The study also revealed that women were less likely to talk about heart disease with their primary care physicians and that nearly 60 percent of women did not believe their symptoms were heart-related.

According to the National Heart, Lung and Blood Institute, heart disease is the No. 1 cause of death for women. In addition, two-thirds of women who experience a heart attack will never make a full recovery.

Women might not even realize they are experiencing a heart attack. Some common symptoms for women are unusual fatigue, shortness of breath, weakness/inability to perform daily activities, nausea, sleep disturbances and indigestion. Some other warning signs are often ignored and erroneously considered “non-cardiac” such as a burning sensation in the back, arms, shoulders or teeth. Actually, any intense symptom that is above the waist should be taken seriously as a possible heart attack.

During a heart attack, blocked coronary arteries prevent blood from reaching oxygen-starved heart muscle. The first step a woman should take if she’s experiencing a heart attack is to call 911 and then chew on an aspirin. Aspirin can improve the chance of survival by reducing the size of the clot, if present, in the coronary artery.

By calling 911, assessment can begin immediately on the way to the hospital. The EMS crew can alert the hospital’s cardiac team so it can begin treatment to open the blocked artery that is causing the heart attack as soon as you arrive at the hospital.

It is also important to remember to never drive yourself to the emergency room. You will lose valuable care that you would have received by the EMS crew, and driving yourself also puts other drivers at risk.

Women must remember to never take a wait-and-see approach to a possible heart attack. The longer a woman waits, the more damage a heart attack can cause.

Remember, if you feel weak or tingly in your FACE, weak or numb in your ARM or your SPEECH becomes slurred, TIME is of the essence. Call 911.

The longer you wait, the more extensive the damage to your brain will be. If given within three hours of the first symptom, there is an FDA-approved clot-buster medication, called tPA, that may reduce long-term disability for the most common type of stroke.

In Missouri, emergency medical services are required to transport acute stroke patients to a designated stroke center rather than the closest facility.

“Hospitals will experience $4.2 billion in cuts between 2013 and 2020,” said Herb B. Kuhn, MHA president and CEO. “Without additional Medicaid coverage, hospitals will continue to experience a high level of uncompensated care and fewer dollars to provide that care.”

Although the uninsured account for a relatively small share of hospital utilization, they account for a disproportionate share of the uncompensated costs that hospitals must make up through various means. Hospitals treating Medicare and Medicaid patients in Missouri also are reimbursed less than the cost of providing care. For uninsured patients and patients with high deductible health insurance plans who can’t afford to pay their deductibles, hospitals often receive little or no compensation.

Underpayment for care provided by government programs and the cost of the uninsured are offset by payments from commercial insurance payers that exceed the cost of care. As a result, individuals and businesses subsidize the cost of these programs and the uninsured. These subsidies — shifting costs from one set of patients to another — constitute a “hidden health care tax” on commercial premiums.

The Affordable Care Act reduced hospital payments through a series of cuts to Medicare and scaled back federal payments to hospitals to help offset the cost of the uninsured. These reductions were made with the expectation that hospitals would see new revenue from patients newly covered by Medicaid and those purchasing insurance through a health insurance exchange. However, in June 2012, the U.S. Supreme Court ruled that the mandate to expand Medicaid was optional for states. The decision placed the delicate balance between payment cuts and new revenue included in the ACA in the hands of state lawmakers.

Without the additional coverage for the working poor included in the ACA, Missouri will continue to experience a large percentage of uninsured citizens. Because of the cuts to hospital payments, the cost of providing care to these Missourians will be shifted to the insured.

The trend in uncompensated care is alarming. Growth in uncompensated care exceeded 90 percent between 2002 and 2011. Throughout the past decade, Missouri’s hospitals provided $10.5 billion in uncompensated care. In 2011, Missouri hospitals provided $1.3 billion in uncompensated care.

Without Medicaid reform, uncompensated care costs could grow to $3.5 billion annually by 2019. Medicaid reform in Missouri would help offset much of the expected growth in uncompensated care costs between 2014 and 2019.

“Cuts to hospitals through the Affordable Care Act and subsequent legislation will significantly reduce hospitals’ ability to provide uncompensated care at the present level,” Kuhn said. “Providing $3.5 billion in uncompensated care would be impossible without unprecedented cost shifting to individuals with commercial insurance.”

Cost shifting could significantly increase the burden on Missouri businesses and individuals. After accounting for the cost of the “hidden health care tax,” annual net earnings for the average privately insured Missourian was $370 lower in 2011 than 2002. However, the decision to reform Medicaid could reduce the “hidden health care tax” burden.

“Cost shifting doesn’t increase the quality or efficiency of health care,” Kuhn said. “And, it is the poorest choice for managing the costs of health insurance for businesses and individuals.

“Missouri has a stark choice. If we reform Medicaid, we can reduce the ‘hidden health care tax’ and allow Missouri business to decrease costs and Missouri workers to keep more of their earnings. If we fail to reform Medicaid, we will see the costs of the uninsured explode. Missouri businesses will struggle to remain competitive, and individuals will pay more for their insurance.”

The Missouri Hospital Association is a not-for-profit association in Jefferson City that represents 152 Missouri hospitals. In addition to representation and advocacy on behalf of its membership, the association offers continuing education programs on current health care topics and seeks to educate the public, as well as legislative representatives, about health care issues.

# # #

“The Affordable Care Act included cuts to hospital payments but offset some of those cuts through increased coverage,” said Herb B. Kuhn, MHA president and CEO. “Without the new revenue from expanded coverage, the numbers don’t add up. That’s bad news for the currently insured and bad news for Missouri’s economy.”

A recent study from the University of Missouri found that Medicaid expansion would create more than 22,000 sustainable jobs. However, not expanding Medicaid would leave the ACA’s cuts in place and require hospitals to make costly decisions about staff, services and infrastructure.

To illustrate the consequences of $4 billion in cuts, the analysis projected the effect of reductions in both workforce and capital investments between 2012 and 2021. The analysis found that cuts of this magnitude would reduce hospital employment by 5,011 through 2021. In addition, because hospital jobs support additional jobs in communities throughout the state, the analysis projected a total job loss using standard economic multipliers. The total job loss, accounting for the ripple effect of hospital community job cuts, would equal 9,019 jobs statewide.

Missouri’s hospitals invest approximately $1 billion annually in their physical plants and properties. Without the offsetting revenue provided by Medicaid expansion, a $4 billion cut to hospital payments could reduce hospital capital expenditures by $1.9 billion through 2021.

“In 2011, Missouri hospitals provided more than $1.1 billion in uncompensated care statewide — a record level,” Kuhn said. “Without expansion and in light of the cuts, this level of care is unsustainable. The cuts will significantly impair hospitals’ ability to invest in the staff, services and facilities necessary to deliver the level of care Missourians expect.”

In addition to the cost to Missouri’s economy through losses in jobs and capital investment, Missouri businesses could bear an increased share of the cost of the uninsured. The cost shift, also known as the “hidden health care tax,” would likely increase in the absence of Medicaid expansion. These costs are borne by businesses and individuals and the $4 billion in cuts could increase the costs by $1.1 billion through 2021.

“This new analysis paints a stark contrast to the earlier work by the University of Missouri on the economic benefits of Medicaid expansion,” Kuhn said. “It paints a picture of a Missouri that pays more in federal taxes and gets less. And, that’s not a direction we can afford to go as a state.”

The Missouri Hospital Association is a not-for-profit association in Jefferson City that represents 154 Missouri hospitals. In addition to representation and advocacy on behalf of its membership, the association offers continuing education programs on current health care topics and seeks to educate the public about health care issues.

# # #

Regional Reports – Workforce Investment Areas

“In 2011, hospitals provided 22 percent more charity care than in 2010,” said Herb B. Kuhn, MHA president and CEO. “For the first time in the state’s history, charity care and bad debt exceeded $1 billion. Since our first report in 2004, charity care has increased 404 percent.”

The report found that the 129 participating hospitals provided $622.8 million in charity care in 2011. Hospitals’ total uncompensated care is comprised of both charity care and bad debt. When they are added together, hospitals reported $1.1 billion in uncompensated care.

“This year’s report demonstrates hospitals’ ongoing commitment to delivering care to members of their communities who are unable to pay. However, it also signals the need for a better system — one that ensures Missourians have expanded access to insurance. Extending health insurance to additional Missourians would help these individuals manage their health more effectively, provide increased access to services in the most appropriate venue and reduce the cost of health care for all Missourians,” Kuhn said.

The Affordable Care Act cuts hospital payments to Missouri hospitals by $3.3 billion from 2013 to 2020. However, these cuts are partially offset by the act’s expansion of Medicaid and premium support for the uninsured to purchase health insurance on a health insurance exchange. If fully implemented, these changes would significantly reduce the cost of the uninsured in Missouri. If Missouri does not expand the state’s Medicaid program as outlined in the ACA, many of Missouri’s poorest residents will remain uninsured, and these costs will continue to be borne by hospitals, taxpayers and those with commercial insurance.

“Absorbing more than $1 billion in uncompensated care annually while facing $3.3 billion in cuts creates an unsustainable situation for hospitals,” Kuhn said. “These new numbers bring even more urgency to the Missouri debate about expanding coverage for the uninsured. Without the offsetting revenue that comes from newly insured individuals, Missourians’ access to high quality and affordable care is in jeopardy.”

There are additional benefits provided to the communities served by hospitals. Medicare and Medicaid programs often pay less than the cost of providing care. In 2011, hospitals absorbed $1.7 billion in the unpaid costs of treating these beneficiaries.

In addition, hospitals’ community benefit investments are often driven by defined areas of local need. In 2011, hospitals donated $36 million to causes in their community and $33 million to free or reduced costs for medical clinical services. Hospitals also contributed $287 million to the education of health professionals to build and sustain the health care workforce.

“Hospitals are important community institutions. They not only provide important health services, but they also strengthen the economic health of the areas they serve,” Kuhn said. “Hospitals are a leading employer statewide, and in many communities — urban, suburban and rural — they are the top employer. Hospitals’ investments in people and infrastructure add significant value to Missouri’s economy.”

The report found that in 2011, participating hospitals employed 142,123 individuals in 119,843 full‐time equivalent positions. The salary and benefits of these individuals totaled $8.4 billion in 2011. Hospitals’ $1.4 billion investment in 2011 for facilities and equipment added to the economic impact. These investments underpin Missouri’s economy, providing support for families and businesses throughout the state.

“Hospitals provide life‐saving care and community‐supporting jobs and investments,” Kuhn said. “The 2012 Community Investment Report demonstrates why hospitals are essential to the state and communities throughout Missouri.”

A recently released report from University of Missouri underscores the economic value of expanding coverage for Missourians.

“Policymakers face a unique opportunity to create more than 20,000 jobs and bring about important improvements in our state’s health care system,” Kuhn said. “By adopting the Medicaid expansion, policymakers can begin to address the unsustainable costs of the uninsured while building Missouri’s economy.”

The Missouri Hospital Association is a not‐for‐profit association in Jefferson City that represents 154 Missouri hospitals. In addition to representation and advocacy on behalf of its members, the association offers continuing education programs on current health topics and seeks to educate the public about health care issues.

# # #

Hospital‐specific data on community benefit and economic impact is available online.

“Medicaid expansion will improve the health of the state and significantly boost the state’s economy,” said Herb B. Kuhn, MHA president and CEO. “It is a win-win for Missouri. The economic activity created by adding $8.2 billion in federal spending to Missouri’s economy will generate nearly $856 million in state and local taxes throughout seven years. And, at a six-year cost of $333 million to the state, Medicaid expansion would be a net gain for state revenue, according to the research.”

Researchers found that the job creation from Medicaid expansion would be large and dispersed throughout the state. The jobs created by the expansion would add $6.4 billion in labor income between 2014 and 2020. The total effects (direct, indirect, and induced) of the original $8.6 billion for the Medicaid expansion are an additional $9.6 billion of value-added output to the state.

“When looking at the cost of health care in Missouri, the ‘hidden health care tax’ that is shifted from underfunding Medicare, Medicaid and the cost of the uninsured is often overlooked,” Kuhn said. “Medicaid expansion will help reduce this cost. Between 2010 and 2014, $434 in health insurance premium growth was attributed to cost-shifting. Across the period 2014-2020, privately insured individuals and families could potentially save nearly $1 billion due to reductions in premiums.”

The report found that while Missouri has one of the lower health insurance premium costs in the U.S. with its average premium of $12,754 for family coverage in 2010, premiums are still a major expense for employers and individuals.

According to the university’s research, as many as 220,000 enrollees would be eligible for the program, significantly reducing the number of the uninsured in the state. Between 2014 and 2020, the federal portion of this state-federal program would cover 96.1 percent of the cost.

“Accepting the expansion would be a good deal for Missourians,” said Ryan Barker, director of health policy for the Missouri Foundation for Health. “There is a strong economic case for expansion, coupled with an important health benefit to the newly enrolled. Having health insurance makes a difference for individuals and families, and these benefits are shared by the business community through a strong, healthy workforce.”

The research was conducted by the University of Missouri School of Medicine’s Department of Health Management and Informatics and Dobson DaVanzo & Associates LLC. Regional reports also are available online.

The Missouri Hospital Association is a not-for-profit association in Jefferson City that represents 154 Missouri hospitals. In addition to representation and advocacy on behalf of its membership, the association offers continuing education programs on current health care topics and seeks to educate the public about health care issues.

Missouri Foundation for Health (MFH) is an independent philanthropic foundation dedicated to empowering Missourians to achieve equal access to quality health services. MFH provides grant funding and education, and fosters community partnerships to promote health improvement, especially for the uninsured and underserved. Since its founding in 2000, MFH has provided more than $480 million in grants and awards to organizations in 84 Missouri counties and the City of St. Louis.

Federal

President

Barack Obama

Views on Health Care

Obama’s Health Care Record (Kaiser Health News)

Mitt Romney

Views on Health Care

Romney on Health Care (Kaiser Health News)

Senate

Todd Akin

Jonathan Dine

Claire McCaskill

State

Missouri Governor

Jim Higgins

Jay Nixon

Dave Spence

Propostion B – Cigarette Tax

Ballot Language - Scroll to Proposition B

Supporters

Show-Me A Brighter Future

Fact Sheet

Social Media: Facebook and Twitter

Propostion E – Health Insurance Exchange

Ballot Language - Scroll to Proposition B

News

Kaiser Health News

State

Prop B opponents in Missouri tie cigarette tax hike to Obamacare
The Kansas City Star, 11/2/12

Proposition E gets little attention before election
Columbia Daily Tribune, 11/1/12

Commentary: Important issues on Tuesday’s ballot
The Examiner, 11/1/12

Editorial: Proposition 1: The mental health sales tax
Columbia Daily Tribune, 10/31/12

Editorial: Missouri ballot decision recap
Springfield News-Leader, 10/31/12

McCaskill, Akin and Dine on health care
Columbia Missourian, 10/31/12

CoxHealth, Mercy and MU make pitch for Prop B tobacco tax
Springfield News-Leader, 10/31/12

Cigarette tax increase on Missouri ballot for third time
St. Louis Post-Dispatch, 11/1/12

MU med school expansion tied to tobacco tax hike
AP/St. Louis Post-Dispatch, 10/31/12

Commentary: Health care reform: Advancing our common good
St. Louis Post-Dispatch, 11/1/12

Commentary: Vote yes on Prop B to save lives, reduce health care costs
St. Louis Post-Dispatch, 10/31/12

Commentary: Prop B revenue would be protected
Springfield News-Leader, 10/30/12

Commentary: Smoking is jeopardizing the health of our students
Columbia Missourian, 10/30/12

Letter to the Editor: Vote yes on Proposition B tobacco tax hike
Columbia Daily Tribune, 10/30/12

Editorial: Proposition B is good tax policy; good for schools
St. Louis Post-Dispatch, 10/27/12

Missouri to vote, again, on part of Obama health law
AP/The Kansas City Star, 10/27/12

Poll suggests voters likely to raise Missouri cigarette taxes
The Kansas City Star, 10/29/12

Health insurers want stability of new health care system
AP/St. Louis Post-Dispatch, 10/29/12

Battle lines are clear on proposed tobacco tax hike
St. Louis Beacon, 10/19/12

Proposition E would require popular or legislative approval for insurance exchange
St. Louis Beacon, 10/19/12

Editorial: Reject attack on Affordable Care Act in Missouri
The Kansas City Star, 10/9/12

Swung state
Slate, 10/3/12

National

Physicians’ PACs lay big money on 2012 races
Politico, 11/1/12

How the health law might be changed by the next president
Kaiser Health News, 11/1/12

Could Romney repeal the health law? It wouldn’t be easy
NPR, 10/30/12

Health insurers ready post-election message: We’re not the bad guys!
The Washington Post, 10/29/12

Obama and Romney on health care
Columbia Missourian, 10/28/12

Editorial: Medicaid on the ballot
The New York Times, 10/29/12

Debate fact check: Analyzing health-care statements
Politico, 10/4/12

How will the election change Medicaid?
Kaiser Health News/PBS, 10/3/12

Democrats and Republicans differ on Medicaid fix
NPR, 10/2/12

The ACA was a starting point in a sea change in health care. As we shift into a more inclusive and accountable system, we should continually evaluate successes and failures as we work to improve the system as a whole.

Hospitals, physicians and the provider community must work together more efficiently to deliver the better, more coordinated care envisioned in the ACA. In addition, we must focus on the health care workforce to ensure caregivers are available for the newly insured to gain access to the system and to prepare for shifts in the model of care.

The conversation about health care will continue. However, after the court’s decision, the path forward is much clearer.

There are more than 84 types of sleep disorders. Treatment depends upon the cause(s). Sleep problems can be caused by factors as benign as a change in living arrangements or as serious as a brain disease or a tumor.

Follow these general guidelines for better sleep hygiene.

• Set a regular time to go to bed — a key component to improving sleep — and adhere to this as closely as possible. If you cannot fall asleep within a reasonable period of time, get out of bed, leave the bedroom and do something nonstimulating. This may be watching a late-night talk show or reading. After 30-60 minutes, try again to fall asleep. The idea is to not spend too much time in bed awake. An association between the bed and an inability to fall asleep can increase the problem.

• Establish a regular wake-up time. No matter how long it took to fall asleep, no matter how little sleep you have had, no matter how flexible the morning schedule is, there should be no “sleeping in.” This will only further confuse and disorganize the internal biological clock.

• Make the sleep environment as comfortable as possible. Make your bedroom dark and quiet, neither too hot nor too cold. Although minor fluctuations in room temperature and firmness of the mattress probably have little impact on sleep, extremes can be disturbing.

• Omit alcohol and caffeine in the late afternoon and evening. For the very sensitive, caffeine intake may need to cease each day by noon. Alcohol is often used as a self-treatment for relaxation and sleep induction, but it is disruptive to the sleep-wake cycle.

• Develop a sleep habit using the bedroom primarily as a place to sleep. Although many people use the bedroom for watching television, preparing work for the following day, eating snacks and paying bills, the person with a sleep problem needs to set the bedroom aside for sleep only.

• Carefully time meals and exercise. In some individuals, a heavy meal late in the evening can severely disrupt sleep. Heavy exercise too late in the evening also can lead to sleep difficulty.

• Some people simply need to relax sufficiently to allow sleep to occur. Relaxation tapes can facilitate this process.

• Since at least 35 percent of those with sleep difficulties have an identifiable psychological cause, some form of treatment should be considered.

Consult your physician if sleeping problems persist. If you or someone you know appears to suffer from a sleep problem, call for help.