Legislative Update Week of April 15th

This week saw a flurry of legislative activity on health issues and other that are big for the medical community, lets get into the review:

House:



Dr. Kenneth Elmassian testifying
to the House Health Policy Committee

This week the House Health Policy committee took testimony on House Bill 4524, the Patient Right to Know legislation. Dr. Kenneth Elmassian, MSMS President-Elect, testified to the committee providing his expertise to the committee on this issue. "It gives patients more information when they are seeking and receiving their health care," Elmassian said. "Let's be honest, the health care system is very confusing. Patients deserve better than the system is currently giving them." The committee members fired back though leaving those in the committee wondering if the legislation would have a hard time getting out. We will be waiting to see what the committee will do in the coming week and we will let you know if the legislation moves further in the process.

Senate:

Dr. Rose Ramirez answering questions
in the Senate Triple R committee.

The Senate Reform, Restructuring, and Reinventing committee this week took its final week of testimony and moved Senate Bill 2 out of the committee to the full Senate Floor for its consideration. We reported before that this legislation would provide a sweeping change to the Public Health code providing independance for NP's CNM's and CNS-C's. For more indepth information on the original bill click on "2" above to obtain bill language and legislative analysis from the Senate Fiscal Agency. Dr. Rose Ramirez, MSMS's Speaker of the House, testified to the committee with her personal professional experience starting out in nursing and then obtaining her MD and working as a physician. "As physicians, our overarching concern is with the well-being of our patients and that the laws and regulations of Michigan lead to health care that is safe, efficient, and of the highest quality.  Patients benefit from having a focused, team-based approach that encourages communication and collaboration among the various members of the team," Dr. Ramirez testified. Through the efforts of the testimony the legislation still made its way out of the committee with a vote count of 6-1.

Budget:

This week saw the Senate Appropriations committee working on their budgets getting them through committee and sent to the full Senate for their consideration. Still left out of the budget was the money for the MSMS supported expansion of Medicaid. Many people around the capitol say that this is a vote that some of the members are either against or uneasy about taking. We could see the budgets get to their final conference committee before a decision is made about the Medicaid expansion.

Auto No Fault:

This week the Governor, along with House and Senate Insurance Chairman, introduced their plan to reform Michigan's Auto No-Fault system. This is round two to a fail attempt last session. That plan created levels of coverage that a individual could purchase that would bring savings to the buyer of the plan. This time around they are taking a different approach by providing a cap for coverage up to $1 Million. Also in the new proposal there will be a pilot program that would provide lower cost insurance for those who in poverty, have a clean driving record, and have a low value vehicle. With this program they are hoping that it will entice those who do not have insurance to purchase it. In terms of fraud they are want to begin an auditor program that will be constantly looking for fraud. With this plan officials say that families with two vehicles could see a yearly savings of $250. 

“Take a good look at this plan: is it really in the public’s best interest? I hardly think so. Capping lifetime benefits at $1 million for the catastrophically injured ultimately will shove the most vulnerable victims onto Medicaid and will pile the financial responsibility to the taxpayers," said John Cornack, President of the Coalition Protecting Auto No-Fault (CPAN). We expect here in the next few weeks that hearings will begin in the appropriate committees.

Stay with MSMS to get the up to date information on twitter @msmsgovtaffairs, on Facebook or online at http://www.MSMS.org/advocacy.

Legislative Update Week of February 18th

The legislature this week continued their work on the budget for the upcoming fiscal year. The House finally has been receiving work done by the committees, allowing for consideration and for the first votes on the House floor for this young legislative session. Let's review the activities of the past week:

House:

The House Insurance committee took its last bits of testimony on Senate Bills 61 and 62, which would provide for the mutualization of Blue Cross in Michigan. The legislation came out of committee lacking the controversial abortion amendments that hampered the legislation last time, hopefully gaining support from the Governor this time without the amendments. The legislation will now head to the House floor where the amendments could be tacked on or added to the legislation, but it is accepted that the House will act on the legislation in the coming week.

Senate:

The Senate Reforms, Restructuring and Reinventing committee meet to continue taking testimony on Senate Bill 2 which would expand the scope of practice for advanced practice nurses. This legislation has been somewhat controversial in the medical community and many have found it interesting that the legislation was sent to this committee rather than the Senate Health Policy committee. It was unclear before the hearing whether or not the committee was going to take action on the legislation but in the end did not. MSMS is continuing to work with the sponsor of the legislation to find a compromise that would be suitable for all of the interested parties. We will keep you up to date on the actions of this legislation.

Appropriations:

Both House and Senate subcommittees meet this week to hear testimony from the largest part of the Department of Community Health budget, medical services or Medicaid. The expansion of Medicaid, which is a policy MSMS supports, was a hotly contested topic among the Senators while their presentation from the Medicaid director, Director Fitton. Many of the Senators on the committee had a hard time of seeing where the savings would come from if the state went ahead and expanded Michigan Medicaid program. Looking at the Medicaid 67% of the money is federal where the state only provides 16% of general fund / general purpose dollars to the program. It will be interesting to see how the expansion will play out in the coming months.

MSMS New Lawmakers Reception:

MSMS, as they do at the start of every legislative session, held its New Lawmakers reception at the MSMS Headquarters in East Lansing. The event was well attended by physicians and lawmakers alike with Senator Roger Kahn, MD and Representative Sean McCann to name a few that joined us. "This is a great opportunity to reach out to our lawmakers", said Raymond Rudoni, MD who is the chair of the MSMS Legislative and Regulations committee. The event went on past its end time and was hailed as a success with participation from medical students to retirees.

Legislative Update (Special Edition)

With the Legislature finally closing its books on the 96th Legislature there were many issues that made their way through the process that kept MSMS on its toes. We provided several letters of support or opposition, provides hours of testimony to the House and Senate, and made hundreds of office visits and phone calls and e-mails. All of this truly helped shape the health policy that Michigan gained over the past two years. Now that the session is over we want to take a look at the issues that affected all of us:

Liability Reform:

Drs Elmassian and Chafty Testifying

The largest victory for MSMS this year was the passage of reforms that would bring Michigan's tort climate back toward what was originally passed by the legislature in 1993. Senate Bills 1115 and 1118 were passed by the legislature in, what some would call, a legendary lame duck session of the Michigan Legislature. These reforms did not come without the battles including five committee hearings in the Senate on these bills which lead to huge crowds in the committee rooms. Those who were for and those against the reforms packed the room wanting to make their presence known to the committee and how they felt.

View at tort reform hearing.

After hours and hours of testimony the Senate committee moved the legislation to the floor and from there the legislation had covered it first real hurdle. Deliberations, discussions, amendments, and speeches against and for the legislation lead us to the final day of working session for the legislature where the House finally took up the legislation on the floor and gave it its blessing to send it to the Governor for his signature. It has been almost twenty years since there has been some significant tort reform for medical malpractice in Michigan until the end of this session, these tort reforms will be good for physicians but more importantly good for patients.

Wayne State Medical Students
 lobbying for Tort Reform.

Earlier in the term MSMS worked on legislation that would allow those physicians who are employed to volunteer in clinics and be provided protections that are afforded to those who are retired and work in the clinics (House Bill 4350). There was contention with this legislation since it provided what some classified as blanket immunity has they had in the later tort reform debate. Working with the members of the Senate, MSMS and other parties were able to come to an agreement that would provide the protection to those who are not contractually compelled to work in clinics to receive the liability protections of those who are retired and volunteering. It was a great day for medicine by opening the door to those physicians who wish to give of their time to help those who need the help the most.

Medical Marihuana:

Dr. Newman testifying to the Senate
Judiciary committee on Medical Marihuana

In this term Medical Marihuana left us with the question of what a "bona-fide patient/physician relationship" was in the eyes of the law. In medicine that question can lead to several answers. The face to face relationship all the way to telemedicine can lead to the definition of a patient/physician relationship. The Medical Marihuana statute stated that grey area that required patients to have this relationship with their physician but did not state what that relationship looked like and left law enforcement and the medical community scratching their heads. Insert House Bill 4851 which for the purposes of Medical Marihuana defined what that relationship looked like. Now patients would have to have contact with their physicians regularly rather that a one and done visit as some were seeing for those who were looking to obtain a certification for Medical Marihuana.

Insurance:

Insurance was an issue that started right away in the session with the attempt by the House to change the Michigan Auto No Fault system. House Bill 4936 wanted to provide levels of coverage that a person can obtain that would provide a certain level of financial coverage for any personal injury that occurred in an auto accident. From the state this was an issue that MSMS was against. Legislators were looking to provide choice for those individuals who were looking to save on car insurance and also provide relief to the Michigan Catastrophic Claims Fund, the fund that covers those gravely injured in an auto accident. Proponents of the legislation stated that the changed needed to happen since in its current form it would bankrupt the system. Opponents of the legislation asked to see the numbers and in the end were never given the opportunity to see the hard data. The House Insurance committee did pass a series of reformed and sent it to the House floor for their consideration but were never able to obtain the votes. Expect this issue back again the new session.

It wouldn't be a complete legislative session if Blue Cross/Blue Shield wasn't involved in some way. This term they had the backing of the Governor and finally found a way to get out from under PA 350 or the Nonprofit Health Care Corporation Reform Act. This act provided the tax breaks that the Blues enjoyed but also provided some requirements that the Blues did not enjoy. With the impending implementation of the health insurance exchange in Michigan, the Governor thought it was time to bring a change to the Blues and give them the ability to compete in the insurance exchange among other reasons and push for legislation to reform the Blues. The Legislature responded and created a nonprofit mutual insurer in the state of Michigan and providing a path to those incorporated under PA 350 to convert into this mutual insurer. This legislation did not come without a cost, requiring that the Blues pay to the state $1.56 Billion from now until 2018. This money will be placed in a health fund used to cover health projects and subsides Medigap policies until 2021 at a cost of $120 Million a year. The Governor received his wish and Senate Bills 1293 and 1294 were sent to his desk where they await his eventual signature.

Helmets:

Before the Legislature left for the summer break this past year they decided to take up an issue that has been on the burners of the legislature for years. They finally made a decision on the age old question, should you be required to wear a helmet while operating a motorcycle? In their opinion you should not be required since it was your individual right to determine whether you ride with a helmet or not. Senate Bill 291 made its way through the legislature going through its ups and downs, being amended several time, and at one point being used in the same conversation the changes with Auto No Fault, but in the end it was finally time according to the legislature to act on this measure. MSMS was adamantly opposed to the legislation reasoning that the having helmet on in an accident will give you the greatest chance to walk away from that accident but the Governor and Legislature did not see it that way and now today we have those who cherish their individual freedoms riding without a helmet. Time will tell if this was a wise decision for Michigan.

Graduate Medical Education:

Every year at MSMS we always face small battles when it comes to the budget, whether it’s trying to get more money for Medicaid, trying to stop the cut to public health funding, or trying to keep J-1 visa waivers in the budget we always have some small battles. One that always continued to come up and we feel will continue to, is the funding for Graduate Medical Education. The Governor has presented his last two budgets to the legislature with significant cuts to the program citing that the priority should be funding Medicaid at a higher level so that physicians will service more patients on Medicaid rather than funding the training of new physicians, fresh out of medical school. We see and understand the investment on Graduate Medical Education and what care this provides to those who need to care the most. Through work and education of the legislators we have been able to stay away from the deep cuts proposed by the Governor and only work hard to absorb small cuts from the legislature. In the coming years we will have to continue this fight to keep GME at its current level rather than seeing another cut to the program.

Affordable Care Act:

This is the only federal issue that made out list this year. We all know about the sustainable growth rate (SGR) and how we face looming cuts into Medicare but somehow Congress always finds a way to kick the can down the road. This time we think it will be the same but with the fiscal cliff casting a shadow on other impending issues, it could take some serious lifting by Congress to get this done on time.

US Supreme Court rendering opinion
in Affordable Care Hearings.

But now on to the Affordable Care Act and the decision from United States Supreme Court that some say rocked and other say solidified the nation in the future of its health care. The Supreme Court upheld the law saying that it was in the taxing authority of Congress to mandate insurance for people and was not within the commerce clause of the US Constitution. This left many states that were waiting for a decision under the gun if they were going to start creating their own health insurance exchanges. As for Michigan an attempt was tried with legislation that was sent from the Senate to the House, Senate Bill 693, but failed to gain the proper support from the committee. The state will now have a state/federal partnership exchange in 2014.

Scope of Practice:

This year the Medical Society found itself involved in looking at the future of medicine and how the team approach to care can continue to grow in Michigan. At the start of the term, physician assistants and physicians came together to find ways to grow their partnership in Medicine and came out of those discussions with Senate Bill 384 which brought more clarification on the relationship between PA's and Physicians, strengthening it, providing greater avenues to provides the best care.
Physical Therapists made an attempt this year to provide direct access for patients, bypassing the physician in House Bill 4603. Nurses also were looking for some clarification on their profession and how they fit into the team approach of medicine with Senate Bill 481. Both of these pieces of legislation did not make through the entire legislative process but MSMS is looking forward to continuing discussions with these groups to better strengthen the medical team in Michigan.

Autism:

Dr. Phillip Wise with Lt. Governor
Brian Calley at the signing of the Autism
Legislation.

This legislative term saw the largest advancement in mental health parity in Michigan in decades. MSMS has always had a long standing policy to support mental health parity in the insurance coverage of treatment of mental health conditions. Michigan took a step towards that this term by requiring the coverage of services surrounding the treatment of Autism. This was a priority of the Lieutenant Governor, Brian Calley; an issue that he worked hard for when he was a member of the Michigan House. Senate Bills 414, 415, and 981 started in June of 2011 with 981 adding in March 2012 and by April 18, 2012 it was the law of the land that insurers had to start to cover Autism services and treatment in Michigan. This is one small victory towards the larger goal of mental health parity.

Claims Tax:

Starting in 2011 there were rumblings from the federal government that the use tax that was set up by Michigan to tax the insurers that held Medicaid plans in Michigan was going to be ruled illegal and could penalize the State by holding back funds for Michigan's Medicaid program. A dilemma was presented to the legislature on what to do to replace the revenue needed to obtain the funds needed for Medicaid. Thus the claims tax proposal was created. Senate Bills 347 and 348 eliminated the use tax and created a claims assessment or tax on each of the insurance claims filed at a 1% level in Michigan. This was supposed to solve the revenue shortfall that would come with the elimination of the Use Tax but that as time moved on it proved not to be the case and this year the Medicaid faces a $140 Million shortfall that has to be filled somehow. The Senate tried to move Senate Bill 1359 which would provide an adjustable rate to make the need for revenue but was rejected by the Senate Appropriations committee. The legislature continues to look for solutions for the shortfall.

Abortion:

Abortion was an issue that seemed to be on the forefront this term with the legislature as looked tightens up regulations surrounding this hot button issue. There were several bills introduced and has testimony taken but in the end, these bills were placed into one large bill House Bill 5711. This legislation took a look at four major issues the legislature felt needed to be addressed: the licensing of facilities that perform abortions, the disposal of remains, and the liability protections needed by a physician who performs abortions, and the use of telemedicine in an abortion. Those against this bill called this issue the War on Women and continued to push for its stall in the House and the Senate. Those efforts did fail and in the early morning hours of the last day of session, the House concurred with the Senate and sent the bill to be enrolled and presented to the Governor. It’s currently uncertain if the Governor will sign the legislation.

Abortion found its way into the blue cross mutualization changes mentioned above with amendments that were added by the House to require that coverage for elective abortions be an opt-in coverage rather than an opt-out situation when purchasing coverage. We will have to wait and see the impact it will have on Michiganders.

Impaired Drivers:

Dr. Spanaki testifying with Senator
Schuitmaker on Senate Bills 402 & 403

An issue that MSMS has been working on for several years was finally accomplished this legislative term by providing liability protections for physicians who report to the Michigan Secretary of State that a person may be impaired to operate a motor vehicle. Senate Bills 402 and 403 started in the Senate Transportation committee and made their way through the entire process landing on the Governor's desk at the end of the second week of December. With the Governor's signature on this legislation physicians can report those patients they feel should not be operating a motor vehicle and let the Secretary of State decide whether that individual should be driving.

Bullying:

A major issue for the MSMS Alliance with past term was the creation of regulations for schools on how to handle instances of bullying. House Bill 4163 was created to provide the school districts have plans in place to handle bullying and plans that are specific to their school district but meet certain requirements required in the act. In December of 2011 Michigan joined other states by have the Governor sign Matt's Safe School Law into law.

Concussions  and High School Athletes:

Watching local high school sports over the past several years there continues to be a push to be faster, be stronger, hit harder and just become more physical overall. With this drive the amount of concussions happening in High School athletics was rising sharply leaving physicians, parents, coaches, and school personal concerned for the safety of the students playing athletics. This lead to the introduction of Senate Bill 1122 and House Bill 5697. Both of these pieces of legislation set into motion procedures that needed to be taken by school personal, what clearance was needed to be obtained by the athlete to compete again and what literature was needed to be provided to the athletes and parents on concussions and their treatment. We are hopeful that this will protect those athletes that want to compete at their highest levels.

With a busy legislative term over, MSMS is looking forward to what the next legislative term will bring. Some of the same issues mentioned today could very well make their way back into the legislative picture in the coming term. Stay with MSMS to get the latest information on issues going through the legislature that affect you and your practice at http://www.msms.org.advocacy. We will be taking a break now until the start of the new term, hope you all have a great new year!

 

Legislative Update: Week of June 11th

As time winds down on the legislative calendar with the summer break coming at the end of Thursday, the activity in both chambers ramped up with the chambers considering school retiree reform, tax reform, the new bridge to Canada, abortion and more. Let's review the activities of the final week before summer break:

House:

With session times being set to earlier times this week, most House committees did not meet this week.

The full House considered several issues this week but one of the most controversial came from the House Health Policy committee, the abortion omnibus, House Bill 5711. This bill was the main part of the three bill package that addressed several issues that Right to Life Michigan considered important to consider. Debate on the floor was emotional, heated, and provided for several gavels from the speaker for inappropriate remarks. Several members from both sides of the aisle had commented on their desire not to vote on the legislation stating that it went way to far based on the comments of supporters of the package said were a problem. After the debate, the House did vote on 5711 with it passing 70-39 (Roll Call # 448).

Senate:

The Senate did have committees this week but were very limited in the time they had to meet. The Senate Insurance committee continued again to take testimony on the Patient's First Reform package. Many stories were with the committee that said their physician had some if not all of the responsibility in their stories and how the package would not allow the physician and those who were wronged to receive the justice they deserve. At the end of the committee they did not take a vote on the package, with it now moving into the summer months.

The Senate Judiciary committee considered and took testimony on several items concerning Michigan's Medical Marihuana program including the MSMS supported House Bill 4851 which defines the patient/physician relationship when dealing with medical marihuana. It is unknown when the committee is expected to vote out the legislation. The Senate Health Policy committee also met to consider Senate Bill 975 which provides an opportunity for a health professional if they choose not to treat based on religious objections to what treatment is required. The committee just took testimony on the legislation similar to what they did last week on the nursing scope expansion bill. It is unknown when the committee will consider the legislation again.

The Senate floor was less lively than the House's this week but they did move a two pieces of legislation that is supported by MSMS. Senate Bills 402 and 403 that provides protections for physicians to voluntarily report patients to the Secretary of State if they believe in their professional judgment that the patient is impaired and not able to drive. Physicians are not making the decision whether the patient can drive or not, that is the duty of the Secretary of State, but it allows them to report and have liability protections for reporting to the Secretary of State. These bills were voted out of the Senate and sent to the House for their consideration.

Now the legislature goes on break until July 18th where they will meet for one day. The MSMS Legislative blog will be taking a break until the Legislature comes back into session unless there is breaking election news to post. Stay with the MSMS advocacy section of the website at http://www.msms.org/advocacy. Also with elections right around the corner your support of the candidates helps keep things like tort reform intact. Go to http://www.mdpac.org to see how you can help!

Legislative Update: Week of June 4th

This week saw the Senate concentrating on finishing up the budget, making this two years in a row that the budget for the state has been finished before the annual summer recess. The House concentrated on its income tax relief package at the beginning of the week and passing more education reforms by the end of the week. Lets take a closer look though at items that have an impact on medicine:

House:

The House Health Policy committee met this week to consider House Bill 5711, 5712, and 5713 which amend the public health code to cover several changes concerning abortion. As with abortion, testimony was very emotional, with the Michigan chapter of Right to Life starting out the testimony. 5711 is an omnibus bill that took four pieces of legislation and smashed them together creating a bill that dealt with fetal remain disposal, liability coverage for those preforming a abortion, and two with coercion and being forced into an abortion. Dr.Matthew Allswede, a obstetrician and President of the Michigan chapter of the American Congress of Obstetricians and Gynecologists testified summing up that with the passage of these bills they face threatening further growing the need for obstetricians in the state. Some members of the committee from both sides of the aisle had issues with the legislation but at the end of the day were forced to vote the legislation out of committee. The bills now await action on the House floor which will happen next week.

The House Judiciary committee was scheduled to meet but was canceled due to the impending problems with Detroit lighting. Hopefully the committee will meet this coming Thursday, pending any other reasons to postpone the hearing.

Senate:

The Senate Health Policy committee met this week, although very briefly, considered and took testimony on Senate Bill 481 which would increase the scope of practice for advance practice nurses. MSMS stands adamantly opposed to the expansion and expressed those concerns with the committee. Since the committee was short on time no action was taken on the legislation and it rumored to be reworked in a way that physicians could consider. Once we have more information, we will be sure to share it, as for now we stand ready to work with the committee and fight irresponsible expansion of scope.

The Senate Insurance committee was also short on time this week but continued taking testimony on the Senate version of the Patients First Reform package (SB 1115-1118). It is also rumored that the committee could consider taking a vote next week on the legislation. Stay tuned for updates.

Elections:

The race for congress in Michigan's 11th district just got dicier as the Secretary of State finds that the signatures to get on the primary ballot may have been forged by someone in Rep. McCotter's campaign therefore not making him eligible for the ballot, leaving a virtual unknown running as the Republican front runner. Former Michigan Senator Nancy Cassis as committed to running a write-in campaign to hopefully win the primary ballot. If this happens, it will be the first time that this has been successful in Michigan for that particular office. Things will now heat up in Michigan's 11th.

On a personal note we at MSMS want to offer our condolences to Senator Goeff Hansen and his family with the loss of their son. All of us at MSMS offer our thoughts and prayers through this difficult time.

Continue to stay with MSMS Legislative Update to gain all the information happening at the capitol and more go to http://www.msms.org/advocacy.

MDPAC needs your help to keep Michigan's tort reform intact! Support MDPAC today at http://www.mdpac.org.

Legislative Update: Week of May 28th

This week saw a flurry of budget activity this week with conference committees meeting throughout the Tuesday, Wednesday, Thursday period. The House also took the time to push a cut in the Michigan income tax that was scheduled to come at the beginning of next year ahead of schedule. The House spent most of Thursday night in session, passing all but the education budget, scheduling an unusual Friday session day for the House. Lets review the rest of the week in Lansing:

Senate:

The Senate Insurance committee continued taking testimony on Senate bills 1115-1118, the Patients First Reform package that amends Michigan's tort reform to protect access to Michigan's patients. MSMS testified last week in the committee, coverage on that can be found in last week article. The committee is expected to take a vote on the legislation this coming Tuesday. The Senate Health Policy committee scheduled a hearing for Thursday to take up Senate bill 481 which would expand the scope of practice and provide independence for advance practice nurses. Due to the budget, the committee was cancelled and scheduled for this coming Wednesday at 9:00am.

House:

The House worked long through the week, even into Friday working on the budget. While waiting for the conference committees to come to a conclusion they had the ability to work on some of the other lingering issues. The House did pass House bill 5338 which would amend the public health code to allow the Director of the Department of Community Health to issue orders to place designer substances on the controlled substances list i.e. K2. As mentioned before the House did pass their version of tax relief by upping the time when the rollback of the income tax would take effect.

Budget:

Budget was the main story this week. The Senate passed through all of its individual budget conference reports and the government omnibus that included everything but education funding. The House did the same with the government omnibus but had to wait until Friday's session to pass the education omnibus or "school bus" as it was affectionately called.

The Department of Community Health budget saw some good come out of the conference report. First the legislature rejected the $17 million cut to GME suggested by the governor; rather the legislature funded it with an extra $8.6 million more than what the governor had proposed and a victory from looking at such a substantial cut. Primary care physicians are going to see a rise in their reimbursement rates from Medicaid as $281 Million of federal funding was put into Medicaid to raise the rates for primary care (excluding ER physicians and some OB services) to Medicare rates. This change was a part of the Affordable Care Act. Investments in Health Kids Dental, Medicaid coverage for Autism, and Health Michigan Fund were all positive and more than had expected. The budget now goes to the Governor for his signature.

For the latest legislative news and activity check out http://www.msms.org/advocacy. Help support those who support you, go to http://www.mdpac.org to find out how you can help!