U.S. inches closer to national single-payer plan conversation

diner771Now that the Obamacare replacement bill has passed the House and is moving on to the more centrist Senate, the real debate begins. What is the true purpose of health insurance, and what is our government’s goal in ensuring we have it?

I learn from my patients every day about the benefits, limitations and contradictions of their health insurance. One charming 60-year-old with severe seasonal allergies insists on seeing his primary care physician every few weeks this time of year, even though their office tells her she doesn’t need to — her antihistamines and nasal spray treatment rarely changes. But she worries that her allergies could be hiding an infection, so their office investigates her sinuses, throat, lungs and ears. She is reassured, and her insurance (which she buys through Maryland’s Obamacare exchange) covers the bill.

If she was responsible for more than a small co-payment for these visits, I’m sure her doctor would see her less often.

We pride ourselves on being a compassionate society, and insurance companies use this to manipulate us into sharing the costs of other people’s excessive health care. Meanwhile, 5 percent of Americans generate more than 50 percent of health care expenses. Why shouldn’t a patient who continues to see me unnecessarily pay more?

The government’s job is to maintain public health and safety. It should ensure that insurance plans include mandatory benefits like emergency, epidemic, vaccine and addiction coverage. The Republican bill would let states apply for waivers to define these benefits differently; it would be a big mistake to drop such coverage entirely. But Obamacare went well beyond these essentials, by mandating an overstuffed prix fixe meal filled with benefits like maternity and mental health coverage that drove smaller insurers with fewer options out of the market. The few that remain often have a monopoly, and premiums rise.

Speaking of compassion, how about some for the 20-something construction worker who can’t afford to pay his rent because his premiums help subsidize overusers like my allergy sufferer? Why shouldn’t a patient who is risk-averse pay more for coverage she might never need, while that construction worker be allowed to choose a cheaper insurance plan that might cover only the essentials?

In addition to limiting the menu of essential benefits, the House bill would let states create high-risk pools for patients with pre-existing conditions who had let their insurance coverage lapse, and who could then be charged premiums more in keeping with their health care needs. This is the only way to make insurance affordable for most consumers; pre-existing conditions will continue to drive up premiums if everyone is compelled to pay the same price.

These risk-pool premiums can and should be subsidized by the government. A recent report from the Kaiser Family Foundation found that high-risk pools can work, but have been historically underfunded. Trumpcare should change that — though it will cost more than the House bill’s $8 billion in additional funding. Drastic cuts to Medicaid should also be reversed, which could help the bill pass the Senate.

But the bill is on the right track. Americans believe that insurance provides access to care, when in fact it is the gatekeeper that often denies care. Many think Obamacare is generous, and yet I often have to fight for essential care for my patients. We need to be more pragmatic, and less emotional, about this issue.

Jimmy Kimmel’s contention this week that a child like his would not receive lifesaving surgery for his congenital heart problem without Obamacare may tug at the heartstrings, but it is neither fair nor accurate. Employer-based health insurance, which covers 170 million Americans, including, no doubt, Mr. Kimmel, would have paid for this infant’s needs with or without Obamacare. Even if the Republican plan replaced Obamacare, and even if the infant didn’t have employer-provided insurance, the treatment would still be covered, either through a traditional plan or a high-risk pool. And at the end of the day, a federal law, the Emergency Medical Treatment and Labor Act, guarantees this kind of treatment, whether we have Obamacare or Trumpcare.

The final question concerns the skyrocketing costs of innovation, and how one-size-fits-all insurance can possibly continue to pay for it. My 93-year-old father, a retired engineer, just received a $50,000 catheter-inserted aortic valve, which was covered by Medicare. But if all such high-tech devices are covered, it will be practically impossible for any insurance company not to go belly-up. The tax-free savings accounts that the House bill would expand and make more flexible are a far better way to pay for this kind of care. Shouldn’t my father and those like him be asked to save their own money for just this sort of rainy day?

Or should we continue to overload health insurance with all our fears and expectations?                                                                                                                                Julie Henry wrote last May that, more than 2,200 physicians announced their support for a proposal for a single-payer national health program (NHP); a related editorial was published in the American Journal of Public Health.

And consider my point last week where the CEO of Aetna as he was announcing the pull out of Aetna from the last two states The CEO of health insurer Aetna told employees in a private meeting that the U.S. should consider a single-payer healthcare system, Vox reported Friday.

“Single-payer, I think we should have that debate as a nation,” Mark Bertolini reportedly said after being asked about the possibility of the GOP’s ObamaCare repeal plan paving the way for a single-payer system.

Earlier last week, Aetna announced it would pull out of the last two states where it was participating in ObamaCare’s markets, meaning it wouldn’t sell any plans for next year on the health exchanges.

In a private meeting where Bertolini faced employee questions, one reportedly asked: “In the news media, it is reporting that the Republican health plan is paving the way to a single-payer system. What are your thoughts on that, and how would it impact Aetna?”

“If the government wants to pay all the bills, and employers want to stop offering coverage, and we can be there in a public private partnership to do the work we do today with Medicare, and with Medicaid at every state level, we run the Medicaid programs for them, then let’s have that conversation,” Bertolini responded.

The CEO “was certainly not advocating for a single-payer system,” Aetna spokesperson T.J. Crawford wrote in an email.

Instead, he was indicating his openness to debating it “while pointing out that public-private partnerships have been the backbone of the more successful government health care programs (examples include administering Medicare Advantage or Medicaid managed care). In other words, partnering works when done the right way,” Crawford wrote.

Sen. Bernie Sanders (I-Vt.) staunchly advocated for a single-payer healthcare system during his Democratic presidential campaign last year, frequently referring to it as “Medicare for all.”

The doctors appear to be fed up with the current healthcare system. “Caring relationships are increasingly taking a back seat to the financial prerogatives of insurance firms, corporate providers, and Big Pharma,” Dr. Adam Gaffney, a Boston-based pulmonary disease and critical care specialist and lead author of the editorial, said in a press release. “Our patients are suffering and our profession is being degraded and disfigured by these mercenary interests.”

Combining current government health expenditures into a single fund would fund the NHP; it would also require a tax increase, which the doctors say will “be fully offset by reductions in premiums and out-of-pocket spending.”

The proposal estimates that the NHP would save around $15 billion annually by cutting administrative costs.

Details of the NHP

Highlights of the NHP proposal include the following:

  • All residents of the U.S. would be covered for all necessary medical care, regardless of immigration status.
  • Coverage would include inpatient and outpatient care, rehabilitation services, mental health services, long-term care, dental care and prescription drugs.
  • Patients could choose to go to any hospital or doctor.
  • Premiums, co-pays, deductibles, and co-insurance would be eliminated.
  • Medical bills for covered services would be eliminated for U.S. residents.
  • Most hospitals and clinics would remain privately owned and operated; they would receive a budget from the NHP to cover all operating costs.
  • Physicians could continue to practice on a fee-for-service basis, or receive salaries from group practices, hospitals, or clinics.

Medicare for All

Democratic presidential candidate Bernie Sanders (I-VT) has also developed a proposal for a single-payer plan, which has been dubbed Medicare for All. Under this system, all US citizens would be automatically enrolled into Medicare.

Various tax revenues, credits and subsidies would finance the program.

According to the Medicare for All website, the plan will cost more than $6 trillion less than the current healthcare system over the next 10 years.

Under the plan:

  • Patients could choose to go to any hospital or doctor.
  • Premiums, co-pays and deductibles would be eliminated.
  • Coverage would include inpatient and outpatient care; preventive care; emergency care; primary care; long-term and palliative care; vision, hearing and oral health care; mental health and substance abuse services, prescription medications and medical equipment, supplies, diagnostics and treatments.

However, a new report from Urban Institute’s Health Policy Center from this week estimated Sanders’ (I-VT) single-payer plan would increase federal spending $32 trillion over the next 10 years – much more than the $13.8 trillion he said his plan would cost and the $15.3 trillion in new revenue he estimated it would raise. This would leave a $16.6 trillion hole the government would need to pay for the single-payer plan, according to the study.

Possible hurdles to a single-payer system

In an article for Vox, Harold Pollack, a liberal healthcare policy expert at the University of Chicago, said: “Single-payer would require a serious rewrite of state and federal relations in Medicaid and in many other matters.” Pollack also said converting to a single-payer system would require complex negotiations to transition people from employer-based coverage.

Additionally, most of the healthcare industry would undoubtedly put up a fight against any single-payer proposal. “The entire supply side of the medical economy would be opposed to efforts to increase the bargaining power of the government and to set prices and terms of care,” Pollack, told Modern Healthcare.

Will Colorado lead the way for the rest of the US?

In November, voters in Colorado considered a ballot measure to implement a single-payer system called ColoradoCare. However, Colorado voters dealt a blow to the idea of a single-payer health insurance, a controversial ballot initiative that would have provided medical coverage to all state residents through a payroll tax.

The idea was backed by progressives, but opposed by the business community, health insurers, Democratic Gov. John Hickenlooper and members of Congress from both parties. About 80% of voters cast ballots against the measure.

It’s the latest blow to the Medicare-for-all approach to healthcare that is supported by liberals like Sen. Bernie Sanders, the Vermont Democrat, who was runner-up to Hillary Clinton for the Democratic Party’s presidential nomination.

The Senate is negotiating its own legislation to repeal and replace much of the Affordable Care Act in secret talks with senators hand-picked by party leaders and with no plans for committee hearings to publicly vet the bill.

“I am encouraged by what we are seeing in the Senate. We’re seeing senators leading,” said Sen. Ted Cruz, R-Texas, one of the 13 Republicans involved in the private talks. “We’re seeing senators working together in good faith. We’re not seeing senators throwing rocks at each other, either in private or in the press.”

Senate Democrats have a different take. “Your morning reminder that under the cloud cover of the FBI story, 13 GOP Senators are still secretly writing a bill to destroy the ACA,” Sen. Chris Murphy, D-Conn., tweeted Monday morning.

Why should America have a Single-Payer System? 

Donald Berwick, MD, who helped launch the Affordable Care Act,(ACA), considered it to be the only health reform this country would need, when he was administrator of the Centers for Medicare & Medicaid Services (CMS) in 2010 to 2011.But 5 years later, Dr. Berwick and millions of other Americans are calling for a new round of reform that would involve much deeper changes: a single-payer system. Dr. Berwick says he still supports the ACA—”It’s been a step forward for the country,” he says—but adds, “The ACA does not deal with problem of waste and complexity in the system.”

Other single-payer advocates are less forgiving. They think that the ACA has pampered the commercial insurance industry, providing it with millions more customers and allowing it to jack up charges to levels that fewer Americans can afford.

The proposed single payer would be the US government.

Consider that the single-payer reform would take an audacious step. It would virtually eliminate the entire commercial insurance industry—with $730 billion in revenues and a work force of 470,000—and replace it with one unified payer. A small vestige of the industry would remain to cover nonessential services, such as LASIK surgery.

Advocates often envision a single-payer system as an expansion of Medicare, as I have mentioned, or “Medicare for all.” Single-payer systems in Canada, Australia, Denmark, Norway, and Sweden—as well as other types of centrally run systems—have much lower per capita health spending and generally better health outcomes than the United States.[1] However, this is also true for non–single-payer systems outside of the United States. The United States simply has the highest healthcare costs, regardless of the system.

Sasha Savisky reported the newly crowned Miss USA is already under fire. Kara McCullough, of the District of Columbia, was asked during Sunday night’s pageant whether she thinks that affordable health care for all U.S. citizens is a right or a privilege. She said it is a privilege. “As a government employee, I’m granted health care and I see firsthand that for one to have health care, you need to have jobs,” the 25-year-old shared. The U.S. Nuclear Regulatory Commission scientist’s answers did not sit well with some viewers, who took to social media to slam her remarks.

I bring this up because the single-payer approach has a moral argument—that everyone should have a right to healthcare—but it also has a practical argument, says James Burdick, MD, a transplant surgeon at Johns Hopkins University School of Medicine and author of Talking About SINGLE PAYER, which will be published later this year. “It’s a more economical way to use healthcare resources,” Dr. Burdick says. “You could reduce expenses and still improve quality. That’s a tremendous opportunity that you don’t have in many other fields.”

But who would manage the single-payer system and if “run” by the government just look at the history of government run health care system here if the U.S.- the Veterans Association Health Care System and the continued problems and frustrations. Even considering these relative failures I am convinced that we will have a single-payer health care system here in this country.



America’s Health Care Costs Are Crushing the Economy and Aetna’s Departure from Obamacare Individual Insurance Market


18221676_1189702134492777_1657203722031334742_nI am frustrated at the attitudes and responses to the election, the Trump administration and the health care battle. The entitled liberals are upset that they lost the election. Trump and his administration are intent on their strategy to replace and repeal Obamacare and change the tax code. And the Democrats are intent on obstructing everything that the Republicans want to pass and blame all their shortcomings on the Russians. They are salivating on the possibility that President Trump may be impeached. What a bunch of entitled, spoiled children! I have never seen so much anger.

During the last 8 years we did realize the shortcomings of Obamacare and seemed to focus on those, instead of the positive improvements to healthcare delivery. But most of all we forget that Obamacare is non-sustainable financially.

Case in point, Health insurer Aetna Inc. said last Wednesday that it would exit the 2018 Obamacare individual insurance market in Delaware and Nebraska – the two remaining states where it offered the plans.

Aetna had already said it would exit the individual commercial market in Virginia and Iowa, after pulling out of several other states last year. Aetna has now “completely exited the exchanges,” the company said in an emailed statement.

Insurers Humana Inc. and UnitedHealth Group Inc. have also pulled out of most of the government subsidized individual health insurance market.

Republicans in the U.S. House of Representatives last week voted to undo the Affordable Care Act often called Obamacare, the signature domestic achievement of former President Barack Obama.

But even if the Republicans’ bill – known as the American Health Care Act – if passed by the Senate it would not solve a critical outstanding issue for insurers looking at 2018: Will the government continue to fund the cost-sharing subsidies that help individuals pay for care?

Health insurers have said they cannot plan amid the uncertainty. In addition, the balance of sick and healthy customers has been worse than expected, and premium rates on the individual insurance market went up 25 percent this year.

“This decision is not a surprise given continued uncertainty about market stability and whether cost-sharing subsidies will continue to flow,” Evercore ISI analyst Michael Newshel said in an investor research note.

He noted that only one health plan remains in both Delaware, where Highmark Blue Cross Blue Shield sells Obamacare coverage, and Nebraska, where Medica still offers coverage but has warned it may exit the program.

Aetna projected around $225 million in losses from its exchange plan businesses this year following a loss of $700 million for 2014 through 2016.

The insurer attributed the losses to “marketplace structural issues that have led to co-op failures and carrier exits, and subsequent risk pool deterioration.” Aetna said it had 964,000 individual commercial plan members as of the end of 2016, but that number dropped to 255,000 at the end of March. Evercore ISI said Delaware exchange sign-ups fell 2.4 percent year-over-year in 2017, while sign-ups in Nebraska fell 3.9 percent, which was close to the 3.7 percent nationwide drop.

Jocelynn Smith reported on the health care costs and how they are a big part of the economic crisis and its burden on the health care here in America. There are the health insurance premiums, the copays and the deductibles. Each year, all those costs go up and far faster than any potential increases that I’m seeing in my paycheck. Health care in America is eating up larger chunks of my income, forcing me to more often skip those doctor visits or cut spending elsewhere in my life.

I’m not the only American making these tough choices about where my money is being spent. Health care is taking a bigger bite out of the wealth of America, putting our entire economy in danger…

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The Taxing Burden of America’s Health Care:

A few weeks ago Ms. Smith’s article took a closer look at the debt burden that Americans are struggling under that will soon have a significant impact on their spending habits despite the fact that we have a Federal Reserve crowing about how we’ve approximately reached full employment and that wage growth is sitting at 2.7% on an annualized basis.

We are seeing more and more Americans reporting that it is difficult to pay their monthly premiums, copays and deductibles.

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The Kaiser Family Foundation (KFF) revealed that insurance premiums soared 213% since 1999 for family coverage purchased through an employer, while wages grew by only 60% and inflation is up 44%.

In fact, health care spending now accounts for more than 17% of the U.S. economy compared to less than 9% in 1980.

Even with insurance coverage, more adults are struggling with health care expenses. A recent survey by the KFF revealed that 43% of adults with health insurance struggled with affording their deductibles, while approximately one-third are having difficulty affording their premiums and copays. Both responses are up from their 2015 levels.

What’s more, the push for more Americans to have insurance coverage has resulted in an increase in what workers are paying for deductibles. In 2016, more than one-half of workers with single-coverage health plans paid a deductible of $1,000 or more compared to 31% of workers in 2011. The average deductible now sits at $1,221, up 63% from 2006.

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In addition, health care insurance premiums continue to rise, jumping nearly 80% over the past decade.

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Cutting Back on Spending:

Americans are having trouble keeping up with rising costs. The KFF survey reveals that 29% of Americans are having problems paying medical bills.

And when we have trouble making ends meet, we start changing our spending habits.

Of those who reported having trouble paying medicals bills, 73% stated that they have cut back on basics such as food, clothing and household items.

What’s more, 27% reported that they have delayed seeking health care they needed, 23% skipped a recommended medical test or treatment, and 21% failed to get a prescription for a medicine due to rising medical costs.

Washington is still at war over Obamacare and the next plan for America’s health care. Regardless of the long-term outcome, Americans are trapped in a situation where costs will continue to rise, and very likely faster than their own income is rising. In that situation, we are facing two possible outcomes:

  • . Americans pay their health care costs to stay healthy but start spending less on things such as clothing, restaurants, entertainment, vacations, household goods, etc. This will result in a decline in economic growth.
  • . Americans cut back on health care — skipping that needed test, doctor’s appointment or prescription medication — which results in poor health in America and an overall reduction in worker productivity. That, of course, leads to less income and less spending.

Either way, the economy is facing the potential for a sharp slowdown as Americans struggle under the increasing burden of health care costs. Unfortunately, I don’t believe that any of the angry people who are yelling at members of Congress really understand the economics, or care about the financial burden of a health care system that has subsidized 11-24 million people, depending on who you believe. How do we finance, or better, continue to financially support the Freebees/ Freeloaders who expect the young healthy people to pay for the those who are too lazy to work or be able to afford the high cost of premiums for insurance coverage.

Maybe we should consider a Single-Payer health care system. Even Aetna Inc. Chief Executive Officer Mark Bertolini , after announcing the exit of Aetna from 2018 Obamacare individual insurance market in Delaware and Nebraska, wants a debate about what a “single-payer” healthcare system in the United States would look like, but said he does not think the federal government should run it.                                          Maybe, we should have this debate!


And the GOP Tries It Again-Repeal Obamacare!


So, this week the GOP persisted with their intent and promise to repeal the Affordable Care Act. Very stupid!!

On its front page, the New York Times, Kaplan and Pear reported that on Thursday, the House “narrowly approved” the American Health Care Act by a vote of 217-213, “as Republicans recovered from their earlier failures and moved a step closer to delivering their promise to reshape American health care without mandated insurance coverage.” The article says no Democrats voted for the bill. 20 Republicans joined them. The Times adds that this passage “keeps alive the Republican dream to unwind” the Affordable Care Act. But the bill “faces profound uncertainty in the Senate, where the legislation’s steep spending cuts will almost certainly be moderated.”

Mr. Shesgreen of USA Today reports that the vote “reflected sharp divisions over the GOP’s proposal, which is a long way from becoming law but still represents a huge victory for House Republican leaders and the Trump administration.” Republicans have “struggled for months to cobble together legislation that would garner the required 216 votes from its own fractured conference.”

Sullivan, Weigel, O’Keefe in the Washington Post reported that the approval of the AHCA “capped weeks of fits and starts for the GOP and represented an enormous victory for President Trump, who repeatedly pledged on the campaign trail last year to repeal and replace” the ACA “but has struggled to secure legislative wins early in his presidency.”

Ehrenfreund in the Post, in a separate article further reported that the AHCA was passed without “an official estimate of how the bill will affect the federal government’s bottom line or how many Americans could go without insurance under the plan.” Therefore, it remains unclear “whether the legislation would save the government money or add to the national debt.” The Congressional Budget Office has “not had time to put together” its “usual estimate of the costs and savings, and independent analysts are uncertain about what the results would be.”

After seven years of repeal-and-replace rhetoric against the Affordable Care Act, two presidential campaigns waged for and against it and a recent high-profile failure, House Republicans passed their bill.

The trouble is this bill is unlikely to ever become law — at least in its current iteration.

Here’s why: While the bill passed the House (narrowly) Thursday afternoon, it still has to go to the Senate. It’s being done with a wink and a promise that the Senate will overhaul substantial portions of the bill.

“This thing is going to the United States Senate. It’s going to change in my view in the United States Senate in some way,” Rep. Tom Cole of Oklahoma, a deputy whip in the House, told NPR’s Morning Edition. (Cole is one of the people in charge of making sure Republicans have the votes.) “Then we have to have a conference to work out the differences. If we can do that, then it has to still pass the House and the Senate again before it ever gets to the president. So at some point, you just have to move.

Sure, the Senate is controlled by Republicans, also, but they have an even slimmer majority there with equally fractious divisions. If they lose three votes, the bill goes down. Sen. Tom Cotton of Arkansas has been doing a delicate dance on Medicaid expansion. His state took federal money to expand Medicaid, but he has called it a “welfare program” and said “able-bodied adults” shouldn’t be on it.

After an angry town hall, he changed his tune, saying the House bill was “moving too fast; I didn’t think it got it right.” He also has indicated he is against it in its current form because, “I simply think that it’s not going to work to bring down premiums for working Arkansans or working Americans around the country.”

Other senators, like Lisa Murkowski of Alaska, Susan Collins of Maine, Bob Corker of Tennessee, Rob Portman of Ohio and Bill Cassidy of Louisiana, are in favor of repeal, but they want something “stable” to replace it. They have indicated that affordability, coverage and rural access (like what the bill means for rural hospitals) are key.

Senate Majority Leader Mitch McConnell is going to allow amendments. That means the bill will change. And if even a comma is inserted, it has to pass the House — again.

And that is inevitably going to bring back this whole game of whack-a-mole in the House.

Exhausted yet?

Wait, there’s more. Because Democrats aren’t going to sign on to something that guts the coverage mandates of the Affordable Care Act, Republicans can’t get 60 votes to advance the legislation.

So to pass it, they’re going to have to use the process known as reconciliation. That allows legislation to pass with just a majority (plus one). But there’s a catch — it has to be tied to the budget.

Get ready to hear a whole lot more about the “Byrd Rule.” What’s that? The Committee for a Responsible Federal Budget explains it this way:

“Although reconciliation bills are granted many privileges that are not available to most other legislation (see Reconciliation 101), they remain bound by several conditions. Some of these restrictions championed by former Senator Robert Byrd (D-WV) and established in Section 313 of the Budget Act are jointly referred to as the ‘Byrd Rule.’ The Byrd Rule disallows ‘extraneous matter’ from being included in a reconciliation bill, extraneous matter being defined in three major categories of restrictions.

“First, reconciliation legislation must only involve budget-related changes and cannot include policies that have no fiscal impact, that have ‘merely incidental’ fiscal impacts, or that increase the deficit if the committee did not follow its reconciliation instructions (including proposals outside of a committee’s proper jurisdiction—more on this below). Second, reconciliation bills cannot change Social Security spending or dedicated revenue, which are considered ‘off-budget.’ And finally, provisions in a reconciliation bill cannot increase the deficit in any fiscal year after the window of the reconciliation bill (usually ten years in the future) unless the costs outside the budget window are offset by other savings in the bill.”

The umpire of what qualifies under the Byrd Rule is the Senate parliamentarian. Her name is Elizabeth MacDonough. Politico wrote of her in 2015: “She may very well be the most powerful person in Washington in determining how far Republicans can go in trying to repeal Obamacare. As the Senate parliamentarian, MacDonough will make the decisions on which pieces of the law qualify to be repealed using a complicated budget procedure called reconciliation. Her decisions would allow Senate Republicans to vote to kill major provisions of the health care law under a simple 51-vote majority without giving Democrats a chance to filibuster.”

MacDonough was appointed in 2012, and even though she is liked on Capitol Hill by both sides, past parliamentarians (known colloquially on the Hill as “parls”) have come under fire because the majority party didn’t like how they ruled. More from Politico:

“Republicans protested decisions by then-parliamentarian Alan Frumin in the 2010 health care reform fight, when Democrats used the budget fast-track tool to pass a small part of the Affordable Care Act. In 2001, Republicans fired Robert Dove as parliamentarian after he ruled against them on how many reconciliation bills could be used. That was actually his second stint in the job: Democrats had fired Dove when they took the majority in 1987.”

Reconciliation — and what fits and doesn’t fit into it — isn’t the GOP’s only complication. Their biggest one is the policy itself. It has a lot of shortcomings. The nonpartisan Congressional Budget Office said of the last iteration of the House bill that it would save money but leave some 24 million without insurance.

So the GOP bill would be less generous in terms of benefits and cover fewer people. And the only reason it would save money is that the repeal bill would cut $880 billion from Medicaid. That would break President Trump’s promises of “insurance for everybody” and “no cuts to Social Security, Medicare & Medicaid.”

The CBO won’t get out an analysis of the bill before Republicans are planning to vote. Politically, that gives them a chance to wipe their brows and not have to defend something that could be difficult to defend.

It’s morally questionable, though, to vote on something without knowing its cost or consequences. And what happens when the CBO score does come out — and they’ve already voted for it without the opportunity to make changes?

And there’s the issue of the popular pre-existing conditions provision in Obamacare — which requires insurance companies to cover people with pre-existing conditions.

Trump claimed as late as this week that this bill would guarantee that people with pre-existing conditions would continue to be covered. But Republicans’ attempts at doing that are very different from the way Obamacare achieves it.

The GOP plan would essentially allow states to take sicker people out of the broader pool of people buying coverage and put them into a “high-risk pool.” That, in theory, would bring down the cost of insurance for healthier people, but drive up the cost for the sick. Depending upon how much costs increase, that could shut some or many of the people who definitely need health care out of the insurance market.

High-risk pools haven’t shown great results where they have been currently implemented. Part of the problem has been funding. That’s why Trump picked up two more votes with a proposal for $8 billion more for those pools, but experts say that’s most likely not even enough.

The U.S. government already has very high profile high-risk pools, Medicare and Medicaid. Medicare — health care for the elderly — is popular but expensive.

A big point of Obamacare was to not go down that potentially problematic funding lane. Healthier people might pay a little more, but if you got sick, it wouldn’t bankrupt you.

So why the rush to get this through if it has all these holes and may not be what eventually becomes law anyway? Politics. The House finally has a chance to tell its base it did something, it passed something to repeal and replace Obamacare.

The House goes on recess next week, and Republicans want to get this done and hand President Trump a win before then.

It’s a huge relief for House Speaker Paul Ryan, who was feeling the heat of not being able to govern House Republicans. It’s a huge relief for Trump, who has been made to look ineffectual with no legislative wins to speak of in his first 100 days and little other major accomplishments in that time — despite Republicans being in charge of the White House, House and Senate.

However, hours after the GOP-controlled House narrowly passed a bill to repeal and replace ObamaCare, a Republican senator said the bill has “zero chance” to pass the Senate as is. Sen. Bob Corker, R-Tenn., said the sweeping health care passed Thursday would not pass quickly through the Senate without major adjustments. The New York Post reported that moderate senators are concerned about the bill’s Medicaid reductions.                                   “The safest thing to say is there will be a Senate bill, but it will look at what the House has done and see how much of that we can incorporate in a product that works for us in reconciliation,” Sen. Roy Blunt, R-Mo., told The Washington Examiner.                                                                                                                                       The revised American Health Care Act passed Thursday on a 217-213 vote.                                                                                                     “We’re going to get this finished,” President Trump declared in a celebratory Rose Garden event, surrounded by Republican congressional allies shortly after the vote. He vowed premiums and deductibles will be “coming down” and the Affordable Care Act is “essentially dead.”                                                                                                                           The passage marked Republicans’ biggest step yet toward replacing the Obama administration’s signature domestic policy law. The bill heads next to the Senate, however, where it faces an uncertain fate.                                                                                  All Democrats voted against the bill on the House floor Thursday afternoon, warning it would jeopardize coverage; 20 Republicans voted no. Implying the GOP would lose seats in 2018, Democrats sang, “Na Na Hey Hey Kiss Him Goodbye” toward the end of the voting.                                                                                                                                                 But GOP leaders cheered the result.                                                                                  “Welcome to the beginning of the end of ObamaCare,” Vice President Pence said in the Rose Garden.                                                                                                                               Trump, praising House Speaker Paul Ryan, said he’s confident in Senate passage and predicted an “unbelievable victory.”                                                                               Democrats, though, continue to rail against the legislation that would overhaul many key provisions of ObamaCare. Lawmakers took to the floor to call it a “gut punch to America,” and a boon for billionaires and “undertakers.”                                                   “This disastrous bill has been condemned by almost everyone,” House Minority Leader Nancy Pelosi, D-Calif., said Thursday at a press conference. She said the latest version is “worse” than the original and rejected claims it would protect those with pre-existing conditions.                                                                                                                                      “This is a scar that they will carry,” Pelosi said of House Republicans who vote for the plan.                                                                                                                                                Here’s a rundown of key provisions in the American Health Care Act and what would happen if the Senate approves them and the bill becomes law.                                     Buying insurance                                                                                                                           The bill would no longer require people to buy insurance through the marketplaces created by the Affordable Care Act, also known as Obamacare, if they want to use federal tax credits to buy coverage. It also would eliminate the tax penalty for failing to have health insurance coverage, effectively doing away with that requirement altogether.                                                                                                                                          In place of that mandate, the bill encourages people to maintain coverage by prohibiting insurance companies from cutting them off or charging more for pre-existing conditions as long as their insurance doesn’t lapse. If coverage is interrupted for more than 63 days, however, insurers can charge people a 30 percent penalty over their premium for one year.                                                                                                                                                    Tax credits                                                                                                                                        The House Republican plan would eliminate the income-based tax credits and subsidies available under the Affordable Care Act, replacing them with age-based tax credits ranging from $2,000 a year for people in their 20s to $4,000 a year for those older than 60.                                                                                                                                                        That means some people will see their costs go up while others would pay less, depending on your age and where you live. This Kaiser Family Foundation interactive map shows how the change would play out across the country.

Untitled.interactive map

The map shows that a 27-year-old who makes $30,000 a year would see costs rise about $2,000 in Nebraska but fall by about the same amount in Washington state. A 60-year-old, however, would see costs rise almost everywhere, with increases of almost $20,000 a year in Nebraska.                                                                                                                           Both Kaiser and the Congressional Budget Office found that, on average, older people with lower incomes would be worse off under the Republican plan than under the Affordable Care Act.                                                                                                                        Tax cuts                                                                                                                                             The bill eliminates nearly all the taxes that were included in the Affordable Care Act to pay for the subsidies that help people buy insurance. Those cuts, which add up to about $592 billion, include a tax on incomes over $200,000 (or $250,000 for a married couple); a tax on health insurers and a limit on how much insurance companies can deduct for executive pay; and a tax on medical-device manufacturers.                                       Medicaid                                                                                                                                           The AHCA would make dramatic changes to Medicaid, the federal-state health program for the poor and disabled. The Affordable Care Act allows states to expand eligibility for Medicaid to single, nondisabled adults with incomes slightly above the poverty line, with the federal government picking up most of the cost. That meant single adults who earn up to $15,800 a year could qualify in the 31 states, plus the District of Columbia, that expanded Medicaid. About 10 million people enrolled under that expansion.                                                                                                                 The Republican plan would gradually roll back that expansion starting in 2019 by cutting the federal reimbursement to states for anyone who leaves the Medicaid rolls. People often cycle in and out of the program as their income fluctuates, so the result would likely be an ever-dwindling number of people covered.                                                         The House bill also converts Medicaid from an entitlement program, in which the government pays all the health-related costs for those who qualify, to a grant program. The federal government would give states either a set amount of money for each Medicaid enrollee or let them choose to receive a fixed-dollar block grant. The Congressional Budget Office estimated in March that the bill would cut Medicaid spending by $880 billion.                                                                                                               Pre-existing conditions                                                                                                                The AHCA maintains protections for people with pre-existing conditions, with some important exceptions (see waivers, below). That means that someone with high medical expenses pays the same premium for the same policy as anyone else his age in his area.                                                                                                                                     State waivers                                                                                                                                   This section of the bill essentially amounts to an optional, state-level full repeal of Obamacare. It would give states the ability to apply for a waiver that lets them opt out of most of the regulations and consumer protections that were included in the Affordable Care Act.                                                                                                                                          States could apply for waivers that would allow insurance companies in their states to do three things: 1. Charge older people more than five times what they charge young people for the same policy; 2. Eliminate required coverage, called essential health benefits, including maternity care, mental health and prescription drugs that were required under the Affordable Care Act; and 3. Charge more for or deny coverage to people who have pre-existing health conditions, such as cancer, diabetes or arthritis.                                                                                                                                      The waivers could also impact people with employer-based insurance, because insurers could offer policies that have annual and lifetime benefit limits, which are banned under the Affordable Care Act, and some companies may choose those policies for their workers to lower premiums.                                                                                                      States that get waivers would very likely see insurance companies offer many more policy options, some with fewer benefits and lower premiums.                                        Those states would be required under the law to create some other way to ensure that people with expensive illnesses are able to get health care, and the law provides up to $138 billion over 10 years for such programs, typically called high-risk pools.           However, an analysis released Thursday by consulting firm Avalere Health concludes that that amount would be inadequate for providing full health coverage for the number of people who now buy insurance in the individual market and have medical problems.                                                                                                                 Overall impact                                                                                                                                The House approved the bill Thursday without a full Congressional Budget Office analysis of its costs and how many people would be covered.                                              The CBO report from March concluded that over 10 years, 24 million fewer people would be covered under the bill that otherwise would have had insurance under current law.                                                                                                                                    That analysis also predicted that the House bill would cut federal deficits by $337 billion over those same 10 years.                                                                                                   However, changes to the bill since then would allow states to accept block grants for Medicaid; add about $38 billion for high-risk pools and maternity and childbirth care; and offer states waivers from regulations created by the Affordable Care Act. It’s unclear how much these changes would affect the original CBO score.                                             The Senate will review the House bill but will write its own version over the next few weeks, said Sen. Lamar Alexander, R-Tenn., chairman of the Health, Education, Labor and Pensions Committee.                                                                                                               “We want to get it right,” Alexander said Thursday on the Senate floor. “There will be no artificial deadlines.”                                                                                                                            If the Senate passes its own bill, the House will either have to approve the Senate version or negotiate a compromise with senators, Alexander said. Any compromise bill would need to be approved by both the House and Senate before being sent to President Trump to sign.                                                                                                                                                The New York Times in an article by Abelson, Thomas, reported that in “a rare unifying moment,” hospitals, physicians, health insurers, and some consumer groups are, “with one voice,” calling for “significant changes” to the health care bill that passed the House. Greenwood) reported in The Hill that the American Medical Association “blasted” House GOP lawmakers for passing the AHCA, and warned “the bill could turn back the clock on protections for patients with pre-existing conditions.” AMA President Andrew W. Gurman, MD, stated, “The bill passed by the House today will result in millions of Americans losing access to quality, affordable health insurance and those with pre-existing health conditions face the possibility of going back to the time when insurers could charge them premiums that made access to coverage out of the question.” He added, “The AMA urges the Senate and the Administration to work with physician, patient, hospital and other provider groups to craft bipartisan solutions so all American families can access affordable and meaningful coverage, while preserving the safety net for vulnerable populations.” After this week I am convinced that our Congress, or at least the House of Representatives, and that includes both parties are truly dysfunctional. Remember GOP, if this new health care act doesn’t improve the health care of our country, cover all of those subsidized patients out there, they will pay for it by losing their majority in both the House as well as the Senate, and NOTHING will get accomplished in the rest of President Trumps final years. My prediction is that as the months drag on and realistic minds take control, the new health care system will look more and more like a modified Obamacare. What do you all think?




Trump Says Obamacare Is ‘Exploding.’ It’s Not. Is It or Isn’t It?? Let’s Check the Facts!

18118480_1177588472370810_8140217210283723144_nPresident Trump is doing his best to put a good face on defeat in his party’s attempt to replace the Affordable Care Act, also known as Obamacare. He is predicting that the Affordable Care Act will explode. Let’s explore further.

Danielle Kurtzleben and Alison Kodjak reviewed the concept of the explosion of the ACA and notes that Trump’s strategy is simple: declare that the law is failing. And he is selling that message in his own distinctly Trumpian way: concocting it out of simple, bold words and then hammering that message home, over and over: Obamacare, in his words, will “explode.”

Here it is, his own words “The best thing we can do, politically speaking, is let Obamacare explode,” he said in the Oval Office on Friday after the GOP health care bill went down. “It’s exploding right now.” Is it or will it??

Again on Twitter a few Saturday’s ago, he repeated his case: “ObamaCare will explode and we will all get together and piece together a great healthcare plan for THE PEOPLE. Do not worry!”

The law has its problems — but it is far from “exploding,” using any reasonable definition of the word. Here is a quick rundown of where the Affordable Care Act stands right now, what’s going well and what’s not so great.

What’s Working?

1) The exchanges are stable!

Supporters of the current health law received something of a boost last week with the Congressional Budget Office’s initial assessment of the Republicans’ bill. If the Affordable Care Act were kept in place, the CBO wrote, the exchanges wouldn’t explode at all.

“The non-group market would probably be stable in most areas under either current law or the [Republican] legislation,” the nonpartisan office wrote.

The CBO cites two reasons:

First, it said the law requiring people to buy insurance or pay a penalty works to bring people into the market, further stabilizing the customer base.

Second, and more importantly, a strong majority of people who buy insurance through the marketplaces get financial help from the government to pay their premiums, and those subsidies rise when premiums rise. So those people are likely to continue buying insurance through the marketplaces.

2) … In part because many people are shielded from premium hikes.

Indeed, premiums have climbed substantially in some states’ exchanges, but PolitiFact found this week that “most people purchasing health care through the marketplace didn’t feel it.” (The fact-check organization was vetting former President Obama’s claim that most exchange enrollees “have experienced no average premium hike at all.”)

A study by the Kaiser Family Foundation shows that a 40-year-old who makes $30,000 could have paid the same $208 a month for an average marketplace health insurance policy in both 2016 and 2017, as long as they were willing to shop for the best price.

3) The uninsured rate has fallen — a lot.

Probably the biggest positive supporters of the Affordable Care Act point to is the fast-falling rate of people who don’t have health insurance. Before the ACA, more than 16 percent of the population was uninsured. Then in 2013, the first year that the Obamacare marketplaces went live, the uninsured rate fell to 13.3 percent, and then to 10.5 percent in 2015, and to 8.9 percent in the first half of 2016, the lowest ever.

Much of that decline is because many low-income people became eligible for Medicaid under the Obamacare expansion of that program. The rest are people who bought insurance through those exchanges.

That has had knock-on effects throughout the health care industry. Most notably, hospitals are losing less money, because they don’t have to treat as many people in emergency rooms who don’t pay their bills. The American Hospital Association says that uncompensated care dropped from 6.1 percent of their expenses in 2012 to 4.2 percent in 2015. At the end of this post I will show what would happen if the GOP repeals the ACA.

The Analytics:

Under Obamacare, Uninsured Rate Expected To Hold Steady

The CBO recently estimated that the share of U.S. residents under age 65 who are uninsured would hold steady under the Affordable Care Act (commonly known as Obamacare) in the coming decade. In contrast, the recent Republican plan, the American Health Care Act, would have led to much higher uninsured rates.

ACA Not Failing.14) Premiums are holding steady (but don’t praise Obamacare for that)

One more point that’s not exactly great, but is an improvement: Premiums continue to grow for enrollees in employer-provided plans, but that growth is slower than it was in the years prior to the Affordable Care Act’s passage.

However, the law doesn’t appear to have played a big part in slowing that growth.

The Kaiser Family Foundation’s Gary Claxton told FactCheck.org recently that it’s difficult to figure out exactly how much Obamacare affected employer premiums — there are “so many moving parts,” he said — but he doesn’t believe there’s much of an effect.

“There was nothing fundamentally large about the ACA overall which had a noticeable effect” on those premiums, he said. Fredric Blavin, a senior research associate at the Urban Institute, likewise told FactCheck that any effects on premiums were likely small.

That works against both the Obama administration, which implied that it was slowing down premium growth, and the Trump administration, which has blamed the Obama administration for premium growth.

For example, the Kaiser Family Foundation found in 2013 that a slowing economy probably had something to do with the slowing growth, as FactCheck.org noted. Not only that, but deductibles have grown quickly in recent years, helping to keep premiums down. Ultimately, Obama’s health law doesn’t seem to have held premiums down all that much — but it also hasn’t caused them to explode.

What’s not working?

1) Few insurance options for many Americans.

The Affordable Care Act does have its weaknesses. As more companies have pulled out of the exchanges, Americans are left with fewer choices in their coverage. In many parts of the country, as Trump and his fellow Republicans often point out, enrollees in the insurance exchanges have only one choice of insurer.

An analysis by the Kaiser Family Foundation found that five states — Alabama, Alaska, Oklahoma, South Carolina and Wyoming — have only one insurance company selling policies on the Obamacare exchanges.

And the share of the population that has three or more companies to choose from fell from 85 percent in 2016 to 57 percent this year.

The uncertainty over the future of the Affordable Care Act exchanges has likely made this situation worse. Insurers have to decide in the next few weeks whether to offer policies on the federal and state exchanges for 2018. Humana has already announced it intends to leave the exchanges altogether.

2) Big premium hikes for some Americans.

And while it’s true that many Americans in the exchanges — 64 percent, according to PolitiFact — haven’t seen their out-of-pocket spending on premiums rise, around one-third did. Those premium hikes were steep in some states, such as Arizona, which saw its average premiums more than double. And for those who were shielded from rising premiums by subsidies, the government picked up that much more of the bill.

3) Higher deductibles making health care more expensive for many.

And premiums aren’t the extent of health care spending. For most people, out-of-pocket costs such as deductibles and co-payments have also risen. The average deductible for workers getting individual insurance through their employers was $1,478 last year. That’s up by 49 percent over five years. That helps counterbalance the slower growth in premiums.


The Share Of Workers With High-Deductible Insurance Plans Keeps Rising

More and more, workers in workplace insurance plans are taking on the costs of their health care by paying higher deductibles — the below chart shows the share of people enrolled in employer-sponsored health plans that have annual deductibles of $1,000 or more for single coverage. Small firms in particular tend to impose higher deductibles; many have used them as a strategy to control costs.ACA Not Failing.2 4) (Very) (very) expensive health care

One more sign of problems with U.S. health care today: The U.S. spends much more on health care than other countries do — more than $9,400 per capita per year, as of 2016, compared to around $3,800 for other developed countries.

That’s not caused by the Affordable Care Act — this was a problem before the bill was passed — but it’s a sign that there’s still a lot that could be done to improve the U.S. health care system and I have stated time and time again that there is a need to find a way to pay for “an affordable health care system.”

And remember the problems, which would be created if the GOP gets its way and repeals the ACA/Obamacare. Put into raw numbers, here’s how the growth in the number of uninsured looks: In 2018, the number of uninsured would be 14 million larger under the Republican bill than under Obamacare. In 2026, it would be 24 million larger. Look at the following chart:Untitled.ACA not exploding.3That big upswing in 2018 would be largely attributed to repealing the penalties that came as part of the individual mandate — not having a fine would lead lots of people to decide not to get insured. In addition, rising premiums would deter some from buying insurance.                                                                                                                                             In subsequent years, Medicaid changes would account for an increasing number of uninsured, eventually hitting 14 million. The rollback of the Affordable Care Act’s Medicaid expansion would begin in 2020, cutting the number of people on the program. In addition, no states would be able to take up the expansion in the future, further dropping the number of potential Medicaid enrollees.                                                       Again, all of you politicians get real and understand that the Democrats and President Obama came up with a health care system with a great vision-Health Care for All. But we know that there are a number of things that are not working as I have pointed out. So, work together and Make Things Work and Find a Way of Paying for It. In future posts I will undertake the challenge of how to pay for the health care system based on the successes and failures of other countries.

Right now I have to get back to editing our book, back form the publisher with suggested edits. If we are lucky the book will be released form the publisher in a few months. I never knew how difficult it would be to get a book published. Look forward to our book, which we hope will lead to further improvements in the way medicine is delivered: “The Search for Excellence in Clinical Practice: A Handbook on Clinical Process Improvement for Providers.”


Heroin Deaths Surpass Gun Homicides for the First Time, CDC Data Shows and the Deaths are Showing Some Scary Combinations

16996227_1121895594606765_8941719947237340675_n-2Christopher Ingraham reported this surprising statistic and I decided to review this horrible epidemic due to its effect on my hometown that reported almost 300 overdoses last year in our little “Mayberry” town. Also, I was depressed on reading the article in THE WEEK, “The last word”, about John and Leigh Ann Wilson’s daughter and her battle with addiction to heroin and her relapse and final overdose and death. We are losing the battle. What is the winning strategy? Look at these graphs and the data.

Heroin deaths.1

Opioid deaths continued to surge in 2015, surpassing 30,000 for the first time in recent history, according to CDC data released Thursday. That marks an increase of nearly 5,000 deaths from 2014. And worse is that the deaths involving powerful synthetic opiates, like fentanyl, rose by nearly 75 percent from 2014 to 2015 and I will discuss the fentanyl impact in more detail later in this post.

Herion deaths.2

Heroin deaths spiked too, rising by more than 2,000 cases. For the first time since at least the late 1990s, there were more deaths due to heroin than to traditional opioid painkillers, like hydrocodone and oxycodone.

“The epidemic of deaths involving opioids continues to worsen,” said CDC Director Tom Frieden in a statement. “Prescription opioid misuse and use of heroin and illicitly manufactured fentanyl are intertwined and deeply troubling problems.”

In the CDC’s opioid death data, deaths may involve more than one individual drug category, so numbers in the chart above aren’t mutually exclusive. Many opioid fatalities involve a combination of drugs, often multiple types of opioids, or opioids in conjunction with other sedative substances like alcohol.

In a grim milestone, more people died from heroin-related causes than from gun homicides in 2015. As recently as 2007, gun homicides outnumbered heroin deaths by more than 5 to 1.

Heroin deaths.3

These increases come amid a year-over-year increase in mortality across the board, resulting in the first decline in American life expectancy since 1993. Congress recently passed a spending bill containing $1 billion to combat the opioid epidemic, including money for addiction treatment and prevention. “The prescription opioid and heroin epidemic continues to devastate communities and families across the country—in large part because too many people still do not get effective substance use disorder treatment,” said Michael Botticelli, Director of National Drug Control Policy, in a statement. “That is why the President has called since February for $1 billion in new funding to expand access to treatment.”

Much of the current opioid predicament stems from the explosion of prescription painkiller use in the late 1990s and early 2000s. Widespread painkiller use led to many Americans developing dependencies on the drugs. When various authorities at the state and federal levels began issuing tighter restrictions on painkillers in the late 2000s, much of that demand shifted over to the illicit market, feeding the heroin boom of the past several years.

The Drug Enforcement Administration warns people about the dangers of Fentanyl, a synthetic opioid that can be 40 to 50 times stronger than heroin. (Drug Enforcement Administration) Drug policy reformers say the criminalization of illicit and off-label drug use is a barrier to reversing the growing epidemic.

“Criminalization drives people to the margins and dissuades them from getting help,” said Grant Smith, deputy director of national affairs at the Drug Policy Alliance. “It drives a wedge between people who need help and the services they need. Because of criminalization and stigma, people hide their addictions from others.”                                 A study reported in a new study in JAMA Psychiatry shows that the increase in deaths didn’t affect everyone equally. By comparing responses from the 2001-02 National Epidemiologic Survey on Alcohol and Related Conditions to results from the 2012-13 version, authors Silvia S. Martins, MD, of Columbia University’s Mailman School of Public Health, and colleagues found that increases in heroin use disorder among some groups were concentrated in just a few groups. The biggest change came in the racial makeup of users. In the 2001-2002 responses, nonwhites more commonly met criteria for heroin use disorder than did whites. But a decade later that had completely flipped: the rate among whites doubled from the previous period and was nearly double that of nonwhites, among whom the rate had raised only a little.                                                                                                                                   Robin Lubbock reported for WBUR that there’s a clear culprit in the rising drug overdose death count in Massachusetts, but it’s not heroin. It’s the synthetic opioid fentanyl. Seventy-five percent of the state’s men and women who died after an unintentional overdose last year had fentanyl in their system, up from 57 percent in 2015. It’s a pattern cities and towns are seeing across the state and across the country, particularly in New England and the Rust Belt states.                                                                                         Fentanyl may be especially lethal because it’s strong, it’s mixed with other drugs in varying amounts unknown to the user, and it can trigger an overdose within seconds. “It happens so fast, like instantly, as soon as you do the shot,” says Allyson, a 37-year-old woman who started using heroin in her late teens. “In the past, it an overdose was something that you saw happening, like, you could see the person start to slow down, their color would start to turn blue, and then they would go out, within 10 minutes or so,” Allyson says. With fentanyl, there’s no progression. “Now it’s instant,” she says. Allyson leans back in a chair at the AAC Needle Exchange in Cambridge, Mass., and tugs the hood of her gray sweatshirt down to her eyes. We’ve agreed not to use her full name or the full names of any people in this story who buy illegal drugs, so as not to harm their future job prospects.                                                                                                                                 Allyson is a regular client at the needle exchange, where manager Meghan Hynes urges everyone to carry naloxone, the drug that reverses an overdose. Hynes uses her own kit every few weeks.                                                                                                                    “Recently we had a guy leave the bathroom and all the color just drained from his face, like immediately, and he just turned blue,” Hynes says, describing what’s become a typical fentanyl overdose. “I’ve never seen anyone turn blue that fast. He was completely blue and he just fell down and was out — not breathing.” Hynes bent over the man turning blue to pump his heart, but she couldn’t. He was hit with “wooden chest,” a side effect of fentanyl that may be increasing the death toll. “Your chest seizes up. You literally have paralysis and that’s obviously really dangerous, because if someone needs CPR, you can’t do it,” Hynes says. “And in this situation it spread, so he had lockjaw and his mouth was only open a tiny, tiny bit. And so I could hardly even do rescue breathing for him.”                                    Breathing for overdose patients is critical because brain cells can die after just five minutes without oxygen. Hynes revived the man on the floor. Because of the increasing overdoses she sees with fentanyl in the mix, she urges clients to stick to a dealer they know, and use with a buddy.                                                                                                       Many drug users also inject a small amount before they give themselves the full shot.”But it’s really hard to tell these days, even if you do a tester shot,” Allyson says, because the grains of fentanyl that could kill you aren’t mixed uniformly in a bag. That’s a lesson she learned one death-defying night a few months ago. Allyson, who is homeless, spent the night in a tent with a friend. She woke up and used the last of a bag from the day before to get herself going. “And I actually said to my friend, I said, ‘Wow, I can’t believe I only saved myself this much.’ It was a very small amount, like a third of what I did the night before,” Allyson says, shaking her head. “I overdosed on it.”                                                           The friend had enough naloxone in the tent, which was far from a road or hospital, to bring Allyson back from the dead.                                                                                           Fentanyl is an opioid 50 times more powerful than heroin. There’s a legal, Food and Drug Administration-approved version. But labs in China are churning out cheap versions of fentanyl that dealers are selling on the streets mixed with fillers, heroin or other drugs.                                                                                                                        Buyers have no idea how much fentanyl they are getting or how much risk they are taking with every injection. So, these days, drug users who frequent this needle exchange assume there’s fentanyl in every bag they buy.                                                                      “Most of us know that that’s what we’re getting,” says Sean, who started using heroin more than 20 years ago. “And if you don’t believe it, you’re living in a fairy tale world.”                                                                                                                               There’s no reliable way for drug users to test the contents of bags bought on the street. Eddie relies on taste. “It’s slightly bitter, but it’s mainly sweet if it’s fentanyl. If it’s heroin, you can tell right away because it’s got a bitter taste and it’s a long-lasting aftertaste,” Eddie says. “I will not put anything in my arm before I taste it.”

Eddie and Allyson say they try to avoid fentanyl. But when their last dose of drugs starts to wear off, they’ll take anything to avoid withdrawal, which they describe as the flu on steroids with fever, vomiting, diarrhea and high anxiety. “It literally feels like your skin is crawling off. You’re sweating profusely,” Allyson says. “Your nose is running, your eyes are running. And that’s all you can focus on. You can’t think.”

Some drug users seek fentanyl because it’s a more immediate rush and intense high. But Allyson doesn’t like it. She says a fentanyl high fades much more quickly than heroin’s, which means she has to find more money to buy more drugs and inject more often, which leads to more risk. When fentanyl fades, she and Eddie say, they are more likely to take other drugs. “You’re getting a fast rush but it doesn’t last, so people are mixing,” Allyson says.

At 37, Allyson is having experiences most Americans don’t face until much later in life. “As of two days ago, 30 people that I know have passed away. Basically my entire generation is gone in one year,” Allyson says. “It’s the fentanyl, definitely the fentanyl.” Older drug users who have been through other epidemics say this moment with fentanyl is the worst they’ve seen. A man named Shug twists a towel in his hands.

“Addicts are dying, like, every day. It’s crazy, man,” Shug says, his eyes filling with tears. “Nobody seems to give a damn.” Shug is grateful for the needle exchange, which hasn’t lost anyone to an overdose. But on the streets outside, the death toll keeps rising.

As I watched the methadone clinic in our town I was amazed at how the “clients” were observed selling their methadone to each other and fighting over their “locked” boxes, which they were given before holidays. Molly Walked reported that methadone-related overdoses accounted for nearly one in four deaths related to prescription opioids in 2014, despite a recent decline in drug overdose deaths involving methadone, said researchers from the Centers for Disease Control and Prevention.

Overall, the rate of methadone-overdose deaths increased 600% from 1999 to 2006 (from 0.3 persons per 100,000 to 1.8 per 100,000) before declining to 1.1 per 100,000 in 2014, reported Mark Faul, PhD, and colleagues.

While the drug accounted for only 1% of all opioid prescriptions, methadone-related deaths were responsible for 22.9% of opioid-related deaths in 2014, the authors wrote in the Morbidity and Mortality Weekly Report,

In an attempt to explain this decline in methadone-related mortality, the researchers noted that the FDA issued a Public Health Advisory in December 2006 that linked methadone to reports of respiratory depression and cardiac arrhythmias, among other serious side effects. Moreover, in January 2008, there was a voluntary manufacturer restriction that limited the distribution of the 40 mg formulation of methadone.

Faul and colleagues also examined methadone prescription by insurance type and found that prescriptions for methadone accounted for a higher portion of all opioid prescriptions in the Medicaid population compared with the commercially insured population — 0.85% weighted versus 1.1%, respectively.

Further, the team investigated the role that Medicaid preferred-drug-list (PDL) policies played in these potential deaths, examining the rates of fatal and nonfatal methadone overdose among Medicaid enrollees in two states where methadone was listed as a preferred drug on its PDL (Florida and North Carolina) versus one state where methadone was not listed on the PDL (South Carolina). Not surprisingly, overdose rates were significantly lower in South Carolina than in both North Carolina and Florida:

  • Florida: 1.75 per 100,000 persons, 95% CI 1.57-1.94
  • North Carolina: 1.67 per 100,000 persons, 95% CI 1.35-1.98
  • South Carolina: 0.81, 95% CI 0.65-0.96

“Given that methadone prescribing rates are higher among persons enrolled in Medicaid, strategies to reduce methadone prescribing among persons in this population might further reduce injuries and deaths from methadone,” the authors wrote. “If confirmed by additional studies, other states could consider Medicaid drug utilization management strategies such as PDL placement among other evidence-based strategies.”

The researchers examined three sources for these data: Drug overdose deaths and mortality rates were calculated through National Vital Statistics System Multiple Cause of Death mortality files and bridged U.S. Census data for 1999-2014. Truven Health’s MarketScan database for commercial claims and encounters was examined and compared with information from Medicaid multistate databases for 2014. Finally, Health Care Utilization Project data were examined from three states to determine whether a state’s policy was associated with higher methadone morbidity and mortality rates. Heroin Use Disorder by Race

The problem was most pronounced among young people, 18-29 years old. In 2001-02, all age groups reported similar rates. 2012-13, though, the rates among young users were up nearly five-fold, more than for any other age group.

Use disorder rates were up for all income and education groups, relatively evenly. While men saw a larger bounce in their rates than their female counterparts, the gap between the two genders’ reliance remained steady. Heroin Disorder Change by Gender

The authors believed their results could help lead to more focused efforts to curb the heroin epidemic.

“Promising examples include expansion of access to medication-assisted treatment, educational programs in schools and community settings, overdose prevention training in concert with comprehensive naloxone hydrochloride distribution programs, and consistent use of prescription drug monitoring programs,” they wrote. But now we are seeing in states where naloxone is an over the counter drug, that addicts are trying to reach higher and higher “highs” with a “dedicated safe driver” not shooting up so that they can rescue the higher high addicts.

We are only fooling each other to think that these strategies will work. Other countries are successfully de-criminalizing the addicts but continue to treat the dealers severely.

We have to take the drugs off the market or find a way of blocking the narcotic/opioid  receptors using an implantable device to slowly release the blocking agent. We need something, a strategy that reduces the addiction potential, or reduces the amount and the ease of purchasing these drugs, etc.

What we are commonly using now in our in our armamentarium for pain control is just not working. We physicians should take some of the blame, but only some of the blame. Surgeons prescribe postoperative opioids as well as other physicians in their practices and there needs to be a change in the aim of controlling pain using multimodal therapy using non-opioids medications and other therapy.

How many overdoses and deaths are we going to allow before we get serious about this epidemic? Physicians need to take the lead in this battle and the patients need to become more involved in their care and realize that erradicating all pain is a slippery slope and can lead to chronic addiction, which often results in very bad outcomes-often death.


The VA Health Care System, Are We Making Any Progress?

15439960_1053735618089430_7095899501210775916_nThis morning as I was finishing my breakfast and reading the news, here in California I came across this article, which reinforced my feelings regarding the VA system, yes a single payer, government run health care system. Basically, since last I wrote about the failures they still have not made much progress. Imagine this headline-

Veteran patients in imminent danger at VA hospital in D.C., investigation finds. Donovan Slack in USA TODAY, wrote that conditions are so dangerous at the Department of Veterans Affairs Medical Center in Washington, D.C., that the agency’s chief watchdog issued a rare preliminary report Wednesday to alert patients and other members of the public. The VA inspector general found that in recent weeks the operating room at the hospital ran out of vascular patches to seal blood vessels and ultrasound probes used to map blood flow.

The facility had to borrow bone material for knee replacement surgeries. And at one point, the hospital ran out of tubes needed for kidney dialysis, so staff had to go to a private-sector hospital and ask for some. The hospital, which serves more than 98,000 veterans in the nation’s capital, lacks an effective inventory system, the inspector general determined, and senior VA leaders have known about the problem for months and haven’t fixed it. Investigators also inspected 25 sterile storage areas and found 18 were dirty.

“Although our work is continuing, we believed it appropriate to publish this Interim Summary Report given the exigent nature of the issues we have preliminarily identified and the lack of confidence in VHA adequately and timely fixing the root causes of these issues,” VA Inspector General Michael Missal wrote.

The inspector general rarely issues such preliminary findings. The last time appears to have been in January 2015, when his office found lapses in urology care at the Phoenix VA were endangering patients and required “immediate attention.”

The VA set up an incident command center on March 30 when the inspector general notified officials about the problems in Washington; it sent logistics specialists, technicians and managers to fix the problems.

Such actions, Missal said, are “short term and potentially insufficient to guarantee the implementation of an effective inventory management system and address the other issues identified. “Further, shortages of medical equipment and supplies continued to occur confirming that problems persisted despite these measures,” he wrote.

After the report’s release Wednesday, the VA issued a statement saying that the medical center director, Brian Hawkins, was relieved from his position and placed on administrative duty, “effective immediately.”

“The department considers this an urgent patient-safety issue,” the statement said. “VA is conducting a swift and comprehensive review into these findings. VA’s top priority is to ensure that no patient has been harmed. If appropriate, additional disciplinary actions will be taken in accordance with the law.”

New VA Secretary David Shulkin told USA TODAY earlier this week that he welcomes outside oversight with hopes it will help him fix the beleaguered agency. The inspector general’s investigation, which stemmed from an anonymous complaint on March 21, found that during the past three years, there have been 194 reports that patient safety has been compromised because of insufficient equipment.

Among the findings:

  • In February 2016, a tray used in repairing jaw fractures was removed from the hospital because of an outstanding invoice to a vendor.
  • In April 2016, four prostate biopsies had to be canceled because there were no tools to extract the tissue sample.
  • In June 2016, the hospital found one of its surgeons had used expired equipment during a procedure
  • In March 2017, the facility found chemical strips used to verify equipment sterilization had expired a month earlier, so tests performed on nearly 400 items were not reliable

Missal said that the practices have placed patients at “unnecessary risk,” though so far, the Office of Inspector General has not determined if patients were harmed. “The OIG’s work is continuing and will include an assessment of whether patient harm has resulted from any of these inventory practices in its final report on the Medical Center,” he wrote.

Before they get to work on reforming the U.S. Department of Veterans Affairs, Congress and the White House might want to take a closer look at the last time they tried it — a $16 billion fix called the Veterans Choice and Accountability Act of 2014, designed to get veterans medical care more quickly.

NPR and local member stations have been following that money, including the $10 billion for vets to get care outside the VA system. The Choice Act also channeled about $2.5 billion for hiring more doctors, nurses and other medical staff at VA medical centers. The goal of the hiring money was to address a simple math problem. The number of veterans coming to the VA has shot up in recent years, and the number of medical staff has not kept pace. The idea was that more caregivers would cut wait times.

But an investigation by NPR and local member stations found that: the VA has about the same number of new hires as the VA would have been projected to hire without the additional $2.5 billion; the new hires weren’t sent to VA hospitals with the longest wait times; and the VA medical centers that got new hires were not more likely to see improved wait times.

San Diego’s wait-time dilemma

San Diego’s experience is typical. The Southern California city is home to one of the largest concentrations of post-9/11 veterans, and when the Veterans Choice Act passed, the San Diego VA had some of the country’s worst wait times for mental health care in particular. The act was meant to help former soldiers like Charlie Grijalva, who was diagnosed with PTSD when he was still in the Army.

Back in 2014, Grijalva lived with his wife, Gloria, in Imperial Valley — about two hours from the VA hospital in San Diego. After spending 18 months deployed in Afghanistan, and a year in Iraq, he started having suicidal thoughts.

The VA tried to help him. Early in 2014, the doctors there seemed to get his prescription right. By summer, his psychiatrist had left the VA, but Grijalva was transferred to a nurse practitioner. He missed an appointment in September 2014, according to records provided by the VA, but the new provider agreed to refill his prescription over the phone.

Because San Diego’s wait times were so long, under the new Choice program, Grijalva qualified to see a private doctor outside the VA system. He had an initial consultation with the private psychiatrist near his home, but he didn’t live to begin treatment. In December 2014, his medication ran out.

Grijalva had a young family and a new baby on the way. His wife said he insisted on giving his kids a magical Christmas. “He said, you know, ‘I want to do what I did as a kid,'” Gloria Grijalva said. “Play some Christmas music. Have the kids decorate the tree, drink hot chocolate. … Even though he was feeling the way he was, he wanted to have that kind of Christmas for his kids.”

It wasn’t to be. A few days before Christmas, his wife found him. He had hanged himself a few hours after he texted her, “I love you.”

“He has told me when he was at his lowest that [he] ‘didn’t want my kids to see me like this; I don’t want to put my kids through this,’ ” she said.

His VA records show Grijalva went to one last appointment at the VA in San Diego, scheduled in December. His medication arrived just before his death. Around the time of his death, the VA was just beginning to implement the Veterans Choice Act.

San Diego seemed like a prime candidate to get extra staff. But the NPR and local member station analysis of the VA’s own data show that San Diego got far fewer new staff members than it requested, and also fewer than many other VA centers that didn’t have such bad wait times.


No logical staffing pattern

The VA data show no logical pattern for distributing the 12,000 doctors, nurses and other medical staff hired under the Choice Act. David Shulkin became head of the Veterans Health Administration after that law passed, but has been overseeing the reform since 2015. Last fall, he told NPR that the Choice hires were based on a survey of VA medical centers.

“Our goal is to get [the medical centers] the health professionals that they need. So that’s the Choice money. We wanted everybody to go out and execute on it, and to use that money as quickly as possible because we have a sense of crisis,” said Shulkin, who has been nominated to become secretary of the Department of Veterans Affairs. His confirmation hearing is expected this week. He also said the VA focused on places where the staff was most needed. Thirty-three medical centers were “prioritized” between the VA’s 168 hospitals.

But the VA data show that prioritized medical centers didn’t always get more resources than others. Los Angeles was prioritized and got only about 108 new hires from the Choice money. Dallas, a similarly large center, got almost three times as many (298), even though Dallas was not “prioritized” and didn’t have particularly bad wait times.Untitled.VA.2Albuquerque, N.M., and Cincinnati have about the same volume of appointments. But Albuquerque had among the worst wait times in the country for mental health, while Cincinnati was among the best. The VA’s data show both received the same number of psychiatrists from the Choice money.

Wait times across the board have not come down, though the VA says that’s because of a continuing surge in demand from patients. And Shulkin stressed that wait times are not the most important measure of health care. He says efficiency is up and the number of veterans waiting for urgent care has shrunk from tens of thousands to a mere dozen or two. Still, it was the long wait times — and the harm they did to veterans — that drove Congress to pass the Choice Act.

Slow hiring in a tough market

Doctors and nurses are scarce nationwide. In the economic centers where many vets live, medical professionals often find better offers at private hospitals. And in rural or remote areas, there often are very few doctors or nurses available to work at either VA or private hospitals.

Shulkin knows that his hiring process is cumbersome. “The complexity of hiring puts us at a disadvantage with the private sector. We are very fortunate that people wait and turn down private sector jobs because this is where they want to work and this is the mission … but frankly we have to be competitive,” he told NPR last fall.

Shulkin came to the VA from the private sector, he said, to get the department in step with best practices. He has succeeded in getting some salaries up to private-sector levels. But the roughly $2.5 billion from the Choice Act resulted in a net gain of only a few thousand doctors and nurses, across a system that serves about 9 million veterans.

That’s partly because the VA’s process is so slow that about 13 percent of candidates drop out during the months-long lag time after they are hired. NPR and local member stations spoke with more than half a dozen current VA employees about this problem, but none agreed to be quoted. Almetta Pitts is a former VA employee who used to work at the VA in Seattle. Waiting to start that job nearly left her broke.

“It took about six months. And so I had to think about ways to just put my money together to be able to really be able to pursue this job,” she said. Pitts liked the VA. She interned at the VA in Seattle while pursuing her master’s in social work. Her mother, an Army vet, was already working there as a federal police officer. After a series of interviews, Pitts was notified she had been hired.

“I received my acceptance letter and it did inform me that I started that September and I was like ‘Oh my gosh, I’m so excited,’ but … ‘Wow, it’s like May.’ ”

During the four months of waiting, Pitts moved back in with her mom to save money until the job started. She ended up working for the VA for 13 months and was laid off. At the time, Human Resources offered to help find another job at a VA out of state. She loved her work helping traumatized veterans, but Pitts decided she had to move on.

Budget shuffling

Another reason the $2.5 billion bump didn’t seem to raise the VA’s staffing levels may have more to do with Washington bureaucracy than health care. NPR found that the rate of increase in VA staff after the Choice money was not noticeably different than past years without it. The Choice hiring money from Congress mostly replaced, instead of augmented the VA’s normal hiring budget, which freed up less restricted money to take care of other needs. Shulkin defends how the money was spent. “When you’re given a budget you face a number of new stresses on those resources. You have increases in pharmaceuticals, you have your wage increase, you have your leasing cost increases, you have IT increases. So without the Choice money, we would not have been able to have maintained the type of hiring that we were doing and expanded the type of hiring we were doing,” Shulkin told NPR in December.

This sort of budgeting strategy is common in Washington, according to Phil Carter, of the Center for New American Security. “It makes complete sense for a self-interested bureaucracy to hire with that money first. I think VA hired staff with this money will all intention of improving access and quality. I think the VA leadership found it harder to do that,” he said.

Carter says that the VA has a difficult time projecting what needs it will have across a system of 168 hospitals nationwide, and that the VA may just have been hiring at its maximum capacity in a tough market. “But I don’t see malice here, just the basic inefficacy of American bureaucracy,” Carter said.

But some Republicans in Congress do see something more malicious — a shell game to free up money from congressional restrictions. A spokesman for the House Committee on Veterans Affairs said: “It was a money grab, with no plan on where to put people and VA used the funds to fill existing vacancies for the most part.”

I don’t know how we can send our men and women out to fight wars that we can’t win, but more importantly the politicians that decide to send our men and women into war, into harms way can’t fund and run efficiently a health care system to comfort and mend those that are harmed by the weapons of modern war. This is embarrassing and just plain wrong.                                                                                                                                        We need some hardliner leaders who will fire when needed and hire and train those who are truly interested in giving our Veterans the best care because they have given their all for each and everyone of us in fighting for our country and our values.

Also, remember when you think of a government run, single payer health care system that this is what we may be getting as the answer to all our health care delivery problems- the conundrum. I will discuss in more detail the single payer system and what it adds or detracts from the future of health care in the U.S.A.

Are we all ready for this and how are we going to pay for it???

We better be!!!

They Are At It Again! Pence Presented A New Healthcare Offer to Freedom Caucus-GOP Get Real and Listen to your Voters and the Patients!

16831845_1116900401772951_1540332812797294563_nThis never ends even though the likelihood of a successful “new” health care policy passing in either the House or the Senate is wishful thinking. The White House is still trying to revive its healthcare reform push with a new bill that would include popular provisions from the Affordable Care Act (ACA) but also allow states to opt out of them. Vice President Pence and other White House officials presented an idea at the Freedom Caucus meeting to allow states to choose to apply for waivers to repeal two ObamaCare regulations that conservatives argue are driving up premiums.

Those two regulations detail ObamaCare’s essential health benefits, which mandate which health services insurers must cover, and “community rating,” which prevents insurers from charging sick people higher premiums.

Conservatives had previously called for the bill to repeal those regulations outright, but the deal now being discussed would give states a choice by allowing them to apply for a waiver from the federal government.

Freedom Caucus members expressed openness to the proposal but cautioned that they need to review the legislative text, which they hoped would be available within the next 24 hours.

Multiple lawmakers said the White House was hoping to have a vote as soon as this week, though Rep. Mark Meadows (R-N.C.), the Freedom Caucus chairman, cautioned against setting “artificial” deadlines.  “There is no deal in principle; there is a solid idea that was offered,” Meadows told reporters after the meeting. “We’re certainly encouraged by the progress we seem to be making,” he added.

He said that repeal of the two regulations in question would provide enough yes votes to pass the bill but cautioned that the Freedom Caucus needs to review the legislative language and make sure it is adequate. Meadows said last Monday night that lawmakers who were previously opposed to the American Health Care Act have switched their position because there is currently a lack of detail.

House leadership had not taken a hands-on approach so far to the revived negotiations and as recently as last week was essentially saying the bill was dead.

There is also the question of how moderates would respond to the proposal. Centrists previously objected to adding repeal of the essential health benefits to the bill.

Rep. Chris Collins (R-N.Y.), a member of the centrist Tuesday Group, argued that giving states the choice, and making them meet certain standards in putting together a waiver application, could allay centrist concerns.

White House officials met with a group of centrists, as well as House Energy and Commerce Committee Chairman Greg Walden (R-Ore.) earlier in the day. It’s still unclear whether the changes would pass muster under Senate rules governing a filibuster. Meadows indicated that officials are checking to at least make sure that the changes would not be “fatal” to the entire bill under the rules, though it is still possible the provisions would end up being struck out in the Senate.

While Meadows emphasized that the ban on denying coverage to people with pre-existing conditions would not be repealed, Democratic health experts point out that allowing insurers to charge sick people higher rates could effectively put coverage out of reach.

Meadows argued that a “stability fund” under the measure could subsidize higher premiums to bring down the cost for sick people. Lawmakers are also looking at better directing those $115 billion in stability fund dollars to target them toward reducing premiums.

Meadows indicated there would not be time for a Congressional Budget Office analysis of the changes if the new bill were voted on this week, which is sure to draw an outcry from some. That would mean lawmakers would not be certain of the cost or coverage effects of the bill when they voted.

Yasmeen Abutaleb and David Morgan discussed whether the House would reach healthcare deal before two-week break. Well, that isn’t going to happen and now the Congress is on Easter/Passover break. Deep divisions cut short Republican hopes for a quick revival of Obamacare replacement legislation on Wednesday, as Congress prepared to leave town for a two-week recess without a deal to end party infighting.

“We are going to go home tomorrow without a deal,” Congressman Chris Collins, a Republican moderate in the U.S. House of Representatives, told reporters last week.

A White House ally, Collins said days of negotiations had broken down over conservative demands to allow states to waive popular Obamacare policies that protect sick people from price discrimination and allow young adults to stay on their parents’ healthcare plans until age 26.

He said the hard-line conservative House Freedom Caucus was “moving the goal posts” for negotiations, risking potential support from moderate Republicans.

Both sides of the debate had warned that the Republican push for healthcare reform, one of President Donald Trump’s top campaign promises, could lose momentum if lawmakers left without a deal to bridge fissures that led to the legislation’s failure on March 24, when House Speaker Paul Ryan canceled a vote.

Earlier last Wednesday, Heritage Action Chief Executive Mike Needham told reporters his conservative group was looking at ways to target House moderates known as the Tuesday Group, with attack ads in their districts and other tactics.

But Ryan told a forum that the discussions had been “very productive” and emphasized that Republican leaders have not set a deadline for agreement. “We can keep working this for weeks now,” Ryan said. “We’ve got time to figure this out.”

Republicans have been railing against President Barack Obama’s Affordable Care Act since its enactment in 2010. On Tuesday, some Republican lawmakers expressed hope the Trump White House would unveil a healthcare bill. Some conservatives said a vote by the House was possible this week.

The legislation has not yet emerged, despite talks with Republican lawmakers led by Vice President Mike Pence. A House Republican leadership aide said on Wednesday that plans remained on track for the divided chamber to begin a more than two-week recess by mid-afternoon on Thursday.

Representative Mark Meadows, chairman of the hard-right House Freedom Caucus, late on Tuesday said, “There’s a concern on my part that if we’re making real progress, that going home sends the wrong message.”

Meadows told reporters on Wednesday he had not yet heard from the White House about timing of the next negotiation session. Still, the negotiations will allow lawmakers to return to their home districts and tell voters they are trying to deliver on a campaign promise that helped them win election.

In an interview with Axios and NBC television, House Majority Leader Kevin McCarthy said Republicans will produce a healthcare bill, but did not provide a timetable.

Late last Tuesday, following a closed-door meeting with House Republicans, Pence told reporters there was “good talk, good progress” toward a bill. He did not elaborate. Republican lawmakers said that efforts are now focused on maintaining Obamacare’s essential health benefits, such as mental health coverage and maternity care. But states could apply for waivers if they could improve coverage and reduce costs. If major portions of Obamacare are repealed, there were discussions of creating a “backstop” so premiums do not spike for people with chronic illnesses in high-risk insurance pools.

Rob Garver was correct when he stated that the new Obamacare Repeal Plan would leave the hard decisions to the States, as Rep. Collins pointed out. It can be hard to know which of President Trump’s tweets to take seriously sometimes, but evidently, his claim that the White House and Republicans in Congress are still working on health care reform after last month’s debacle with the American Health Care Act was true. According to The Washington Post, the White House is pressing an alternative version of the bill in an effort to win over both the hard right Freedom Caucus and the more moderate elements of the party, which combined to block a vote on the AHCA in March.

House Republicans found themselves in a bind weeks ago when President Trump was demanding they vote to pass the extremely unpopular AHCA, a bill that had the support of about 17 percent of the country according to public opinion polls. It was unpopular largely because it would result in some 24 million Americans to be without health insurance within a decade — 14 million by choice — and would dramatically drive up costs for older Americans and the poor.

The Freedom Caucus was upset that the bill didn’t go far enough, demanding a rollback of multiple elements of the ACA that the bill didn’t touch, such as requirements that insurers not discriminate against people with pre-existing conditions and that they offer a suite of “essential” health benefits with every plan and more. Their object, above all, was to drive down the cost of insurance premiums.

House moderates, at the same time, were balking at the changes already in the AHCA, concerned that many fewer Americans would be insured and that costs would skyrocket for the poor and older Americans who were not yet eligible for Medicare.

The version of the bill now being considered would not solve those problems so much as avoid them. The plan would be to push decisions about issues like essential benefits and coverage requirements, again, down to the state level.

For example, the proposal would allow states to drop the “community rating” requirement of the ACA, which demands that insurers charge the same amount for coverage for people who are the same age. In effect, this is a backdoor way of eliminating the ACA’s ban on discriminating against people with pre-existing conditions. While insurers would still be nominally required to offer policies to people with existing illnesses, there would be no limit on what they could charge them. Just as it was in the days before the ACA, sick people would be effectively priced out of the market for health insurance.

Similarly, the proposal would allow states to eliminate the ACA’s requirement that insurance policies purchased with government subsidies cover a set of standard benefits, including hospital stays, outpatient procedures, addiction and mental health treatment, maternity care, and more. The new plan would allow states to create a system in which people could use federal dollars to buy insurance plans that offer far less protection from health-related costs than the ACA requires.

This last move would create at least the possibility that states could achieve one of the key goals articulated by members of the Freedom Caucus: driving down average health insurance premiums. But it would do so in the same way that removing the requirement that new cars have brakes and airbags would make automobiles more affordable.

The hope among supporters of the plan is that by allowing the sale of bare-bones policies, the change would reduce the number of people who lose coverage under the new rules. However, it’s not clear that the Congressional Budget Office and the Congressional Joint Committee on Taxation would be willing to play ball when they score the bill. Last year, the CBO made it plain that for purposes of analyzing the effects of healthcare legislation, it would not consider people “covered” by insurance unless they were substantially protected from major financial risks.

The upside of this plan, from the perspective of the White House and Congressional Republicans, is that it would allow them to claim that they have kept their promise to repeal and replace the Affordable Care Act while avoiding the hard work of crafting a measure that solves the thorny problems that repealing the bill creates.

As with the original version of the AHCA, Republicans in the House can’t count on getting any Democratic votes for this iteration of the ACA replacement plan. So, assuming the changes are sufficient to win over the Freedom Caucus, the big question is the reaction of the more moderate members of the Republican conference.

Will the fig leaf of devolving key decisions to the states be enough political cover, or will the latest attempt to repeal the ACA cause another fracture in the party, albeit along a different fault line?

One doctor interviewed stated that when it comes to healthcare, Republicans need to take a Hippocratic Oath to do no harm and I wholeheartedly agree.

When we become a doctor, most of us spend time in an emergency room that admits and treats the kind of hard-working, low-income working families. For many of them, the ER was their first and last resort after avoiding the doctor for years because they had no health insurance.

We didn’t check a patient’s political affiliation before treating them. We didn’t check the party affiliation of the other doctors and nurses, either, and they didn’t ask us for ours. Rather, we worked together as a team, following through on the Hippocratic Oath we had taken to treat patients to the best of our ability and, above all, to “do no harm.”

We have treated patients before the passage of the Affordable Care Act, and treated patients after, just as the legislation was beginning to take effect. We noticed firsthand that many patients stopped fearing the cost of their ER visit as more were covered by health insurance. When they pulled out their insurance cards, we could tell they felt peace of mind.

If only politicians were required to take an oath to do no harm. Since gaining a majority in Congress, most Republicans have been actively working to bleed the ACA dry so that it will fail, thereby fulfilling their own prophecy. They voted repeatedly to repeal the law and sued to stop it in court. Now that they have full control of government, they’re trying to sabotage it.

After Republicans pulled Trumpcare from the House floor last month, President Trump responded with a blame-filled diatribe in the Oval Office — 10 minutes of finger-pointing in which he offered up the cynical hope that our healthcare system will “explode.” The president of the United States actually stated that letting the healthcare system “explode” was “the best thing we can do politically speaking.”

It still seems that the Republicans aren’t interested in improving the ACA; they’d rather attack it for political gain. More recently, the Trump administration has stopped promoting the open-enrollment period for health insurance plans, a move that is now being investigated by the Office of Inspector General in the Department of Health and Human Services. The idea, apparently, is that if people don’t know by what date they need to sign up for a plan, they won’t enroll, fewer people overall will be covered, premiums will rise for everyone else, and the administration will have even more grounds for saying the ACA doesn’t work.

Coupled with the absurd failure of Trumpcare, these deliberately destructive moves lay bare what many of us suspected all along — the Republicans aren’t interested in improving the ACA; they’d rather attack it for political gain. Trump and the Republican leadership have been fundamentally dishonest to the American people for the purposes of winning votes and securing power. This is exactly what disgusts voters about Washington. With the right wing up in arms over their failure to repeal the ACA, Republicans are sure to try again. But they seem to have learned no lessons from their first attempt. They continue to show no intention of reaching across the aisle to work on commonsense solutions.

According to some policy experts, the Trump administration could immediately reduce the size of deductibles and other healthcare costs for low-income Americans by permanently funding cost-sharing reductions — federally subsidized discounts that Republicans have filed lawsuits to prevent. Republicans could also instantly repair the ACA’s risk corridor provision, a program that helped insurers to share risk and offset losses, and which Republicans effectively undid in 2014, driving dozens of insurers out of the marketplace. Unfortunately for the American people, Trump has made it clear that these solutions are not in his political interest.

To the White House and Republican leadership: When are you going to get it? Even after years of attacks and sabotage, surveys are telling us Americans want the Affordable Care Act. But they want it to work, and they want Republicans and Democrats to work together to make it better.

I address you, the politicians, especially the GOP, who are doing real harm to real people for your own political gain. You’ve undercut the ACA every step of the way and now you own it. You claim you want a healthcare system that covers more people and reduces costs, and that’s what Democrats have been working to achieve. When you’re ready to get serious, take an oath to do no harm and quit the sabotage and partisan games. Only then can we work together to help people and remember the principles that I have already laid out for a health care system that would benefit us all.