Living (NCIL) EVV Task Force. This is an edited version of that interview.

What is Electronic Visit Verification System (EVV)?
The U.S. 21st Century Cures Act, signed into law December 2016, requires all home health care services and personal care services paid by Medicaid to use electronic visit verification (EVV) systems. This means that each visit made by an individual to assist a disabled consumer in their home must be tracked through an electronic method starting January 1, 2020.

Under the new mandate, the EVV system must verify the following:

• Date of service
• Location of service
• Individual providing service
• Type of service
• Individual receiving service
• Time the service begins and ends

DI:  For the last few years, MassHealth has announced plans to try out and phase in EVV.  Have any trials actually been conducted here?
Carr:  Not to my knowledge.There was some mention about piloting it in a small Frail Elder waiver, but I'm not sure if that ever happened.
 
DI:  What is happening in other states, and how does that relate to your concerns?
Carr:  Some states are utilizing software that actually uses facial recognition and/or fingerprints of PCA workers, as well as GPS tracking of exact location of both parties. Draconian measures like these are having a disastrous impact on an already shrinking pool of PCA worker candidates, as well as consumers’ well-being.  I mean, who wants to be tracked via GPS like a criminal with an ankle bracelet? We've seen a growing number of incidents nationally where new applicants for PCA work or even existing ones refuse to be monitored in this invasive manner and have their privacy violated, so they either don't take the job or are leaving. Disabled employers are left without attendant coverage, and some have had to go into the local emergency department in their hospital as a result or end up in nursing homes.
 
DI:  Is there any less personally invasive measure that satisfies section 12006(a) of the 21st Century Cures Act?
Carr:  We are advising MassHealth to adopt the CA model (no facial recognition or biometrics, no GPS tracking, service location is simply entered as ‘home’, ‘community’ or ‘both.’)
 
DI:  Is the announced 2020 statewide EVV implementation a hard deadline, some wonder, given that implementation in 2019 was announced in mid-2018 but didn't happen?
Carr:  As I understand it, MassHealth is planning to apply to the feds for a one-year ‘good faith extension’ to January 2021. Last year, advocates nationally were successful in pushing Congress to pass legislation that extended the 2019 implementation requirement to January 1, 2020.
 
DI:  We understand that SEIU California Local 2015 has joined in solidarity with consumers in strongly opposing EVV in CA.  Has our SEIU 1199 taken a position on EVV?
Carr:   Recently I learned that SEIU 1199 in Massachusetts has decided to adopt the same position as their sister local in California and oppose geo-tracking and biometrics of PCAs and, support the so-called California model. This is great news and very much welcomed by not only PCAs, but also by PCA employers like us.

 DI:  Bottom line:  What can we do about EVV?
Carr:  If you like the PCA Program the way it is, tell your PCM and MassHealth directly, “If it ain’t broke, don’t fix it.” And let your Rep. in Congress know of your strong objection to EVV; when they passed the 21st Century Cures Act, they probably did not intend to treat PCA consumers and their workers like criminals. Urge your Rep. to co-sponsor DeGette’s bill.

DI:  We understand from sources that MassHealth is planning a redesign of the PCA Program. Do you have any clues as to what the redesign might look like?
Carr: No, not really. I do know that they've assembled a working group to study the issue, but nothing has been brought to light that I’m aware of. There's no transparency happening, which is baffling to me because by sharing the work they're doing incrementally, the community has an understanding of the process and areas being looked at. This would give MassHealth the opportunity to avoid surprising the broader PCA consumer community with a model that could evoke (a)  negative response. Personally, I would prefer moving to a Cash & Counseling model, in which a person’s approved PCA hours would be ‘monetized’ by multiplying those hours by the current PCA Program hourly wage; these funds could then be used by the consumer to purchase a self-directed mix of services. This would make it possible for the consumer, for example, to pay higher wages for more difficult tasks or for shifts that are hard to cover, like weekends.
 

DI:  That seems a bit of a stretch from where we are now. Do you think it likely MassHealth will actually go that route?
Carr: Let's hope so. However, it’s important to note that 70 percent of PCA Program consumers use surrogates; folks like you and me who actually self-direct are now a distinct minority. So I would not be surprised to see the PCA Program move in the direction of an Agency with Choice model, in which Home Health Agencies have a key role. MassHealth already uses this model in other programs it operates. I'm hoping that it's a blend of both with, flexibility to move between each model depending on circumstances. I guess we'll have to wait and see.

-From Disability Issues newsletter - Summer 2019, Disability Issues, July 30, 2019.

The state could do more to integrate food into health care as a way to address chronic conditions and avoid some health care spending, a new report found.

The Food is Medicine State Plan, a joint effort of the Center for Health Law and Policy Innovation of Harvard Law School and service provider Community Servings, focused on nutrition's link to chronic diseases like diabetes or cardiovascular disease, and the notion that food can act as medicine when meals are tailored to meet the specific needs of people living with or at risk for certain serious health conditions.

About one in 10 households in Massachusetts struggles with food insecurity, or not having consistent access to enough food for a healthy and active lifestyle, leading to $1.9 billion in annual health care costs that could be avoided, the report said.

Though Massachusetts has programs that try to address the issue of food insecurity and inaccessibility of fresh foods, the report said access to food as medicine programs remains limited in the state and across the country. But as consumers think more about the food they eat, and as Massachusetts shifts its Medicaid program into an Accountable Care Organization model, the report says the time is now to integrate food and medicine.

The report said there are 736 food pantries, meal programs, food rescue organizations and produce voucher programs in Massachusetts, but only 63 of them work with health care providers or tailor meals to meet specific medical needs.

The new ACO system, the report said, provides a ripe opportunity to integrate food is medicine policies because program requirements and financial incentives are changing to leverage community-based resources.

"For example, MassHealth will require ACOs to screen patients for health-related social needs, including food insecurity," the report said. "Starting in January 2020, ACOs will also receive Flexible Services funding that can be used to provide access to services that respond to health-related social needs, including Food is Medicine interventions."

The report's authors recommend that professional medical societies and providers work together to increase provider nutrition education and referral capacity, that MassHealth issue guidance on food insecurity and malnutrition screening protocols, and that insurers incentivize provider networks to screen for food insecurity and make resource referrals part of patient care.

The Legislature should "explicitly recognize Food is Medicine as a priority through legislative action and within the state budget" by funding a pilot program to evaluate the impact of Food is Medicine within the MassHealth population, providing enough funding to meet the demand of the Healthy Incentives Program and by funding the Prevention and Wellness Trust Fund.

To build on the report, its organizers in the coming months plan to convene three task forces within the Massachusetts Food is Medicine Coalition to focus on strategies to address some of the issues identified in the report.

One task force will look at ways to improve the capacity of health professionals to identify and address the need for food is medicine interventions in patients. Another will "lead a statewide effort to establish standards for Food is Medicine interventions in the Commonwealth" and the third will develop research plans to advance the public health and medical understanding of food insecurity and food is medicine programs.

-See the full WBUR story.

-Thanks to Kristen Risley for forwarding.

The majority of people living in Massachusetts' biggest cities are renters. Renters make up about two-thirds of occupied housing units in the city of Boston, as well as in neighboring Cambridge and Somerville, and renters make up more than half of residents in all of Massachusetts’ 15 largest cities.

And the cost of rent has gone up in recent years — an overall increase of about 15 percent since 2011 in the commonwealth’s 15 largest cities. The increase has been much sharper in many communities. In Cambridge, gross rent has increased by about 23 percent, or nearly a quarter, since 2011; in Lynn, it’s increased by about 19 percent, or just less than one-fifth.

But rising rents only tell part of the story.

A WGBH News analysis of data collected by the U.S. Census shows that behind the seemingly straightforward fact of rising rents is a much more complicated picture. Our analysis found that between 2011 and 2017, the most recent period for which reliable data was available, the change in rent burden — rent measured as a percentage of household income — has varied drastically among Massachusetts’ largest cities.
The reasons for these differences are complex, involving differing trends in property values and incomes, as well as demographic changes as an overall influx of new residents into Massachusetts cities reshapes local housing markets.

But the overall trend is clear: a dearth of affordable and family rental housing across the Greater Boston area is increasingly squeezing renters. In its most recent annual "Greater Boston Housing Report Card," The Boston Foundation faulted suburban zoning laws that prevent the construction of multi-family rental housing as one of the chief drivers of this problem.

Our analysis found other patterns within this larger trend that further complicate the picture of rent burden across and within Massachusetts cities.

Among those findings: In many of the commonwealth’s least wealthy cities, residents have seen a sharp increase in the percentage of their income spent on rent. In several cities with booming economies — like Boston, Somerville and Cambridge — the rent burden has been relatively flat, and in some cases has actually decreasedoverall.

And those city-wide trends belie still more complicated differences within cities themselves, where changing rent burdens can vary drastically from neighborhood to neighborhood, painting a complex picture of winners and losers when it comes to housing affordability and uneven benefits from recent economic growth.

The city of Lowell saw the greatest increase in rent burden among the commonwealth’s largest 15 cities between 2011 and 2017, with residents paying 12% more of their household incomes in rent in 2017 than in 2011. The cities of Springfield, Worcester and Newton also each saw significant increases in overall rent burden.

Conversely, the city of Somerville saw the greatest decrease in rent burden — overall, Somerville residents paid 7 percent less of their household incomes toward rent in 2017 than in 2011, followed by the cities of Lawrence, Brockton, Cambridge and New Bedford.

In Boston, families paying more than one-third of household income toward rent are concentrated in a few neighborhoods: Roxbury, Dorchester, Mattapan, Roslindale, parts of East Boston, Allston, Hyde Park, parts of West Roxbury and Jamaica Plain.

Meanwhile, renters in the city's wealthiest neighborhoods may be paying higher rents, but they are paying significantly less of their overall income toward rent.

Put another way: In Boston, It's easier for wealthy renters to rent in expensive neighborhoods than it is for less wealthy renters to rent in neighborhoods that would seem, on paper, to be less expensive to live in.

The greatest concentration of these rent-burdened census tracts are in neighborhoods that have been traditionally working-class and low-income, and which have seen rapid gentrification in recent years — especially the Roxbury-Dorchester-Mattapan corridor.

The data bolsters concerns by residents of these neighborhoods, their elected officials and housing advocacy groups, that the city's less-wealthy renters are under increasing strain when it comes to being able to afford rent.

-See the full WGBH story.