The Centers for Medicare and Medicaid Services (CMS) unveiled price data today for more than 3,000 U.S. hospitals, revealing large price variations between hospitals around the nation, including in Cincinnati.

For treating chest pain, charges from three Cincinnati hospitals varied by thousands of dollars: Bethesda North charged on average $17,696, Christ Hospital charged $12,000 and University Hospital charged $10,130.

But the initial charge seems to have little relation to what Medicare ultimately paid out. In the three cases for chest pain, Medicare on average paid $3,242 to Bethesda North, $3,657 to Christ Hospital and $5,463 to University Hospital.

In other words, University Hospital charged about 57 percent of what Bethesda North charged, but University Hospital was ultimately paid 68 percent more.

The price variation wasn’t exclusive to chest pain, either. For major joint replacement or reattachment of a lower extremity without major complications, Bethesda North charged $61,947 and was paid $12,712 on average, Jewish Hospital charged $38,465 and was paid $14,069 on average and University Hospital charged $46,463 and was paid $20,116 on average.

In fact, all of the 100 metrics tracked by CMS had at least some degree of variation in charges and payments. Whether it was chest pain, joint replacement, diabetes or cardiovascular complications, prices always varied between hospitals — sometimes greatly, other times by a little.

The data from fiscal year 2011 shows how much hospitals initially charged Medicare for the 100 most frequently billed discharges and how much Medicare ultimately paid out. The difference between charges and payments is usually large because Medicare negotiates prices down.

CMS says the price discrepancy is happening at hospitals all around the nation: “As part of the Obama administration’s work to make our health care system more affordable and accountable, data are being released that show significant variation across the country and within communities in what hospitals charge for common inpatient services.”

Still, some health care advocacy groups say Ohio is doing worse than other states. A study from Catalyst for Payment Reform and the Health Care Incentives Improvement Institute gave Ohio and six other states a “D” for health care price transparency, based on the states’ laws and regulations. That was actually better than 29 other states, which flat-out flunked with an “F.” Only New Hampshire and Massachusetts received an “A,” the highest grade possible.

Even then, the Catalyst for Payment Reform and the Health Care Incentives Improvement Institute cautioned in the study that their grades were given on a curve, which means all states would likely fare worse if the organizations measured them based on ideals instead of comparatively.

Many health care experts and advocacy groups claim the price variation is caused by a lack of transparency in the health care system, which gives hospitals free reign to charge without typical market checks (“Healthy Discussion,” issue of April 10).

Remember when we blogged a couple of weeks ago about how Greater Cincinnati has some of the worst air pollution in the nation? Yep, the American Lung Association's report, "State of the Air," gave us an "F" for ozone pollution, a "D" for 24-hour particle pollution and a "fail" for year-round particle pollution. That put us at the 10th worst spot in the country for year-round particle pollution and 14th worst for ozone pollution.

Solar and wind energy provider Pear Energy, which currently operates in all 50 states, released yesterday its "Dirty Dozen" compilation, a list of the 12 utility providers emitting the greatest carbon dioxide (CO2) emissions, a type of greenhouse gas. CO2 emissions, of course, are the gunk released into our atmosphere when we burn fossil fuels like gas, coal or oil. Excess CO2 in our atmosphere is directly linked to global warming.

Coming from a company that wants to sell you energy itself, it's good to approach the list with a little skepticism, but the methodology seems transparent; according to the website, all rankings were determined by total CO2 emissions in 2010 of power producers with retail operations that have carbon intensities above the national average emissions rate (stats were sourced from Environmental Protection Agency data).

While Duke Energy was pinpointed as the nation's worst offender, several other Ohio energy providers also earned accolades, including American Electric Power (No. 2), NRG (No. 8) and First Energy (No. 11).

First Energy is the utility provider that in 2012 partnered with Duke Energy locally to bring Cincinnati an electric aggregation program, allegedly useful for both lowering electricity rates and increasing use of renewable energy sources with group buying power. Last month, CityBeat covered allegations that First Energy was focused on weakening energy efficiency standards under Ohio's Clean Energy Law, supposedly to protect prices from shooting up for its customers.

Today is primary election day in Ohio, but there are no ballot items in Cincinnati. Some Hamilton County precincts outside the city have ballot issues, which are listed here. Polls will be open between 6:30 a.m. and 7:30 p.m.

An amendment snuck into the budget bill approved by the Republican-controlled Ohio House would force universities to decide between providing the proper documentation for voting to out-of-state students or getting extra money from out-of-state tuition rates, prompting concerns from Democrats that Republicans are attempting to limit voting opportunities once again. Republicans spent a bulk of the lead-up to the 2012 election approving measures that limit voting, including a later-repealed set of laws that greatly reduced early voting hours.

About 82 percent of all Leadership in Energy and Environmental Design (LEED) certified buildings in Ohio are in Cincinnati, and the reason is likely local tax incentives, which allow Cincinnatians to eliminate property taxes for up to 15 years by retrofitting businesses and homes in an environmentally friendly manner. CityBeat covered Cincinnati’s successes in solar energy here and FirstEnergy’s campaign to weaken Ohio’s energy efficiency standards here.

If legislators fail to take up the Medicaid expansion, the issue could appear on the ballot on November 2014. Supporters of the expansion, including Gov. John Kasich, say the expansion will help insure hundreds of thousands of Ohioans and save the state money in the next decade, but Republican legislators say they’re concerned the federal funds backing the expansion will eventually dry up. CityBeat covered the Ohio House budget bill, which effectively rejected the expansion for the time being, here.

The Ohio Department of Transportation says 2,230 bridges in the state need repairs, but there’s not enough funding to make it happen.

Ohio banks are warning of possible cyberattacks that could happen today. The Ohio Bankers League and the Ohio Credit Union League said the attacks would impact online services but not the security of customers’ bank accounts.

The Cincinnati/Northern Kentucky International Airport has the second highest airfares in the nation, according to statistics released by the U.S. Department of Transportation’s Bureau of Transportation Statistics.

Cincinnati-based Procter & Gamble was ranked No. 7 in a ranking for top 50 most diverse companies by DiverseInc.

Sometimes human brains make people do bad things, such as enjoying high-calorie foods even when the foods aren’t delicious.

An amendment snuck into the budget bill passed by the Republican-controlled Ohio House on April 18 would force public universities to decide between charging lucrative out-of-state tuition rates or providing out-of-state students with documents required for voting in Ohio, raising concerns from Democrats that Republicans are attempting to limit voting opportunities in the state once again.

The measure would force public universities to classify students living on campus as in-state if they receive utility bills or official letters that can be used for identification when voting in Ohio.

Out-of-state tuition rates are typically higher than in-state tuition rates, which means universities would be giving up potentially millions in revenue to provide out-of-state students with the proper documents.

For universities, the measure adds a financial incentive to hold on to the documents. For out-of-state students, that could mean a more difficult time getting the documents to vote in Ohio elections.

Students can vote in Ohio if they have lived in the state for at least 30 days, but voting requires proper identification and proof of residency. Utility bills and official letters qualify, but student identification cards do not.

Republicans have been quick to defend the measure, while Democrats have been quick to oppose it. For both sides, there’s a clear political motivation: In the 2012 elections, 63 percent of Ohio voters aged 18 to 29 supported Democratic President Barack Obama, while only 35 percent supported Republican Mitt Romney, according to exit poll data.

Ohio House Speaker William Batchelder justified the measure to the Toledo Blade: “The real issue for local areas in particular [is], what happens when somebody from New York City registers to vote. How do they vote on a school levy? How do they vote on a sheriff’s race? To me, there is a significant question, particularly the levies, as to what having people who don’t have to pay for them would do in terms of voting on those things.”

The comments prompted a response from Ohio Democrats, particularly attorney general candidate David Pepper, a Greater Cincinnati native.

“It’s startling to see one of Ohio’s leaders voicing such a blatantly unconstitutional justification for this cynical law,” Pepper said in a statement. “The Constitution guarantees an individual’s right to vote, regardless of what views they espouse (‘how ... they vote’), whether they own property, or where they hail from originally. The Speaker’s comments would quickly become Exhibit A in a successful Constitutional challenge of this scheme to keep Ohio’s college students from voting.”

Pepper’s statement went on to cite three U.S. Supreme Court cases to support his argument: Kramer v. Union Free School District No. 15 from 1969, Carrington v. Rash from 1965 and Dunn v. Blumstein from 1972.

In Kramer v. Union Free School District No. 15, the court argued any laws that discriminate against certain types of voters must endure strict judicial scrutiny because “any unjustified discrimination in determining who may participate in political affairs or in the selection of public officials undermines the legitimacy of representative government.” The ruling struck down a New York statute that said those participating in school board elections must be property owners, the spouses of property owners, lessors or a parent or guardian of a child in the school district.

Pepper’s statement claims the ruling invalidates Batchelder’s argument: “The Court rejected the state’s argument (identical to the Speaker’s) that only those two groups had a primary interest in such elections.”

In Carrington v. Rash, the Supreme Court ruled states may not limit voting based on how someone may vote: “‘Fencing out’ from the franchise a sector of the population because of the way they may vote is constitutionally impermissible. ‘[T]he exercise of rights so vital to the maintenance of democratic institutions’ ... cannot constitutionally be obliterated because of a fear of the political views of a particular group of bona fide residents.”

Similarly, Dunn v. Blumstein struck down Tennessee’s one-year residency requirements for voting in a ruling that said residents recently coming from other states can’t be barred from voting: “[T]he fact that newly arrived [Tennesseeans] may have a more national outlook than long-time residents, or even may retain a viewpoint characteristic of the region from which they have come, is a constitutionally impermissible reason for depriving them of their chance to influence the electoral vote of their new home State.”

The Ohio House’s budget bill amendment is only one of many attempts from Ohio Republicans to limit voting opportunities in the state since 2011.

In 2011, the Republican-controlled legislature and Gov. John Kasich approved two laws that reduced early voting hours. Democrats and third-party groups threatened to bring the legislation to referendum, but the Republican-controlled legislature and Kasich repealed most of the measures and restored expanded early voting in Ohio before the referendum came to a vote. A federal court also restored early voting for all Ohioans for the three days prior to Election Day, which the previous repeals had only brought back for military voters.

In 2012, Ohio Secretary of State Jon Husted, a Republican, invoked uniform early voting hours, effectively eliminating most weekend voting, and made last-minute changes that placed the burden of proper identification on voters instead of poll workers, which Democrats argued made verifying provisional ballots more difficult.

When asked to justify some of the measures, Doug Preisse, close adviser to Kasich and chairman of the Franklin County Republican Party, wrote in an email to The Columbus Dispatch, “I guess I really actually feel we shouldn’t contort the voting process to accommodate the urban — read African-American — voter-turnout machine.”

The race-based reasoning prompted a harsh response from Democrats, who claimed Republicans were trying to suppress minority voters who tend to vote for Democrats.

Beyond voting rights, the Ohio House budget bill defunds Planned Parenthood and forgoes the Medicaid expansion (“The Chastity Bunch,” issue of April 24).

The budget bill still has to be approved by the Ohio Senate and Kasich to become law.

The First District County Court of Appeals heard arguments over the city’s parking plan and emergency clause powers today, with both sides making similar arguments as before — except this time the city acknowledged it will probably have to move forward with layoffs because the city only has a few weeks remaining before it has to balance the budget for fiscal year 2014, which begins July 1. The city claims it can use emergency clauses to expedite legislation, such as the parking plan, by eliminating a 30-day waiting period and the possibility of a referendum, but opponents argue the wording in the City Charter doesn’t justify terminating referendum efforts. If courts side with opponents, the city’s plan to lease its parking assets to the Port Authority, which CityBeat covered here, will likely appear on the ballot in November, forcing the city to lay off cops, firefighters and other city employees instead of using the parking plan to help balance the budget.

It’s looking more and more likely that Cincinnati Police Chief James Craig will take the top police job in Detroit, despite Cincinnati officials asking Craig to reconsider. Previously, Councilman Charlie Winburn, the lone Republican on City Council, pushed city officials to do more to encourage Craig to stay, but City Manager Milton Dohoney Jr. said Craig’s motivations may be personal because his family resides in Detroit, a city that is in desperate need of a turnaround.

Ohio’s tea party groups are preparing to either split from the Republican Party or punish Republican leaders for recent actions, according to The Columbus Dispatch. Tea party groups have been particularly upset with Gov. John Kasich’s endorsement of the Medicaid expansion, which CityBeat covered in further detail here and here, and Ohio Republicans’ election of Matt Borges, who once lobbied for a gay rights group, as chairman of the Ohio Republican Party. Since the 2010 elections, tea party groups have kept political footholds in some areas, but they have consistently lost favor with voters.

In case you missed it, here was CityBeat’s news coverage for the current week’s issue, which went online late because of Internet issues:

• News: “Think of the Children: Local leaders pledge to support efforts to put more low- and middle-income kids in preschools.”
• City Desk: “City Manager Defends Streetcar in Light of Budget Gap.”
• Commentary: “The Many Merits of Cycling Infrastructure.”

A portion of the Ohio House budget bill would make it more difficult for out-of-state students to vote in Ohio by forcing public universities to decide between extra tuition money and providing documents that students need to vote. Republicans say the rule is meant to lower tuition and prevent out-of-state students from voting on local issues they may know little about, but Democrats, backed by university officials, say the rule suppresses college-going voters, who tend to support Democrats over Republicans.

Ohio Senate President Keith Faber said there is no substantial Republican support in the Ohio House, Ohio Senate or governor’s mansion for so-called “right to work” legislation. The lack of support for the anti-union laws, which prevent unions and employers from making collective bargaining agreements that require union membership, may be linked to 2011’s voter rejection of Senate Bill 5, which would have limited public unions’ collective bargaining and political powers. S.B. 5 was one reason unions, including the Republican-leaning Fraternal Order of Police, supported Democrats in 2012.

Despite security concerns in the aftermath of the Boston Marathon, Sunday’s Flying Pig Marathon had a record 34,000 participants.

Ohio gas prices are trending up this week.

Now on Kickstarter: Genetically modified plants that glow.

A new interactive map shows hydraulic fracturing, or "fracking," is flourishing in U.S. areas where water is already scarce — a potentially bad sign for Ohio counties that are allowing the water-intensive drilling process within their own borders.

The map from advocacy group Ceres shows northeast Ohio counties with fracking activity are made up of low, medium-to-high and high stress areas, with most of the identified fracking wells in medium-to-high and high stress areas.

The website explains Ohio's experience is actually better than the national trend: "In the map below, one can see that almost half (47 percent) of shale gas and oil wells are being developed in regions with high to extremely high water stress. This means that more than 80 percent of the annual available water is being withdrawn by municipal, industrial and agricultural users in these regions. Overall, 75 percent of wells are located in regions with medium or higher baseline water stress levels."

Fracking is a relatively new drilling process that involves pumping millions of gallons of water underground to fracture shale and reveal oil and gas reserves. CityBeat previously covered Ohio's fracking boom in further detail here.

As Ohio debates the Medicaid expansion, a new study from Harvard researchers revealed access to Medicaid in Oregon led to better mental health outcomes and reduced financial strain, but no short-term gains were found in physical health outcomes.

The study, which was released Wednesday by The New England Journal of Medicine, had its most positive findings in mental health outcomes, with Medicaid recipients showing 30 percent lower rates of depression in comparison to people without health coverage. Medicaid recipients had a rate of depression of 21 percent, while those without coverage had a rate of 30 percent.

But the gains did not apply to physical health outcomes. When looking at cholesterol, blood pressure and blood sugar levels, there was no significant difference between Medicaid recipients and people without coverage. The three measures were chosen because they typically reveal better health results within two years and they're easy to obtain.

Still, the study doesn't rule out the possibility of long-term gains. The study found increased rates of diabetes detection and management, which could lead to better physical health outcomes in the future.

Medicaid enrollment also reduced financial strain, allowed patients to use more preventive services and nearly eliminated catastrophic out-of-pocket medical expenses, according to the study.

The study was conducted by looking at Medicaid recipients in Oregon, which enrolled 10,000 people into Medicaid out of nearly 90,000 applicants through a lottery approximately two years ago, giving researchers the first major randomized pool of Medicaid recipients to study.

A previous study from Harvard researchers, including the lead author of the Oregon study, found that Medicaid expansions improved mortality rates, coverage, access to care and self-reported health. That study looked at three states that expanded Medicaid and compared them to neighboring states that did not.

The Oregon study comes at a time when legislators are debating whether Ohio should use federal funds to expand its Medicaid program. Even though Republican Gov. John Kasich supports the expansion, Republican legislators say they're concerned the federal funds will eventually dry up, leaving the state to find a solution for hundreds of thousands of new Medicaid enrollees. Democrats are joining Kasich in supporting the expansion, with Ohio Senate Minority Leader Eric Kearney recently calling it a "no-brainer."

The Health Policy Institute of Ohio found the Medicaid expansion would insure nearly half a million Ohioans and save the state money in the next decade.

The budget bill that recently passed the Republican-controlled Ohio House would forgo the Medicaid expansion while leaving room to consider further Medicaid reforms down the line ("The Chastity Bunch," issue of April 24).

City Manager Milton Dohoney Jr. gave his suggestions for fixing the streetcar budget gap Tuesday, and CityBeat analyzed the details here. The suggestion, which include temporarily using front-loaded Music Hall funds and pulling money from other capital projects, are capital budget items that can't be used to balance the city's $35 million operating budget deficit because of limits in state law, so if City Council approved the suggestions, the streetcar would not be saved at the expense of cops, firefighters and other city employees being laid off to balance the operating budget.

Ohio Senate Republicans seem unlikely to take up so-called "right to work" (RTW) legislation after it was proposed in the Ohio House. RTW legislation prevents unions and employers from making collective bargaining agreements that require union membership to be hired for a job, significantly weakening a union's leverage in negotiations by reducing membership. Since states began adopting the anti-union laws, union membership has dropped dramatically around the nation. Democrats, including gubernatorial candidate Ed FitzGerald, were quick to condemn the RTW bills and compare them to S.B. 5, a 2011 bill backed by Republican Gov. John Kasich and Ohio Republicans that would have limited collective bargaining powers for public employees and significantly reduced public sector unions' political power.

Hamilton County commissioners approved a county-wide collaborative between health and government agencies to help reduce the county's infant mortality rate, which has exceeded the national average for more than a decade. Funding for the program will come in part from the sale of Drake Hospital to UC Health.

With a 7-2 vote yesterday, City Council updated its "responsible bidder" ordinance, which requires job training from contractors working with the Metropolitan Sewer District, to close loopholes and include Greater Cincinnati Water Works projects. Councilman Chris Seelbach led the charge on the changes, which were opposed by council members Chris Smitherman and Charlie Winburn.

Ohio Senate Democrats are still pushing the Medicaid expansion, which the Health Policy Institute of Ohio found would insure 456,000 Ohioans and save the state money in the next decade. Ohio House Republicans effectively rejected the expansion with their budget bill, which the Ohio Senate is now reviewing. CityBeat covered the Ohio House budget bill in further detail here.

The state's Public Utilities Commissions of Ohio approved a 2.9 percent rate hike for Duke Energy, which will cost customers an average of $3.72 every month.

Concealed carry permits issued in Ohio nearly doubled in the first three months of the year, following a wave of mass shootings in the past year and talks of federal gun control legislation.

Real headline from The Cincinnati Enquirer: "How much skin is too much skin for teens at prom?"

A Pennsylvania woman who had been missing for 11 years turned herself in to authorities in Florida.

New research shows early American settlers at Jamestown, Va., ate each other.

City Manager Milton Dohoney Jr. released a memo yesterday detailing how the streetcar project's $17.4 million budget gap could be fixed by pulling funds from various capital projects and issuing more debt, upholding a promise he made at a contentious City Council meeting Monday.

The five-page memo says none of the proposed capital funding sources can be used to balance the city's $35 million operating budget deficit because of limits established in state law, which means the streetcar project is not being saved at the expense of cops, firefighters and other city employees being laid off to balance the operating budget.

"Neither Capital nor TIF funds can be used to help with the operating budget deficit that the City is facing," the memo reads. "They are separate sources of funds and by State Law, cannot be used for operating expenses like police and fire personnel."

At least $5.4 million would be temporarily pulled from the $10.6 million planned for the Music Hall renovation project, but the redirected Music Hall funds would eventually come back in capital budgets for fiscal years 2017, 2018 and 2019. City spokesperson Meg Olberding explained in an email that moving funds around would not hinder the Music Hall project.

"The use of $5.4 million of Funds set aside for Music Hall this year is money currently sitting in a fund for this year that will not be needed this year," she wrote. "Funds for Music Hall will not be needed until 2016, the agreed upon deadline for fundraising for the Music Hall renovation with the Music Hall Revitalization Company. Therefore, the City is still keeping its commitment to Music Hall, while also advancing the streetcar project."

About $6.5 million would be taken from infrastructure projects surrounding the Horseshoe Casino, including funds that would otherwise go to lighting the trees along Reading Road and a study that would look at adding a turn lane from Reading Road. The memo acknowledges the trade-off, but it also justifies the redirected spending: "However, since the Streetcar passes within two blocks of the Casino Site, it is a project within the Casino Area that both benefits the TIF District and the Casino."

The memo also recommends pulling $400,000 that was originally set for traffic signal replacement, which would be used for the traffic replacement component of the streetcar project.

Another $500,000 would come from funding currently set for water main relocation and replacement. The memo says the water main funding is simply Water Works' share: "Of the $21.7 million cost overrun for the Streetcar project, approximately $1 million was for water main relocation (and) replacement work. Water Works' share of this is $0.5 million."

The remaining $4.6 million would come from the city issuing general capital debt, which would be paid back through a small portion of the income tax that is established in the City Charter for permanent improvement purposes. The memo acknowledges this would cost other economic development and housing projects $340,000 a year over the next 20 years, but it claims the funding is justified because the streetcar project is a permanent improvement project.

The memo outlines other vague capital funding options that could be used to balance the budget, but Dohoney does not explicitly recommend them.

The memo also leaves open the possibility of future sources of funding, including $15 million that could be opened up if the city prevails in court against Duke Energy over who has to pay for moving utility lines to accommodate streetcar tracks — but this was money that was originally supposed to go to neighborhood development projects — and the sale of remaining city-owned land at the Blue Ash Airport.

City Council still has to consider and approve the memo's recommendations for them to become law.