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R. Hamlar, M.B.A., M.D.

Professor, New York University Long Island School of Medicine

I have been raising a grandchild for 14 years, and we have another family member who is also on Tenn Care. For these two family members, Tenn Care has been their link to self care and wellness. We are law abiding citizens, my husband is a disabled vet and this is the only insurance we can get at the moment for a family of five. People are not like the senators and representatives who come from rich families who have access to healthcare that the average or below average person can not obtain. Growing up beneath the poverty line, TennCare provided vital healthcare services for me and my siblings. I will forever appreciate that, and the opportunities good health created for me to improve my circumstances as I grew. I want to see these services continue to be provided for those who so desperately need them. As a nurse, I have seen the devastating consequences of being under insured or uninsured. I have taken care of cancer patients who have had to file bankruptcy just to afford the lifesaving chemo for their spouse or child. I have taken care of those in their last days, being kept comfortable as they say goodbye to friends and loved ones. It was through hospice that they were able to afford the nursing care and medications to keep them in a some what comfortable state. Those patients and their families would be left to the painful, long, and heartbreaking process of death. If you support and uphold this proposal, you are deciding that some people are more deserving of a peaceful death then others. This proposal will only perpetuate the already longstanding inequalities that have cost this country trillions of dollars. The idea that this could be passed is not only threatening to me, my neighbors, and my family, but to the state of Tennessee itself. Without preventive care and quality care for that matter, we are also perpetuating the costs of more intensive care for diseases that could have been managed with proper and immediate care. Cutting services, allowing nonphysicians to set limits that will impair the health of children, and ultimately forcing independent physicians to align with hospitals is the path to singlepayer model to which I, as a lifelong political conservative, am strongly opposed. The state should not be allowed to make changes to the Medicaid program without federal oversight or eliminate federal standards. I have heard too many stories of people harmed by mismanagement and poorly planned laws. We have custody of three grandchild that depend on Tenncare for their health care needs we can not afford to lose coverage as we are older and live on a fixed jncome to survive. Please realize that so many people depend on Tenncare we should not have to choose between food or health care. Many Tennesseans have been dropped from Medicaid in the past and there is great uncertainty about how the state would manage the program with less government oversight. My adult daughter with Intellectual disabilities depends on Medicaid for her only health insurance now that both her parents are retired. It helps her to have a job, have transportation, and be involved in the community. Instead of using block grants, Tennessee should accept the expansion of Medicaid to cover many more of our citizens. As a citizen of Tennessee for almost 40 years, watching and reading the news has shown me that the current state of our TennCare is really sad. Tennessee is the last state I would trust with a blank check to do as it pleases with federal funding. In the last few years, it has seen a 20% percent increase in the number of uninsured children. Of the 100,000 children who lost coverage, TennCare does not know how many children were actually ineligible and how many lost their coverage due to administrative issues. Our previous governor tried to get the state legislature to expand Medicaid and cover 300. Because of this lack of health insurance, 12 rural hospitals have closed in Tennessee, leaving 21 counties without immediate access to an emergency room. Listed in the block grant proposal, is an item to restrict patients to one medication only.

The paper notes that 5 of 7 cases in which the healthcare providers had not recommended removing the infants from the residence had overt recurrent re-bleeding. This contrasts with only 1 of 21 infants experiencing overt pulmonary bleeding after changing the home environment (Dearborn et al. Interestingly, our analysis of their data suggests that if the infant returned to his original home environment, he would have an average number of 1. Efforts to identify pathologic mechanisms by which toxigenic fungi might lead to this syndrome have yielded important information. Hodgson and Dearborn reviewed the data and pointed out that significant supporting evidence for a plausible mechanism now exists from in vivo studies of laboratory animal models of respiratory toxicology and in vitro data documenting changes at the subcellular or biochemical level by mold spores or Stachybotrys mycotoxins (Hodgson and Dearborn 2002). Specifically, several reports have been published indicating that hemorrhagic inflammation occurs in the lungs of mice or rats after experimental intra-tracheal instillation of Stachybotrys spores (Nikulin et al. It is also of note that animal experiments indicate that a variety of other mycotoxins (from fungi genera other than Stachybotrys), including aflatoxins and roridins, can cause increased vascular fragility and pulmonary hemorrhage (Ammann 2000). For example, studies have documented that Stachybotrys spores can alter surfactant metabolism in mice (Mason et al. Specifically, there were decreased collagen matrix fibers in lungs of infant rats and young mice in the vicinity of these spores. The authors indicate that these changes may lead to degradation of the extracellular matrix and compromise the integrity of pulmonary capillaries (Yike et al. This enzyme was found to cleave several compounds in lung tissue including proteases inhibitors, peptides, and collagen (Kordula et al. Methanol extraction of the Stachybotrys spores removes the trichothecene mycotoxins and denatures the spore proteins. When these methanol-treated spores are tested in the rodent models, the toxic effects on the lungs are significantly reduced (Rao et al. Trichothecene mycotoxins from Stachybotrys have been documented to induce inflammatory changes and apoptosis in cultured cell systems (Lee et al. Other current research seeks to understand the local dose and toxicity of inhaled mycotoxins. The published literature clearly outlines the uncertainty of current knowledge and calls for further research to clarify exposures, pathologic responses, and mechanisms of injury. A difficulty revolves around the management of cases of acute pulmonary hemorrhage and hemosiderosis, and the appropriate assessment of homes with water damage. Experience with infants with this syndrome supports removal of these infants from the environment in which the illness developed until water damaged and mold contaminated materials are fully remediated. It also supports rigorous avoidance of tobacco smoke because cases have recurred in the presence of tobacco smoke after removal from the home. Summary and Conclusions on Effects of Mycotoxins There is abundant evidence for a role of ingested mycotoxins in human disease, and there is significant clinical evidence of a role for fungal spores and toxins by the respiratory route in military and agricultural settings following massive exposures. Laboratory studies in animals and at the cellular level provide supporting evidence for direct toxicity of fungal spores and mycotoxins in mammalian lungs. However, for humans residing or working in water-damaged buildings, the role of airborne fungal spores and toxins in the etiology of non-allergic disease remains controversial. Epidemiologic and clinical evidence raise the additional question of potential synergy between mycotoxin effects and environmental tobacco smoke. Recent reviews have concluded that scientific proof of the notion that the presence of fungal mycotoxins in indoor environments can lead to disease in humans is lacking (Robbins et al. But there certainly is sufficient evidence available in the literature in support of this hypothesis to say that it also cannot be excluded. If we follow the usual framework for risk assessment in environmental toxicology, the identification of a hazardous agent depends on converging lines of evidence from three or four areas of investigation: epidemiology, in vivo (whole animal) toxicology, in vitro testing (in isolated cell systems or cell-free systems), and structure-activity analyses (Faustman and Omenn 1996). In general, our knowledge of the chemistry of mycotoxins has only begun to advance to the point where structure-activity relations can contribute, and the epidemiology supporting this hypothesis has often been judged as weak. But the available toxicology data would appear to grant significant support for the biologic plausibility of the hypothesis. In addition, there is the continued experience in Cleveland, where over 30 cases have occurred, 90 percent of them from environments containing Stachybotrys (Dearborn et al. Clinical and basic scientific research continues to explore the hypothesis that fungal exposure in indoor air of water-damaged buildings can cause pulmonary hemorrhage in infants and children, as well as other diseases in adults.

The stumbling block is that we usually document awareness via our ability to verbalize, a province largely of the left hemisphere. Well outside of the fact that it is likely difficult to shave with no opposable thumb and challenging to balance yourself on two limbs when you are used to moving about on four, there is another, neurocognitive reason why your pets do not shave. In 1970, a comparative psychologist named Gordon Gallup (Gallup, Nash, Potter, & Donegan, 1970) was investigating the behavior of animals in front of mirrors as a way to measure social behavior systematically when he stumbled on the fact that most organisms react to their mirror reflection as if it were a member of the same species; that is, they responded to their mirror reflection with species-specific social behaviors (threats, attempts to mate, spitting, barking, feces throwing, among other reactions). Animals that can recognize themselves in mirrors ought to use the mirror to examine their newly marked anatomy. It turns out that only our closest living relatives-the great apes (chimpanzees, orangutans, and gorillas)- posses the ability to use their mirror reflection like humans do (Gallup, 1982). What is the importance of mirror selfrecognition for neuropsychology, and who cares whether chimps can do it It turns out that the ability to recognize yourself in a mirror is strongly related to your sense of self, or self-awareness, which allows you to engage in a number of adaptive social behaviors, for example, empathy, sympathy, deception, and so on (Gallup, 1982). Meaning relative to other parts of their brain and their body, great ape frontal lobes are larger than would be expected by chance. Therefore, the investigation of self-recognition in nonhuman primates provides us with insights into the neuropsychological and possible clinical underpinnings of self and consciousness in humans. In fact, there are several neuropsychological conditions that are marked by deficits in selfprocessing. The most notable is a condition known as "mirror sign," or mirror selfmisidentification syndrome (Breen, Caine, & Coltheart, 2001). Patients with mirror sign are able to use mirrors to recognize objects, and even other people, but when asked about their own reflection, they often respond as if their mirror reflection was a stranger who was following him or her around. Usually untroubled by their disorder, family members report that patients act "funny" or "strange" at home, often surprising themselves as they walk past mirrors. Some patients do complain that their new counterpart does not talk to them, which does create some frustration. Neuropsychologically, these patients are marked primarily by right hemisphere dysfunction, which suggests that the capability to process information about the self may be localized to regions of the right frontal lobe. This notion has recently been confirmed by several functional magnetic resonance imaging investigations of self-face recognition (Platek, Keenan, Gallup, & Mohamed, 2004; Platek et al. Several other neuropsychological conditions are marked by subtler deficits in selfprocessing. Split-brain patients must reformulate a sense of completeness by making their experiences accessible to both halves of their brains through external cross talk. They can largely do this by moving their eyes to capture both visual fields and verbalizing out loud so that each hemisphere hears what is available to the other hemisphere. Within us, many brain and body processes are either automatic or unavailable, and thus typically remain unconscious to the mind. For split-brain patients, the hemispheres are physically unavailable to each other. The brain is not communicating internally, but the subjective experience is of one mind. The challenge for the split-brain patient is to consciously integrate each half of the cerebral hemispheres that have been made surgically unconscious of each other. The common saying "we only use 10% of our brain" might be better thought of as "our conscious mind may be aware of only a percentage of what our brains do and are capable of. But they can be brought into awareness via techniques such as biofeedback, and can then be modified by the conscious mind. Many have wondered what might be possible if aspects of the unconscious mind became conscious. What hidden potential could people then develop, such as becoming conscious during the "unconscious" state of sleep or developing senses and perception beyond what is now commonly thought possible This may sound like the stuff of science fiction, but researchers have documented lucid dreaming (see later). It is also reasonable to assume that scientists will find ways to study the limits of sensory-perceptual experiences. Boundaries between the concepts of the conscious mind and the unconscious mind are blurring. The challenge now before brain science is to understand the workings of these aspects of mind and to relate them to brain states and processes.

The instances of this could be limited because most residents receive medications through the Medicare Part D program. Many of these individuals have profound life-limiting conditions from traumatic brain injuries or, in some cases, developmental disabilities. Second, efforts by the facility to adopt formulary changes would likely increase burdens on attending physicians. It is already difficult to attract qualified physicians to practice in long-term care. Imposing a closed formulary could exacerbate the burdens on long-term care facilities and their attending physicians. As noted above, elsewhere in the Waiver Draft, TennCare explicitly states Amendment 42 does not rely on reductions to eligibility or benefits in order to achieve savings under the block grant. For example: the state proposes that it have the flexibility under this demonstration to vary benefits packages for different members based on medical factors or other considerations (p. We appreciate the efforts TennCare has made to develop a system that provides the right "aligned incentives" in both quality and appropriate reimbursement for facilities. The state proposes that it have the flexibility under this demonstration to vary benefits packages for different members based on medical factors or other considerations. As part of Amendment 42, TennCare seeks a complete exemption from the provisions of 42 C. Such a scenario would provide significant flexibility to TennCare, but may result in a very high cost to providers and beneficiaries with respect to transparency and opportunities for input. In the draft of Amendment 42, TennCare proposes to use the flexibility granted by Section 1115 and 1115A to promote a comprehensive redesign of the Medicaid program with respect to financing and, in some areas, how benefits are delivered to eligible individuals. Because TennCare proposes such an extensive redesign, it should also propose certain additional provisions that ameliorate longstanding issues providers, and especially longterm care providers, have with the existing administrative features of the TennCare program. Sufficient measures could be included to recoup funds paid for individuals who ultimately do not become eligible. Similarly, in requesting relief from certain onerous provisions of the managed care regulations at 42 C. Part 438, TennCare could also request authority in its waiver changes that make the provider change of ownership process more streamlined and efficient, and to simplify the increasingly complexities of credentialing of providers by managed care organizations. Funding for Excluded Populations: How will funding for populations not included in the block grant be preserved, especially during economic downturns Future Inclusion of Excluded Populations: If the block grant is successful, would the state plan to move currently excluded populations into the program in the future Transparency and Stakeholder Input on Modifications: Given the flexibility and fewer approvals the state is requesting from the federal government, how does the state plan to solicit stakeholder feedback and what processes would there be to ensure transparency related to any state level program changes For example, on page 2 of the Waiver Draft TennCare states, "TennCare now finds itself in a position of needing to identify or develop new, innovative care delivery approaches that may require short-term investments of new dollars, but which will-over time-reduce (or at least contain the growth of) the cost of care. Impact on Medicaid Funding Mechanisms: How does the state anticipate existing Medicaid financing mechanisms. Conclusion We thank you for the opportunity to comment regarding TennCare Amendment 42. We understand this draft is the initial stage in the development of a block grant process with numerous steps to follow that may result in substantial changes to the current proposal. Those changes may significantly alter our perspective with respect to our comments. Unauthorized use, dissemination, distribution, or reproduction of this message is strictly prohibited and may be unlawful. We oppose the proposal to implement block grant funding and ask the state to not submit the proposed waiver provisions not required by state law. While the proposal includes an adjustment for unexpected enrollment growth, it does not account for other changes in program needs. Tennessee would remain responsible for other unexpected increases in per-person TennCare costs, such as increased costs due to public health crises or innovations in medical treatment. In these situations, the state may not be able to provide the additional funds needed to cover cost increases and may look to cut benefits, eligibility, and/or provider rates.