VOR reply to Congress on the meaning of Olmstead, July 2018

Mary Lazare is the Principal Deputy Administrator and Acting Commissioner on Disabilities at the federal Administration for Community Living (ACL). Remarks that she made at the Autism Society of America 2018 National Conference in July set off an uproar among some disability advocates who claimed that she said she favored segregating people with disabilities. 

According to an article in Disability Scoop, "Talk Of Segregating People With Disabilities Alarms Members Of Congress" by Michelle Diament, 7/18/2018, "The lawmakers said they were told that Lazare said she believed the Supreme Court came to the wrong conclusion in the landmark Olmstead v. L.C. case, which affirmed the right of people with disabilities to access community-based living, and that she prefers segregated and institutional settings." The problem is that there is no complete transcript of her remarks, no recording of her remarks, and conflicting third-hand reports from people who claimed to hear the remarks or at least heard of them from other people. Her subsequent Tweet of Apology and Regret is ambiguous, but she does say "We also recognize Olmstead gives people the right to other choices [than 'community living']". That part is exactly right.

Three members of Congress wrote to the ACL wanting to know more about Lazare's remarks, but also revealing a misunderstanding of Olmstead that is consistent with a misinterpretation that some advocacy groups have been promoting since 1999. VOR wrote to the three lawmakers "to emphasize the need for ICFs/IID in a full continuum of care and to clarify the true meaning of Olmstead for these lawmakers and their associates."

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VOR Reply to Congressional Letter to the ACL

July 22, 2018

Representative Jan Schakowsky, 115th Congress, Illinois District 9
Representative Greg Harper, 115th Congress, Mississippi District 3
Representative Jim Langevin, 115th Congress, Rhode Island District 2

Cc:
Lance Robertson, Administrator, Administration for Community Living
Mary Lazare, Principal Deputy Administrator, Administration for Community Living

Dear Representatives Schakowsky, Harper, and Langevin:

We are writing in response to your July 13th letter to Administrator Lance Robertson of the Administration for Community Living (ACL) regarding comments made by Principal Deputy Administrator Mary Lazare at the recent ASA [Autism Society of America] Conference. As there is no actual record of Ms. Lazare’s comments, we can only conclude that some of her statements deviated from the past positions expressed by the ACL, which have held that everyone does better in the community. Since the conference, accusations have flown around the internet, accusing the ACL of trying to re-institutionalize everyone and reverse the course of the last 30 years. We are concerned by the level of anger and hyperbole to which this issue has been raised.

Our concerns are legitimate, as our organization has been mischaracterized in many of these online diatribes. VOR is a national non-profit organization, founded in 1983 by families of individuals with intellectual disabilities (IDD). Many of our members have loved ones with severe/profound intellectual disabilities or behavioral problems. Many are non-verbal, non-ambulatory, have PICA or self-injurious behaviors, are subject to frequent seizures, or are medically fragile. Some families have loved ones with far less extreme disabilities, but feel that their needs are not being properly addressed by our health care system. VOR advocates for a full continuum of care, respecting the rights of all to the level of care that is most appropriate to their needs. We support the goal of community integration for those who desire inclusion, but we also support the need for high quality care, comfort and stability offered by Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) for those who have higher levels of need. We advocate for choice, and for supporting a full range of options to meet the diverse needs and goals of this population. Unlike other advocacy groups, VOR does not rely on government grants for funding. We are self-supported by membership dues and donations.

In response to the uproar about Ms. Lazare’s purported comments and your letter to the ACL, we are concerned that the 1999 Olmstead Decision continues to be misrepresented by advocates and by members of Congress. Olmstead is a well-balanced decision, supporting the ideal of providing access to the most integrated setting, but admitting that for some, the most integrated setting may be an “institution” (ICF/IID). The justices recognized the need to support ICFs/IID as part of a full continuum of services. The balance of Olmstead has been overlooked or ignored by many who quote only the passages about supporting what has become a mandate for integration-for-all.

Please read the accompanying document for further reference about the full meaning of Olmstead.

For years, our families have been told that their loved ones can receive the same level of support in HCBS waiver settings. We disagree. ICFs/IID are a vital component of our safety net. They are well regulated and must meet rigorous standards to qualify for certification from CMS. The current CMS State Operations Manual for ICFs/IID, Appendix J, contains 247 pages of requirements and protocols for treatment. There is no equivalent for HCBS waiver settings. While the level of service provided by ICFs/IID are not appropriate to most persons with IDD, they are vital to those with high levels of need.

In January, 2018 the HHS Office of the Inspector General, the ACL, and the HHS Office of Civil Rights issued a joint report addressing the under-reporting of critical incidents (abuse and neglect) of individuals with intellectual disabilities in HCBS waiver settings. This followed a November 21, 2016 series “Suffering in Secret” by the Chicago Tribunei and a 2011-2012 series “Abused and Used” in the NY Times. Just two days ago, the Auditor General of the State of Illinois issued a report on the performance of DHS oversight on the state’s CILA (group home) program, which found systemic failures in Illinois’ licensing and oversight of taxpayer-funded group homes for adults with disabilities. Even more distressing are the facts in the case of Georgia earlier this decade. A determination by the U. S. Department of Justice led the state to closing many of its ICFs/IID, without ensuring that the HCBS system was prepared to handle the medically fragile IDD population. The consequences were tragic. Over the years that ensued, many people died. A March, 2015 article in the Augusta Chronicle reported that 500 individuals died in group homes in the previous year.

Our purpose in this letter is not to point fingers or to say that one form of care is better than another. It is to say that the system as a whole needs to be re-evaluated, that we need to do better with the resources we have and build up every asset and resource we have. We need to stop diverting time, energy, and funds on ideologies and on committees and organizations that serve only a portion of our IDD population and devote our resources to direct care of individuals, sufficient wages for Direct Support Professionals, monitoring our system for abuse, neglect, and misuse of funds, moving people from the waiting list to appropriate services, and strengthening all of our existing forms of residential care, services, and employment opportunities.

The time has come to drop the dogmas that divide us and learn to support each other, to work to address the needs of all of our members and their families. Our waiting lists are too long. Too many of our people are underserved. Too many of our people are not receiving the right level of services and supports. Too much money is being wasted, spent on oversight agencies that fail to provide oversight or being diverted to lobbying groups that support their own self-interest instead of the interests of those they are tasked to serve.

Thank you,

Hugo Dwyer – Executive Director, VOR
Joanne St. Amand – President, VOR

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See also, 

• "Ensuring Beneficiary Health and Safety in Group Homes..."
• "Suffering in Secret: Illinois hides abuse and neglect of adults with disabilities"
• New York Times, 2011 - 2012: "Abused and Used"
• Illinois: "Performance Audit of the July 2018 DHS Oversight of the CILA [Group Home] Program"
• Georgia: "Girl’s death among 500 in one year in community care"

Justice Kennedy - A Moderating Influence for Choice in the 1999 Olmstead Decision

VOR is a national nonprofit advocacy organization that has for 35 years supported the right of individuals with intellectual and developmental disabilities (I/DD) to receive services and supports according to their individual choice and need, regardless of setting.

Below is a post from the VOR FaceBook page, 6/27/18, commenting on Justice Kennedy's resignation from the Supreme Court and his importance as a moderating influence on the 1999 Olmstead decision. 

Many federally funded advocacy groups and agencies have misinterpreted Olmstead as a mandate for "Community Integration for Everyone" . In Olmstead, the Supreme Court did not prohibit institutional care for those who need it or attempt to define or delineate the types of settings that are permitted or prohibited under the Americans with Disabilities Act. To the contrary, Olmstead recognized the need for States to maintain a range of facilities for the diverse needs of persons with developmental disabilities: "Unjustified isolation, we hold, is properly regarded as discrimination based on disability. But we recognize, as well, the States' need to maintain a range of facilities for the care and treatment of persons with diverse mental disabilities, and the States' obligation to administer services with an even hand." Olmstead v. L.C., 527 U.S. 581, 597 (emphasis added) 

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VOR comment on the resignation of Justice Kennedy:

With Justice Kennedy's resignation as a Supreme Court justice, I wanted to post part of the Olmstead Decision ruling, that also quotes part of the Amicus brief that VOR filed at that time. The Olmstead Ruling ensures choice for our individuals to live in the least restrictive environment for their needs. It does NOT mean everyone has to live in a community setting.

Here is part of the ruling, and something we need to continue to share with legislators, some who still do not know and understand the real meaning of Olmstead.

"However, a majority of Justices in Olmstead also recognized an ongoing role for publicly and privately operated institutions: 'We emphasize that nothing in the ADA or its implementing regulations condones termination of institutional settings for persons unable to handle or benefit from community settings...Nor is there any federal requirement that community-based treatment be imposed on patients who do not desire it.'" Id. at 601-602.

A plurality of Justices noted: “[N]o placement outside the institution may ever be appropriate . . . ‘Some individuals, whether mentally retarded or mentally ill, are not prepared at particular times - perhaps in the short run, perhaps in the long run - for the risks and exposure of the less protective environment of community settings ’ for these persons, ‘institutional settings are needed and must remain available’” (quoting Amicus Curiae Brief for the American Psychiatric Association, et al, [including VOR]). “As already observed [by the majority], the ADA is not reasonably read to impel States to phase out institutions, placing patients in need of close care at risk... ‘Each disabled person is entitled to treatment in the most integrated setting possible for that person—recognizing on a case-by-case basis, that setting may be an institution’[quoting VOR’s Amici Curiae brief].” Id. at 605.

Justice Kennedy noted in his concurring opinion, “It would be unreasonable, it would be a tragic event, then, were the Americans with Disabilities Act of 1990 (ADA) to be interpreted so that states had some incentive, for fear of litigation to drive those in need of medical care and treatment out of appropriate care and into settings with too little assistance and supervision.” Id. at 610."

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See also, VOR Olmstead Resources.

VOR comments on the 17th (2016) anniversary of Olmstead:

"Recently, the Department of Justice (DOJ), and the Administration for Community Living (ACL) issued press releases celebrating the 17th Anniversary of the Olmstead decision. VOR shares their view that there is much to celebrate in opening doors to community living for people with intellectual and developmental disabilities (I/DD) who are able and wish to take advantage of such opportunities. Unfortunately, their ideological preoccupation with one key part of Olmstead, community integration, at the expense of the other key part, choice, has reduced options for all people with I/DD. This crimped and, VOR would submit, inaccurate application of the plain language of Olmstead has done significant harm to many of our most disabled citizens.

"By insisting that all people with I/DD live and work in the community, the DOJ and ACL are treating people with I/DD as a monolithic group, not as the individuals they are. DOJ and ACL are substituting the wishes of the government for that of the person with I/DD or, where relevant, the legal guardian. While their policies have opened doors for the less severely disabled, they have closed important doors for the more severely disabled. Many of these individuals have lifelong needs that require a very high level of care, the kind often found only in public and private Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID), sheltered workshops, and facility-based day programs."

VOR Celebrates the ADA and Recognizes the Full Meaning of the Olmstead Decision

From VOR, the best Website for Olmstead Resources: 

The Department of Justice (DOJ) recently recognized the 17th anniversary of the U.S. Supreme Court Olmstead decision by pointing out the strides that have been made in providing more opportunities for individuals with disabilities in mainstream American life. As we celebrate this aspect of the Olmstead decision, let us not forget the fullness of the ruling and the emphasis the Court placed on individual choice to protect health and safety and the basic rights of individuals with intellectual and developmental disabilities (I/DD). 

Too often, some disability rights advocates and federal agencies have read Olmstead as a mandate for all individuals with I/DD, regardless of their individual needs, to be served in community-only settings. Federal “Olmstead enforcement” activities are an example of how some have misread the Olmstead decision and the Americans with Disabilities Act (the ADA) to the detriment of the individual rights of those who were intended to be the beneficiaries of these landmark actions. Driven by the DOJ Civil Rights division and the Administration for Community Living (ACL) of the Department of Health and Human Services, these activities are aimed at eliminating opportunities for individuals with I/DD to live and work in more structured, congregate settings which provide higher levels of care, including nursing, therapy and behavioral supports. While community living may work well for many people who are capable of making decisions with a little help, congregate settings furnish life-sustaining services for those who need more care to assure their health and safety.

By closing down congregate homes and specialized work settings for individuals who choose and require these programs, Olmstead enforcement actions have had the effect of denying Americans with I/DD the freedom to choose where they live and work and with whom they associate, even going so far as to indicate just how many people with I/DD may live and work together in the same setting.

In pursuing its one-size-fits all agenda, the DOJ fails to appreciate that it is undermining its own recognition of the fact that people with I/DD are not a monolithic group and should be treated as individuals:

"...public entities are required to ensure that their actions are based on facts applicable to individuals and not on presumptions as to what a class of individuals with disabilities can or cannot do,” (U.S. Dept. of Justice analysis of ADA)

Ironically, DOJ enforcement activities target the homes and workplaces of many of the most fragile individuals with disabilities, despite the Civil Rights Division’s pledge,

“to uphold and defend the civil and constitutional rights of all individuals, particularly some of the most vulnerable members of our society." (Emphasis added.)

These actions which restrict freedoms for people with I/DD are happening in direct contradiction to the law and Supreme Court decision that DOJ and ACL profess to be upholding. 

Fortunately, a fair and honest reading of Olmstead provides a path that maximizes the living and work options for individuals with I/DD. While encouraging the maximum community integration, Olmstead makes the individual with disabilities the ultimate arbiter of what she or he believes is best. The Court's respect for choice is recognized in the second prong of the holding which gives the individual the right to reject a placement, regardless of what anyone else thinks is best for her or him:

“(b) the transfer from institutional care to a less restrictive setting is not opposed by the affected individual,” Olmstead v. L.C., 527 U.S. 581, 587 (1999).

Justice Ginsburg expanded on the reason for this right in her majority opinion:

“...[N]othing in the ADA or its implementing regulations condones termination of institutional settings for persons unable to handle or benefit from community settings...Nor is there any federal requirement that community-based treatment be imposed on patients who do not desire it." Olmstead, at 601 – 602.

Justice Ginsburg went to explain the ongoing role of large facilities in her concurring opinion:

“[For some individuals, no placement outside the institution may ever be

appropriate . . . . ‘Some individuals, whether mentally retarded or mentally ill,

are not prepared at particular times - perhaps in the short run, perhaps in the

long run - for the risks and exposure of the less protective environment of

community settings;’ for these persons, ‘institutional settings are needed and

must remain available.’ ” . . . Each disabled person is entitled to treatment in the most integrated setting possible for that person – recognizing on a case-by-case basis, that setting may be an institution” Olmstead, at 605.

Sadly, the DOJ and ACL actions sweeping all individuals with I/DD into a monolithic group that can only be served in one officially sanctioned manner (i.e. small houses in urban settings) have led to tragic results for thousands of individuals with severe and profound I/DD, both in terms of quality of life and longevity of life. Investigative reporting by newspapers across the country (including The Washington Post and The New York Times) have documented the tragedies that have befallen people with I/DD when they have been forced out of their congregate care homes into a community unprepared to meet the health and safety needs required for their very survival.

Intermediate Care Facilities for individuals with Intellectual Disasbilities (ICF/IID), disability farms, intentional communities, sheltered workshops and facilty-based day programs all serve people with more intensive needs yet are labeled by the DOJ as "institutional" and out of compliance with Olmstead. Thus, the tragedy warned against by Justice Kennedy in Olmstead has come to pass:

“It would be unreasonable, it would be a tragic event, then, were the American with Disabilities Act of 1990 (ADA) to be interpreted so that States had some incentive, for fear of litigation, to drive those in need of medical care and treatment out of appropriate care and into settings with too little assistance and supervision.” Olmstead, at 610.

By focusing on the freedom of the individual to choose from a range of options, the ADA and the Olmstead decision reflect a uniquely American attitude toward services for the disabled, as well as the inherent goodness and compassion of the American people. Congress and the Supreme Court did not intend for the ADA and Olmstead to be used to eliminate opportunities and basic freedoms for our most vulnerable citizens. Rather, this law was meant to expand choices and protect rights.

The Congress must not allow DOJ and ACL to misuse Olmstead and the ADA to create a sub-class of American citizens whose personal lives are dictated by a one-way-suits-all lifestyle. As we celebrate the ADA and the anniversary of Olmstead, let’s protect and promote their full meaning so that all Americans with disabilities can live safe and happy lives of their choosing.

VOR is a national disability advocacy organization which supports a full continuum of quality care options for individuals with disabilities and individual choice of services. VOR supports community settings for those who choose and can benefit from them, but we also recognize and advocate for individuals with profound and other high needs who choose and require more intensive care in congregate settings.

Understanding Guardianship Part 1 : Facts and Data

Opposition to guardianship for people with developmental disabilities by disability rights advocates has been growing over the last twenty years as more funding becomes available for promoting alternatives to guardianship. Supported Decision-Making (SDM) is the most recent initiative that promotes “a process in which adults who need assistance with decision-making…receive the help they need and want to understand the situation and choices they face, so they can make life decisions for themselves, without the need for undue or over broad guardianship” [from “Supported Decision-Making: An Agenda for Action”, 2014, p.1]. The Federal Administration on Community Living (ACL), under the U.S.Department of Health and Human Services, has given millions of dollars in funding for multi-year projects to promote and do research on Supported Decision-Making. Among those receiving grants are the Quality Trust for Individuals with Developmental Disabilities for their National Resource Center for Supported Decision-Making and the Burton Blatt Institute at Syracuse University in New York.

While slogging through articles and reports on guardianship and its alternatives, I was struck by how little data is available on guardianship. Very few reports make distinctions between guardianships for people with severe developmental  disabilities, people with mental illness, physically incapacitated adults, and aging citizens who can no longer handle their own affairs or are affected by Alzheimer’s or other forms of dementia. To illustrate the importance of making these distinctions, my son Danny, who has been profoundly mentally and physically disabled since birth, has never accumulated property or wealth and is unlikely to be the target of unscrupulous probate attorneys who want to get their hands on his loot. Our guardianship is the best tool we have to make sure he is not taken advantage of and that his rights are protected. My mother, however, who lived to be 98 years old and had some degree of dementia by the time she died, was a good example of someone who had everything in place for my father and I to make decisions for her and could have been at greater risk of exploitation if she had been forced into a court-appointed guardianship.

Another question is, who are the guardians? It appears that the vast majority are close family members or friends of the person needing guardianship. Guardianship abuse from family members can occur, but it appears that corporate or state guardians with dozens of wards are far less likely to attend to the needs and wishes of people under guardianship. More stringent regulation of corporate and state guardians may be warranted, but family guardians may be overly burdened by too many requirements aimed at professional guardians and may not need the same kind of monitoring and supervision by the court. 

Much of the reporting on abuses in guardianship (see the National Association to Stop Guardian Abuse) is anecdotal. These anecdotes are rarely quantified to give an overall idea of the extent or causes of guardianship abuse. Although there are horrific stories about what can happen to people under guardianship, we rarely see stories about unpaid family guardians who defend their family members against agencies and individuals who, through neglect or the intentional desire to do harm or simply to save money, exploit vulnerable people with disabilities. And then there are advocacy organizations who claim to know better than the family what people need and are often the recipients of funds for projects that may conflict with the interests of the people the advocates claim to represent. 

Speaking of anecdotes, this has to do with guardianship procedures at our local Probate Court. In 1996, we filed a petition for guardianship for our son Danny. The Court appointed an attorney to represent him, ostensibly to protect his rights and to make recommendations as to his need for guardianship and whether he had any objection to my husband and I becoming his co-guardians. The attorney never called us to find out more about Danny. My husband and I finally met him in the hallway outside the courtroom 15 minutes before the hearing at which time the attorney thought I was the caseworker from Community Mental Health who would be submitting a report to the Court on Danny's condition. Near the end of the hearing, the attorney turned to Danny and asked Danny, who has never been able to talk or communicate in any specific way, if he had anything he would like to say to the Judge. Danny did not respond. Afterwards, we assume the attorney collected his $600 from the Court, the going rate for attorneys representing people who are too poor to pay attorney’s fees. There are lots of conclusions I could have drawn from this one instance of an attorney neglecting his duties, but I talked to other families who had good experiences with court-appointed attorneys who were both caring and fair.

With that said, this is a report from Michigan called the “Task Force on Guardianship and Conservatorships; Final Report, September 10, 1998”. The Task Force was created in 1996 by the State Court Administrative Office (SCAO) after news stories were published about abuses by a professional guardian in Wayne County. 25 people were appointed to the Task Force, including probate court judges, probate court registers and staff members, both houses of the Michigan Legislature, relevant executive  branch agencies, several advocacy groups, the State Bar Association, academia, and members of the probate bar.

The goals of the Task Force were to make recommendations on the following topics:

• Reduction in the use of guardianships and conservatorships;
• Guarantee of an appropriate number of qualified and concerned guardians;
• Guarantee of adequate monitoring of guardians and court operations; and
• Institution of needed standards, training, and education.

The report said that two-thirds of the probate courts did not keep a statistical record of the total number of guardianships and of the percentage of guardianships that are limited (or partial) as opposed to plenary (or full). Although the idea of the Task Force was instigated by abuse by a professional guardian, it found that the vast majority of people filing guardianship petitions were family members or close friends of the person. Guardians often had guardianship recommended to them by other agencies or professionals. 

Here are some of the recommendations of the Task Force:

To reduce the use of guardianships and conservatorships, it recommended that local resources be established to assess the need for guardianship and develop alternatives to guardianship. It also recommended that an effort be made to educate personnel in hospitals, nursing homes, and other medical or psychological personnel to emphasize presumption of competency and alternatives to guardianship.

To reduce the unnecessary appointments of guardians, the Task Force recommended collecting better screening information on court forms, requiring court-appointed attorneys to include an evaluation of the functional capacity of the potential ward, and more training for judges on cognitive and physical impairments, mental illness, and the aging process. It would have been helpful to know how the Task Force ascertained whether a guardianship was unnecessary and how many unnecessary guardianships were found, but that was not mentioned in the report. 

Recommendations on how to better manage guardianships and conservatorships included minimum ethical standards for professional guardians, compelling courts to comply with statutes and court rules, requiring annual review of accountings, and restrictions on real estate transactions involving the ward’s property. These recommendations seem obvious and it is surprising these were apparently not already implemented by the courts that handle guardianships.

In addition, the report recommended that the Courts should increase the recruitment and training of volunteer guardians, and more guardians who are state-agency-funded and -monitored should be provided as guardians of last resort. This is also surprising, considering that the main complaint was that too many people had court-appointed guardians. The shortage of guardians available for appointment by the court is often mentioned in other reports on guardianship.

The report also includes this statement:

“Many of the recommendations may increase costs to the local funding units or state agencies. Implementation of such recommendations must only be done with a corresponding increase in appropriations to cover costs to avoid any unfunded mandates.”

Some members of the Task Force belonged to organizations that would later become recipients of the type of funding recommended by the report. This included representatives of Michigan Protection and Advocacy Services and the director of the Washtenaw Association for Community Advocacy, a local affiliate of the ARC. They received funding from the Michigan DD Council from 2002 - 2004 for the “Preventing Guardianship” project. 

More to come….

See also Comments to the National Council on Disability on Guardianship and Supported Decision-Making

The Revolving Door : Sharon Lewis from the Administration on Community Living moves on to a private sector consulting firm

Sharon Lewis, like so many government appointees before her, has left her job at the federal Administration on Community Living (ACL) and has moved on to a position in a private sector consulting firm. The ACL is an agency under the U.S. Department of Health and Human Services that administers programs for people with disabilities and older adults. Her departure from the agency was announced in December 2015. She is now employed by a Healthcare consulting and research firm called Health Management Associates.

Sharon Lewis was the Principal Deputy Administrator and co-founder of the Administration on Community Living. She has collaborated with multiple federal and state agencies and led controversial reforms in Home and Community-Based Services (HCBS) policy and regulations. Over the years she has also worked closely with disability advocacy groups.

There is apparently nothing untoward or improper about her accepting a position with a consulting firm. Her experience and contacts will make her an unusually valuable addition to the team. 

The idea of “The Revolving Door”, however, raises questions about the people in Washington overseeing programs for people with disabilities. Are they working for us or are they angling for their next job? Maybe a little of both? The greatest conflict of interest that I see is when advocates for people with disabilities move back and forth between government agencies and advocacy groups. Their watchdog role in monitoring government for people with disabilities is inevitably compromised by the interests of the federal agencies that pay them. These conflicts need to be disclosed regularly and individuals and groups that operate independently of government need to be assured of the opportunity to be heard so as not to be drowned out by federally-funded advocates.

Michiganders may be interested in knowing that Health Management Associates has a Michigan component that includes Steve Fitton, a former State Medicaid Director, and Rich VandenHeuvel, a behavioral health executive with several community mental health agencies and regional Prepaid Inpatient Health Plans (PIHPs).

See more on the Revolving Door.

The Center for Responsive Politics at OpenSecrets.org is a non-partisan, independent and nonprofit group that tracks money in politics and its effects on elections and public policy. Of the “The Revolving Door”, the organization says, “…[it] shuffles former federal employees into jobs as lobbyists, consultants and strategists just as the door pulls former hired guns into government careers…While officials in the executive branch, Congress and senior congressional staffers spin in and out of the private and public sectors, so too does privilege, power, access and, of course, money.”