Why are we paying such outrageous prices for Drugs? Bernie Sanders Tells Big Pharma: Stop Making Americans Pay Twice!

20155997_1259287067534283_3245201182130017517_nRecently President Trump told the Big pharmaceutical companies and their CEOs to cut their prices and move their production back into the U.S. Josh Keefe wrote that while both political parties have denounced the rising cost of prescription drugs, neither Democrats nor Republicans have done much to address the problem. But this summer, a new tool to restrict the rising prices of drugs developed with taxpayer dollars has been introduced by the two U.S. senators who don’t belong to either party.

The mechanism works like this: Drug manufacturers who take federal money to develop drugs must keep their U.S. prices in line with the prices they charge in other economically advanced nations — typically much lower than drug prices in the U.S.

The system would prevent pharmaceutical companies from effectively double-charging U.S. consumers by using their tax money for research and then charging them some of the steepest prices in the world at the pharmacy. Pharmaceutical companies, who pour millions of dollars into both the Democratic and Republican parties, are against the idea, which is perhaps why the fix is being pushed by Bernie Sanders of Vermont and Angus King of Maine, the only independents in congress.

The U.S. has the highest level of per capita pharmaceutical spending of any nation on Earth, according to the Organisation for Economic Co-operation and Development (OECD). And while Americans spend more than any other country to buy their drugs, they also spend more than any other country to develop those same drugs.

Senator Angus King introduced an amendment into a military spending bill that would require drug makers keep drug prices in line with pharmaceutical costs in other countries.

In June, King successfully added language to the 2018 military spending bill (still working its way through Congress) that would allow the Department of Defense to take away exclusive patents from drug companies that benefitted from DoD funding if their drug price in the U.S. rises above the median price in seven foreign countries with similar economies.

Then last week, Sanders introduced legislation that would tie the prices of drugs made with government funding to costs in other countries. Unlike King’s language, Sanders’ bill would expand the concept beyond the DoD. The bill requires companies taking federal funds to develop drugs to enter into “reasonable pricing” agreements with the Secretary of Health and Human Services.

“Under this insane system, Americans pay twice. First, we pay to create these life-saving drugs, then we pay high prices to buy those drugs,” wrote Sanders in a New York Times op-ed. “Our government must stop being pushovers for the pharmaceutical industry and its 1,400 lobbyists.”

The bill defines a “reasonable price” as no more than the lowest prices charged in countries with GDP and per capita income similar to the U.S. (The bill specifically pegs pricing to countries in the Organization for Economic Co-Operation and Development.)

The proposal is the latest salvo in Sanders’ effort to stop the military from granting French pharmaceutical company Sanofi Pasteur the exclusive right to sell a Zika vaccine.

“The days of allowing Sanofi and other drug makers to gouge American consumers after taking billions in taxpayer money must end,” Sanders told HuffPost this week. “That is why I am introducing legislation to demand fairer, lower prices for the Zika vaccine and for every drug developed with government resources.”

But just how much government support the industry receives is up for debate. While industry estimates put total annual private R&D spending by biopharmaceutical companies at about $60 billion per year, the government’s contribution is much harder to nail down. The National Institutes of Health, the government’s main funder of health research, told International Business Times in a statement that “there is no exact number which would accurately capture NIH investment” in drug development. In total, NIH spends about $32 billion on medical research annually.

Last year, the National Center for Science and Engineering Statistics estimated that in 2014, total federal government R&D spending on pharmaceuticals and medicines was just $267 million. But that number takes into account only money given directly to drug makers.

“Federal support of biopharma R&D isn’t going to take the form of big checks cut to companies,” Scott Hinds, a pharmaceutical industry analyst for investment research firm Sector and Sovereign Research told IBT in an email. “Rather, it’s going to come through funding grants and research for academics, government employees, and other non-industry scientists.”

“Typically, then, if anything of commercial value is discovered in this sponsored research, those compounds will be sold or licensed to drug companies who have the capital and resources to spend on later phase (more expensive) clinical development necessary to bring them to market,” Hinds said.

Other experts told IBT federal support of drug development goes well beyond just funding research.

“It’s not so much the money we are actually spending through NIH. We are providing huge value to companies in tax credits, other incentives, expedited FDA approval, exclusivity agreements… all of these are benefits,” Rachel Sachs, an associate professor at the Washington University in St. Louis School of Law told IBT.

Sachs cited a 50 percent tax credit for the development of “orphan” drugs as an example of the government’s support of the pharmaceutical industry. The value of that orphan drug tax credit is estimated to be worth $50 billion between 2016 and 2025, according to the Treasury Department.


Big pharmaceutical companies spend nearly double on advertising as they do on research and development. Maybe Congress could look into drug prices?

But the benefits flow both ways between the pharmaceutical industry and Washington, which is why the Sanders bill faces an uphill battle to reach the floor for a vote. The bill was sent to the Senate Health, Education, Labor, and Pensions committee, which are chaired by Lamar Alexander. Pharmaceutical and health products companies gave more to Alexander’s campaigns between 2011 and 2016 than did any other industry, according to the Center for Responsive Politics. And even if the bill gets to the floor, it would face opposition from the industry’s 1,350 lobbyists, who don’t come cheap. The pharmaceutical and health products industry has spent a remarkable $144 million on lobbying so far in 2017, more than double what the defense industry has spent over the same time period.

“Proposals to insert a reasonable pricing clause ignore the substantial R&D investments and risks undertaken by the private sector in developing and bringing a new medicine to patients,” the Pharmaceutical Research and Manufacturers of America (PhRMA), which has spent $14 million on lobbying so far this year, told IBT in a statement. “Such proposals undermine critical intellectual property rights and incentives, create substantial uncertainty for companies and establish completely arbitrary criteria for taking intellectual property. This could chill critically needed collaborations and investment by the private sector to address some of our most serious unmet medical needs.”

Most surveys reflect what is included in the following graph, that they favor actions to keep drug costs down. Do they realize that malpractice adds a tremendous addition to the cost of all drugs??


The pharmaceutical industry, which says it costs $2.6 billion to bring a drug to market (while spending more on marketing than research) made a similar argument against “reasonable pricing” more than two decades ago, when it successfully persuaded the Clinton administration to repeal a “reasonable pricing” rule implemented by President George H.W. Bush.

An example of the increase of drug prices in one year.


Allowing Americans to purchase lower-priced medicines from other countries would save the federal government alone more than $6 billion, according to a new analysis from the Congressional Budget Office. The report comes as the pharmaceutical industry has ramped up its lobbying — including against a legislative initiative that would let Americans purchase lower-priced medicines from countries such as Canada.

Untitledpharm.5   Under existing law, drug makers are permitted to produce pharmaceuticals abroad and then import them into the United States, where on average they charge Americans the highest prices for medicines in the world. However, while drug makers themselves are allowed to import medicines, current law prohibits U.S. consumers and pharmaceutical wholesalers from doing so, even when the same medicines are sold at much lower prices abroad.

Spending millions on campaign donations and lobbying, the pharmaceutical industry has for years successfully fought off legislation to end the prohibition. This year — nearly 17 years after President Bill Clinton’s administration killed Democrats’ drug importation legislation — the importation initiative has once again been renewed. Looking to take advantage of President Donald Trump’s promise to lower drug prices, Vermont Sen. Bernie Sanders, along with 21 Democratic lawmakers, introduced the Affordable and Safe Prescription Drug Importation Act on Feb. 28. The bill was referred to the Senate’s Committee on Health, Education, Labor, and Pensions.

CBO estimates that the change would in total reduce federal government drug spending by more than $6.8 billion over ten years, including a reduction of $5.1 billion in direct spending and roughly $1.7 billion in increased revenue.

Before introducing the new legislation, Sanders and Democratic Sen. Amy Klobuchar of Minnesota in January introduced a budget amendment allowing Americans to purchase drugs from Canada. In contrast to typical party-line votes, 13 Republicans voted with the Democrats in supporting the amendment, while 13 Democrats joined the remaining Republicans in voting it down. The tally was 52-46 against the amendment.

Among the Democrats who voted against the cost-saving measure was potential 2020 presidential candidate Sen. Cory Booker of New Jersey, a state that is home to several major pharmaceutical companies including Bayer USA, Johnson & Johnson and Merck & Co. As The Intercept reported, Booker’s argument for voting against the measure was the same as that of the primary pharmaceutical trade organization, the Pharmaceutical Research and Manufacturers of America (PhRMA). Both Booker and pharmaceutical representatives argue that drugs from Canada have insufficient safety standards.

“Any plan to allow the importation of prescription medications should also include consumer protections that ensure foreign drugs meet American safety standards,” said Booker in a statement to Jezebel. In the 2014 election, when Booker ran for Senate, he had the highest total — over $220,000 — in campaign donations from the pharmaceutical manufacturing industry of any member of Congress.

Like Booker, the drug industry’s lobbying group, PhRMA, warns that Canada can’t properly regulate the medicine that is shipped through its borders. However, Canada does not suffer from problems with poor quality or counterfeit drugs.

“My first response to that is, show me the dead Canadians. Where are the dead Canadians?” said Republican Minnesota Gov. Tim Pawlenty in 2003 as he unsuccessfully asked the federal government to allow his state to import cheaper drugs from the United States’ northern neighbor.

Some drugs sold in the United States are in fact “fully manufactured overseas, or made in the United States but have some foreign ingredients,” according to the Food and Drug Administration, which for this reason already has in place a robust mechanism for inspecting drugs across the globe.

Critics, including writers at conservative think tanks such as the Cato Institute, argue that importing drugs would also import foreign price controls that, they claim, would drastically cut the drug companies’ funds for research and development of future drugs.

After intense pressure from progressives, Booker reversed course and teamed up with Sanders and other Democrats to sponsor the Affordable and Safe Prescription Drug Importation Act in February. That, however, did not eliminate all Democratic Party opposition to the initiative.

During May deliberations over an FDA authorization bill, Sanders, and Democratic Sens. Bob Casey and Elizabeth Warren proposed an amendment allowing for the importation of drugs from FDA-approved facilities in Canada. The amendment was  “laden with protections,” according to Casey. But Democrats Patty Murray (WA) and Michael Bennet (CO), two big beneficiaries of pharmaceutical company’s campaign cash, voted against it in committee, and it failed 13-10.

Overall, campaign spending by the pharmaceutical industry is skyrocketing. Congressional donations from pharmaceutical PACs are up 11 percent as compared with a similar time frame in 2015, and donations to ranking members of health-related committees have risen by 80 percent from two years ago. Lobbying is also on the rise, according to a Kaiser Health News analysis.

After the 1980 Bayh-Dole Act, private researchers could patent intellectual property they developed using federal funding. But by the late 1980s, outrage over the $8,000 annual cost of AIDS drug AZT, which was the only drug approved for treatment of the disease at the time, prompted the Bush administration to implement price control measures. In 1989, NIH was granted the right to review the introductory prices of drugs that were produced with government research, over the objections of the pharmaceutical industry.

“The Bush administration felt it was appropriate to expect some concessions on pricing if the government was involved in the drug and funding research,” James Love, director of Knowledge Ecology International, told IBT. Love researched the original rule while working for Ralph Nader’s Center for the Study of Responsive Law in the early 1990s.

But unlike the specific criteria for reasonable pricing put forth in the Sanders bill, the Bush rule was a bit ambiguous. “The agreements said something to the effect that it had to show some relationship between price and government’s role in developing the drug… Nobody really knew what it meant,” Love said.

Just six years later, the Clinton administration rescinded the order on the grounds that it was harmful to innovation.

“The pricing clause has driven industry away from potentially beneficial scientific collaborations… without providing an offsetting benefit to the public,” NIH Director Dr. Harold Varmus said at the time. “Eliminating the clause will promote research that can enhance the health of the American people.”

Additionally, most of us always thought that a generic was an exact copy of a brand-name drug. Perhaps the patent expired, and another company was free to make the same chemical compound. Perhaps the capsule compound could be different, or some of the inert ingredients might be different, but the chemical functioning drug itself was identical.

Psychiatrists often use a drug called Concerta, which is an extended release form of Ritalin that may work for 12 hours. With Concerta, parents could give a child a pill before the child left for school, eliminating midday trips to the school nurse’s office for a new dose.

Concerta’s secret was the way the pill slowly released the medication. The pill absorbed fluid as it passed through the body, and pumped the active drug out of a laser-cut hole.

However, the FDA recently announced that two of the three available Concerta generics, one made by Mallinckrodt Pharmaceuticals and the other by UCB, could no longer be considered the equivalent of the brand and, in most states, could not be automatically substituted by pharmacies for the brand name.

The agency said that although it considered the drugs to be safe, its own lab tests and other analyses suggested that their effectiveness began to wear off much more quickly — after about seven hours. That time frame is important, because the pill can be taken only once a day. What about the generic equivalency? Under F.D.A. rules, generic companies do not need to use the same mechanisms to produce copycat versions of long-acting drugs. The manufacturers must instead prove that their products release the drug into the body at the same rate as the brand-name drug. The Mallinckrodt and UCB products use different techniques, which may account for the shorter effectiveness. (So they are NOT equivalent!)

In spite of all this, The FDA allowed the companies to continue selling their drugs but gave them six months to either prove the drugs were equivalent, or remove them from the market.

Seven months later, the deadline has passed and the drugs are still being sold. Major pharmacies like CVS and Rite Aid continue to stock and sell them.

Now as a physician, I have no objection to good quality generic medications. But these drugs are not generic equivalents and never were. Just because of a drug has the same result does not mean it is a generic equivalent. But, even more important as a patient of mine pointed out the difference in the prices between the brand name and generic drug are huge and now we find out that the generics are not the equivalents…Something is wrong here.

Another part of the equation is where the insurance companies control how we treat our patients including the restriction on the drugs that we can prescribe.

At least sometimes the private insurers eventually let you get the medication that you need after you beg. Medicaid is currently requiring chart note, a letter, and forms including the number of months of treatment for anything not explicitly covered. They have ridiculous algorithms in place, e.g. never a PPI first, will question reason if you want it for more than 6 weeks; if you have something more exotic that does not have “spastic” or “spasticity” in its billed diagnoses list, e.g. Rett syndrome or Alexander disease, they make us go through the process for expensive drugs even though they are more effective. They are busy pretending not to know the difference between “experimental” vs. off-label, and will even deny FDA approved drugs if they can pretend to think the evidence is too preliminary.

It’s just great to practice 10 years in the past and realize no benefits from recent breakthroughs. Do I blame them or the price gouging pharmaceutical companies or the horrible system here in the USA that allows healthcare for-profit with no negotiability on prices, and labeling of any charitable price break or co-pay/deductible coverage as fraud?

I think the parents are going to have to rise up and take stronger actions than we the physicians who are without any power. But most them are swamped with trying to negotiate the systems of “service” that have been progressively stingier with any kind of family support or home care, and progressively more demanding of more and more documentation. They act as if the profiteers won’t just fabricate the documentation that the rest of us struggle to complete honestly but successfully on a daily basis.

Please get involved and get educated. We the people need to correct the mess because our Congress has no idea what the real answers are.

The Opioid Crisis!….What is the Real Answer????

opoid023Yes, more professional golf to help you get through the weekend. But more was happening in all our communities in the form of drug addiction and its effects on all of us. President Trump declares opioid crisis a national emergency. Wagner of The Washington Post reported that President Donald Trump on Thursday declared the country’s opioid epidemic is “a national emergency.” Trump delivered the announcement “to reporters outside a national security briefing” in Bedminster, New Jersey, adding his Administration is “going to spend a lot of time, a lot of effort and a lot of money on the opioid crisis.” The Post says the declaration of emergency will permit the Administration “to remove some barriers and waive some federal rules enabling states and localities to have more flexibility to respond.”

Recently our Town Council and Health Department was “gifted” with funds from the Governor to combat the Opioid catastrophe. Is throwing money at the problem the answer????                                                                                                                                  Health Officer Outlines Plan Of Attack! Our local reporter, Denae Spiering reported that in our small neighborhood Dr. Frieda Wadley, Talbot County health officer, has outlined how the Talbot County Health Department plans to spend the $79,000-plus it has received from the state to fight the growing epidemic within the county.

On July 7, the Maryland’s Opioid Operational Command Center, Department of Health and the Governor’s Office of Crime Control & Prevention announced more than $22 million to fight the heroin and opioid epidemic in the state.

A previous article announced that the first quarter report for fatal overdose data showed that for our small county the fatal overdose numbers had increased significantly since last year’s first quarter report. Worse than that is that fentanyl-related deaths have more than doubled compared to last year’s first quarter’s report.

So what are they decided is the right way to combat this crisis? Their solution-the health officer outlined their plan. She said that $50,000 would be used for recovery houses in the county with $45,000 going to beds for clients and initial assistance for independent living arrangements. And another $10,000 will help recovery houses with appropriate urine screening for residents, especially for individuals who are not able to pay and have no direct source of funding.

She then said that $12,000 will be used to pay for initial visits for treatment of uninsured clients, while the health department care coordination team simultaneously helps those clients in getting health care coverage.

Additionally, the local public schools will receive $5,000, which will be broken down to two areas-$3.000 to add age appropriate curriculum to all grade levels, focusing specifically on the harms related to addition, and $2,000 to assist with teaching materials for the new curriculum.

First, what are the real numbers?

By the Numbers: The Real Opioid Death Rate is what? A Study finds many states underestimate the size of the opioid epidemic. Matt Wynn, a staff writer for the MedPage reported that there’s been more and more pressure for the government to tackle the opioid epidemic head-on. But in a piece published in the American Journal of Preventive Medicine, Christopher Ruhm, Ph.D., of the University of Virginia, argues that there could be a big hang up: even with all the hand-wringing, we’re still underestimating the size of the opioid epidemic.

That’s because a big chunk of death certificates that list overdose as a cause of death — 25% in 2008, and 20% in 2014 — don’t report what drug was to blame. The rate of the discrepancies varied dramatically from state to state, further exacerbating the problem at the local level.

To get a better sense of the scope, Ruhm corrected the data using information from death certificate reports where at least one drug category was identified to impute drug involvement for cases where drug involvement categories were left unspecified. He applied models to each case based on several variables to predict probabilities of opioid involvement.

His corrected results ended up increasing the number of opioid deaths by 24% nationally. The effect was especially pronounced in certain states. Rhode Island had the information filled out in 99% of cases and didn’t see much of a change. But in some cases the correction was extreme. Pennsylvania, for example, had more than double the number of deaths under the corrected model. That change shot the state up the rankings as well. While the official number pegs the state as having the 32nd highest opioid mortality rate, the corrected figures skyrocket it up to seventh highest in the nation.

The maps below show the original, uncorrected overdose figures as well as the corrected results Ruhm calculated. Use the map toggle to switch between the two.

“Corrected rates … yielded a more coherent geographic pattern than reported,” Ruhm wrote in the study.

The corrected rates show a concentration in the Mountain States and Rust Belt.

So, why am I so concerned regarding the “new” strategy for managing the opioid crisis. First, you can’t solve the crisis by throwing money at the problem unless the strategy was a true solution and it isn’t.

Consider the following: Beach Town Tries To Reverse Runaway Growth Of ‘Sober Homes’!                                                                                                                                           Greg Allen reported that Delray Beach’s charming downtown, palm trees, and waves attract locals, vacationers and, increasingly, drug users who come here to try to get off opioids. In some parts of the small Florida community, there’s a residential program for people recovering from addiction — a sober living house or “sober home” — on nearly every block. Sometimes two or three or more.

On a block where resident Michelle Siegel was walking a dog recently, there are at least six sober homes. She says “you can usually tell” by the white vans and “no trespassing” signs out front.

“I have walked down the street sometimes and seen kids just passed out, face down on the ground,” she says. “And you ask them if they’re OK and they’re like, ‘Yeah, yeah, I was just tired. I was sleeping.’ And you don’t know whether you should get them help; whether you should leave them alone.” What a wonderful addition to your neighborhood!

In South Florida, there’s been runaway growth of these residential programs. As group homes for people recovering from addictions, the Americans with Disabilities Act and also the Fair Housing Act protect sober homes. Those federal laws have made it difficult for local communities to limit or otherwise regulate the facilities.

And the nation’s epidemic of opioid abuse has created new opportunities for insurance fraud. Under federal law, health care insurance pays for the costs of recovery. That’s led to a boom in residential programs to treat addiction, and also growth in deceptive marketing by some programs, fraudulent claims and what’s known as patient brokering.

The state attorney for Palm Beach County, Dave Aronberg, convened a special task force to study opioid abuse and the drug recovery industry, with a report released early this year.

Aronberg says while there are many legitimate sober homes, there are also many others operated by unscrupulous providers. They tap into insurance money by offering free rent and getting kickbacks from outpatient drug treatment centers. Aronberg calls the practice of “patient brokering” a scheme.

“The outpatient treatment center van picks your residents up three times a week to go drug test them,” he says, “which is then billed to insurance at very high rates.”

Treatment centers bill insurance companies not just for drug tests but also for other services, like group counseling, massage, and acupuncture. They share the money with the people supplying the patients, Aronberg says.

“In return,” he says, “you as a sober home owner, you get a nice check for patient brokering — which is what you’ve done.”

Although they’re in Delray Beach for recovery, residents of sober homes can find easy access to heroin and other drugs. The city’s fire rescue crews responded to more than 1,300 overdose calls last year — many of sober homes.

“We respond there sometimes repeatedly in the same shift,” says Matt Pearce, an EMS captain. On one recent night, he says, “they responded to the same sober home two times within 10 minutes, both for overdoses.”

With a cost of $2,500 for each EMS call, these overdoses have put a strain on the city’s budget. Much worse is the human toll. Countywide, nearly 600 people died of overdoses last year.

It’s a problem for Delray Beach and for people with addictions who are often lured by marketers to South Florida on false pretenses.

“They make the individual on the other line think that they’re a doctor and they’re diagnosing them,” Aronberg says, “when, in reality, they’re only reading from a script given to them by the treatment center which is paying them.”

Rather than operating on a recovery model, Aronberg says, unscrupulous sober homes and treatment centers operate on a “relapse cycle,” which bring clients back time and again for treatment that is covered by health insurance.

Neill Timmons has seen how reputable facilities can work — from both sides. “I’m in recovery myself,” he says, “six years next month.” Timmons runs four houses for sober living in another Palm Beach County community, Boynton Beach.

Like other reputable operators, he doesn’t receive payments through arrangements with drug treatment centers. He says for someone going through recovery, landing in a good sober home can make all the difference. Of his residents, he says, “They’re not certain … if they want to stay sober the rest of their lives or return back to use. And they’re struggling with what they need to do … if they do want to stay sober.”

A good facility, he says, “should really guide and give them some guidance toward recovery.”

Timmons and others who run good facilities want more regulation. They’re pleased by a law, recently signed by Florida’s governor, that increases the penalties for patient brokering and deceptive marketing.

A study commissioned by Delray Beach, and released in May, found at least 250 sober homes in a town of just 60,000 — about a quarter of them operating under the city’s radar.

The town’s mayor, Cary Glickstein is no fan of the drug recovery industry and sober homes — or of the problems he says they’ve brought to his city. He runs down the list — “patient brokering, drug trafficking, human trafficking, prostitution. It’s a Pandora’s Box of problems that the unscrupulous operators bring to a community.”

Glickstein is confident a new ordinance just adopted by Delray Beach will enable the city to crack down on sober homes. It requires them to be certified by an independent trade association and limits their presence to no more than one per block.

After adopting a similar ordinance, officials in Prescott, Ariz., say the number of sober homes in their community is now a third of what it once was.

We are also forgetting the non-addicted people who live around the “sober-homes”, which become havens for recidivist addicts, whose property values have plummeted. They can’t sell their homes even if they want to and have to put up with addicts vomiting on their front lawns and attracting all sorts of felons. Did we also forget the other facets to the opium addiction epidemic in our communities…Human trafficking????? This where those involved in human trafficking inject teens with heroin and forcing them into prostitution.

Additionally, the gangs in each and every city depend on the drug trade to make their money and support the gang community. These are not the physicians giving them prescription drugs, as we are fast to blame.

What’s the real solution?

A ‘Vaccine (as proposed) For Addiction’ Is No Simple Fix. Richard Harris recently wrote that it’s always appealing to think that there could be an easy technical fix for a complicated and serious problem.

For example, wouldn’t it be great to have a vaccine to prevent addiction?

“One of the things they’re actually working on is a vaccine for addiction, which is an incredibly exciting prospect,” said Dr. Tom Price, secretary of Health and Human Services.

He was talking to reporters earlier this week after the White House discussed the recommendations from a government commission tasked with suggesting ways to cope with the nation’s opioid epidemic.

But, as is so often the case, there’s no quick fix on the horizon for an epidemic that is now killing more Americans than traffic accidents.

Researchers have been working on vaccines against addictive drugs, including nicotine, cocaine, and heroin, for almost two decades.

“Like any other vaccine, you inject the vaccine and you use your immune system to produce antibodies,” says Dr. Ivan Montoya, acting director of the division of Therapeutics and Medical Consequences at the National Institute on Drug Abuse. “In this case, the antibodies are against the drugs of abuse.”

So antibodies generated by a heroin vaccine, for instance, would prevent the molecules that cause euphoria from getting into the brain. (The vaccine actually targets morphine and a related chemical, since heroin breaks down into those components before crossing into the brain, Montoya says. It doesn’t block endogenous opioids — the brain’s built-in painkillers.)

The trick would be getting your body to produce enough antibodies to soak up a surge of drug injected into the bloodstream. “That is the biggest challenge, to get enough antibodies,” Montoya tells NPR.

That’s apparently a major reason that previous attempts to make a nicotine vaccine for smokers failed, he says. “The second challenge is getting the person to be vaccinated on a regular basis.”

These vaccines aren’t like the measles vaccine that you receive once or twice for a lifetime of immunity. Multiple shots per year would likely be required. So the strategy would only work in people who were actively trying to recover from a drug addiction. And people addicted to heroin who decide to get high could switch to some other opioid — like fentanyl, carfentanil, or oxycodone.

Kim Janda, a professor of chemistry at the Scripps Research Institute, says he’s thinking about developing a vaccine that targets both heroin and fentanyl. But his first priority is to test a heroin vaccine in people. So far, he’s used funding from the National Institutes of Health to test his potential vaccine in rodents and monkeys.

Human trials will cost tens of millions of dollars. The NIH generally doesn’t fund that kind of study and hasn’t made an exception for the opioid crisis. So Janda is hoping to get the money he needs from a pharmaceutical company, as other opioid vaccine developers have done.

He’s optimistic that human tests could begin in 18 months once he has funding, though it would take much longer than that to find out whether the vaccine is actually safe and effective.

Janda knows that a vaccine would supplement, rather than replace, the current approaches to treating addiction.

“I think we need to look at other ways of treating opioid addiction,” he says, “and I think this can help.”

Researchers at the Walter Reed Army Institute of Research and at the University of Minnesota are also developing vaccines against opioids, but so far none has been tried in people.

What about time release capsules that release slowly chemicals that either cancel the effects of opioids or make the addict severe ill if they inject or take narcotics by mouth, etc. I was the trial dummy for a drug called Antabuse for severe alcoholics. No. I’m not nor was I ever an alcoholic, but when I was in the orient I became ill with a parasitic disease and the drug that I was given had the same effect as the drug Antabuse. When I was in Hong Kong to visit a friend he took me out to dinner. I asked that the chief make sure to cook all the alcohol off the Peking duck, but you can surmise what happened. I was sick for 3 days. It was horrible. Why not a drug like Antabuse for opioids, etc??

My concern is that throwing money and declaring a national emergency solves nothing unless there are a viable strategy and solution. What are the solutions? Having these homes only produces more problems if you can’t get the drugs off the market/street, especially when the cost of heroin and fentanyl is so cheap and accessible. By having Narcan/naloxone over the counter may decrease overdoses but more seriously may increase the level of overdoses that the medical community sees as the addicts try to get even higher with the knowledge that someone will save them.

Seeing the results of the methadone clinics is worrisome as I over and over watch the clients that appear daily, weekly and monthly with very few cures coming and going through our town’s 2 clinics. And the people that own these clinics are making a killing and we the taxpayers are footing the bills.

We need to fully understand all these issues before we throw money at the crisis.

Unfortunately, we are progressively taking the power of law enforcement from those who do it best…the police. The excuses from the liberal groups are the police are too aggressive. Think about that when your own son or daughter overdoses and is found dead with a needle stuck in their arm.

Wake up!!!!!

The Time For Single-Payer Is Now! Maybe, Maybe Not!

pelosi008When presented with an unexpected up-or-down vote on single-payer health insurance, not a single Democrat supported it. Joe Newman, via the Public Citizen, reported that little more than a week ago the Democrats not only looked a gift horse in the mouth, they gave it back, too. The gift? An up-or-down vote on single-payer health insurance, under which the federal government would provide health insurance for all Americans and covering the more than 20 million Americans still uninsured under the Affordable Care Act. Not a single member of the Democratic caucus supported it. This seems so obviously a mistake that it bears to ask the question: Why didn’t they vote for it? The short answer is, congressional Democrats are afraid.

This past week an unexpected champion took up the cause of single-payer health insurance: Republican Senator Steve Daines of Montana. His amendment to the Republican health care plan would replace the bill and cover all Americans. It was plainly a tactic to get Democrats on the record in support of single payer. The Democrats didn’t go for it; 43 members of the Democratic caucus voted “present” and five members voted “no.”

Until now, the Democratic Party has been largely occupied with pushing back against the Trump administration’s agenda: seeking to block unqualified and ultra-right judicial nominees, insisting on investigations into Trump’s collusion with Russia, mobilizing against efforts to repeal the Affordable Care Act. This has been somewhat successful on a policy level, as the administration has yet to achieve a single significant victory in Congress. But in terms of politics, it is not enough for Democrats to be the not-Republicans — a lesson learned in 2004 and again in 2016. The Democrats must not only propose an affirmative agenda, something toward which they recently took steps, but show they are willing to fight for it. The single-payer amendment presented an opportunity to do that by showing leadership and mettle.

We elect people we trust to lead us, not to blindly follow popular opinion. It is no surprise, then, that the endorsement of prominent politicians can actually increase support for the policy. Marriage equality provides a good example. Prior to Obama’s announcement in May 2012 of his support for same-sex marriage, only a handful of politicians on the national stage had done so. At that point, support stood at a bare 50 percent in favor and had only recently emerged from the mid- to low-forties. Within months, support jumped to 53 percent and by a year later it had climbed to the high fifties. Though this is not conclusive alone, it stands to reason that as more and more national politicians—nearly the entire Democratic caucus in both the House and Senate—announced and explained their support, they convinced their constituents of the policy’s legitimacy.

We can see the beginnings of this with single-payer health insurance. In March 2014, a mere 21 percent of Americans supported single-payer health insurance, and only 47 percent said the government has a responsibility to make sure all Americans have health insurance coverage. After Bernie Sanders made this one of his key issues in his 2016 presidential run, it grew to 28 percent support for single-payer in January of this year, and then 33 percent as of a month ago. Support is particularly strong, nearly half, among Millennials, regardless of party affiliation. Likewise, around 60 percent of Americans now believe that it is the government’s responsibility to ensure that all Americans are covered by health insurance. Democrats should have seized on the chance to make this an issue, going out and working with progressive groups to convince Americans to finally insure all of us, rather than running scared

Skeptics might note that support for single-payer is currently substantially lower than support for marriage equality was, the stakes are likewise far lower: this is merely an amendment in the midst of an extremely complex health care debate, with the mid-term election over a year away. These conditions actually make support for the amendment more valuable, not less. Given the effects of national politicians endorsing policy and seeking to convince their constituents, support for single-payer could grow substantially over the next 16 months.

Moreover, though unlikely, it could have passed. Cynics might scoff, but historical precedent demonstrates the possibility. Originally, the Civil Rights Act of 1964 did not prohibit sex discrimination. That change was due to the effort of segregationist Southerners who sought to delay the vote on the Act and fracture the fragile coalition seeking to pass the bill. Many proponents of the Civil Rights Act opposed the amendment, concerned that it would doom the legislation—but it passed regardless. Ironically, many of the “yea” votes were Southern Democrats who believed it would sink the law entirely. When the dust settled, women suddenly found themselves, at last, protected by federal anti-discrimination legislation.

Though the facts are not precisely parallel now, the miscalculation by segregationists shows that a simple amendment—the sex amendment was a one-word addition to the bill—designed to implode a more moderate effort, or to embarrass those who support it, can change history. The same could have happened here if only the Democrats had gathered their courage.

Finally, Americans deserve to know where their representatives stand on single-payer health insurance. A majority of Democrats—52 percent—now support single-payer health care, and it is a priority for many of us. If we are supposed to make educated decisions in the voting booth, if we want to send representatives to Washington who share our values, the fact that congressional Democrats are so shy to discuss, let alone vote, on single-payer militates against our ability to do just that. It is disingenuous at its very best.

As Democrats, we need to get our act together. It is not enough to reveal the Trump administration to be an omnishambles populated by cretins; we must go further. We must present an agenda that speaks to the problems they face daily; whether the administration has colluded with Russia is of no import to a family worrying about how to afford their medical bills. It is time to say: 22 million uninsured Americans is 22 million too many. Campaign on that. Vote on that. The moment for milquetoast liberalism is over.

The big question- Is the U.S. Ready for a Single-Payer Health Care System? Sandro Galea reviewed this issue and noted that ironically, as congressional Republicans have been trying to replace the Affordable Care Act, the ACA’s popularity is at an all-time high, and the majority of Americans now believe that it is the federal government’s responsibility to provide health care for all Americans. This shift in sentiment suggests that a single-payer system — a “Medicare for all” — may soon be a politically viable solution to America’s health care woes.

This system has long been an aspiration of the far left, yet even the right now seems to acknowledge its growing likelihood. Following his decision not to support the Better Care Reconciliation Act (BCRA), the Senate Republican leadership’s latest attempt to replace the ACA, Senator Jerry Moran, Republican of Kansas, warned in a statement: “If we leave the federal government in control of everyday health care decisions, it is more likely that our health care system will devolve into a single-payer system, which would require a massive federal spending increase.” (The BCRA, which failed in the Senate, would have kept the basic contours of the ACA but greatly reduced its ability to provide care.)

Although congressional Republicans remain uncomfortable with universal coverage as a concept, some seem to understand that the American people are coming to see health care as a right. It is very difficult to imagine how universal coverage could be sustainable over the long run without a central payment system.

While there may be openings for bipartisan compromise to address the weaknesses of the ACA,  the core of the ACA framework is unstable — a hostage to the market and political fortune. By contrast, a single-payer model stands to be much more durable and provides a chance to build a health care system around the well-being of patients rather than the profits of providers and insurers. Thirty-three percent of the American public now supports a single-payer system — a 5% increase since January.

To be sure, some important players remain opposed to a single-payer system. One is the American Medical Association. It favors an ACA-like structure that subsidizes insurance for low-income individuals and families and argues that a single-payer system would stymie private-sector innovation, create long waiting periods, and offer less patient choice. However, the AMA is far from a disinterested party. Indeed, it was an early resister of alternatives to our current fee-for-service system, fearing a more progressive model could diminish the independence and entrepreneurial capacity of its members.

Not surprisingly, insurance and pharmaceutical industries, which have a strong economic self-interest in maintaining the status quo, are also against the single-payer model. Opponents warn that a single-payer model could lead to a wholesale bureaucratization of the health care system by the federal government, or even to socialized medicine.

But are these concerns warranted? Doctors who fear losing their autonomy need only look north to see how a single-payer system can work without encroaching on the independence of physicians. Canada has had a single-payer model for decades, and there’s no government takeover of its health care system in sight. Most services are still provided by the private sector, and most physicians are still self-employed. While health expenditures remain high, Canadians nevertheless enjoy better health outcomes at lower cost than the United States, whose population’s health is mediocre despite ever-higher spending on medical care.

Canada’s success stems from a few basic tenets. Its system is structured around a federal requirement to provide coverage for necessary services such as doctor and hospital visits. While the cost of this care is covered by the taxpayer, the task of providing it is decentralized to each of the country’s 13 provinces and territories. Each region has wide latitude to innovate — as long as it honors the basic guarantee of providing free point-of-care treatment to all citizens for certain essential services, funded through a central payer. This is an important point. The single-payer approach is often characterized as a gateway to Byzantine regulation. Yet the reality is it is a fundamentally simple, even elegant, concept: Everybody gets the coverage that everybody pays for. Within this framework, there is much room for maneuver.

If implemented correctly, a centralized payment structure can create a health care system that is genuinely organized around health. It may seem counterintuitive to suggest that the U.S. system is not organized around health, but this truth has long been obvious to anyone who follows this issue or to anyone who has ever had to seek care in a time of need. Over and over, we have seen how the U.S. health care system produces a vast array of increasingly expensive drugs and treatments that few can access without high-quality insurance.

A single-payer model could change this — not by nationalizing health care outright but by incentivizing new payment structures such as bundled payments, accountable care organizations, and other population-based models. Unlike a fee-for-service arrangement, these models do not tether provider compensation to the frequency and expense of care. Bundled payments — which provide a fixed-dollar amount for a particular type of care (e.g., replacing a knee) delivered over a set period of time — would encourage greater efficiency in care by having providers compete on the basis of quality and price.  And capitation, by compensating providers per assigned patient, would open the door to an increased focus on prevention, which would save time and resources.

While such innovative payment models are possible within the current fragmented payer system — indeed, the Centers for Medicare and Medicaid Services has been a leader in innovating — a single-payer system immediately creates an opportunity for wide-scale adoption of new approaches that can transform health in the United States. With a health system reoriented toward stopping disease before it starts, rather than treating it once it strikes, we may even start to see more health investments go beyond health care, targeting the social, economic, and environmental factors that create the conditions for disease in society.

Decades of opposition have tinted Americans’ view of a single-payer system’s potential. But there is no reason to think that the status quo is immutable. It did not, after all, come about organically; it is the product of years of influence strategically wielded by powerful stakeholders in business, medicine, and politics. These stakeholders were able to advance their agenda in large part because Americans had not come to view health care as an essential collective right. This is changing. Turning this growing view into policy will require a national agreement that health care is a value worth paying for. The country is not there yet, but it no longer feels that far off.

Have also questioned Bernie Sanders Medicare for all goal. Is this what we want?

Thankfully, the GOP did not pass Paul Ryan’s repeal and replace bill for Obamacare.  Immediately after, we see a headline hopefully concluding, “Medicare for all may be next.”  Shannon Tapia in her article “Single payer: Yes! Medicare for all: No! noted that in Medicare’s current form, this would be devastating for the health of America.  I treat many Medicare patients; I know a heck of a lot about Medicare.  Most people don’t.  They just see it as a great perk of turning 65 in America and the social health care we offer to elderly and disabled.  I did too until I became a physician who sees many Medicare patients.

Medicare originated in 1966 in recognition that we needed to do a better job as a nation at caring for our aging and disabled who could not get employer-provided insurance.  In 1989 the Omnibus Budget Reconciliation Act established a fee schedule for Medicare payments.  This assigns “relative value units” or RVUs to everything we do for our patients in medicine.  The formula that determines RVUs disproportionately favors procedural care to time-based care.  Essentially, Medicare pays and incentivizes medical providers to do things to patients and actually disincentivizes physicians from taking their time with patients.

If you wonder why the doctor-patient relationship is not doing well right now, wonder no more.  Trust takes time.  Even family doctors who take Medicare have to turn their practice into a patient or low-risk procedure mill to make ends meat.  Medicare will pay a physician between $70 to $80 to freeze off a wart, a procedure that takes about 2 minutes to do, and 1 minute to document in an EMR.In contrast, I can spend an hour with an elderly patient with multiple complicated issues, addressing their concerns, reviewing and adjusting their many medications, and coming up with a plan and then having to take 30 minutes later to document what happened and get paid essentially the same amount (about $80) had I just spent 3 minutes removing a wart and sending them out the door.  Is it any wonder that geriatrics is a dying field?

In contrast, I can spend an hour with an elderly patient with multiple complicated issues, addressing their concerns, reviewing and adjusting their many medications, and coming up with a plan and then having to take 30 minutes later to document what happened and get paid essentially the same amount (about $80) had I just spent 3 minutes removing a wart and sending them out the door.  Is it any wonder that geriatrics is a dying field?

There was a time, however, when despite the RVU working against physicians who primarily use their time and knowledge to diagnose and care for patients, physicians still did it because they could make a decent living while being fulfilled in the solace they were helping.  But times have changed.  My father was a general practitioner.  He went to medical school in St. Louis, on the Army’s “scholarship.”  No loans needed.  Students today get out of medical school with roughly $200,000 -$340,000 in debt at anywhere from 7 to 15 percent interest that accrues quarterly.

The physicians today in their fifties to seventies truly cannot comprehend the financial sacrifice new physicians make when committing to primary care today.  But, it’s not all about the money.  There is far more paperwork, tracking of useless data, nonpatient care related work that we are forced to do that merely detracts from the already limited time we have to see patients and develop a relationship.  And we have to deal with this burden from day 1 of our practicing lives.  Many of the older docs have moved into administrative roles yet still remember clinical practice how they experienced it.  In turn, they create detrimental policies and regulations to feed metrics in the name of “quality” all while being clueless as to what it is like to actually treat patients in the modern era.

Some might argue that by expanding Medicare for all, it would cover less complicated patients so the current model shouldn’t be a problem.  I’d also beg to differ on that one.  Doing things to people, even prescribing medications, is dangerous and should not be taken for granted.  Medicare still incentivizes doing more invasive things for the least complicated patients.  Say we expand it to everyone, and a 22-year-old comes in with a cough she’s had for five days.  It’s viral.  Viruses are the worst.  There is no treatment other than time and support.  But convincing patients of this when they know I have the power to prescribe a Z-pak and they always get better on the Z-pak (20 percent of the effect of any treatment is placebo) takes a long empathetic conversation.

You know what is quick and easier?  You got it, just writing the darn script and moving on to the next person so I can get paid more.  And then we have massive bacterial resistance to azithromycin (the Z-pak) and C. diff is on the rise.

The numbers on all accounts point to the reality that Medicare’s RVU system of paying providers is causing worse outcomes, is unsustainable in cost and is not attracting young talented physicians to the most needed primary care fields.  I wonder how many of the new family docs will inevitably succumb to 10-minute visits with high procedures and more referrals to costly specialists or ultimately opt-out of Medicare and insurance for direct primary care?  Medicare spent 650 billion dollars in 2015.  An underestimate suggests 200 billion dollars (or 30 percent) was spent on beneficiaries in their final year of life.  That means we as a medical community, despite probably knowing the patients were dying, kept doing procedures and tests and more treatments to people because that is what we are paid to do.

American culture indoctrinates us that death is optional.  It’s really not.  But why would a physician take the time explain to a patient and family the reality of their situation, a conversation that is exhausting and challenging for everyone involved, when they are paid about 5x more to just offer another procedure or test and move on?  And then we spend billions of dollars doing things while ignoring the essentials that require time, and we get the worst outcomes.   The current Medicare, if expanded to all, will only exacerbate the costly failures of our current system.

A single-payer universal coverage system?  Yes, please, maybe!  But not Medicare as we know it.  Heed the geriatricians now while you still can.  We’re the most needed physician endangered species.

Where do we want to go from here? It was just a standard congressional committee statement: “This committee will hold hearings beginning the week of September 4th on the actions Congress should take to stabilize and strengthen the individual health insurance market so that Americans will be able to buy insurance at affordable prices in the year 2018.”

But that joint statement Tuesday from senators Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), the chairman and ranking member, respectively, of the Senate Health, Education, Labor, and Pensions (HELP) Committee, was met with great interest on Capitol Hill and elsewhere, with many media outlets running stories about the announcement.

In the wake of the Senate Republicans’ failure last Friday to pass a “skinny repeal” of the Affordable Care Act (ACA), President Trump expressed his disappointment in Congress, tweeting, “3 Republicans and 48 Democrats let the American people down. As I said from the beginning, let ObamaCare implode, then deal. Watch!”

But the HELP Committee leaders had other ideas. “Unless Congress acts by September 27, when insurance companies must sign contracts with the federal government to sell insurance on the federal exchange next year, millions of Americans with government subsidies in up to half our states may find themselves with zero options for buying health insurance on the exchanges in 2018,” Alexander said in a statement. “Many others without government subsidies will find themselves unable to afford health insurance because of rising premiums, co-pays and deductibles.”

“There are a number of issues with the American healthcare system, but if your house is on fire, you want to put out the fire, and the fire, in this case, is the individual health insurance market,” he continued. “Both Republicans and Democrats agree on this. Our committee had one hearing on February 1 on this subject, and we’ll work intensively between now and the end of September to finish our work in time to have an effect on the health insurance policies sold in 2018.”

Alexander said he had urged the Trump administration to continue paying cost sharing reduction (CSR) subsidies — payments to insurers that help low-income enrollees on the ACA’s insurance exchanges pay their out-of-pocket costs — until late September to give Congress time to work out its own deal to continue them. The president had threatened to stop making the payments if a new healthcare bill was not approved quickly.

Legislation to shore up the markets also should include “greater flexibility for states in approving health insurance policies,” Alexander said. Although he didn’t specify what he meant by greater flexibility, some Senate Republicans have urged that insurers be allowed to issue policies that do not cover all of the “essential health benefits” required under the ACA, as well as policies that charge older enrollees higher premiums than currently permitted.

Any solution that is passed by Congress to help the markets should be “small, bipartisan, and balanced,” Alexander added.

Alexander also praised a recent move by the state of Alaska, which received a waiver from the U.S. Department of Health and Human Services for its plan to “reinsure” health insurers that have high-cost patients. “This waiver ought to be a big help for Alaska as it works to stabilize the state’s individual insurance market,” he said in a July 11th statement.

Will anything happen in the Senate by the Sept. 27 deadline? “Senator Alexander’s committee is not likely to enact legislation by late September, but they will help to set the tone for the debate going forward,” Michael Sparer, Ph.D., JD, chair of the department of health policy and management at Columbia University in New York City, said in an email.

While Alexander and Murray make their plans for the HELP Committee, a group of about 40 House Democrats and Republicans have unveiled their own proposal. The group, known as the Problem Solvers Caucus, has a five-point plan for rejuvenating the ACA’s insurance markets:

  • Create a “stability fund” to help states reduce premium costs for those with pre-existing conditions
  • Repeal a medical device tax
  • Loosen the employer mandate by applying it to businesses with 500 or more employees, as opposed to 50 or more under current law
  • Encourage state experimentation to reduce costs and increase coverage
  • Guarantee the CSR payments

Congress and the White House don’t have much time to lose. In addition to the insurers’ Sept. 27 deadline, the next CSR payment is due on Aug. 21, so “if the administration intends not to make the August payment, it must announce its decision soon,” wrote Timothy Jost, JD, professor of law emeritus at Washington & Lee University, in Lexington, Va., in a blog post for Health Affairs.

There is also another fly in the ointment when it comes to the CSR payments: a federal court on Tuesday granted a motion to allow 16 Democratic state attorneys general to participate in any actions related to the CSRs. Specifically, the order allows them to file briefs and to block any settlements or appeal rulings in favor of blocking the payments. The ruling involved a lawsuit known as House v. Price that was filed in 2014 by Republican members of Congress who objected to the White House being able to make the CSR payments.

This new wrinkle “will complicate any effort by the president to quickly end the subsidies,” Sparer noted.

What Congress should do about the ACA “depends on who they are trying to help,” Edmund Haislmaier, senior research fellow at the Heritage Foundation, a right-leaning think tank here, said in a phone interview. “It’s not clear that the Republicans and the Democrats are trying to solve the same problem. For example, [making] the CSR [payments] would affect people getting coverage through the exchange, but it doesn’t do anything for people who are off the exchange and seeing their premiums go up and have no subsidies. Those are the people that Republicans were trying to address with regulatory relief in the legislation that failed.”

He noted that even if the CSR payments were to stop, the people in the exchanges who receive subsidies — those making 250% or less of the federal poverty level — wouldn’t really be affected because if the insurers raised their premiums to compensate, the government would simply increase the number of the subsidies, which are given as tax credits.

“Are you trying to salvage the exchanges and the ACA subsidy structure, or are you trying to provide a benefit to people outside the exchange — the middle class who don’t see subsidy relief and want this thing repealed, which is what the Republicans want to do?” Haislmaier said. Allowing insurers to sell less comprehensive policies and varying premiums more by age are examples of provisions that could help these consumers through lower premiums, he contended.

But, maybe this latest turn of events will continue the discussion between both parties, a true bipartisan effort, so that we/they can actually get things done to improve health care delivery for all.

‘Skinny’ Obamacare Repeal Bill Fails in Senate; Three Republicans voted no on the measure and is this any Surprise?

19274859_1229067190556271_652402407450294860_nJoyce Frieden reported that in a session that lasted into the wee hours of Friday morning, the Senate voted down a “skinny” bill to repeal the Affordable Care Act (ACA), dealing a big blow to the chamber’s Republican leadership.First of all, what a dumb name for the bill! Who in their right mind would vote for a “Skinny” Health Care Bill?

The vote was 49-51 to defeat the bill — known as the Health Care Freedom Act — which would have repealed the employer and individual mandates but would have left other elements of the ACA in place. It also would have defunded Planned Parenthood and repealed the medical device tax. Along with all of the Senate’s Democrats and its two Independents, three Republicans — John McCain of Arizona, Lisa Murkowski of Alaska, and Susan Collins of Maine — also voted against the bill.

“This is a disappointment, a disappointment indeed,” Senate Majority Leader Mitch McConnell (R-Ky.) said after the vote. “I regret that our efforts were simply not enough this time.”

“I imagine many colleagues on the other side are celebrating, but the American people are hurting and they need relief,” he continued. “Now I think it’s appropriate to say, ‘What are [Democrats’] ideas?’ It will be interesting to see what they suggest as the way forward.” He immediately knocked down one idea: “Bailing out insurance companies with no thought of any kind of reform — that’s not something I want to be part of, and I suspect there are not many folks over here that are interested in that.”

Senate Minority Leader Chuck Schumer (D-N.Y.) adopted a conciliatory tone. “I’d say to [McConnell] that we’re not celebrating; we’re relieved that the millions of people who would be so drastically hurt by the proposals put forward will be able to maintain their healthcare,” he said. “But as I have said over and over again, Obamacare is hardly perfect. It did a lot of good things but it needs improvement.”

“I would suggest we turn the page … And I hope one part of turning the page is we go back to regular order and work [together] to improve Obamacare,” he continued. “There are suggestions we’re interested in that come from the other side of the aisle. So let’s turn the page and work together to improve our healthcare system.”

Democrats Oppose the Measure! Any surprise in this vote?

Senate Minority Leader Chuck Schumer (D-N.Y.) urged Republicans to vote against the bill. “Listen to what the CBO said; it said that skinny repeal would cause 16 million Americans to lose insurance and millions would pay 20% more for premiums starting next year — not 3 years from now but in January,” he said. “One of the promises Republicans made was to bring down premiums, but this would break that promise.”

“You don’t vote to advance terrible legislation and hope it gets better in conference,” he added. “Let’s not forget — months ago the House voted to pass their bill because they hoped it would get better in the Senate. Well, it hasn’t gotten better yet.”

Sen. Sheldon Whitehouse (D-R.I.) pointed out that most medical organizations opposed the bill. “Who did the magicians who came up with this listen to? They obviously didn’t listen to the doctors,” he said. “The American Medical Association is opposed, the American Academy of Family Physicians is opposed to this bill … the American Heart Association is opposed to this bill … Rural hospitals are warning that this could end their very existence.”

And a Single-Payer version was also shot down!

Before the skinny repeal bill was debated, the Senate voted on a single-payer bill introduced by Sen. Steve Daines (R-Mont.). “The amendment I’m putting forward here today is … a carbon copy, down to every last comma and period, of Rep. [John] Conyers’ [single-payer House] bill, which has 115 Democratic cosponsors as I speak.”

“I believe Montanans and the American people deserve to debate different ideas,” said Daines. “Earlier today Sen. [Bernie] Sanders suggested that my amendment was intended to embarrass Democrats. Sen. Sanders, my amendment shouldn’t embarrass anyone; I’m trying to show the American people who is supportive of socialized medicine and who is not. Tell the American people what you think. I think we should vote No on this; what say you?”

Sanders decried Daines’ move as a “political trick” to force some Democratic senators into an uncomfortable political position. “I hope this is really a breakthrough on the part of my Republican colleagues,” he said. “I hope they recognize that the U.S. should join every other major country on earth in recognizing that healthcare is a right, not a privilege.”

“I hope that’s what Mr. Daines will be saying, but I kinda think that’s not what he’ll be saying,” said Sanders. “If Mr. Daines is serious, let us work together, but now is not a time for political games.”

Daines’ bill failed 57-0, with Sanders, an independent, and 42 Democrats voting “present”. Besides all 52 Republicans, those voting No included Sen. Angus King (I-Maine) and Democrats Joe Manchin of West Virginia, Jon Tester of Montana, Heidi Heitkamp of North Dakota, and Joe Donnelly of Indiana.

The Daines bill “was an explicit ruse, intended to waste some of the 20 hours of debate time and an attempt to taunt and then ’embarrass’ Democrats into formally admitting that they are all socialists,” said Jay Wolfson, DrPH, JD, associate vice president of USF Health, in Tampa, Fla., in an email to MedPage Today. “It was an old state legislative trick in which a member introduces a bill and then votes against it. Single-payer is not achievable in the current Congress in any event.”

“Cadillac Tax” Repeal Passes

The Senate also voted down an amendment by Sen. Luther Strange (R-Ala.) to make the premium tax credits offered through the Affordable Care Act subject to the Hyde Amendment, which bars federal funds from being spent on abortion. The amendment, which required 60 votes to pass, went down by a vote of 50-50.

They did pass one amendment, which was to repeal the “Cadillac tax” on high-cost health insurance plans. The amendment passed by a vote of 52-48.

As the day wore on, some Republican senators expressed their misgivings about the skinny repeal bill. “We’ve been asked by the leadership … to vote for the ‘least common denominator,'” Sen. Lindsey Graham (R-S.C.) said at a news conference at which he appeared with Sen. Ron Johnson (R-Wisc.) and McCain. “The pitch is if we go to conference, we can get my [alternative] bill scored, we can get Sen. [Ted] Cruz’s bill scored … That makes eminent sense to me, with one condition — that we actually go to conference.”

On the other hand, Graham added, “The skinny bill as policy is a disaster; it’s not a replacement in and of itself.” He particularly objected to the bill’s elimination of the employer mandate, which he said would increase premiums while keeping most of the ACA in place. “And we politically own the collapse of healthcare. So we’re not going to do that with our vote. What we’ll do is move the process along.”

House Speaker Paul Ryan issued a statement Thursday that appeared to be intended to reassure anxious senators — but with some caveats. “If moving forward requires a conference committee, that is something the House is willing to do,” he said.

“The reality, however, is that repealing and replacing Obamacare still ultimately requires the Senate to produce 51 votes for an actual plan. The House remains committed to finding a solution and working with our Senate colleagues, but the burden remains on the Senate to demonstrate that it is capable of passing something that keeps our promise, as the House has already done. Until the Senate can do that, we will never be able to develop a conference report that becomes law.”

The defeat of the Senate bill capped a difficult few days for Senate Republicans. On Tuesday, things were looking up when senators narrowly voted to proceed with a debate on a repeal bill, although it was not yet clear which bill that would be. But on Wednesday, the Senate voted down two bills — first a bill to repeal the ACA without a replacement, and then a second bill — the Better Care Reconciliation Act — to repeal and replace the law.

As the title of this blog post suggests this lack of progress shouldn’t be a surprise considering that States have already tried versions of ‘Skinny Repeal’ and it didn’t go well! J. Scott Applewhite from the AP in his latest article reviewed this bit of history. Betting that thin is in — and might be the only way forward — Senate Republicans are eyeing a “skinny repeal” that would roll back an unpopular portion of the federal health law. But health policy analysts warn that the idea has been tried before, and with little success.

Senators are reportedly considering a narrow bill that would eliminate the Affordable Care Act’s “individual mandate,” which assesses a tax on Americans who don’t have insurance. The bill would also eliminate the ACA’s penalties for some businesses – those that have 50 or more workers and fail to offer their employees health coverage.

Details aren’t clear, but it appears that — at least initially — much of the rest of the 2010 health law would remain, under this strategy, including the rule that says insurers must cover people who have pre-existing medical problems.

In remarks on the Senate floor Wednesday, Sen. Minority Leader Charles Schumer, D-N.Y., said that “we just heard from the nonpartisan Congressional Budget Office that under such a plan … 16 million Americans would lose their health insurance, and millions more would pay a 20 percent increase in their premiums.” The CBO posted its evaluation of the GOP’s proposed plan Wednesday evening.

Earlier in the day, some Republicans seemed determined to find some way to keep the health care debate alive.

“We need an outcome, and if a so-called skinny repeal is the first step, that’s a good first step,” said Sen. Thom Tillis, R-N.C.

Several Republican senators, including Dean Heller of Nevada and Jeff Flake of Arizona, appear to back this approach, according to published reports. It is, at least for now, being viewed as a step along the way to Republican health reform.

“I think that most people would understand that what you’re really voting on is trying to keep the conversation alive,” said Sen. Bob Corker, R-Tenn. “It’s not the policy itself … it’s about trying to create a bigger discussion about repeal between the House and Senate.”

But what if, during these strange legislative times, the skinny repeal were to be passed by the Senate and then go on to become law? States’ experiences with insurance market reforms and rollbacks highlight the possible trouble spots.

Let’s consider the parallels.

By the late 1990s, states such as Washington, Kentucky and Massachusetts felt a backlash when some of the coverage requirement rules they’d previously put on the individual market were lifted. “Things went badly,” said Mark Hall, director of the health law and policy program at Wake Forest University.

Premiums rose and insurers fled these states, leaving consumers who buy their own coverage (usually because they don’t get it through their jobs) with fewer choices and higher prices.

That’s because — like the Senate plan — the states generally kept popular parts of their laws, including protections for people with pre-existing conditions. At the same time, they didn’t include mandates that consumers carry coverage.

That goes to a basic concept of any kind insurance: People who don’t file claims in any given year subsidize those who do. Also, those healthy people are less likely to sign up, insurers said, and that leaves insurance companies with only the more costly policyholders.

Bottom line: Insurers end up “less willing to participate in the market,” said Hall.

It’s not an exact comparison, though, he added, because the current federal health law offers something most states did not: significant subsidies to help some people buy coverage. Those subsidies could blunt the effect of not having a mandate.

During the debate that led to the passage of the federal ACA, insurers flat-out said the plan would fail without an individual mandate. On Wednesday, the Blue Cross Blue Shield Association weighed in again, saying that if there is no longer a coverage requirement, there should be “strong incentives for people to obtain health insurance and keep it year-round.”

Survey says-individual mandate is still unpopular in voter polls!

About 6.5 million Americans reported owing penalties for not having coverage in 2015.

Polls consistently show, though, that the individual mandate is unpopular with the public. Indeed, when asked about nine provisions in the ACA, registered voters in a recent Politico/Morning Consult poll said they want the Senate to keep eight, rejecting only the individual mandate.

Even though the mandate’s penalty is often criticized as not strong enough, removing it would still affect the individual market.

“Insurers would react conservatively and increase rates substantially to cover their risk,” said insurance industry consultant Robert Laszewski.

That’s what happened after Washington state lawmakers rolled back rules in 1995 legislation. Insurers requested significant rate increases, which were then rejected by the state’s insurance commissioner. By 1998, the state’s largest insurer — Premera Blue Cross — said it was losing so much money that it would stop selling new individual policies, “precipitating a sense of crisis,” according to a study published in 2000 in the Journal of Health Politics, Policy and Law.

“When one pulled out, the others followed,” said current Washington Insurance Commissioner Mike Kreidler, who was then a regional director in the federal department of Health and Human Services. The state’s individual market was volatile and difficult for years after. Insurers did come back, but won a concession: For a time, the insurance commissioner lost the power to reject rate increases. Kreidler, first elected in 2000, reclaimed that authority.

Predicting the effect of removing the individual mandate is difficult, although Kreidler said he expects the impact would be modest, at least initially. Subsidies that help people purchase insurance coverage — if they remain as they are under current law — could help blunt the impact. But if those subsidies are reduced — or other changes are made that further drive healthy people out of the market — the impact could be greater.

“Few markets can go bad on you as fast as a health insurance market,” said Kreidler.

As for employers, dropping the requirement that those with 50 or more workers must offer health insurance or face a financial penalty could mean some workers would lose coverage. But their jobs might be more secure, said Joseph Antos, a health care economist and resident scholar at the American Enterprise Institute.

That’s because the requirement under the ACA meant that some smaller firms didn’t hire people or give workers more than 30 hours a week — the minimum needed under the ACA to be considered a full-time worker who qualified for health insurance.

The individual mandate, he added, may not be as much of a factor in getting people to enroll in coverage as some think because the Trump administration has indicated it might not enforce it anyway — and the penalty amount is far less than most people would have to pay for health insurance.

However, the individual market could be roiled by other factors, Antos said. “The real impact would come if feds stopped promoting enrollment and did other things to make the exchanges [— the state and federal markets through which insurance is offered —] work more poorly.”

“Couple caught in ‘financial spiral’ jump to their deaths.” And the media plays up the tragedies so people believe that health care reform is the problem. Consider this latest suicide reported by Shawn Cohen, Tamar Lapin and Natalie Musumeci. A pair of Manhattan parents claiming financial woes jumped to their deaths early Friday — leaving double suicide notes pleading that their two kids be cared for, law enforcement sources told The Post.The bodies of 53-year-old chiropractor Glenn Scarpelli and his wife, 50-year-old Patricia Colant, were found in the middle of the street on 33rd Street between Park and Madison avenues in Murray Hill after the pair jumped from the ninth-floor window of a 17-story corner office building on Madison Avenue at about 5:45 a.m., police said. Glenn, whose office was on the same floor of the building where the couple jumped, titled the suicide note found in his pocket, “WE HAD A WONDERFUL LIFE.” It was typed on a piece of white paper. His wife also had a suicide note in her pocket that read, “in sum and substance,” according to a source, “‘Our kids are upstairs, please take care of them.’” “Patricia and I had everything in life,” the man’s note read. But it also touched on the couple’s “financial spiral” and how “we can not live with” the “financial reality,” sources said. A law enforcement source at the scene told The Post that authorities at first believed that the couple struggled with health care costs. But an NYPD spokesman said later that there was no mention of medical-cost struggles in the notes. The couple was in debt, another source said.

Most physician organizations expressed gratitude and relief following the Senate’s early-morning defeat on Friday of a bill to partially repeal the Affordable Care Act (ACA).”The American College of Physicians (ACP) applauds the Senate for voting to reject the ‘skinny’ ACA repeal legislation that would have greatly harmed our patients,” ACP president Jack Ende, MD, said in a statement. “This legislation … would have put tens of millions of Americans at risk of losing health insurance coverage, and all Americans at risk of losing critical patient protections.”

“No version of legislation brought up this year would have achieved the types of reforms that Americans truly need: lower premiums and deductibles, with increased access to care,” he continued. “We now urge the House and the Senate to move forward in a bipartisan manner, working through ‘regular order,’ to make improvements to the ACA.”

The vote was 49-51 to defeat the bill — known as the Health Care Freedom Act — which would have repealed the employer and individual mandates but would have left other elements of the ACA in place. It also would have defunded Planned Parenthood and repealed the medical device tax. Along with all of the Senate’s Democrats and its two Independents, three Republicans — John McCain of Arizona, Lisa Murkowski of Alaska, and Susan Collins of Maine — also voted against the bill.

“This is a disappointment, a disappointment indeed,” Senate Majority Leader Mitch McConnell (R-Ky.) said after the vote. “I regret that our efforts were simply not enough this time.”

The American Medical Association (AMA) focused on the future in its short statement, issued minutes after the final vote. “While we are relieved that the Senate did not adopt legislation that would have harmed patients and critical safety net programs, the status quo is not acceptable,” said AMA president David Barbe, MD. “We urge Congress to initiate a bipartisan effort to address shortcomings in the Affordable Care Act. The first priority should be to stabilize the individual marketplace to achieve the goal of providing access to quality, affordable health coverage for more Americans.”

“On behalf of the patients we care for, we thank the Senate for voting to protect the health of millions of Americans — including those on Medicaid and with preexisting conditions — whose coverage was in jeopardy,” Darrell Kirch, MD, president, and CEO of the Association of American Medical Colleges, said in a statement. “Now it is more important than ever that Congress and the administration work together to improve the current system and ensure that all Americans have access to affordable, comprehensive coverage. The most immediate concern is stabilizing the health insurance market through continued, predictable funding of cost-sharing subsidies.”

The American Academy of Pediatrics (AAP) was grateful that the Senate defeated the bill but also had other concerns. “Our work is not over,” said AAP president Fernando Stein, MD, in a statement. “We turn now to the looming reauthorization of the Children’s Health Insurance Program, a bipartisan success story providing coverage for nearly 9 million children. We turn now toward other pressing issues that matter for children, like child welfare reform, with renewed resolve.”

Some health policy experts were surprised by the vote’s trajectory. “Last night’s vote to me was something that I never thought I would see: people being asked to pass clearly a bad piece of legislation just to keep the process going,” Paul Ginsburg, PhD, director of the USC-Brookings Schaeffer Initiative for Health Policy, told MedPage Today in an interview. “I’m amazed that it still got 49 votes, because so many Republicans had been so critical of ‘skinny repeal’ on its own … I think it had gotten to a point of absurdity.”

The next step for Congress is to find a way to manage the immediate problem of struggling markets in certain areas of the country, said Ginsburg, who is a member of the Medicare Payment Advisory Commission (MedPAC) but was speaking for himself. “The one thing they are most likely to agree on is reinstating reinsurance” — insurance policies to cover costs for health insurers who end up with unexpectedly high-cost patients. Republicans in Congress aren’t likely to be inclined to let the ACA fail, he said, because “sabotaging” the insurance markets could hurt them in the next election.

Ginsburg also said he wouldn’t be surprised if more states chose to adopt the Medicaid expansion — broadening eligibility to those just above the poverty line.

In the vote’s aftermath, “I think that debate [over] how Medicaid should be financed and structured is probably forever with us,” said Diane Rowland, ScD, executive vice president of the Kaiser Family Foundation, in an interview. She noted that the Trump administration still has a lot of discretion to influence the program through waivers that could include the use of cost-sharing and work requirements.

Trying to pass a skinny repeal bill in the first place was a “fool’s errand,” according to Bob Laszewski, president and founder of Health Policy and Strategy Associates, an Alexandria, Va. consulting firm. “How did McConnell think he was going to do any better bringing 240 House Republicans — including the Freedom Caucus — into a process that he could get no more than 45 Republican votes for in his own Senate?” he wrote in a blog post.

For a bipartisan solution to emerge, two conditions must be satisfied, Laszewski said. First, “Democrats will have to admit the problems with Obamacare are more than ‘imperfections’ — they will have to admit that Obamacare has been a dismal failure for those who have no choice but to buy their health insurance in the individual health insurance market and make too much money to qualify for a subsidy.”

And second, “Republicans will have to admit that most American households not eligible for Medicare, employer-based health insurance, or the pre-2014 Medicaid program, cannot afford to buy health insurance on their own — even if we had 2013 premium rate levels.” I believe that we all knew that this GOP couldn’t create a health care system that would first be approved by the Democrats and second to substitute for the ACA, even with the ACA’s problems.

Now Bernie Sanders said today that he would introduce a single payer health care system. Sen. Bernie Sanders (I-Vt.) said Sunday that he will “absolutely” introduce legislation on single-payer healthcare now that the Senate GOP’s bill to repeal ObamaCare has failed. Let’s look at the single payer health care system next week. Are we ready for it??

I’ll leave you with the Gordon Lightfoot lyrics the Paul Ryan recited for the “Sinking of the Wreck of the Edmund Fitzgerald” :

“The ship was the pride of the American side
Coming back from some mill in Wisconsin
As the big freighters go, it was bigger than most
With a crew and good captain well seasoned
Concluding some terms with a couple of steel firms
When they left fully loaded for Cleveland
And later that night when the ship’s bell rang
Could it be the north wind they’d been feelin’?

The wind in the wires made a tattle-tale sound
And a wave broke over the railing
And every man knew, as the captain did too,
T’was the witch of November come stealin’
The dawn came late and the breakfast had to wait
When the gales of November came slashin’
When afternoon came it was freezin’ rain
In the face of a hurricane west wind

When suppertime came, the old cook came on deck sayin’
Fellas, it’s too rough to feed ya
At seven pm a main hatchway caved in, he said
Fellas, it’s been good t’know ya
The captain wired in he had water comin’ in
And the good ship and crew was in peril
And later that night when his lights went outta sight
Came the wreck of the Edmund Fitzgerald”

What’s next? As I said let’s discuss the Single Payer System, which the Democrats missed out in getting their eventual wish!


Repeal Is Dead! Long Live What and Will the Health of 1 of Their Senators Affect the Outcome?


ship958Shannon Firth, Washington correspondent for MedPage recently discussed the present situation with Repeal and Replace, that is, the Better Care Reconciliation Act/BCRA. Revision after revision and one yanked vote after another, the long-held Republican dream to repeal-and-replace the Affordable Care Act (ACA) appeared to be evaporating last Tuesday.

On the previous Monday night, following the announcement that two more Republican senators would vote down the Senate’s Better Care Reconciliation Act (BCRA), bringing the total defections to a total of four — Republicans could only afford to lose two — Senate majority leader Mitch McConnell (R-Ky.) issued a statement, saying plans to “repeal and immediately replace” the ACA would not succeed.

While pulling the BCRA from a vote, he pledged to vote on a straightforward repeal with a 2-year transition, or “repeal-and-delay” as some have called it.

McConnell both conceded the failure of the BCRA and pushed for a new vote on the House-passed bill, which could lead, through amendment, to a “clean repeal” with a 2-year delay. During that time, Republicans could allegedly reach consensus on a suitable replacement, The Washington Post reported.

McConnell cited the ACA repeal bill of 2015, which Congress passed and then President Obama vetoed, as an example.

But even that plan fell flat: three moderate senators, Sen. Shelley Moore Capito (R-W.Va.), Sen. Lisa Murkowski (R-Alaska), and Sen. Susan Collins (R-Maine) panned the push for repeal-and-delay, according to The New York Times.

“I did not come to Washington to hurt people,” Capito said in a statement, explaining that she couldn’t eliminate Obamacare without a replacement.

Despite the opposition, McConnell said Tuesday afternoon that he would hold a vote “in the near future,” according to The Atlantic.

Meanwhile, President Trump urged a repeal-and-delay strategy. He tweeted, please someone take the President’s Blackberry away from him, Tuesday morning that one way to achieve that goal would be by amending Senate rules: “The Senate must go to a 51 vote majority instead of current 60 votes. Even parts of full Repeal need 60. 8 Dems control Senate.” Crazy!?!

But overhauling Senate rules “for a short-term gain isn’t worth it, no matter what bill we’re voting on,” said Charles Sauer, a policy fellow at the Goodman Institute.

What was the Senate’s Next Move?

“Put up or shut up,” is how Tom Miller, a resident fellow at the conservative American Enterprise Institute, translated McConnell’s message to his Republican colleagues.

He said he believes McConnell intended to force a vote on the repeal-and-delay idea in order to prove to conservative proponents of “repeal-only” just how few votes they’d get. The New York Times has already confirmed such a plan is unpopular with enough moderates to sink any such vote.

The bottom line is that Republicans failed, he said. “They are not going to be able to mark up a bill that changes current law.”

Miller suggested that, while many Republicans say they want a repeal, “when it comes to the voting, they don’t want to do it.” They aren’t ready to face the consequences of a repeal, he added.

“The normal adage is when you’re in a hole, stop digging. Eventually, they will stop digging,” Miller said.

Maybe not: some conservative stakeholders continue to dig in on repeal.

“Every single Senate Republican should vote to begin debate. They owe it to their constituents and the nation,” said Michael Needham, CEO of Heritage Action for America, the policy arm of the Heritage Foundation, a conservative think tank, in a press statement on Tuesday.

Needham went onto say that Republicans should vote to approve the 2015 ACA repeal bill, noting that because it is a partial repeal, “it will mark just the first step in a long process toward unraveling the damage caused by Obamacare.”

Asked whether the 2015 bill had the votes to pass, the Heritage Action team was uncertain.

“Given the number of senators flip-flopping on their 2015 votes, the exact count is unclear. But regardless of what passes — if anything passes at this point — there will still need to be an incredible amount of work restoring choice and competition in the individual marketplace,” added Dan Holler, vice president for Heritage Action, in a follow-up email.

On the question of a possible bipartisan compromise, Kavita Patel, MD, a nonresident fellow at the Brookings Institution, a liberal think tank, was skeptical.

“You can’t get [Sen.] Murkowski and [Sen.] Lee on the same page,” said Patel, who is also a primary care internist at Johns Hopkins in Baltimore.

If Republicans can’t find agreement in their own party, they’re unlikely to find consensus with Democrats, she noted. “But Republicans will be forced to take action to stabilize the market”, she said.

“I know Trump would like to let [the ACA] implode, but these are all congressional Republicans. They have to go back home, and they’ve got to face people, and that’s hard,” she said.

Robert Laszewski, president of Health Policy and Strategy Associates, characterized the concept of a “bipartisan solution” as a “smokescreen.”

“What is the compromise? How do you compromise rolling back Medicaid or not rolling back Medicaid? … What have the Democrats offered that comes close to what Republicans want?” he asked, noting that Republicans are opposed to an “Obamacare bailout” of insurers and certainly wouldn’t support single-payer health insurance.

Even if there were enough moderate Republicans willing to team up with Democrats, McConnell would have to be willing to introduce that bill for a vote, which he would be very unlikely to do, Laszewski said.

He argued that a bipartisan fix isn’t urgently needed because he predicts the individual insurance markets will stabilize, as he outlined in a recent blog post on his website, and even be profitable in 2018.

Others like Michael Cannon, director of health policy studies at the Cato Institute, took the unusual tack of arguing that bipartisanship wasn’t necessary, because of the BRCA, despite McConnell’s statement to the contrary, is not in fact dead.

“You can certainly read it, as ‘This bill we were trying to put together is not going to happen,'” he said. He opined that McConnell’s suggestion to put forward a repeal-only bill could be a “power play.”

While both Lee and Moran said they would not vote to agree to a motion to proceed, they were willing to negotiate, Cannon pointed out.

After McConnell proves that repeal-only is unpopular, then he can renegotiate the BCRA and say to the members and both ends of the ideological spectrum, “you gotta work with me … you’ve gotta give up something to get what you want,” Cannon said.

If nothing else, it’s clear that Republicans “own” health care, and will be held responsible for what comes next.

“If people start losing coverage and having massive premium increases as a result of [the Republicans] failure to come together on a good policy, I think they’ll be held accountable for that,” said Sabrina Corlette, JD, a research professor at the Center on Health Insurance Reform at Georgetown University here.

She said the decision to pull the BCRA was a good one, but, unlike Laszewski, her concerns about the insurance markets have not diminished. “The ACA depends on the voluntary participation of private insurance companies that have to set premiums based on what they know the rules of the road to be … Without leadership from Washington as to what those [rules] are I’m very concerned that people may lack affordable coverage options this fall.”

Corlette argued that McConnell’s best move right now would be to gather his committee chairmen and ranking members together to find a bipartisan solution to shore up the insurance markets. But she acknowledged such an approach requires walking “a very narrow path” that could be even more challenging in the House, “assuming Paul Ryan wants to keep his speakership.”

Major healthcare societies didn’t hold back in their criticism of repeal-and-delay, or the ongoing debate.

“Repeal-and-delay creates a high likelihood of lost coverage, poorer health, and financial instability for millions of Americans and their families. We urge the Senate to return to the drawing board and consider more limited, targeted solutions to our healthcare challenges,” wrote Bruce Siegel, MD, MPH, president and CEO of America’s Essential Hospitals in a press statement.

“The health reform debate is by no means over. Congress must begin a collaborative process that produces a bipartisan approach to improve healthcare in our country,” said David Barber, MD, president of the American Medical Association in a press release. “The status quo is unacceptable. A near-term action is needed to stabilize the individual/nongroup health insurance marketplace. In the long term, stakeholders and policymakers need to address the unsustainable trends in healthcare costs while achieving meaningful, affordable coverage for all Americans. The American Medical Association is ready to work on short- and long-term solutions.”

McCain’s health problems arise at a crucial time for Senate Majority Leader Mitch McConnell (R-Ky), who had hoped to bring the Better Care and Reconciliation Act, the GOP’s latest bill to repeal and replace the Affordable Care Act, to the Senate floor for a vote this week. Without McCain, it is possible that McConnell would lack the needed votes and as a result, further action on the bill will be delayed until McCain returns to the Senate.

Republican senators attempting to save their stalled effort to repeal and replace Obamacare in a late-night meeting Wednesday were interrupted with news of Sen. John McCain’s brain cancer diagnosis.

Sen. John Hoeven, R-N.D., told reporters that the senators learned of McCain’s brain cancer diagnosis during the meeting and asked Sen. James Lankford, R-Okla., to say a prayer for McCain.

“It was very emotional, almost kind of stunned disbelief for a minute, then we asked James Lankford to lead us in prayer,” Hoeven said.

“It was a sobering moment,” Sen. Ted Cruz, R-Texas, said.

Sen. Lindsey Graham, R-S.C., called McCain, who said he wanted to get back to work as quickly as possible.

“I’m going stay here a little bit longer, take some treatments and I’ll be back,” McCain said, according to Graham. Read on because as of Friday that seems to have changed.

McCain’s office announced Wednesday that the senator had an aggressive brain tumor surgically removed and was reviewing future treatment options, including chemotherapy. McCain, a war hero and the chair of the Senate Armed Services Committee, is a key figure in the conference.

The health care meeting included skeptics of Sen. Mitch McConnell’s repeal and replace bills, such as Sen. Lisa Murkowski, R-Alaska, Sen. Shelley Moore Capito, R-W.Va., and Dean Heller, R-Nev., as well as administration officials Health and Human Services Secretary Tom Price and Medicaid chief Seema Verma. Senate leadership billed the meeting as Republicans giving a replace plan “one more shot” after talks stalled earlier this week.

Senators streaming out of the late-night meeting said some progress had been made, but conceded McCain’s likely absence from the chamber during treatment made an already tricky process even harder. “Obviously it makes things difficult,” Sen Bob Corker, R-Tenn. said.

The 52-person Republican caucus has failed to get 50 votes to support a replacement plan so far, and McCain’s absence reduces their numbers further. McConnell scheduled a vote on a repeal-only bill on Tuesday but encouraged Republicans to try to agree on a replacement plan before that date. Right now, senators aren’t sure what they’ll be voting on this Tuesday — a motion to proceed on an updated version of repeal and replace they would then amend, or straight repeal. And it seems unlikely they have enough votes to start the debate on either measure at this point.

Friday it was announced that Senator McCain would be taking time off to undergo radiation and chemotherapy for his brain tumor. What will that do to the goals, progress or lack of progress in the Senate? Now add the names of Senator Jeff Flake from Arizona and Nevada’s Dean Heller, who has harshly criticized the Senate plan, who are in serious trouble for re-election. The tables could easily turn against the GOP getting anything done at all.

The Congressional Budget Office predicted a straight repeal would lead to 32 million fewer Americans having health insurance over 10 years if Congress does not replace it with an alternative plan. McConnell says Congress would come up with a replacement plan during the two-year delay before repeal goes into effect.

Before leaving the Capitol last week, McCain urged his party to start over on health care and come up with a new plan through an open committee process, instead of behind closed doors. A few of his Republican colleagues agree, but McConnell hasn’t given up yet.

Senators were still “throwing out ideas” in the meeting, according to Hoeven, but no breakthroughs were made. Asked whether they were close to a deal, Sen. Pat Toomey, R-Penn., said it’s “hard to say.”

Murkowski said she wasn’t sure how she would vote Tuesday because she doesn’t know what she’d be asked to vote on. “It’s difficult for me to say yes or no on whether to proceed because it’s not certain what we would be proceeding to,” she said. When asked what senators would be voting on, Cruz said those conversations were ongoing.

And the White House has already started on their next strategy to bring the ACA down. President Donald Trump’s administration has ended Affordable Care Act contracts that brought assistance into libraries, businesses and urban neighborhoods in 18 cities, meaning shoppers on the insurance exchanges will have fewer places to turn for help signing up for coverage.

Community groups say the move, announced to them by contractors last week, will make it even more difficult to enroll the uninsured and help people already covered re-enroll or shop for a new policy. That’s already a concern because of consumer confusion stemming from the political wrangling in Washington and a shorter enrollment period. People will have 45 days to shop for 2018 coverage, starting Nov. 1 and ending Dec. 15. In previous years, they had twice that much time.

Some see it as another attempt to undermine the health law’s marketplaces by a president who has suggested he should let “Obamacare” fail. The administration, earlier this year, pulled paid advertising for the sign-up website HealthCare.gov, prompting an inquiry by a federal inspector general into that decision and whether it hurt sign-ups.

Now insurers and advocates are concerned that the administration could further destabilize the marketplaces where people shop for coverage by not promoting them or not enforcing the mandate compelling people to get coverage. The administration has already threatened to withhold payments to insurers to help people afford care, which would prompt insurers to sharply increase prices.

I think that more and more of the voters are getting sick and tired of both parties playing games. Consider this article written by Andy Slavitt, Opinion columnist, who commented that the health care roller coaster ride has left Americans feeling increasingly sick to their stomachs. It has been ugliness at every turn.                                                                     In just the past week, Sen. Ted Cruz, R-Texas, insisted on a backroom amendment to undermine insurance markets. Vice President Pence was called on the carpet for stretching the truth in belittling the Medicaid program he aimed to cut in Ohio. Senate Majority Leader Mitch McConnell offered payoffs to fellow Republicans, trying to buy their loyalty for a bill that hurt their states. And to top it off, McConnell was caught red-handed by Sen. Ron Johnson, R-Wis., telling moderate Republicans not to worry about voting for Medicaid cuts because they would never actually happen.

What kind of games are our elected officials playing????

But the rushed deals, the untruths, the payoffs, the threats and the double-dealing were all only a precursor to President Trump’s response to the chaos. Apparently caught off guard, he first insisted on a vote to repeal the Affordable Care Act with no replacement, and then blamed the Democrats and anyone who voted against him, and finally implied that he would both allow the ACA to fail and take no responsibility for its failure. “The Dems scream death as Obamacare dies!” he tweeted Wednesday and then summoned senators to the White House to pressure them with statements that couldn’t withstand fact checking.

You can’t blame ordinary Americans for being exhausted by the whole ordeal. As one reporter met this week with cancer patients in Nevada, out in front of Republican Sen. Dean Heller’s office, there was no relief, only continued fear of Trump. As one woman put it to that reported, what’s he going to try to do next?

It’s time for the grown-ups in Washington to make themselves known. If we’ve learned anything, it’s to take Trump at his word when he claims he will take vengeful action if he doesn’t “win.” If he can’t get a health bill through Congress, he has plenty of ability to damage the Affordable Care Act through pure mismanagement. He can drive premium hikes and insurer pullouts by stopping cost-sharing payments that keep coverage affordable for low-income Americans. Already, Trump has destabilized the markets by refusing to enforce the law, which has increased prices and reduced competition. More games are not what Americans are looking for from the president.

The ACA is far from perfect, but it is also far from broken, yet! Most Americans live in areas that are quite stable, and according to a new report on 2017 exchange results, insurance companies have stemmed losses and are on solid financial ground. And this is not true. Quite a number of exchanges in severe trouble have folded. But, insurers are indicating that what they need now is enough certainty from Washington for them to be able to stay in the market, expand, and make their premiums more competitive. This statement and others from the insurance companies tell the real tale; the insurance companies are the principal forces really in charge.

If the administration refuses to provide that certainty by making cost-sharing payments, Congress should authorize the payments. If the administration refuses to enforce the law, Congress should hold oversight hearings to hold the White House to it. If the administration spends its resources making propaganda videos to scare people from enrolling instead of helping Americans enroll, the General Accounting Office needs to investigate.

And if Trump’s actions violate the law and cause Americans harm, he will end up in territory familiar to him — in court. At this point in his presidency, he has well trained his opposition. Each provocative, harmful action by Trump creates an opposite and forceful reaction of anger, fear, and resistance. People with disabilities and parents of medically fragile children have made it clear they can and will not surrender without a fight. In an echo of his immigration battles, legal experts, advocates and policy experts are already amassing to help.

Accepting the ACA as the law of the land after all that has transpired might not be in Trump’s DNA. As a result, he is unlikely to achieve what great presidents have a knack for, reading a situation well enough to turn a loss into a win.

Americans seem ready to see the politics of health care die down and crave the leadership that will put their concerns ahead of party loyalty. There are some in Washington who are not mired in subterfuge and games, notably three Republican women: Sens. Susan Collins of Maine, Shelley Moore Capito of West Virginia and Lisa Murkowski of Alaska.

The strongest message is coming from a group of governors, among them Republicans Brian Sandoval of Nevada, John Kasich of Ohio and Charlie Baker of Massachusetts, and Democrats Steve Bullock of Montana, John Bel Edwards of Louisiana and John Hickenlooper of Colorado. They are giving us a sorely needed vision of bipartisan statesmanship. But they also realize that if this Better Care Act gets passed, much of the Medicaid woes will be passed on to the states to finance and administer with efficiency and attention to the huge fraud.

Trump and McConnell are planning yet more arm-twisting followed by another vote next week to either repeal the ACA or jam through some tragically inadequate replacement. Anything can happen. More than ever, America is looking for grown-ups in Washington to stand up, make themselves known, and move us somewhere constructive. Mark my word, if they don’t grow up and act, or better yet perform like the Senators and Congressmen and women that we voted for, 2018 will be a sorry message to all elected officials!!





Reality Testing in Our Youth and Maybe the Rest of Us!

aid959I was finishing my breakfast Friday morning when my youngest daughter expressed her frustration with her up coming year in Pala Alto and some of the decisions that she has to make. She commented that she really didn’t want health care insurance and had reviewed with me the huge cost-$5,000. That is more than 15% of the salary that she would be getting. We had discussed the various plans including competitive premiums, deductibles, coverage, and exclusions.

She was frustrated and wanted to know why she just couldn’t purchase health care insurance. I had to point out to my very liberal, Anti-Trump daughter that this was not a choice. Why? Because her favorite president, former President Obama and the Democrats passed into law the Affordable Care Act which, by law requires everyone to purchase health care coverage, i.e. insurance.

I did explain the rationale for that requirement and that it was not such a bad idea. But having the healthy working youth pay for everyone else who doesn’t want to work or participate in their own health and well being is non-sustainable. Many young workers were, in fact, taking the tax penalty. However, over time as the penalty increases, this also becomes untenable along with the fact that they still also don’t have health care coverage.

So, the question still looms now and in the future, is “allowing” our healthy as well as unhealthy patients to choose not to have health care coverage a good idea? You think we live in a democracy and people should be able to choose not to purchase health care coverage if they don’t want to. But for obvious reasons when they need it and don’t have it, it becomes very expensive and the system now pays for it. Remember my comment last week that a person who shows up at an Emergency room with an injury or sickness that needs care, the ER can not turn the person away due to rules called EMTALA.

In 1986, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay. Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual’s ability to pay. Hospitals are then required to provide stabilizing treatment for patients with EMCs. If a hospital is unable to stabilize a patient within its capability, or if the patient requests, an appropriate transfer should be implemented.

So, this safety net already exists. But it is very expensive, often not paid for and puts a huge onus on hospitals and caregivers. Therefore, I understand the call for basic coverage for all. The question is if Congress is going to push for reduced taxes and Medicare and Social Security are in trouble financially, how do we pay for the universal/ Medicare for All, expanded Medicaid, or any of the various extrapolations of guaranteed coverage for all when a large population does have skin in the game and there are no penalties for not contributing to the funding of a universal system? We are looking at a socialized system, which is non-sustainable and we can’t keep expecting the youth to continue to fund those that can but refuse to work and abuse the system.

Now we learn that the GOP has a newer health care bill, the Better Affordable Care Bill, or what ever they call it this time. Who are the winners and who are the losers. Let us look again and compare.

Gisele Grayson, Alyson Hurt, and Alison Kodjak put together a few comparison charts, which help to get a true idea of the progress or lack of progress. The GOP’s latest proposal to repeal and replace the Affordable Care Act hews closely to the earlier bill that didn’t win enough support among lawmakers to bring to a vote.Untitled.1Untitled.2Untitled.3Untitled.4Untitled.5Untitled.6Perhaps the biggest change in the document released Thursday is that it leaves in place the Affordable Care Act taxes on wealthy individuals. It uses that money to reduce the number of people left without insurance coverage by the law’s changes. This latest version adds $70 billion to a fund for states — bringing the total to $132 billion — to help support coverage of low-income people.

It also would allow insurance companies to offer health plans without the consumer protections included in the Affordable Care Act, or Obamacare. That means insurers could sell stripped-down policies that cover fewer conditions and offer fewer benefits than currently allowed under the law.

Those plans would very likely be cheaper than the policies currently offered on the Obamacare exchanges. But for people who would like to purchase plans that cover the essential health benefits mandated by the Affordable Care Act, including mental health coverage, addiction treatment, maternity care and prescription drug coverage, costs could go way up. The word here is could! The states are already looking into inefficiency and fraud and how to cover those that need the safety net of Medicaid.

The nonpartisan Congressional Budget Office hasn’t yet analyzed the new bill. It weighed in on the earlier Senate bill, saying that proposal would result in 22 million fewer people having health coverage in the next 10 years, compared with under the Affordable Care Act. Of those, 15 million would lose Medicaid coverage. That version was projected to lower the deficit by billions over 10 years — but that may have changed as the latest version offers billions more for state grants and also doesn’t repeal as many of the Obamacare taxes.

Yet this new variant is the same as its predecessor when it comes to subsidies to help individuals pay for insurance. It would mostly reduce subsidies and cause out-of-pocket costs to rise, as the CBO said about the previous bill. It’s not yet clear how the state grants would alter that dynamic.

Sens. Lindsey Graham, R-S.C., and Bill Cassidy, R-La., aren’t on the list of likely “no” votes for the Republican health care bill, but that isn’t stopping them from offering up an alternative option.

As Senate Republicans were set to meet Thursday morning to learn about the newest version of their party’s bill to repeal and replace Obamacare, Graham and Cassidy went on CNN to float an entirely different approach.

The Graham-Cassidy amendment would keep most taxes from the Affordable Care Act in place and take the money raised and send it back to the states in the form of block grants. The states could then use it to create a state-specific system for providing health insurance.

“If you like Obamacare, you can reimpose the mandates at the state level. You can repair Obamacare if you think it needs to be repaired. You can replace it if you think it needs to be replaced,” Graham said on CNN. “It’ll be up to the governors. They’ve got a better handle on this than any bureaucrat in Washington.”

Graham said there will be a formula — not yet figured out — to decide how much money each state gets.

Many governors, including some Republicans, have expressed concerns about the Senate version of the health care plan. Ohio Gov. John Kasich, a Republican, said Friday that the draft bill “is still unacceptable.” He cited “deep” cuts to Medicaid and the lack of power it gives states to “innovate in order to cope with those reductions.”

Graham and Cassidy would get rid of the requirement that individuals must have insurance coverage and employers have to offer insurance to full-time employees. The repeal of the individual and employer mandates is a key Republican request. Legislation that doesn’t include it would have a hard time passing the Senate.

Cassidy’s office said that under the Graham-Cassidy plan, federal funding for Medicaid would “continue to grow in a sustainable manner, adjusted for inflation,” but they provided no details on how that would work.

The phase-out of Medicaid funding under the current bill is a critical issue for a handful of moderate lawmakers who are currently undecided on the bill. Thirty-two states, including Washington, D.C., expanded Medicaid under the Affordable Care Act, and lawmakers in both parties worry about what will happen to people enrolled in the program under the current bill.

Graham and Cassidy insist they aren’t trying to sink the GOP leadership’s health care bill — called the Better Care Reconciliation Act — and are hoping to offer their option as an amendment once the bill is brought to the Senate floor.

“We’re going to support Mitch’s effort with his new plan, but we want an alternative and we’re going to see which one can get 50 votes,” Graham said. “We’re not undercutting Mitch, he’s not undercutting us.”

But Graham is also putting the groundwork in place in case McConnell’s health bill fails — currently, it’s unclear whether it even has the 50 votes needed to be brought to the floor. Graham has reached out to at least one Democrat, moderate Sen. Joe Manchin of West Virginia, to see whether he’d be interested in talking.

Manchin spokesman Jonathan Kott said Manchin would talk about repairs to Obamacare, as long as Republicans stopped trying to repeal it.

On CNN Thursday, Graham told Democrats why he believed they should support the bill. “You’re gonna have to go to your governor in your state and say, ‘We don’t trust you with this money, we trust the bureaucrats more,'” Graham said. “That’s going to be hard politics if we keep the taxes in place for Democrats because they’ve gotta pick between a Washington bureaucrat and their own people in their state.”

“I think it’s provocative. What Lindsey has done a good job of doing is talking to governors about what they want, and it appears the answer is more money,” South Carolina Republican Sen. Tim Scott told USA TODAY. Scott said the proposal could be a way “to get governors satisfied.”

“I think it’s intriguing,” said Nevada Sen. Dean Heller. “I think we ought to take a closer look at it.” Heller’s announcement that he opposed the first Senate repeal bill was a key tipping point, and ultimately McConnell had to scrap a planned vote on the bill. Heller has not yet said whether he supports the new Republican bill.

Maureen Groppe, Eliza Collins and Deirdre Shesgreen stated that Senate Republicans hope their latest proposed bill to replace Obamacare will attract enough votes from the moderate and conservative wings of their party to pass next week.

But there are at least five hurdles that could derail efforts to reach consensus. They include:

  1. The bill still makes major cuts to Medicaid

More than 14 million Americans gained eligibility for Medicaid through Obamacare, and they could lose that coverage under the Senate bill, which phases out federal funds by 2024 for expanded Medicaid coverage.

That’s a problem for some moderate Republicans, who worry that their most vulnerable constituents will be harmed. Sen. Susan Collins, R-Maine, cited those cuts in a tweet Thursday saying that she will vote against a procedural motion to bring the bill to the floor, known as a “motion to proceed.”

Still deep cuts to Medicaid in Senate bill. Will vote no on MTP. Ready to work w/ GOP & Dem colleagues to fix flaws in ACA.

Patients who rely on Medicaid to get treatment for opioid abuse also could lose that coverage, undermining efforts by moderate GOP Sens. Rob Portman of Ohio and Shelley Moore Capito of West Virginia to boost federal support to fight the epidemic in their states. However, the bill does provide $45 billion in additional funding for opioid treatment, in an effort to lure Portman, Capito, and others.

  1. It does not fully repeal Obamacare

Conservatives want a complete repeal of the Affordable Care Act, especially its taxes. This bill would not do that.

While it eliminates taxes on health insurance, prescription drugs, medical devices and high-cost employer-sponsored plans, the legislation leaves in place Obamacare taxes on wealthy Americans to help subsidize coverage for lower-income people.

Sen. Rand Paul, R-Ky., a conservative with a libertarian bent, said he cannot support a bill that leaves so much of Obamacare in place. His spokesman said the senator plans to vote against the motion to bring the GOP legislation to the Senate floor next week.

“I pledged to the voters to repeal Obamacare, I think it’s a disaster,” Paul said Thursday on Fox News. “But this bill doesn’t repeal it. It keeps about half of the Obamacare taxes, it keeps most of the Obamacare regulations, it keeps most of the Obamacare subsidies, and it creates a giant new insurance bailout Superfund of about $200 billion. This isn’t repealed by any means, shape or form.”

  1. It still raises costs for older Americans

Groups representing older Americans — who traditionally vote in higher numbers — are blasting the bill for continuing to impose an “age tax” on Americans 55 to 64, who are still too young to benefit from Medicare.

“AARP reiterates our opposition to the Age Tax which would allow insurance companies to charge older Americans five times more than everyone else for the same coverage,” the organization said in a statement Thursday. The organization has 38 million members 50 and older.

Democrats signaled that they would hit Republicans hard during next year’s congressional elections if they vote for this provision.

“Premiums for so many people aged 55 to 64 will go way up,” said Minority Leader Chuck Schumer, D-N.Y., in a speech on the Senate floor Thursday. “Americans in their sixties could be paying tens of thousands of dollars more than they do today.”

  1. It still defunds Planned Parenthood

The bill would block Planned Parenthood from receiving Medicaid funding for a year. Federal law already prohibits the organization from using federal funds to perform abortions, but the bill would also prevent the group from using Medicaid money to offer birth control services, treat sexually transmitted diseases, and provide other medical care.

Most Republicans support defunding Planned Parenthood, but two key moderates — Collins and Sen. Lisa Murkowski, R-Alaska — are strong supporters of the group and have consistently opposed efforts to defund it.

“I, for one, do not believe that Planned Parenthood has any place in our deliberations on the Affordable Care Act,” Murkowski said in an address to Alaska state lawmakers earlier this year. “Taxpayer dollars should not be used to pay for abortions, but I will not vote to deny Alaskans access to the health services that Planned Parenthood provides.”

  1. Two GOP senators are offering a potentially attractive alternative

Sens. Lindsey Graham, R-S.C., and Bill Cassidy, R-La., offered an alternative Thursday that they said could attract more support than the bill introduced by GOP leaders.

Their plan would send the current federal funding for Obamacare, estimated at about $110 billion last year, to the states in the form of block grants that governors could use however they want. Graham said states could keep Obamacare in place or replace it with a new system.

“Instead of having a one-size-fits-all solution from Washington, we should return dollars back to the states to address each individual state’s health care needs,” Graham said.

Sen. Ron Johnson, R-Wis., who opposed an earlier version of the GOP health care bill and is undecided on the latest version, said the Graham-Cassidy alternative “actually has some appeal to me.”

Reviewing the tables that I included one wonders, does anybody except me see how this is progressing? The GOP revisionary bills are becoming more and more to parallel the Affordable Care Act/Obamacare as the Republican Senators with reasonable “brains” realize that there are some parts of the ACA that are “good” and important enough to get their new health care bill to have any chance of passing in the Senate. But, also there are some well thought out parts of the ACA that do make the delivery of health care better. I know, I shouldn’t have stated that I think parts of the ACA are good for patients, but there are good parts to this well-thought out bill. The problem, as I continue to stress is that it is not sustainable and that there are flaws that if our Congress were really concerned would work together to modify the ACA to make it work for all.

I will look more at many questions that you all may wonder about and I promise I will try to clear some of the murky waters that probably are confusing any ability to understand really what the new bills and all the revisions mean to all of us.

Fact check: Deaths from the GOP health care bill?

echo970I’m getting pretty tired of hearing the continual beating of the drums warning of how many deaths will result from the Repeal of Obamacare. Also, the CBO evaluation is predicting the huge numbers of people without health insurance.

But what are the real numbers?

Lori Robertson and Robert Farley reported that House Minority Leader Nancy Pelosi has said, “hundreds of thousands of people will die” if the Senate health care bill becomes law. But what does the research say about the impact of health insurance on mortality rates?

There are several studies backing up the idea that those who lack health insurance have a higher chance of dying prematurely than those with insurance, as they found when they looked at this issue in 2009.

But the research uses terms like “could” and “suggests” and “cannot definitively demonstrate a causal relationship,” not the definitive “will” favored by opponents of the bill. We can’t say whether any specific projection is a correct or valid number.

Democrats have made this a talking point. “We do know that many more people, hundreds of thousands of people, will die if this bill passes,” Pelosi said on CBS This Morning on June 26. In a July 2 interview on CNN’s State of the Union, Sen. Bernie Sanders said “tens of thousands of people every single year will die” if the Affordable Care Act were repealed entirely, without a replacement.

Later in that interview, Sanders said that “no one knows exactly the number” but that one study said, “up to 28,000 people a year … will die” from the increase in the uninsured under the Republican bills. He and Pelosi are referring to an analysis by the left-leaning Center for American Progress.

We’ll explain how that study reached its conclusions, as well as what other research has found.

The analysis by CAP concluded that if coverage losses in the Senate bill mirrored losses in the House bill, then the legislation “would result in 217,000 additional deaths over the next decade.”

At the time Pelosi made her statement, the Congressional Budget Office hadn’t yet released its analysis of the Senate’s Better Care Reconciliation Act, but it did later in the same day. The CBO concluded that the Senate bill would increase the number of uninsured by 22 million in 2026, compared with current law. The CBO’s estimate for the impact of the House health care bill, the American Health Care Act, had been 23 million more uninsured in 2026, compared with current law.

Using the 23 million figure from CBO and a study on mortality in Massachusetts after it passed sweeping health care changes in 2006, the CAP report extrapolated that “the coverage losses from the Senate bill would result in 27,700 additional deaths in 2026” and 217,000 over 10 years.

A professor of social epidemiology and two graduates of the Harvard T.H. Chan School of Public Health, as well as two CAP staffers wrote the CAP report. (The Harvard researchers later gave updated figures for the Senate bill — 26,500 extra deaths in 2026 and “208,500 unnecessary deaths” over a decade.)

The CAP report has limitations, which the authors acknowledged. And its specific figures are the midpoint of a range. There’s a 95% confidence interval associated with the 27,711 excess deaths estimate, meaning, “we are 95 percent confident that the true number of annual excess deaths will be between 9,583 and 46,000,” the authors explain.

What are the limitations to those numbers? The CAP report took a study about Massachusetts and applied it to the entire country, and it took a study about the impact of increasing those with insurance and applied it to the opposite scenario — the number with insurance declining under the GOP health care bills.

The Massachusetts study, published in the Annals of Internal Medicine in May 2014, compared changes in mortality rates for adults age 20 to 64 in the state from 2001 to 2005 and 2007 to 2010 to a control group of counties in other states. Massachusetts passed health care legislation in 2006, often called Romneycare, that was similar in many ways to the federal Affordable Care Act, passed in 2010.

The conclusion of the Massachusetts study: The state’s health care law was associated with a decrease in deaths. The study showed that “The Massachusetts 2006 health care reform was associated with significant reductions in all-cause mortality over 4 years of follow-up relative to a control group of similar counties in states without reform. Reductions were concentrated in causes of death that were more plausibly amenable to health care and in populations most likely to benefit from expanded access, particularly residents of counties with lower incomes and higher pre-reform uninsured rates.”

The authors found a drop in mortality of 8.2 per 100,000 adults and said that — along with an increase in insurance coverage in the state — implied for “approximately every 830 adults who gained insurance, there was 1 fewer death per year.”

The CAP report simply did the math — applying that finding to the country at large using the CBO’s estimates for the increase in the uninsured under the GOP bills.

The lead author of the Massachusetts study, Benjamin D. Sommers, an associate professor of health policy and economics at Harvard, told us the CAP report was “a reasonable attempt to project mortality effects based on prior research.”

“The authors do mention some of the main limitations of this approach that I also would have pointed out — namely, that Massachusetts is of course not identical to the U.S. as a whole, and withdrawing coverage may not have produced mirror image effects as expanding coverage,” Sommers said.

The Massachusetts study noted that the state differed from the rest of the country in many ways, including having lower mortality, higher income and the highest per-capita number of physicians. “The extent to which our results generalize to the United States as a whole is therefore unclear,” the authors wrote.

“But the ACA was modeled after Massachusetts health reform, so I do think it’s probably the best gauge we have for this projection,” Sommers said. “It’s hard to pin down any specific number with certainty, but I think the CAP projections are at least plausible.”

Sommers said he would use less definitive language than the politicians. He said Pelosi was “taking what is a reasonable projection and stating it as a fact; I would have used the caveats above and been a bit less definitive — but I’m a researcher not a politician!”

There are also limitations to the study on Massachusetts, as with most studies. It’s difficult in research to prove causality — that one thing directly causes another — and that was the case here. The authors noted, “We do not have individual-level insurance information and thus cannot directly link mortality changes to persons gaining insurance coverage.” They said it was possible that the reduction in mortality was caused by other factors in the state, though the study controlled for economic measures and didn’t find that mortality similarly declined for elderly adults in the state — who would have been covered by Medicare and largely unaffected by the health care changes.

Other research by Brendan Saloner, an assistant professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health, states that told “no single study is as good as looking at the full body of research.” And while not all studies have found health improvement related to insurance coverage, the “preponderance of studies, especially the well-done studies, find that gaining insurance coverage, especially for low-income people, improves health and reduces mortality risks.”

Let’s look at some of the research:

  • A 2017 review of studies over the past decade — published in the New England Journal of Medicine with Sommers as the lead author — concluded: “Insurance coverage increases access to care and improves a wide range of health outcomes. Arguing that health insurance coverage doesn’t improve health is simply inconsistent with the evidence.” On the specific issue of whether coverage saves lives, the review described three recent studies, including the Massachusetts study. We’ll describe the other two, on Medicaid expansion, below.
  • A 2012 study published in the New England Journal of Medicine, also with Sommers as the lead author, compared three states that substantially expanded Medicaid (before the Affordable Care Act) to neighboring states that did not expand Medicaid. It concluded, “State Medicaid expansions to cover low-income adults were significantly associated with reduced mortality as well as improved coverage, access to care, and self-reported health.” The study looked at five years before and after expansions of Medicaid eligibility in New York, Maine and Arizona. Among the limitations: “We examined three expansion states, and the results are largely driven by the largest (New York), so our results may not be generalizable to other states.”
  • The Oregon Health Insurance Experiment, published in the New England Journal of Medicine in 2013, provided mixed results. The study, whose lead author, Harvard’s Katherine Baicker was a coauthor on the two studies above, compared data from 6,387 adults who were able to apply for Medicaid coverage in Oregon through a lottery drawing to 5,842 adults who were not selected. The authors concluded: “This randomized, controlled study showed that Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years, but it did increase use of health care services, raise rates of diabetes detection and management, lower rates of depression, and reduce financial strain.”

The study measured three health indicators — blood pressure, cholesterol and glycated hemoglobin levels (which measure diabetic blood sugar control) — over a two-year period. The time period studied was among its limitations; it said “the effects of insurance in the longer run may differ.” The study didn’t address mortality rates; an earlier working paper on the first year of the Oregon experiment said “not surprisingly” researchers didn’t see “any statistically significant improvement in survival probability” during the short time frame with few deaths.

  • A 2014 study published in the Journal of Clinical Oncology looked at cancer diagnoses among 39,447 people age 20 to 40 between 2007 and 2009 and concluded that “young adults who are uninsured may be more likely to present with metastatic disease, be undertreated, and die after a diagnosis of cancer relative to those who are insured.”
  • A 2017 study in the journal Medical Care determined that the provision in the ACA allowing young adults to stay on their parents’ plan until age 26 “was associated with a 6.1% decline in monthly disease-related mortality” and no significant difference in external-trauma mortality, such as from accidents. The study compared mortality in 19- to 25-year-olds to that of a control group of 26- to 30-year-olds in 2008-2013.
  • Among older research: A 2004 study published in Health Affairs found that the uninsured among those age 55 to 64 had a 3% higher risk of dying over an eight-year period, calculating that 13,000 yearly deaths “may be attributable to the present lack of insurance coverage among the near-elderly.” It used data from the Health and Retirement Study, sponsored by the National Institute on Aging, and controlled for socioeconomic factors.
  • In March 2009, Dr. John Z. Ayanian of the National Academies’ Institute of Medicine testified to Congress on the review by the Committee on Health Insurance Status and Its Consequences of nearly 100 studies released since 2002. He described the uninsured as being more likely to delay or forgo preventive care, medications and treatment. His written testimony said: “Uninsured adults are also more likely to be diagnosed with later-stage cancers compared to their insured peers. If hospitalized for a serious acute condition, such as a heart attack, stroke, or major trauma, uninsured adults are more likely to die after admission to a hospital. Uninsured adults are 25 percent more likely to die prematurely than insured adults overall, and with serious conditions such as heart disease, diabetes or cancer, their risk of premature death can be 40 to 50 percent higher. Fortunately, our Committee also found good news to report: when uninsured people acquire health insurance they can experience both immediate and long-term improvements in their health.”
  • In 2002, the Institute of Medicine, drawing on previous research that found a higher mortality risk for the uninsured, determined that 18,000 nonelderly adults died because they lacked health insurance in 2000. A 2009 study, published in the journal Health Services Research and authored by Richard Kronick, who later headed the Agency for Healthcare Research and Quality, said that finding was “almost certainly incorrect.” Kronick’s study found no difference in mortality between the uninsured and those with employer-sponsored insurance after adjusting for demographic, health status and health behavior factors.

This body of research looked at the impact of already being uninsured, or the impact of gaining coverage. The CAP report, as we noted, examined the opposite situation — declining insurance coverage.

That’s a challenge in applying past research to the proposed health care legislation. “We’ve never seen large scale reductions in insurance coverage” such as those projected by the CBO, Johns Hopkins’ Saloner notes.

The 2017 review of studies in the New England Journal of Medicine noted that critics of the ACA have contended that benefits from insurance gains depend on the type of coverage — that Medicaid coverage isn’t beneficial, while private insurance is. (That’s one argument in a February paper published by the conservative Manhattan Institute that said the “best statistical estimate” for lives saved by the ACA was “zero.”)

“But there is no large quasi-experimental or randomized trial demonstrating unique health benefits of private insurance,” the NEJM review said. It said that “further research is needed to assess the relative effects of various insurance providers and plan designs.”

The Congressional Budget Office projects that the Senate health care bill would increase the number of uninsured Americans by 22 million in 2026 — a figure that both sides in the debate are distorting:

Sen. Bernie Sanders wrongly claims the bill “would throw 22 million Americans off of health insurance.” Actually, some would prefer not to buy insurance. In fact, CBO estimates that 15 million more would be uninsured next year alone “primarily because the penalty for not having insurance would be eliminated.”

 Conversely, House Speaker Paul Ryan says of the 22 million, “It’s not that that people are getting pushed off our plan. It’s that people will choose not to buy something they don’t like or want.”

That’s inaccurate, too. Under the bill, some would no longer be eligible for Medicaid and others would not be able to afford coverage.

The White House sought to discredit the CBO estimate, tweeting that the agency’s analysis of the Affordable Care Act in 2010 was off by “100%.” The “CBO estimated that 23M would be covered in 2017,” the tweet said. Actually, CBO was pretty close. The number of people without insurance has declined by 20 million since 2010.

On June 22, Senate Republicans introduced the Better Care Reconciliation Act — their version of legislation to repeal and replace the Affordable Care Act, which was signed into law by former President Obama in 2010. As with the House version, CBO projected a sharp increase in the number of people without insurance, compared with current law.

In a report issued June 26, CBO and the Joint Committee on Taxation said the Senate bill “would increase the number of people who are uninsured by 22 million in 2026 relative to the number under current law, slightly fewer than the increase in the number of uninsured estimated for the House-passed legislation.” CBO estimated an increase of 23 million under the House bill.

“By 2026, an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law,” CBO said.

As we saw with the CBO estimate of the House bill, both sides distorted what CBO said about the increase in the number of uninsured. (See “The 24 Million Talking Point” and “Spinning the CBO Report.”)

Shortly after CBO released its report, Sen. Bernie Sanders went to the Senate floor and spoke about the agency’s analysis of the bill.  “According to CBO, and that report just came out a few hours ago, this bill would throw 22 million Americans off of health insurance …”

A day later, House Speaker Paul Ryan appeared on Fox & Friends and gave a different spin on the 22 million figure in the CBO report (at about the 36-second mark of the video). “What they’re basically saying at the Congressional Budget Office is if you’re not going to force people to buy Obamacare, if you’re not going to force them to buy something that they don’t want, then they won’t buy it. So it’s not that that people are getting pushed off our plan. It’s that people will choose not to buy something they don’t like or want.”

In fact, CBO said it’s a combination of both: some people being thrown off and others opting not to buy insurance they don’t like or want.

The biggest jump in the number of uninsured Americans under the Senate bill would occur in the first year and largely because, as Ryan says, people who were forced to buy health insurance would opt not to purchase it. The Senate bill eliminates a tax penalty for not having insurance. For tax year 2016, the tax was $695 or 2 percent of your income, whichever is higher. “CBO and JCT estimate that, in 2018, 15 million more people would be uninsured under this legislation than under current law — primarily because the penalty for not having insurance would be eliminated.”

In particular, CBO says healthier people would leave the market, driving up premiums in the short-term. “Under the Senate bill, average premiums for benchmark plans for single individuals would be about 20 percent higher in 2018 than under current law, mainly because the penalty for not having insurance would be eliminated, inducing fewer comparatively healthy people to sign up,” CBO says.

However, the CBO said it didn’t expect the elimination of the requirement to have insurance to affect those now with Medicaid. “The agencies do not expect that, with the penalty eliminated under this legislation, people enrolled in Medicaid would disenroll,” CBO report said.

CBO expects there would be “15 million fewer Medicaid enrollees by 2026 than projected under current law. The decline would be, in large part, due to proposed Medicaid changes contained in the Senate bill — which reduces Medicaid spending by $772 billion by 2026.

The ACA expanded eligibility to all individuals under age 65 who earn up to 138 percent of the federal poverty level, and the federal government currently pays 95 percent of the cost for the expansion population. But, under the Senate bill, states that already have expanded Medicaid would get reduced federal funding, beginning in 2021. And states that haven’t yet expanded eligibility could only do so at their standard federal match rates, which average 57 percent.

“Some of that decline would be among people who are currently eligible for Medicaid benefits, and some would be among people who CBO projects would, under current law, become eligible in the future as additional states adopted the ACA’s option to expand eligibility.”

Also, federal Medicaid payments to states would no longer be open-ended. The bill would cap the amount of federal funding that states can receive per Medicaid enrollee, beginning in fiscal year 2020. That would “shift a greater share of the cost of Medicaid to states over time” and force states to adopt a mix of cost-saving options, including cutting benefits, eliminating optional services and restricting eligibility for enrollment, CBO says.

For those buying insurance on the individual market, CBO says some who would otherwise be insured under current law would be discouraged from buying it under the Senate bill. For example, CBO says that “few low-income people would purchase any plan,” because the cost would be prohibitive. “Under this legislation, starting in 2020, the premium for a silver plan would typically be a relatively high percentage of income for low-income people. The deductible for a plan with an actuarial value of 58 percent would be a significantly higher percentage of income — also making such a plan unattractive, but for a different reason. As a result, despite being eligible for premium tax credits, few low-income people would purchase any plan, CBO and JCT estimate.”

CBO says that the increase in the number of uninsured “would be disproportionately larger among older people with lower income — particularly people between 50 and 64 years old with income of less than 200 percent of the federal poverty level.” For example, CBO says that single individuals who are 64 years old and earn $26,500 (175 percent of federal poverty level) would have to pay $6,500 in net premiums for a silver plan after receiving a government tax credit — $4,800 more than they would under current law.

Untitled.CBO numbers      On the day that CBO released its report on the Senate bill, the official White House Twitter account posted a tweet that was critical of CBO’s past estimate on the Affordable Care Act. In particular, the White House criticized CBO’s projection for the number of nonelderly people (under age 65) that would be covered by the ACA.

FACT: when ‪#Obamacare was signed, CBO estimated that 23M would be covered in 2017. They were off by 100%. Only 10.3M people are covered.

Let’s set aside the obvious math error. The difference between 23 million and 10.3 million is 55 percent, not 100 percent.

More important, the White House tweet says — as administration officials have said in the past — that CBO was wrong about the number of people who would be insured by the Affordable Care Act. But, as we wrote, CBO was actually pretty close to accurate on the overall number of people who would gain insurance under the law. What CBO got wrong was the mix of insured: There were more people who gained insurance through the Medicaid expansion than CBO expected, but fewer people that obtained coverage through the ACA exchanges.

To briefly recap: CBO issued its official estimate of the cost and effects of the Affordable Care Act on March 20, 2010, and then updated its estimates in July 2012 after the Supreme Court ruled that states could not be forced to expand eligibility for Medicaid.

In its 2012 report, CBO projected that there would be 30 million uninsured people under 65 years old in 2016. The actual number was 28.2 million in 2016, according to the latest figures from the Centers for Disease Control and Prevention’s National Health Interview Survey. The number of uninsured fell from 48.2 million in 2010 to 28.2 million in 2016.

The graphic that was attached to the White House tweet ignored the fact that the number of people without insurance declined by 20 million since 2010. Instead, it focused on the number of people who purchased insurance on the insurance exchanges created by the ACA.

CBO estimated that in 2016 there would be 23 million getting policies through ACA exchanges. The actual number was 10.4 million during the first half of the year, according to the Centers for Medicare & Medicaid Services.

However, that’s just half the story. CBO underestimated the number of people who would enroll in Medicaid under the expansion of the health care program for low-income Americans.

CBO projected that 10 million people would enroll in Medicaid by 2016. But 14.4 million adults had enrolled in Medicaid through March 2016 as a result of the Affordable Care Act’s expansion of the program, according to an analysis by the nonpartisan Kaiser Commission on Medicaid and the Uninsured.

But what all the numbers are missing is that many of the states are already “adapting to the possible changes in Medicaid. There is soo much inefficiency and fraud. More and more states are seeking changes to their programs. Indiana and Maine, for example, are among states that have proposed work requirements for able-bodied adults in the program. (Indiana estimates that a quarter of those required to work won’t and “will have HIP [Medicaid] eligibility suspended until compliance has been demonstrated.”) States say that by making Medicaid contingent on work, potential beneficiaries will be incentivized to find jobs that offer health insurance.

Wisconsin is asking the federal government to approve a drug-testing requirement, saying it will help get people into treatment and prepare them for jobs. Arizona wants to cap the amount of time certain nondisabled adults can remain on Medicaid to five years, taking a page from the welfare reform playbook of the 1990s. And Utah is proposing a limit on the number of adults without dependent children who can enroll in its Medicaid program.

Such requests are popping up all across the country, according to a recent analysis by the Kaiser Family Foundation, a nonprofit think tank.

So far, the Trump administration hasn’t approved any of these requests, but it signaled in a letter to governors in March that it would be more flexible than the Obama administration, which did not approve requests from Indiana and Arizona in the past.

“We commit to ushering in a new era for the federal and state Medicaid partnership where states have more freedom to design programs that meet the spectrum of diverse needs of their Medicaid population,” wrote Health and Human Services Secretary Tom Price and Verma.

People dying after Obamacare “is repealed”, yes, but not because people are losing their health care insurance. Many didn’t want or still can’t afford health care coverage because of high premiums and very high dedutibles. They will still die, but everyone forgets that due to many long term regulations patients can not be refused care in an emergency situation and will continued to be cared for. Let’s stop beating the drums of catastrophe and start working for a bilateral solution to the health care crisis!!

Next I will discuss how the Senate health care bill will affect the Insurance industry and the rest of us!