In Oakland, California, a program called EMS Corps trains young men to become certified emergency medical technicians. Students with disadvantaged backgrounds get an intensive five-month course, as well as a powerful, new outlook on what they can do in life and for their neighborhoods. Sarah Varney of Kaiser Health News reports in collaboration with the NewsHour.
With more people obtaining health insurance under the Affordable Care Act, places like Harborview Medical Center are providing much less “charity” (uncompensated) care. The Emergency Department there is as busy as ever, though.
Patients who use drugs containing hydrocodone as a pain reliever or cough suppressant are going to have to jump through more hoops to get them starting next month.
The Drug Enforcement Administration is reclassifying so-called “hydrocodone combination products” (HCP) from Schedule III to Schedule II under the Controlled Substances Act, which will more tightly restrict access. Vicodin, for example, is an HCP because it has hydrocodone and acetaminophen.
The final regulation, which takes effect Oct. 6, will mean that patients generally must present a written prescription to receive the drug, and doctors will no longer be able to call in a prescription to the pharmacy in most instances.
Many patients with painful chronic diseases, including cancer, take hydrocodone combination products
In an emergency, doctors will still be able to call in a prescription, according to the new rule. And although prescription refills are prohibited, a doctor can, at his discretion, issue multiple prescriptions that would provide up to a 90-day supply.
These measures don’t satisfy consumer advocates or pharmacists who are opposed to the new rule. Continue reading
By Michael Ollove
Athens, Georgia—When Georgia public high schools were asked several years ago to devise a policy to govern sports activities during periods of high heat and humidity, one school’s proposal stood out: It pledged to scale back workouts when the heat index reached 140.
Those who understood the heat index, the combined effects of air temperature and humidity, weren’t sure whether to be appalled or amused. “If you hit a heat index of 140,” said Bud Cooper, a sports medicine researcher at the University of Georgia who examined all the proposed policies, “you’d basically be sitting in the Sahara Desert.”
The policy reflected an old-school, “no pain, no gain” philosophy, a view that athletes need to be pushed to their physical limits—or beyond them—if they and their teams are to realize their full potential.
In some places, state, school and sports officials are recognizing that the zeal of coaches, players, and parents for athletic accomplishment must be subordinated to safety. Increasingly, they are adopting measures to protect student athletes from serious, even catastrophic injuries or illnesses that can be the consequence of a blinkered focus on competitiveness. Continue reading
This story is part of a partnership that includes NPR and Kaiser Health News.
CENTENNIAL, COLO. – When they get a call for medical help, most fire departments scramble both an ambulance and a fully-staffed fire truck.
But that’s way more than many people really need, says Rick Lewis, chief of emergency medical services at South Metro Fire Rescue Authority in the Denver suburbs.
“It’s not the prairie and the old West anymore, where you have to be missing a limb to go to the hospital. Now it’s a sore throat, or one day of cold or flu season sometimes, and that can be frustrating for people, I know it is.”
It’s kind of like an urgent-care clinic on wheels.
Ambulance crews aren’t required to transport everyone who calls, but Lewis says crews fear lawsuits if they were to leave and a patient got worse. Also, ambulance companies typically don’t get paid unless they take somebody to the hospital.
So Lewis teamed up with Mark Prather, an emergency room doctor, to come up with a better way. Continue reading
By Michelle Andrews
When you need emergency care, chances are you aren’t going to pause to figure out whether the nearest hospital is in your health insurer’s network. Nor should you.
That’s why the health law prohibits insurers from charging higher copayments or coinsurance for out-of-network emergency care.
Beware, you could be left on the hook for substantially higher charges than you might expect.
That’s all well and good. But there are some potential trouble spots that could leave you on the hook for substantially higher charges than you might expect. Continue reading
Scott Paul knew he needed to head to the emergency room on a recent Sunday after his foot became so painful he couldn’t walk.
The one thing that gave him pause was the thought of having to wait several hours next to a bunch of sick people.
But his wife, Jeannette, remembered she’d seen Dignity Health television commercials featuring a woman sitting in a hospital waiting room and then cutting to the same woman sitting on her living room couch as words come up on the screen: “Wait for the ER from home.”
“I’ve been in emergency rooms before, so I thought I’d see if this worked out,” she said, and went online to book an appointment for her husband at Dignity’s St. Mary’s Medical Center in San Francisco. Continue reading
Someone who has a cardiac arrest in King County has a greater chance of survival than anyone else in the world, according an analysis by county officials.
The survival rate for cardiac arrest in King County hit an all-time high of 62 percent in 2013, the analysis found.
By comparison, the cardiac survival rates in New York City, Chicago, and other urban areas have been recorded in the single digits.
According to the analysis, the cardiac survival rate in King County has risen over the past decade or so, from an above-average 27 percent in 2002 to 62 percent in 2013.
Strategies that have contributed to the rise include: Continue reading
by Lois Beckett
ProPublica, March 4, 2014
More than 20 percent of civilians with traumatic injuries may develop PTSD. Trauma surgeons explain why many hospitals aren’t doing anything about it.
Undiagnosed post-traumatic stress disorder is having a major impact on injured civilians, particularly those with violent injuries, as Propublica detailed last month.
One national study of patients with traumatic injuries found that more than 20 percent of them developed PTSD.
But many hospitals still have no systematic approach to identifying patients with PTSD or helping them get treatment.
We surveyed 21 top-level trauma centers in cities with high rates of violence. The results show that trauma surgeons across the country see PTSD as a serious problem. Continue reading
The American College of Emergency Physicians has given Washington state a “near failing D+” in the its annual state-by-state report card assessing the nation’s emergency services.
Overall the state ranked 35th in the nation, down from its ranking of 19 in the College’s 2009 report, which that year gave Washington a C.
by Lena Groeger
Some medical conditions require and receive immediate care. People who are having heart attacks or who have suffered life-threatening injuries are typically seen by doctors as soon as they arrive at the hospital.
But in less urgent cases, patients arriving at the emergency room can wait for hours before seeing a doctor, receiving pain medication, having tests, or being admitted to the hospital.
And unless you had the foresight to call ahead, there is little way to know how long your visit will take.
Today ProPublica launching an interactive news application called ER Wait Watcher, which gives you a little more information to work with.
The app, which uses nationwide data recently released by the federal government, shows you how long it takes, on average, to see a doctor or other licensed professional at hospitals near you, plus the time it takes to drive there.
In many cases, the hospital closest to you may not be your best bet, because of long waiting times. Traveling farther may get you in front of a doctor sooner.
If you think you’re having a heart attack, or if you’ve suffered a serious injury, you should not use ER Wait Watcher. Please call 911. The ambulance will take you to the closest hospital, and won’t be as affected by traffic because it can speed and run red lights.
The app uses data from the Centers for Medicare and Medicaid Services on measures of “Timely and Effective Care.” These measures are based on a year’s worth of data that CMS updates quarterly (the last update was Dec. 12, 2013).
It includes averages for:
- How long patients tend to wait before seeing a doctor,
- how long they spend in the emergency department before being sent home or admitted to the hospital,
- and how many leave without being seen at all.
All data is reported voluntarily by hospitals, which have a financial incentive to participate.
ER Wait Watcher also estimates in real time how long it would take to drive to nearby hospitals based on current traffic conditions. It fetches this data directly from Google, so travel times will change throughout the day.
While minutes matter when you’re having a medical emergency, longer wait times are not always an indicator of worse care. For example, emergency rooms that see more patients with behavioral health problems like alcohol abuse may have much longer wait times; it may take hours for a patient to sober up enough to be safely discharged.
And time is not the only important factor, of course, so the app also includes patient satisfaction scores and other hospital quality measures to help you make an informed decision about which emergency room to go to.
The federal data includes what researchers say are important quality metrics for the nation’s emergency departments. According to Dr. Jeremiah Schuur, an emergency physician at Brigham and Women’s Hospital in Boston, the most useful measure from a patient’s perspective is waiting time — the time from when a patient walks in the door to when he sees a doctor.
Other emergency room measures, such as total length of stay at the hospital, may vary more depending on condition (a head fracture may take longer than a dislocated elbow) or on other patients (some hospitals treat sicker patients).
But whether or not a patient is seen quickly is a measure that can be compared across hospitals, says Schuur.
CMS’s move to standardize how to measure the quality of emergency care is especially needed now. In the last two decades an increase in ER patients, many of them older and sicker, has led to overcrowding.
Nationwide, ambulances are now turned away once a minute from overcrowded ERs and hospitals have difficulties in finding specialists to take emergency calls.
Some patients leave in frustration without being seen at all, while others can wait many hours for a hospital bed to become available. This confluence of problems led the Institute of Medicine to warn that emergency rooms in the United States are “at a breaking point.”
Overcrowding is not just an annoyance, and doesn’t just affect the people who come in complaining of a headache. A study of almost a million admissions to 187 California hospitals found that patients who were admitted after going through a very crowded emergency room were at 5 percent greater odds of dying than those admitted after passing through a less-crowded emergency room.
To tackle the problem, some experts advocate more measurement. Publicly releasing quality metrics can drive meaningful improvements in emergency care, according to a recent article in Health Affairs, a health policy journal. And the strategy has had some success in the past.
In 2004 hospitals began to publicly report a quality measure called “door-to-balloon time.” It refers to the time between a heart attack patient’s arrival at the emergency room and the moment of surgical intervention (which can sometimes involve inflating a thin balloon inside a heart artery).
CMS used door-to-balloon time to determine a portion of a hospital’s Medicare payment. Since then, emergency departments have focused a great deal of effort and money on identifying patients with heart attacks by screening them at triage. This has led to improvements in care for heart attack patients.
But not all measurements have had the same success. In 2005, England tried implementing another measure — a “four-hour rule” for the length of time a patient could stay in the emergency room before being sent home or admitted to the hospital. The country’s health service mandated that hospitals reach this four-hour time limit for 98 percent of their patients.
While nearly all hospitals met the goal, many also found ways to game the system, for example transferring patients to another doctor right before the clock ran out.
Since 2010, England has relaxed this measure and introduced new ones such as time to triage and percentage of patients who left without being seen.
Some U.S. emergency departments advertise their own quality care metrics, for example by posting waiting times on their websites, on billboards or on smartphone apps.
For people with conditions that are not life-threatening, this information allows them to postpone their trip or avoid a busy hospital altogether.
Theoretically this could help distribute patients more effectively and avoid pockets of crowding, improve patient satisfaction and serve as an incentive for hospitals to speed up their services.
But that information may not be reliable, or useful for comparing hospitals. On their own websites, hospitals are free to advertise any definition of “waiting time” they choose.
While one hospital could choose to count the time from when a patient arrives to when she is evaluated by a doctor, another could decide it’s when a patient is seen by a triage nurse, or receives a welcome from the hospital greeter.
In order to solve these discrepancies, CMS established standard definitions and a common metric with which to accurately compare different hospitals.
The agency defines its own “waiting time” measure as the time from when a patient walks in the door to when he is evaluated by a licensed provider (a doctor, physician assistant or nurse practitioner). CMS says its specifications state clearly who qualifies, to avoid confusion.
A caveat: Hospitals may record these times inaccurately. In most cases someone must manually write down the time a patient was seen, so the times are not always precise. To combat this, some emergency rooms outfit doctors and nurses with electronic badges that wirelessly record exact times.
According to CMS, hospitals have 30 days to review their data before submitting it to the government. The agency places most of the responsibility on hospitals for making sure their data is correct before doing so.
Instead of emphasizing timeliness, future measures could look at effectiveness of care or how well emergency departments utilize resources, according to Dr. Schuur. While the newly released data is extremely important to enable individual hospitals to improve their operations, he said, “consumers should be aware that there is much more to the quality of an emergency room than how quickly they see you.”
From Public Health – Seattle & King County
The survival rate from cardiac arrest in King County has reached an all-time high of 57 percent, according to a new report released today by King County Executive Dow Constantine. Most other parts of the nation have survival rates that hover around 10 percent.
“People are alive today in King County who would not have survived in most other places in the country,” said Executive Constantine. “Our EMS/Medic One system delivers rapid, high-quality critical care wherever you are.”
The Emergency Medical Services (EMS)/Medic One 2013 Annual Report highlights this achievement and other activities that place this EMS/Medic One system among the world’s best. The Executive has sent the report to the Metropolitan King County Council.
In 2012, the EMS system in King County responded to 172,700 calls to 9-1-1, including 48,010 for Advanced Life Support (ALS), the most serious or life-threatening injuries and illnesses. The average medic unit response time stayed steady at 7.5 minutes.
“Survival from cardiac arrest is the signature of quality for any EMS/Medic One system, and we continue to set the standard,” said Dr. David Fleming, Director and Health Officer for Public Health – Seattle & King County.
King County’s cardiac survival rate has increased from an above-average 27 percent in 2002 to 57 percent today. (Note to editors: graphic showing increases in King County cardiac survival rates is attached.)
The King County EMS/Medic One system is managed by the Emergency Medical Services Division of Public Health – Seattle & King County, and relies on a close partnership of thousands of professionals with fire departments, paramedic agencies, EMS dispatch centers, and hospitals to provide emergency care and save lives.
The full EMS 2013 Annual Report is available at www.kingcounty.gov/health/ems.
By Annie Feidt, Alaska Public Radio
Dr. Linda Smith walks into a room at Providence Alaska Medical Center, ready with a stethoscope and a huge grin.
She teases her patient, Dawn Dillard, saying that her spiky hair recently resembled a “faux hawk.”
Dillard found out she had uterine cancer a year ago. Her oncologist gave her a year to live. The 57-year-old has beaten those odds, but now her kidneys are failing.
After the laughs are over, Smith sits down on the edge of Dillard’s bed, leans in, and starts talking about a surgical procedure to help her kidneys.
And unlike hospice care, it is not offered only in the final months of life. Smith works on pain management, coordinating care and even does some counseling. Dillard, who is now in chemotherapy again, really appreciates it.
“I can’t even say how much she’s helped me,” Dillard says. “Just little things. You know, showing me things like breathing techniques. Sort of like mediation, just ways to focus on things that are positive and happy rather than focusing on your sickness and how crappy you feel.”
Becoming A Better Listener
Two years ago, Linda Smith was a very different kind of doctor.
She worked in the emergency room at the busy Anchorage hospital, where the goal was to quickly stabilize a patient and move on.
But two decades into her career, she started to question how she was caring for patients at the very end of their lives.
She remembers putting patients on breathing tubes and hearing family members say things like, “I know Dad didn’t want this, but we’re just not ready to let him go.”
“I started to have a lot of regret about doing things to people that were painful and uncomfortable and were prolonging their suffering,” Smith says. She thought, “if I only had the time to sit down with the family, I probably wouldn’t be doing these things.”
In 2011, Smith enrolled in a one-year palliative care fellowship at Providence. She had a lot to learn. She found out she was a bad listener. And she was abrupt. As an ER doctor, sometimes she was so busy she didn’t even sit down to deliver devastating news.
“I can remember saying to families things like, ‘I’m sorry, there’s nothing more I can do.’ And I realize now that sounds like abandonment to many people when you say you can’t do anything more. And the reality is I may not be able to do anything more to the patient that will make them survive, but there’s a lot more that I can do. I always can do more.”
A lot of what Smith does is talk to people. She doesn’t advocate for or against treatment, but she wants patients and their families to understand their decisions.
If a doctor puts in a breathing tube, for example, that may extend a patient’s life, but they won’t be able to eat or talk. If they die with a tube in, the family will miss hearing their last words.
So now Smith sits down for hard conversations and looks patients and their family members right in the eye. Earlier this year, she was called in to consult with the wife of a patient who was dying.
“When I entered the room,” Smith says, “The wife said to me, ‘I know who you are.’ And I said, ‘Oh. OK.’ And she said, ‘I don’t want to talk with you and I don’t want to like you because you’re here to talk about death and dying, aren’t you?'”
Smith had a short conversation with the woman, and left her a book on difficult end of life choices. She went back to visit her the next day.
“And she said, ‘You know, I so tried not to like you. And what you had to say. And I really realize that we need to have this discussion now, don’t we?’
“And I said, ‘When you’re ready, we’re ready to have that discussion.’ And she said, ‘I’m ready now,'” Smith recalls.
There’s a shortage of doctors who provide palliative care, and the need is growing as baby boomers slide towards old age.
Smith was planning to go back to the emergency room. But interactions like that one persuaded her to stay in palliative care. Now she works more and makes less money. Some days, she wonders if she’s crazy.
But then she gets to visit a patient like Dawn Dillard.
Back in her hospital room, Dillard and Smith talk about having a second procedure. Smith leaves and calls Dillard’s other doctors. They end up agreeing that the second procedure isn’t really necessary after all. So instead of staying another night in the hospital, Dillard is back home by the end of the day.
This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.
By Kelsey Miller
The majority of older patients who go to emergency departments in several nations around the world are likely to start out with complex conditions that deteriorate after their visits, according to a study published in the June 25 issue of Annals of Emergency Medicine.
Researchers from the Centre for Research in Geriatric Medicine at the University of Queensland, Australia, studied patients 75 years or older in emergency departments around the world to paint a picture of the unique problems they face — and how ERs can change to better serve them.
Lead author Dr. Leonard C. Gray said older people who arrive at emergency departments are more likely to have “geriatric syndromes” such as immobility, confusion and incontinence. The findings also indicated that for many, functional and cognitive issues increased afterward.
“These problems increase the complexity of care, and require specific interventions to ensure the best results,” Gray said in an email.
Researchers studied 2,282 patients in 13 different emergency departments in seven countries including Australia, Belgium, Canada, Germany, Iceland, India and Sweden.
They looked at medical records, talked to hospital staff and interviewed the patients directly about their cognitive function, mood, comprehension and more. Researchers also tracked the patients’ progress for 28 days after their ER visit.
Before coming to the ER, 54 percent were independent and didn’t require help for daily activities. After, only 33 percent were still listed as ”completely independent.”
The number of patients studied who displayed symptoms of cognitive impairment rose 6 percent after their trips to the ER, and the number of those who could not walk without assistance rose 23 percent.
Though the study fails to look into specific reasons why these older patients were negatively affected by ER visits, researchers say the numbers should be a signal for hospitals.
“With population aging, and relative reductions in severe health problems among younger age groups, the proportion of patients in the [emergency department] who are older is likely to increase,” Gray said. “Therefore, the case for designing the [emergency department] to cater for the needs of older people will escalate continuously.”
Such steps could include simple changes in furniture or lighting or more complex changes such as staff training and risk minimization.
“It seems not a matter of ‘if,’ but rather ‘when’ adjustments should be made,” Gray said.
This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.
When bombs exploded in Boston and a monster tornado tore through Oklahoma, paramedics and emergency medical technicians ran toward danger. As first responders, they put their own lives at risk in order to save the lives of others.
Yet EMTs and paramedics are governed by a haphazard patchwork of rules that vary widely by city and state. And their wages differ widely as well (see infographic), from a high of $52,930 a year in Washington, D.C., to a low of $25,900 a year in Kansas.
The national average wage was $34,370 in 2012, according to the Bureau of Labor Statistics. In smaller and rural communities, EMTs and paramedics are often volunteers.
|EMT Legislation This Year|
|Source: The National Conference of State Legislatures.|
Accidents and violence-related injuries are the leading cause of death for Americans under age 44, but there is no federal agency responsible for coordinating or guiding emergency services that respond to these incidents. What federal funding is available drips from faucets in several different departments.
In tough economic times, emergency services often are on the chopping block.
A survey of Emergency Medical Services leaders in the 200 largest cities found 44 percent had cut services last year, according to the Journal of Emergency Medical Services.
It found 28 percent of big-city EMS agencies had a hiring freeze or were not filling vacancies, some for the third consecutive year.Fifteen percent reported layoffs. Twenty-one percent had no cost-of-living or pay-for-performance increases, some for the fourth year, the journal said.
“Several states have made catastrophic cuts to state EMS offices over the last few years, causing reductions in staff,” said Dia Gainor, executive director of the National Association of State EMS Officials (NASEMSO). She singled out Alabama, New York and Iowa.
A recent investigation by the Des Moines Register found Iowa’s EMS system “broken.” Staff in Iowa’s EMS bureau has been cut 40 percent and its budget reduced by more than one-third since 2009, resulting in delayed inspections of EMS providers and less oversight, the paper reported.
Detroit’s EMS system has been “decimated” by layoffs, and other cities have had furloughs, layoffs and “rolling brownouts” in which a response office shuts down for a day, said Don Lundy, president of the National Association of Emergency Medical Technicians, a federal advocacy group.
Unlike public health, fire and police departments, emergency services are the new kids on the block. In the 1960s, a town’s mortician might respond to a car crash in a hearse. The federal government took a leadership role in the 1970s, developing the nationwide 911 phone system and establishing EMTs as a profession. But funding dropped dramatically in the early 1980s.
“Since then, the push to develop more organized systems of EMS delivery has diminished, and EMS systems have been left to develop haphazardly across the United States,” the Institute of Medicine reported in 2006.
The report, “Emergency Medical Services: At the Crossroads,” described the nation’s EMS system as one of “severe fragmentation, an absence of systemwide coordination and planning, and a lack of accountability.”
Even the number of EMTs and paramedics is uncertain.
The Bureau of Labor Statistics said there were 232,860 paid EMTs and paramedics in 2012, based on its survey of employers.
In a 2011 report, the National Highway Traffic Safety Administration (NHTSA) said there were 826,111 certified EMTs and paramedics, based on a survey of state EMS officials.
This number includes part-time, unpaid volunteers and those who receive stipends, as well as full-time paid staff. They work in a wide range of settings, including hospitals, clinics, law enforcement agencies, fire stations, oil rigs, Indian reservations, ambulances and air transport.
NHTSA also said the BLS doesn’t distinguish between EMTs and paramedics and doesn’t identify EMS cross-trained as firefighters.
States with the highest number of paid EMTs and paramedics are California, New York, Pennsylvania, Texas and Illinois, according to BLS.
The states with the highest concentration of paid emergency workers compared with the national average are Maine, Tennessee, Delaware, South Carolina and Kentucky.
BLS economists said smaller states depend more heavily on paid EMS workers because they have smaller pools of volunteers.
“For a long time, EMS has been on the short end of the straw,” said Lundy of the EMTs association. He’s director of Charleston County EMS in South Carolina and has been an EMT for 38 years. “A lot of communities don’t understand the true value the emergency medical service brings to the community.”
Until there’s a problem or crisis. Lundy cited Washington, D.C., which has been plagued with complaints about poor service and long wait times for ambulances.
The city’s fire chief recently told the city council only 58 of 111 ambulances were in service, the city had only 245 paramedics (well short of its goal of 300), and some paramedics have responsibilities other than field work or responding to calls.
A key problem, Lundy and others say, is the lack of dedicated federal EMS funding.
“As we stand here today, there’s no federal funding for EMTs, no grants for the local level. There are grants for fire services, and about 2 percent of that money may go for non-fire EMS grants,” he said.
“There are a lot of very dedicated volunteers who are funding their organizations through barbecue chicken dinners on Saturday nights,” Lundy said. “That’s very sad because they are on the front lines of the health care people get every day. If you opened a hospital and made the staff throw chicken dinners every week to pay the bills, people would think you were crazy.”
A dozen states don’t fund EMS at all, the National Conference of State Legislatures reported in a study last year. Federal grants are available for state trauma systems through the U.S. Department of Health and Human Services, the NHTSA and the Department of Homeland Security. Some of that money can be used for EMS.
In addition, charitable foundations and corporations have become a source of revenue. For example, the Duke Endowment poured $5.5 million into emergency medical services in the Carolinas between 2004 and 2007.
“It’s an amalgamation of sources,” said Hollie Hendrikson of NCSL, who wrote the report on state trauma services. “Every state does it a little differently.”
Since the 1970s, when deaths from car crashes were a major concern, the Department of Transportation has housed an EMS office in NHTSA. Emergency services advocates are pushing for a lead federal agency for EMS, a need endorsed by the Institute of Medicine in 2006.
U.S. Rep. Larry Bucshon, R-Ind., a physician, introduced a bill in February that would set up an EMS office in HHS and provide EMS education and training grants. So far, the bill has just six co-sponsors.
Lundy hopes high-profile events like the Boston Marathon bombings will wake people to EMS needs. BLS estimates the need for paid paramedics and EMTs will rise 33 percent from 2010 to 2020, much faster than other occupations.
Stateline is a nonpartisan, nonprofit news service of the Pew Center on the States that provides daily reporting and analysis on trends in state policy.