Week 7 – April 19, 2015
THIS WEEK’S HAPPENINGS
With only two weeks remaining until the end of the regularly scheduled 2015 legislative session, the tension has escalated four ways between the Senate, the House, the executive branch which has now partnered with the House, and the federal Centers for Medicare and Medicaid Services (CMS) over the Low Income Pool (LIP) funding which impacts $2.2 billion of the state budget. On April 14, the long-awaited response from the CMS was delivered to the Agency for Health Care Administration (AHCA). CMS Director Vikki Wachino wrote that “the state’s expansion status is an important consideration in our approach regarding extending the LIP (Low Income Pool) beyond June. We believe that the future of the LIP, sufficient provider rates, and Medicaid expansion are linked in considering a solution for Florida’s low income citizens, safety net providers and taxpayers…” Wachino wrote.
House Speaker Steve Crisafulli (R-Merritt Island) issued a statement critical of both the CMS and the Senate. He reiterated the House position that the discussion between Florida’s Low Income Pool funding and Medicaid Expansion must be treated separately. Senate President Andy Gardiner commented that “The bottom line is: more than ever, today’s correspondence from CMS highlights the link between LIP and expansion and the need to consider a comprehensive Florida solution. Time is of the essence. The Senate remains open to meeting at any time to discuss our free-market approach to expansion or any alternative the House or governor would like to propose.”
That same day, a letter signed by six Florida congressional members – Senator Marco Rubio, Congressmen Ted Yoho, Gus Bilirakis, Richard Nugent, Curt Clawson, and Congresswoman Ileana Ros Lehtinen – was sent to CMS asking the Center to separate the LIP issue from the discussion on Medicaid Expansion, and fully fund the LIP program.
On April 16, Governor Rick Scott officially filed a lawsuit against CMS and the Obama Administration. In essence, the lawsuit stipulates that the Administration cannot coerce the state to expand Medicaid under Obamacare in order to secure funding for LIP. It is unclear as to the final outcome of the lawsuit, and what impact not having LIP funds will have on the budget. The House has maintained its opposition to using budget reserves to cover the LIP funding while the Governor has voiced his opposition to using state funds to cover the program. One thing is now certain, a budget will not be produced by the end of Session on May 1.
House Speaker Crisafulli informed the press corps on April 16 that plans are to complete deliberations on policy related bills in both chambers in the next two weeks and prepare for a call for a Special Session to address the 2015-2016 budget in the weeks ahead. And, on April 21, the Senate Appropriations Committee will hold a workshop for all Senators about the Senate proposal to expand health-care coverage and information about the LIP.
Meanwhile, former Governor Jeb Bush issued the following statement as reported by the Bradenton Herald on Friday, April 17, “The feds and the executive branch and representatives from the House and Senate ought to get together and try to forge a compromise. We need to reform Medicaid and there’s a plan to do that in Florida that’s a pretty good one, so if it was part of that and there are trade offs… that’s how you get past an impasse.” Stay tuned as events unfold…
Child advocates and families are thanked and can celebrate as the Children’s Health Insurance Program (CHIP)/Maternal, Infant, and Early Childhood Home Visiting (MIECHV) legislation crossed the finish line on April 14. The US Senate voted 92-8 to pass a bipartisan bill to reform the Medicare Sustainable Growth Rate (SGR), known as the “doc fix” which has been a headache for Congress for two decades. “This has been a long ordeal that a lot of us have worked on for a long time,” Senate Finance Committee Chairman Orrin Hatch (R-Utah) said ahead of the vote, calling it a “major, major accomplishment.” “It’s a milestone for physicians, and for the seniors and people with disabilities who rely on Medicare for their health care needs,” said President Obama in a statement. “The bill includes reforms to transition Medicare’s payment system from incentivizing quantity to quality in care, and is likely to produce small savings for the government over time, according to the CBO.” Despite these accolades, eight senators opposed the bill, including Sens. Ted Cruz (R-Texas) and Marco Rubio (R-Florida) joined by Sens. Lee, David Perdue (R-Georgia), Ben Sasse (R-Neb.), Tim Scott (R-S.C.), Jeff Sessions (R-Ala.) and Richard Shelby (R-Ala). The SGR bill extends funding for the CHIP and MIECHV programs for two years at current annual levels, enabling continuation of CHIP, including new outreach grants and a 23 percent increase in the match rate, as well as home visiting programs in nearly 800 at-risk communities around the country. The passage of these bills shows that investment in young children continues to be a bipartisan issue in both the US House and Senate. The bill was signed into law by President Obama on April 16.
Children’s Week Children’s Week 2015 drew the largest crowd of all times with more than 5,000 children and caregivers arriving in Tallahassee to draw attention to children’s issues, culminating with the “hanging of the hands” prepared by elementary school children across Florida in the rotunda, and featuring numerous speakers, press conferences and activities such as a youth town hall meeting in which members of The Children’s Trust Youth Advisory Committee (YAC) participated. To coincide with Children’s Week, there were two pivotal press conferences.
KidsWell Florida and the Georgetown Center for Children and Families convened a press conference on April 14 to focus on the release of the Florida Parent Study, which provides new information on the many working parents and families that would benefit from closing the coverage gap. Joan Alker, Executive Director of the Georgetown Center for Children and Families and Leah Barber-Heinz, Chief Executive Officer of Florida CHAIN remarked about the study and how this coverage gap is impacting families in Florida. Bishop Ken Carter who was joined by Bishop Adam Richardson, urged the state to follow a moral imperative to put politics aside and help families.
A significant coverage gap exists for parents whose income exceeds Florida’s extremely low eligibility threshold for Medicaid but who don’t earn enough to receive tax credits for coverage through the federal health insurance marketplace. Experience from other states also shows that an extremely effective way to reduce the uninsured rate for children is to extend coverage to parents so the whole family can get covered. The newly released report from the Georgetown Center ranked Florida 47th in the rate of uninsured children and 49th in the number of uninsured parents in the nation.
Also on April 14, Senate President Andy Gardiner (R-Orlando) joined a coalition of business groups, Senate leaders, healthcare providers and advocates, known as “A Healthy Florida Works”, in a press conference in the chamber of the state’s historic Old Capitol to try to garner House support for the Senate Plan.
Photos: Florida Senate, House of Representatives, Diana Ragbeer, The Children’s Trust and KidsWell Florida
EARLY LEARNING AND SCHOOL READINESS
Early Learning Health and Safety
After weeks of inaction, advocates were pleased to see that the Senate bill to increase health and safety standards at early learning facilities, SB 7006 passed the Senate Appropriations Subcommittee on Health and Human Services on April 14 and now heads to the full Appropriations Committee this coming Tuesday. The following amendments were adopted on April 14:
Removes provisions allowing a district school board or charter school governing board to permit certain four-year-old children to attend public kindergarten under specified conditions which would have had a large fiscal impact; and
Removes provisions for appropriations to be made to the Department of Children and Families for the purpose of implementing the bill. (It is hoped that this cost will be addressed during the budget conference).
The House companion by the House Education Committee, CS/HB 7017 is awaiting action by the full House.
Care of Children
HB 11 by Rep. Ray Pilon (R-Sarasota) and SB 250 by Sen. Chris Smith (D-Ft. Lauderdale), Care of Children exempts certain membership organizations which are affiliated with national organizations, and do not provide child care as defined in FS s. 402.302, but rather provide afterschool care and juvenile delinquency prevention, from licensing requirements and minimum standards for child care facilities. The bill also requires background screening for organization employees under certain circumstances. After weeks of inaction due to fierce opposition to the exemption by some parties, SB 250 was passed unanimously by the members present of the Children, Families and Elder Affairs Committee on April 15. The bill has 3 more committee stops before full Senate consideration. Thus far, there is no movement on the House bill.
This issue has fostered a healthy debate and the possible need to review the Florida Administrative Code rules for Child Care Licensing in order to more accurately define the differences between birth-to-five child care and afterschool programming for 6-12 year olds.
HEALTH AND WELLNESS
CS/SB 478 by Sen. Aaron Bean (R-Jacksonville) and Sen. Arthenia Joyner (D-Tampa) which defines telehealth and telehealth services was passed unanimously by the Appropriations Subcommittee on Health and Human Services on April 14 and now heads to full Appropriations. Seeking to address physician shortages, CS/SB 478 establishes that the standard of care for a telehealth service is the same as the standard of care for a health professional providing in-person services. A telehealth provider is not required to research the patient’s medical history or conduct a physical examination if the telehealth provider conducts an evaluation sufficient to diagnose and treat the patient. Additionally, a telehealth provider must document health care services in the patient’s medical record under the same standard as for in-person care. The bill specifies that a non-physician telehealth provider who is using telehealth and acting within the relevant scope of practice is not practicing medicine without a license. The bill prohibits a telehealth provider from prescribing eyeglasses, contact lenses, or other optical lenses based solely on the use of computer controlled device through telehealth. Additionally, controlled substances may not be prescribed through telehealth for chronic nonmalignant pain. However, this provision does not preclude a physician from using telehealth to order a controlled substance for an inpatient in a hospital or for a hospice patient.
CS/HB 545 Telehealth by Rep. W. Travis Cummings (R-Orange Park) and Rep. Mia Jones (D-Jacksonville) was passed unanimously by the House Health Quality Subcommittee on March 17, and is still awaiting action in the House Health and Human Services Committee.
Child Abuse Death Review (CADR)
HB 7121 by The Children, Families and Seniors Subcommittee and Rep. Gayle Harrell (R-Stuart) relating to child welfare is awaiting full House action. The bill addresses issues related to implementation of landmark child welfare reform legislation – SB 1666 that passed in 2014.
HB 7121 addresses the increased volume of cases reviewed through the Child Abuse Death Review (CADR) process and better aligns it with the newly created Critical Incident Rapid Response Team (CIRRT) process, clarifies the roles of the two types of committees within the CADR process, and imposes specific reporting requirements. It also permits the Secretary of DCF to deploy CIRRTs in response to other child deaths, in addition to those with verified abuse and neglect in the last 12 months. Further, the bill requires more frequent reviews and reports by the CIRRT advisory committee. The bill also requires multi-agency staffing to be convened for cases of alleged medical neglect, clarifying that the staffing shall be convened only if medical neglect is substantiated by the child protection team. In addition, HB 7121 implements the Florida Institute for Child Welfare Report (FICW) interim report recommendations by clarifying legislative intent to prioritize evidence-based and trauma-informed services.
The Senate companion, SB 7078 by Children, Families and Elder Affairs is scheduled to be heard in the Senate Fiscal Policy Committee on April 20.
Mental Health and Substance Abuse
SB 7068 was taken up by the full Senate on April 14 and amended. The following amendments were adopted:
Changes the age requirement from 18 to 21 in the definition of a child or adolescent who has an emotional disturbance;
Inserts a new section 394.761, F.S., on revenue maximization of federal Medicaid funding for behavioral health care as defined in the Social Security Act, 42 U.S.C. s. 1320c-1;
Requires managing entities to use the unique identifier developed by the Department for individuals receiving behavioral health care services by January 1, 2016; and
Allows representatives of local governments, including counties, school boards, sheriffs, and independent taxing districts to serve as voting members even if they contract with the managing entity.
The bill now awaits a full Senate vote and passage. The bill would change the way mental-health and substance-abuse services are administered, coordinate them with primary health care, and seek to increase Medicaid funding for them.
“The bill will lead to more continuity and less fragmentation of services,” Senate Health and Human Services Appropriations Chairman Rene Garcia, R-Hialeah, said in a prepared statement. “People suffering from mental illness and substance abuse will receive more effective treatment, and the service delivery system will be more accountable to the taxpayers who fund these important efforts.”
HB 7119 by the Children, Families, and Seniors Subcommittee is awaiting full House action. The bill makes changes to the statewide system of safety-net prevention, treatment, and recovery services for substance abuse and mental health (SAMH) administered by the Department of Children and Families (DCF). An amendment was added to make the bill similar to SB 7068 in the Health and Human Services Committee on April 9. There was much discussion during the meeting on the creation of a ‘coordinated care organization’ under this bill.
DCF currently contracts with seven managing entities that in turn contract with local service providers to deliver SAMH services. The bill updates statutes that provided DCF initial authority and guidance for transitioning to the managing entity system. The bill makes changes to providing services and enhances operation of this outsourced approach by:
Allowing managed behavioral health organizations to bid for managing entity contracts when fewer than two bids are received;
Requiring care coordination, specifying the services that shall be provided within available resources, and prioritizing the populations served;
Requiring DCF to develop performance standards that measure improvement in a community’s behavioral health and in specified individuals’ functioning or progress toward recovery;
Specifying members for managing entities’ governing boards, and requiring managed behavioral health organizations serving as managing entities to have advisory boards with that membership;
Allowing managing entities flexibility in shaping their provider network while requiring a system for publicizing opportunities to join and evaluating providers for participation; and
Deleting obsolete statutes regarding the transition to the managing entity system.
The bill requires DCF to contract for a study of the safety-net system, with an interim and final report submitted on specified topics. The bill also requires DCF and the Agency for Health Care Administration to report on options for increasing the availability of federal Medicaid SAMH services. Most legislators are in support of the overall reforms, but some have questioned the need to make the system for-profit which Chair Harrell says would empower and incentivize Managing Entities to serve the population more appropriately.
SB 7070 by the Judiciary Committee was unanimously approved by the Appropriations Committee on April 16, and now awaits full Senate action. The bill integrates provisions of the Marchman Act, which provides for a comprehensive continuum of accessible and quality substance abuse prevention, intervention, clinical treatment, and recovery support services, into the Florida Mental Health Act, more commonly known as the Baker Act. The bill provides that an individual may be held for an additional 48 hours beyond the current 72-hour time limit if a physician determines the individual would benefit from detoxification services. Under the bill, individuals that have been involuntarily admitted to a receiving facility or treatment facility within the immediate preceding 36 months may be ordered to involuntary outpatient placement. Individuals that meet specified criteria may be detained in a mental health facility, an addictions receiving facility or a detoxification facility. A court hearing on the involuntary inpatient placement must occur within five court working days after the petition is filed. The Department of Children and Families (DCF) is directed to create a Forensic Hospital Diversion Pilot Program in Alachua, Escambia, Hillsborough and Miami-Dade counties which is to be modeled after the Miami-Dade Forensic Alternative Center.
HB 465 by Rep. Ross Spano (R-Riverview), “Relating to Public Records/Human Trafficking Victims,” passed the full House unanimously on April 16 and now heads to the Senate.
The Senate companion, SB 1106 by Sen. Anitere Flores (R-Miami) passed full Appropriations on April 16 and now awaits full Senate action.
Other bills related to human trafficking include:
HB 467 by Rep. Ross Spano (R-Riverview), “Relating to Public Records/Human Trafficking Victims,” which passed the full House unanimously on April 16 and now heads to the Senate.
SB 1108 by Sen. Anitere Flores (R-Miami), “Relating to Public Records/Identity of a Victim/Human Trafficking Offenses,” which was passed unanimously by the full Appropriations Committee on April 16 and has been placed on the calendar for consideration by the full Senate on April 22.
SB 1110 by Sen. Anitere Flores (R-Miami), “Relating to Public Records/Residential Facilities Serving Victims of Sexual Exploitation and Human Trafficking passed the full Appropriations Committee on April 16 and has been placed on the calendar for consideration by the full Senate on April 22.
Adoption and Foster Care
HB 7013 by Rep. Jason Brodeur (R-Sanford) passed the full Senate on April 14 on a vote of 27:11 and now heads to the Governor for signature. The bill creates a program to advance the permanency, stability, and well-being of children in the child welfare system by awarding incentive payments to community-based care lead agencies (CBC’s) for achieving specified adoption performance standards. CBC’s provide adoption-related services in the state pursuant to contracts with the Department of Children and Families (DCF). The bill allows home-schooling of adopted children and removes a statutory prohibition against adoption by same sex couples.
The Senate companion, CS/SB 320 by Fiscal Policy and Sen. Don Gaetz (R-Destin) seeks to increase the number of adoptions of children from foster care. The bill creates a program to award incentive payments to community-based care lead agencies and their subcontractors for achieving specified adoption performance standards. The bill re-creates a program to provide an additional adoption benefit for qualifying employees of state government who adopt a child from the foster care system. CS/SB 320 passed all its committees unanimously and was substituted for CS/HB 7013 which was then passed by the Senate on a 27:11 vote on April 14 and enrolled.
However, due to loud opposition from some groups, CS/HB 7111 by the Judiciary Committee and Health and Human Services Committee and Rep. Jason Brodeur (R-Sanford) was drafted and passed favorably by the full House on a vote of 75:38. The bill is scheduled to be heard in the Senate Rules Committee on April 20. The bill provides what is referred to as “conscience protection” for private agencies whose “religious or moral convictions” do not permit the children in their care to be adopted by same sex couples. The bill is in response to passage of HB 7013 relating to adoption of foster children that included language repealing the current ban on adoption by same-sex couples.
PERSONS WITH DISABILITIES
Guardian for Dependent Children who are Developmentally Disabled or Incapacitated
SB 496 by Sen. Nancy Detert (R-Venice) was passed unanimously by the Senate Appropriations Committee on April 16 and was placed on the calendar for consideration by the full Senate on April 22. CS/CS/SB 496 addresses a gap that can exist between the time that children with developmental disabilities or delays age out of the foster care system at 18 years old and are appointed a guardian. This bill provides for guardianship proceedings to begin in advance of a child’s 18th birthday when the child is pre-determined by the Department of Children and Families to need a guardian when the child becomes an adult.
The House companion, CS/CS/HB 437 passed the full House unanimously on April 16 and now heads to the Senate.
SB 378 by Sen. Rene Garcia (R-Hialeah) was heard by the full Senate on April 14 with an amendment by Sen. Audrey Gibson (D-Jacksonville) to cap the number of additional citations allowed, to two. The bill is scheduled for full Senate vote on April 22. The bill expands juvenile civil citation by allowing law enforcement to issue a civil citation to youth who have committed a second or subsequent misdemeanor. Civil citation is presently only available to youth who admit to committing a first-time misdemeanor. In addition, law enforcement will be authorized to issue a simple warning to the youth and inform the youth’s parents of the misdemeanor. CS/SB 378 also states that if an arrest is made, law enforcement must provide written documentation as to why the arrest is warranted.
The House companion HB 99 sponsored by Rep. Gwyndolen Clarke-Reed (D-Pompano Beach), was approved unanimously by the House Judiciary Committee on April 14, and now heads for full House action.
Juvenile Criminal History Record Expungement
HB 7103 by the Criminal Justice Subcommittee and Rep. Sharon Pritchett (D-Miramar) passed the Judiciary Committee favorably on April 14 and now awaits full House action. The bill specifies that all records obtained under ch. 985, F.S., as a result of a juvenile being involved in the juvenile justice system, are confidential. However, s. 985.04(2), F.S., creates exceptions if the juvenile is:
Taken into custody for a violation of law which, if committed by an adult, would be a felony;
Found by a court to have committed three or more violations of law which, if committed by an adult, would be misdemeanors; or
Transferred to the adult system.
The Senate companion, CS/SB 1316 by Criminal Justice and Sen. Darren Soto (D-Kissimmee) is awaiting action in the Appropriations Subcommittee on Criminal and Civil Justice although that committee no longer appears to be meeting. The final committee reference, Appropriations was removed.
OTHER BILLS AFFECTING CHILDREN
HB 7063 (formerly PCB CRJS 15-02) by the Justice Appropriations Subcommittee and Criminal Justice Subcommittee, Rep. Ross Spano (R-Riverview) and Rep. Dave Kerner (D-Palm Springs) relating to child pornography passed the House Judiciary Committee unanimously on April 14 and now awaits full House action.
Unlike federal statutes, Florida’s child pornography laws are not as specific in addressing morphed child pornography. As a result, courts have determined that persons that possess, distribute, or transmit such images cannot be held criminally liable. The bill amends the definitions of the terms “sexual conduct” and “child pornography” in ch. 847, F.S., to include morphed images of child pornography. As a result, persons who possess, promote, transmit, etc., morphed child pornography can be held criminally liable. The Senate companion SB 1132 by Senator Abruzzo is not moving.
HB 7065 by the Criminal Justice Subcommittee and Rep. Ross Spano (R-Riverview) passed the House Judiciary Committee unanimously on April 14 and now awaits full House action. The bill is the public records exemption bill to CS/HB 7063 relating to sexual performance by a child and moves its provisions to sections 847.003 and 847.0137, F.S. This bill provides for repeal of the reenacted exemptions on October 2, 2020, unless they are reviewed and saved from repeal by the Legislature. It also provides a public necessity statement as required by the Florida Constitution.
Bills that would allow some individuals to carry guns at public schools and on college campuses face an uncertain future in the Legislature.
CS/HB 19 by Rep. Greg Steube (R-Sarasota) has been sitting on the calendar since April 3 awaiting full House action. The bill allows school superintendents, upon approval of the district school board, to create a school safety designee program through which the school superintendent may designate one or more individuals to carry a concealed weapon or firearm on school property. Weapons or firearms may only be carried in a concealed manner, and must be on the individual’s person at all times while he/she is performing official school duties.
The Senate companion, SB 180 by Sen. Greg Evers (R-Pensacola) was not heard during the scheduled meeting of the Senate Pre-K-12 Committee’s meeting Wednesday, April 15.
Similarly, there has been no action on SB 176 by Sen. Greg Evers (R-Pensacola) that eliminates the statutory prohibition against carrying a concealed weapon or firearm by concealed carry license-holders into any college or university facility. Current law specifically includes these facilities among the places where a concealed weapon or firearm license does not authorize the licensee to “openly carry a handgun or carry a concealed weapon or firearm.” The bill has been awaiting action in the Senate Judiciary Committee since March 17.
The House companion, HB 4005 by Rep. Greg Steube (R-Sarasota) has been sitting on the calendar for full House action since April 2.
OTHER BILLS OF INTEREST
Value Adjustment Boards
SB 972 by Sen. Anitere Flores (R-Miami) relating to Value Adjustment Boards (VAB) passed unanimously in the full Appropriations Committee on April 16 with the following amendments by Senators Negron and Flores:
Revises the definition of the term “common element” for purposes of prorating ad valorem taxes for certain properties under certain circumstances to include those located in the same county as the subdivision and used for at least 10 years exclusively for the benefit of lot owners within the subdivision.
Specifies that if the number of petitions filed increases by more than 10 percent over the prior year, the June 1 deadline is extended until December 1.
Requires that a petition to the VAB must be signed by the taxpayer or accompanied by the taxpayer’s written authorization, valid only for one year and a new written authorization by the taxpayer shall be required for each subsequent tax year.
Revises the entities authorized to determine under certain circumstances that a petitioner owes ad valorem taxes or is owed a refund of overpaid taxes.
Revises the interest rate upon which unpaid and overpaid ad valorem taxes accrue.
Defines the term “bank prime lone rate”.
Authorizes the district school board and county commission to audit certain expenses of the VAB.
Defines the term “good cause’.
Requires the clerk to provide certain notice to a petitioner of a rescheduled hearing requested by the petitioner.
The Revenue Estimating Conference has determined that this bill will have an indeterminate positive impact on local government (school district, county, municipal and special taxing district) revenues and will allow for more budget predictability on the part of such local governments.
The House companion, CS/HB 695 – Ad Valorem Taxation by Rep. Bryan Avila (R-Hialeah) was passed by its two committees of reference, and then heard by the Revenue Estimating Conference this past Friday.
The Children’s Health Insurance Program (CHIP)
On Thursday, April 16, President Obama signed into law the Sustainable Growth Rate (SGR) Children’s Health Insurance Program (CHIP)/Maternal Infant Early Childhood Home Visitation (MIECHV) bill. The compromise legislation extends the current CHIP and MIECHV programs for two years at current levels, with no harmful changes to CHIP as proposed by the Hatch-Upton-Pitts proposal. Further, the bill includes NO harmful offsets to Medicaid, CHIP or the ACA in the package, good news for kids. The bill also includes new outreach grants and a 23 percent increase in the federal match rate, as well as home visiting programs for nearly 800 communities around the country. The passage of this bill shows that investment in young children continues to be a bipartisan issue in both the US House and Senate.
April is Child Abuse Prevention Month
April – Child Abuse Prevention MonthApril is Child Abuse Prevention Month, and Pinwheels for Prevention, a national campaign creating a community-wide commitment to healthy child development, launched its annual awareness campaign in partnership with Prevent Child Abuse Florida (PCA Florida), the Ounce of Prevention Fund of Florida and the Florida Department of Children and Families. First Lady Ann Scott joined leaders at the Capital wearing blue on the morning of April 10 and met with people on the second floor rotunda for pictures and breakfast. Lady Scott says putting an end to child abuse is something she’s always been passionate about.
Wear Blue Day is part of the statewide Pinwheels for Prevention campaign.
To help draw attention to and encourage involvement in child abuse prevention efforts, visit the Ounce of Prevention’s PCA and Pinwheels for Prevention websites.